| Medical Guidelines | Reason for Update |
|---|---|
| Beta-Hemolytic Streptococcus Testing AHS – G2159 | Reviewed by Avalon 4th Quarter 2025 CAB. Description, Policy Guidelines and References updated. Due to standard medical practice and necessary steps for differential diagnoses, the following was removed from the When Covered section: “Reimbursement is allowed for blood culture testing for a streptococcal infection when one of the following conditions is met: For individuals who fail to demonstrate clinical improvement. For individuals who have progressive symptoms or clinical deterioration after the initiation of antibiotic therapy. In cases of suspected prosthetic joint infection.” For the same reason as above, the following was removed from the Not Covered section: “Rapid antigen diagnostic testing (RADT) for a streptococcal infection for individuals with suspected viral pharyngitis.” “MALDI TOF identification of streptococcus.” Removed CPT code 87040 from the Billing/Coding section. Medical Director review 10/2025. |
| Biochemical Markers of Alzheimer Disease and Dementia AHS – G2048 | Reviewed by Avalon 4th Quarter 2025 CAB. When Covered section updated to now allow p-tau/AB42 and t-tau/AB42 ratio in CSF. Now coverage criteria also added to allow p-tau/AB42 ratio measurement in plasma. Then When Not Covered section edited to ensure consistency with these new allowances. Removed deleted CPT code 0551U from Billing/Coding section. Policy Guidelines and references updated. Medical Director review 10/2025. |
| Biomarker Testing for Multiple Sclerosis and Related Neurologic Diseases AHS – G2123 | Reviewed by Avalon 3rd Quarter 2025 CAB. Updated Policy Guidelines without change to policy intent. Medical Director review 10/2025. |
| Bone Turnover Markers Testing AHS – G2051 | Reviewed by Avalon 4th quarter 2025 CAB. Description, policy guidelines, and references updated. Updated When Covered section for consistency and clarity and added: “for individuals with osteoporosis who are about to begin or who are actively being treated with bisphosphonates.” Medical Director review 10/2025. |
| Celiac Disease Testing AHS – G2043 | Reviewed by Avalon 4th Quarter 2025 CAB. Description, Policy Guidelines and References sections updated. When Covered section updated to remove coverage criteria 7, which referred to genetic testing, as the focus of this policy is routine testing for the diagnosis of celiac disease. Removed codes 81376, 81377, 81382 and 81383 from Billing/Coding section. Medical Director review 10/2025. |
| Cervical Cancer Screening AHS – G2002 | Updated Description, Policy Guidelines, and References. Separated statement in When Not Covered to make two statements that now read: “Reimbursement is not allowed for testing for low-risk HPV.” and “Reimbursement is not allowed for all other indications not discussed above for cervical screening.” Remaining coverage criteria statements updates for clarity and consistency. Removed 0500T from Billing/Coding section. Medical Director review 10/2025. |
| Diabetes Mellitus Testing – AHS G2006 | Reviewed by Avalon Q4 2025 CAB. Description, policy guidelines, and references updated. Updated Billing/Coding section to add 82947. No change to policy statement. Medical Director review 10/2025. |
| Diagnosis of Vaginitis AHS – M2057 | Reviewed by Avalon 4th Quarter 2025 CAB. Description, Policy Guidelines, and Reference sections updated. Updates made to all coverage criteria for clarity and consistency. Updated When Covered section to remove NAAT or PCR based identification of Trichomonas and screening for Trichomonas for individuals with risk factors as it is now addressed in Diagnostic Testing of Sexually Transmitted Infections AHS – G2157. Added limit of “no more than one test every seven days” for NAAT panel testing designed to detect more than on type of vaginitis for individuals with signs and symptoms. Added Note 1. Updated When Not Covered section to add: “Reimbursement is not allowed for NAAT testing for Candida (e.g., quantitative NAAT testing) for all other situations not described above.” Updated Billing/Coding section to add 0068U and remove 87661. Medical Director review 10/2025. Notification given 12/10/2025 for effective date 2/11/2026. |
| Diagnostic Testing of Influenza AHS – G2119 | Reviewed by Avalon 4th Quarter 2025 CAB. When Covered section coverage criterion edited for clarity. Updated Note 1 with signs and symptoms of the flu to align with the CDC. Added new Note 2: “Note 2: One influenza test may detect influenza A and/or influenza B. When both influenza A and influenza B are detected by a test represented by CPT codes 87400, 87501, or 87804, up to two units may be billed at a single visit.” Policy Guidelines and References updated. Removed CPT 87631 from the Billing/Coding section. Medical Director review 10/2025. |
| Diagnostic Testing of Sexually Transmitted Infections AHS – G2157 | Reviewed by Avalon 4th Quarter 2025 CAB. Updated policy titles on Related Policies. When Covered Section updated as follows: Added the word “qualitative”to NAAT for clarity purposes. Note 4 and 7 updated to align with CDC. New Note 8 created for Trichomoniasis as it relates to T. vaginalis and expansion of coverage criteria reads as follows, “Qualitative NAAT for T. vaginalis MEETS COVERAGE CRITERIA in the following situations: a) For symptomatic individuals (see Note 7). b) Follow up testing a minimum of three months after initial trichomoniasis diagnosis. c) Annual screening for asymptomatic individuals belonging to a high-risk group (see Note 8). d) Annual screening for asymptomatic individuals who have an HIV infection. e) As a part of follow-up in a victim of sexual assault.” Updated coverage criteria related to PrEP to focus