| Medical Policy | Revision |
|---|---|
| Diagnosis of Idiopathic Environmental Intolerance AHS - G2056 | Reviewed by Avalon 1st Quarter 2026 CAB. Description, Policy Guidelines and References updated. The following edits were made for clarity and consistency: CC2 and CC3, replaced “In all circumstances” with “For asymptomatic individuals and/or during general encounters without abnormal findings,” for clarity. CC4, CC5, CC6, CC8 edited for consistency. CC7 edited for clarity and consistency, as breath hydrogen/methane testing is not allowed under any circumstances. Now reads: “7. Reimbursement is not allowed for breath hydrogen and/or breath methane testing.” Under Billing/Coding removed section titled "Reimbursement". Medical Director reviewed 1/2026. Notification given 2/25/26 for effective date 5/6/26. |
| Diagnostic Testing of Iron Homeostasis and Metabolism AHS - G2011 | Reviewed by Avalon 1st Quarter 2026 CAB. Medical Director review 1/2026. Description, Policy Guidelines, and References updated. Updated policy statement and headers to reflect previous title change. When Covered section updated as follows: Added “(no more than one test per month unless otherwise specified)” to #1. Updated 1.a for clarity. Updated #1. b for clarity and to add frequency “(no more than one test per month unless otherwise specified).” Updated #1.h to include frequencies for chronic kidney disease dependent on if the individual is or isn’t receiving hemodialysis. Added new statement #1. j “For individuals with restless leg syndrome or periodic limb movement disorder.” Added new statement #2. d “For individuals with restless legs syndrome or periodic limb movement disorder.” Updated Note 1 to align with symptoms of hemochromatosis (iron overload) and expand to allow arrhythmias, erectile dysfunction, pain in the knuckles, and provides specificity in the region of abdominal pain. Notification given on 2/25/2026 for effective date 5/6/2026. |
| Laboratory Procedures Medical Policy AHS - R2162 | Reviewed by Avalon 1st Quarter 2026 CAB. Updated section “Panel Reimbursement”; updated statement on concurrent ordering for clarity, added new bullet point and sub-bullet points on repeat multi-gene panel testing: “Repeat multi-gene panel testing is not allowed unless all of the following are true: a. The individual met all necessary criteria to receive genetic panel testing; b. The individual doesn’t have a previously identified mutation that is causative for the disorder being evaluated; c. The panel being requested contains one or more genes that were previously untested.” Updated 4th bullet point under section “Unit Threshold Met (Daily and Historical)” for clarity and now reads: “Scientific or statistical analyses demonstrate a reasonable limitation of the number of units that should be performed within a specified period of time.” Codes 0450U and 0451U deleted from Billing/Coding section. Codes 0614U, 0618U, 0619U, 0622U, 0623U, 0624U, 0625U, 0626U, 0627U, and 0629U added to Billing/Coding section, effective 4/1/26. Medical Director review 1/2026. Notification given 2/25/26 for effective date 5/6/26. |
| Liquid Biopsy AHS - G2054 | Reviewed by Avalon 1st Quarter 2026 CAB. When Covered section updated as follows: 1a and 1b updated for clarity. To align with NCCN guidelines, 1d edited and 1e created. #2 edited to breast cancer types, allowed genes, and timing of testing to align with updated NCCN recommendations. New #4 created. When Not Covered section updated as follows: New #1 created. With changes to the biomarker list for cfDNA/ctDNA in Note 1, former 2, now 3, removed “for all other situations not addressed above,” as NCCN’s recommendations for PD-L1 analysis is by IHC, not liquid biopsy. #3 now reads: “Analysis of PD-L1 by liquid biopsy is considered investigational.” New Notes 1 (list of biomarkers from 1c in When Covered section) & 2 created. Policy Guidelines and References updated. Added CPT codes 0012M, 0013M, 0363U, 0420U, 0452U, 0465U, 0549U, and 0613U and deleted CPT code 0569U in Billing/Coding section. Medical Director review 4/2025. Notification given 2/25/2026 for effective date 5/6/2026. |
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