| Medical Policy | Revision |
|---|---|
| Adaptive Behavioral Treatment for Autism Spectrum Disorders | Description, policy guidelines, and references updated. Coverage criteria updated to reflect current standards care. Specialty Matched Consultant Advisory Panel Review 4/2025. Medical Director review 4/2025. Notification given 4/30/2025 for effective date 7/1/2025. |
| Biomarker Testing for Autoimmune Rheumatic Disease AHS - G2022 | Reviewed by Avalon for 2nd Quarter 2025 CAB. Updated description, policy guidelines, and reference. Updated coverage criteria for clarity on allowed frequency of biomarker testing. Added the following statement to When Not Covered section: “Reimbursement is not allowed for testing for serum biomarkers not discussed above, alone or in a panel (e.g., Seronegative Rheumatoid Arthritis Profile) for the diagnosis of RA.” Added “aisle® DX Disease Activity Index, Early Sjögren’s Syndrome Profile” to When Not Covered statement, now reads: “Reimbursement is not allowed for serum biomarker panel testing with proprietary algorithms and/or index scores (e.g., AVISE CTD, AVISE SLE Monitor, AVISE SLE Prognostic, aisle® DX Disease Activity Index, Early Sjögren’s Syndrome Profile) for the diagnosis, prognosis, or monitoring of SLE or connective tissue diseases.” Medial Director review 4/2025. Notification given 4/30/2025 for effective date 7/1/2025. |
| Genetic Testing for Epilepsy AHS – M2075 | Reviewed by Avalon 2nd Quarter 2025 CAB. Updated policy title on one Related Policy. Policy Guidelines and References updated. Addition of criterion #1 to When Covered section as follows, “Genetic counseling IS REQUIRED for individuals prior to and after undergoing genetic testing for epilepsy and when whole exome sequencing (WES) or whole genome sequencing (WGS) is being considered, counseling must be provided by an ABMGG board-certified medical geneticist or an ABGC board-certified genetic counselor.” Criterion #2 updated by removing age restriction and added WES as allowed testing. Addition of criterion #3 as follows, “WGS is considered medically necessary when WES is unable to identify a causative variant, and the clinical suspicion of a genomic etiology remains in situations where any of the above criteria are met in their entirety.” Note 1 also updated by adding the following, “Panel testing for epilepsy must target 25 or more genes associated with epilepsy.” The word “mutation” changed to “variant” within the coverage criteria. Added the following CPT codes to the Billing and Coding section: 81415, 81416, 81425, and 81426. Medical Director review 4/2025. Notification given 4/30/2025 for effective date 7/1/2025. |
| Human Immunodeficiency Virus AHS – M2116 | Reviewed by Avalon 2nd Quarter 2025 CAB. Updated to Description, Policy Guidelines and References. When Covered Section updated as follows: Updated appropriate testing for screening and follow up in criteria #1 and 2 by adding “antigen/antibody.” Also updated the frequency limit for repeat antigen/antibody screening for HIV infection in criterion #2. New criterion #3 added and reads, “Reimbursement for nucleic acid testing (qualitative or quantitative) for HIV-1 and HIV-2 (no more than one test every month) is allowed for any of the following situations: a. For individuals for whom initial screening was positive for HIV infection. b. For individuals for whom initial screening was indeterminate for HIV infection. c. For individuals for whom recent exposure is suspected or reported.” which then resulted in the following removal, “Reimbursement is allowed for a baseline HIV quantification when the risk of HIV infection is significant, and the initiation of therapy is expected in any of the following situations: a) In an at-risk individual with persistence of borderline or equivocal serologic reactivity. b) In an at-risk individual with signs and symptoms of acute retroviral syndrome (characterized by fever, malaise, lymphadenopathy, and rash).” Added frequency limit to criterion #6. Medical Director review 4/2025. Notification given 4/30/2025 for effective date 7/1/2025. |
| Parathyroid Hormone, Phosphorus, Calcium, and Magnesium Testing AHS - G2164 | Reviewed by Avalon for 2nd Quarter 2025 CAB. Updated description, policy guidelines, and references. Updated coverage criteria to describe all appropriate testing indications for PTH which now reads as follows: Reimbursement is allowed for serum intact parathyroid (PTH) testing in any of the following situations: a. For individuals with abnormal calcium levels; b. One time testing for the diagnosis of hypoparathyroidism for individuals with signs of hypoparathyroidism (see Note 1); c. One test every year for individuals diagnosed with hyperparathyroidism and who have not undergone parathyroidectomy; d. For at least six months following parathyroidectomy; e. At the following frequency for individuals with chronic kidney disease (CKD): For individuals with Grade 3 CKD: One test every twelve months. For individuals with Grade 3 CKD: One test every twelve months; f. For individuals with osteoporosis or low bone mass; g. One time testing for individuals with multiple endocrine neoplasia type 2A (MEN2A) or familial medullary thyroid carcinoma; h. During the initial assessment and diagnosis of pseudohypoparathyroidism and related disorders (see Note 2), i. One test every three months for individuals who have pseudohypoparathyroidism or related disorders (see Note 2) and who are less than 18 years of age; j. One test every year for individuals who have pseudohypoparathyroidism or related disorders (see Note 2) and who are 18 years of age or older. Updated Note 1 to define signs of hypoparathyroidism. Removed “hypoparathyroidism” from Note 1 and created Note 2 to define conditions of pseudohypoparathyroidism and related disorders. Medical Director review 4/2025. Notification given 4/30/2025 for effective date 7/1/2025. |
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