Medical Policy Updates

Notification of Policy Revisions Effective July 16, 2019 (Posted May 14, 2019)

Medical Policy Revision
BRCA AHS-M2003 "NOTIFICATION" Reviewed by Avalon 1st Quarter 2019 CAB. Extensive revisions under When Covered section regarding personal and family history of cancer based on updated NCCN guidelines. Removed wording "Individual has a third-degree relative with breast cancer and/or ovarian carcinoma..." from the criteria on testing for individuals without cancer. Under When Not Covered, added Notes 1-4. Reordered the notes for clarity, added Note 1 concerning ovarian cancer excluding germline tumors, and added a Note 4 concerning what tools are recommended by the USPSTF for clarity. Medical Director review 5/2019. Notification given 5/14/19 for effective date 7/16/19.
Diagnosis of Vaginitis including Multi-target PCR Testing AHS – M2057 "NOTIFICATION" Reviewed by Avalon 1st Quarter 2019 CAB. "Using molecular-based panel testing, including, but not limited to testing such as SmartJaneTM , to test for microorganisms involved in vaginal flora imbalance and/or infertility is considered investigational" was added to list of NonCovered indications. Policy Guidelines updated. Codes 87905 and 0068U added to Billing/Coding section. References added. Medical Director review 4/2019. Policy noticed 5/14/2019 for effective date 7/16/2019.
Evaluation of Dry Eyes AHS - G2138 "NOTIFICATION" Reviewed by Avalon 1st Quarter 2019 CAB. Added additional investigational criteria: Testing for lactoferrin and/or IgE to aid in the diagnosis of patients suspected of having dry eye disease is considered investigational and all other testing used in the diagnosis of patients suspected of having dry eye disease is considered investigational. Added the following CPT codes to "Billing/Coding" section: 82785, 83520, 83861. Medical Director review 5/2019. Policy noticed 5/14/19 for effective date 7/16/19.
General Genetic Testing, Germline Disorders AHS – M2145 "NOTIFICATION" Policies added to Description section. Added item 3 and Note 1 to the When Covered sections as follows: "Germline multi-gene panel testing (See Note 1), defined as multiple gene tests for a medical condition or symptoms/non-specific presentation run on one testing platform, is considered medically necessary according to the guidelines in the preceding coverage criteria and the reimbursement limitations (see section regarding Reimbursement below). Note 1: For references regarding the clinical application of genomic sequencing and for appropriate medical coding, please refer to (ACMG, 2012; AMA, 2019)." Policy guidelines extensively revised. The following revisions were made to the Billing/Coding section: codes 81329, 81333, and 81336 were removed, code 81442 was added along with the reimbursement information. Medical Director review 5/2019. Policy noticed 5/14/19, for effective date 7/16/19.
Parathyroid Hormone, Phosphorus, Calcium, and Magnesium Testing – AHS –G2164 "NOTIFICATION" New policy developed. BCBSNC will provide coverage for Parathyroid Hormone, Phosphorus, Calcium, and Magnesium Testing when it is determined to be medically necessary because the medical criteria and guidelines are met. Medical Director review 4/1/2019. Policy noticed 5/14/2019 for effective date 7/16/2019.
Prescription Medication and Illicit Drug Testing in the Outpatient Setting AHS – T2015 "NOTIFICATION" New policy developed that replaces policy titled "Opioid Testing in Pain Management and substance Abuse". BCBSNC will provide coverage for prescription medication and illicit drug testing in the outpatient setting when it is determined to be medically necessary because the medical criteria and guidelines are met. Medical Director review 4/1/2019. Policy noticed 5/14/2019 for effective date 7/16/2019.
Salivary Hormone Testing AHS – G2120 "NOTIFICATION" Reviewed by Avalon 1st Quarter 2019 CAB. Minor changes to Description Section. Revised NonCovered statement to read: "Salivary hormone testing for the screening, diagnosis, and/or monitoring of menopause, infertility, endometriosis, polycystic ovary disease (PCOS), premenstrual syndrome, osteoporosis, sexual dysfunction, seasonal affective disorder, depression, multiple sclerosis, sleep disorders, or diseases related to aging is considered not medically necessary." Added Cortisol to list of NonCovered tests. Policy Guidelines section and References updated. Medical Director review 4/2019. Policy noticed 5/14/2019 for effective date 7/16/2019.
Thyroid Disease Testing AHS – G2045 "NOTIFICATION" Reviewed by Avalon 4th Quarter 2019 CAB. Added "Individuals with chronic or acute urticaria" to the list of Covered Indications. Added " Testing for thyroid dysfunction in asymptomatic nonpregnant individuals for thyroid disease is considered not medically necessary during general exam without abnormal findings" to list of NonCovered Indications. Updated Policy Guidelines section and References. Medical Director review 4/2019. Policy noticed 5/14/2019 for effective date July 16, 2019.