| Medical Policy | Revision |
|---|---|
| Allergen Testing AHS – G2031 | Reviewed by Avalon 2nd Quarter 2026 CAB. Description, Policy Guidelines, and References updated. Coverage criteria 1 under the When Covered section edited for clarity and now reads: “When limited to allergens chosen for testing based on an individual’s history, physical examination, and environment, reimbursement is allowed for specific IgE in-vitro allergy testing (up to 40 allergen specific antibodies per year).” Added new coverage criteria number 6 to Not Covered section: “Reimbursement is not allowed for specific IgE in-vitro allergy testing when performed on the same day as skin prick testing.” Added code 95004 to Billing/Coding section. Medical Director reviewed 4/2026. Notification given 5/27/26 for effective date 8/5/26. |
| Cardiovascular Disease Risk Assessment AHS – G2050 | Reviewed by Avalon 2nd Quarter 2026 CAB. Policy Guidelines and References updated. Code 83876 added to Billing/Coding section. Updates to When Covered section: “For individuals 18 years of age or older” removed from CC1. Changed “Every 4 years” to “Every 5 years” in CC1) a) i) Added “10-year ASCVD risk cannot be calculated for individuals 39 years of age or younger” to CC1) a) ii). Moved CC1) d) into CC1) b) annual testing based on elevated risk of dyslipidemia. Addition of CC1) b) xiii), 1) b) xiv), and 1) b) xv): “xiii) Family history of elevated lipids xiv. Premature heart disease xv. History of stroke”. Added “therapy (i.e., individuals with hyperlipidemia, transplant patients)” to CC1) c) Annual recommendation changed in CC1) c) iii) to “iii) Every three to twelve months as clinically indicated.” Added “(no more than once every four weeks)” to CC2). Removed CC4). Updates to the Not Covered section: Criteria bullet point 1 updated and now reads "CRP testing (conventional measurement or high-sensitivity measurement) for cardiovascular disease risk assessment", added "myeloperoxidase” to criteria bullet point 4. Removed "For CVD risk assessment" from criteria bullet point 7. Medical Director review 4/2026. Notification given 5/27/2026 for effective date 8/5/2026. |
| Diagnostic Testing of Sexually Transmitted Infections AHS – G2157 | Reviewed by Avalon 2nd Quarter 2026 CAB. When covered section updated as follows: Moving prenatal STI screening from the Prenatal Screening policy into this policy. These can be found under antibody screening for syphilis, qualitative NAAT testing and NAAT screening for chlamydia, and NAAT screening for gonorrhea. “At least three months after initial gonorrhea diagnosis as a TOC.” Added to qualitative NAAT for gonorrhea. Changed serologic testing for HSV-2 to antibody testing for HSV-2. Removed Hepatitis B testing for those being considered for PrEP is now addressed in the Hepatitis Testing: AHS-G2036 policy. When Not Covered section addition as follows: Added “Reimbursement for treponemal Ig testing is not allowed for individuals who are currently diagnosed with a syphilis infection or who have a past history of a syphilis infection.” and replaced “immunoassay” with “antibody and antigen” for clarity on HSV-1 testing and added “antigen testing for HSV-2”, now reads: “Reimbursement is not allowed for antibody and antigen testing for HSV-1 and/or herpes simplex (non-specific type test) and antigen testing for HSV-2.” Addition of antigen testing, now reads: “Reimbursement is not allowed for polymerase chain reaction (PCR) testing, nucleic acid amplification testing (NAAT), and antigen testing for syphilis.” Addition of culture testing, changing “serology” to “antibody and antigen testing”, now reads: “Reimbursement is not allowed for culture testing, antibody testing, and antigen testing for chlamydia or lymphogranuloma venereum (LGV).” Removed HPV, as ordering HPV testing is no longer defined by direct/amplified/quantitative and instead just by HPV type. Changes to the vaginitis policy result in all targeted Trich testing being managed by this policy, results in addition of “6. Trichomonas vaginalis.” Note 7 updated to include Prostatitis. All Notes updated to reference correct coverage/noncoverage stance due to changes in the When Covered and When Not Covered sections. Policy Guidelines and References also updated. Billing and Coding section updated as follows: removed CPT codes:86704, 86706, 87340, and G0499, then added 87140, 87270, 87285, 87320, 87660, and 87810. Medical Director review 4/2026. Notification given 5/27/2026 for effective date 8/5/2026. |
| Human Immunodeficiency Virus AHS – M2116 | Reviewed by Avalon 2nd Quarter 2026 CAB. When Not Covered section addition as follows: “Reimbursement is not allowed for screening for HIV-1 and HIV-2 using an antibody test that does not provide rapid results and does not incorporate antigen testing.” Policy Guidelines and References also updated. Billing and Coding section updated as follows: removed cpt code 86689. Medical Director review 4/2026. Notification given 5/27/2026 for effective date 8/5/2026. |
| Thyroid Disease Testing AHS – G2045 | Reviewed by Avalon 2nd Quarter 2026 CAB. Description, Policy Guidelines, and References updated. Edited When Covered section #1 to divide and clarify criteria using a cascade based approach for thyroid testing (TSH versus fT4/fT3/TT3), while retaining all clinical scenarios and testing frequency in which TSH remains the appropriate first line test. New coverage criteria was added for follow up testing following abnormal TSH results, monitoring of TSH and fT4 in clinical scenarios where initial monitoring with fT4 may be appropriate without requiring an abnormal TSH, and for monitoring of fT4 without concurrent TSH measurement in individuals with secondary hypothyroidism. Revised #6 to specify individuals who have not been diagnosed with autoimmune thyroid disease (e.g., Hashimoto disease, Graves disease). Updated When Not Covered to include only thyroxine binding globulin (TBG), thyrotropin releasing hormone (TRH), and reverse T3 testing. Remaining coverage criteria renumbered and edited for clarity. Medical Director review 4/2026. Notification given 5/27/2026 for effective date 8/5/2026. |
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