on the recommended STI screens for individuals being considered for or actively receiving PrEP. Removed references to screens outside of STIs other than HIV (e.g., measurement of creatine, pregnancy testing). When Not Covered section updated as follows: removed the following, “reimbursement is not allowed for rapid identification of trichomonas by enzyme immunoassay.” Added updated to include direct probe detection as not being allowed for reimbursement for the following microorganisms: Chlamydia trachomatis, Neisseria gonorrhoeae, Herpes Simplex Virus-1, Herpes Simplex Virus-2, Human Papillomavirus, and Treponema pallidum. Policy Guidelines and References updated. Billing and Coding section updated as follows: removed 82565, 82575, 84702, 84703, 86701, 86702, 86703, 86705, 86803, 86804, 87660, 0500T, G0432, G0433, G0435, G0472, G0475, and S3645 and added 87494, 87800, and 0483U. Medical Director review 10/2025. |
| Epithelial Cell Cytology in Breast Cancer Risk Assessment AHS – G2059 | Reviewed by Avalon 4th Quarter 2025 CAB. Medical Director review 11/2025. Updated policy guidelines and added references. No change to policy statement. |
| Fecal Analysis in the Diagnosis of Intestinal Dysbiosis and Fecal Microbiota Transplant Testing AHS – G2060 | Reviewed by Avalon 4th Quarter 2025 CAB. Description, Policy Guidelines and References updated. Codes 82239, 82725, 82784, 83520, 83630, 87177, 87209, 87328, 87329, and 87336 removed from the Billing/Coding section. Medical Director review 10/2025. |
| Fecal Calprotectin Testing in Adults AHS – G2061 | Policy archived. See policy titled: Laboratory Testing for the Diagnosis of Inflammatory Bowel Disease AHS-G2121. |
| Gamma-glutamyl Transferase Testing in Adults AHS – G2173 | Reviewed by Avalon 4th Quarter 2025 CAB. Description, Policy Guidelines and References updated. Added “of the digestive system” to coverage criteria 2 e. under the When Covered section which now reads “e. For individuals with primary or secondary malignant neoplasms of the digestive system.” Medical Director review 10/2025. |
| Genetic Testing and Genetic Expression Profiling in Patients with Uveal Melanoma AHS – M2071 | Reviewed by Avalon 4th Quarter 2025 CAB. Medical Director review 112025. Updated policy guidelines, guidelines and recommendations and references. |
| Genetic Testing for Breast, Ovarian, Pancreatic and Prostate Cancers (BRCA) AHS – M2003 | Reviewed by Avalon Q4 2025 CAB. Medical Director review 11/2025. Updated policy guidelines and recommendations, policy guidelines, and references. Updated coverage criteria 2 and added item (i) “has metastatic (Stage IVB) or node-positive (Stage IVA) prostate cancer.” Edited and organized coverage criteria as well as scientific evidence to align with NCCN guidelines. |
| Genetic Testing for Neurodegenerative Disorders AHS – M2167 | Reviewed by Avalon 4th Quarter 2025 CAB. When Covered section edited for clarity in the subsection, Ataxias, including Friedreich ataxia. No change to policy intent. Policy Guidelines and references also updated. Medical Director review 10/2025. |
| Genomic Testing for Hematopoietic Neoplasms AHS – M2182 | Reviewed by Avalon 4th Quarter 2025 CAB. Medical Director review 11/2025. Updated policy guidelines and references. |
| Human Immunodeficiency Virus AHS – M2116 | Reviewed by Avalon 4th Quarter 2025 CAB. Updated References and Policy Guidelines. When Covered Section updated with additional coverage criteria, added Reimbursement for individuals who will begin pre-exposure prophylaxis (PrEP), for individuals receiving PrEP, or for individuals with elevated risk factors for an HIV infection (see Note 2), screening for an HIV infection with an antigen/antibody combination assay or with a rapid antibody test (see Note 1) is allowed, and Reimbursement for individuals for whom initial screening was positive for an HIV infection, the HIV-1/HIV-2 antibody differentiation assay (see Note 1) is allowed. Note 1 updated to indicate “Antibody and antibody/antigen testing should not be repeated more often than once every 90 days. Nucleic acid testing (qualitative or quantitative) should not be repeated more often than once every month”. Note 2 updated to indicate “ Risk factors for HIV infection: •Men who have sex with men (MSM), men who have sex with men and women (MSM/W), and transgender individuals •Having a sexual encounter with an individual who has an HIV infection •Having had multiple sexual partners since the individual’s last HIV test •Sharing needles, syringes, or other drug injection equipment (e.g., cookers) •Exchanging sex for money or drugs •Having a previous or concurrent STI, hepatitis, or tuberculosis •Having sex with an individual with the above high-risk factors or with an individual with unknown sexual history.” Note 3 (this was previously note 1) updated to “Because differences in absolute HIV copy number are known to occur using different assays, plasma HIV RNA levels should be measured by the same analytical method. A change in assay method may necessitate re-establishment of a baseline.” When Not Covered Section updated to include “Reimbursement is not allowed for HIV antigen testing independent of antigen/antibody testing” as a clarification. Medical Director review 11/2025. |
| Immunopharmacologic Monitoring of Therapeutic Serum Antibodies AHS – G2105 | Reviewed by Avalon 4th Quarter 2025 CAB. Description, Policy Guidelines, and References updated. No changes to policy statement. Medical Director review 10/2025. |
| In Vitro Chemoresistance and Chemosensitivity Assays AHS – G2100 | Reviewed by Avalon Q4 2025 CAB. Medical Director review 11/2025. Updated policy guidelines and references. No change to policy statement. |
| Laboratory Testing for the Diagnosis of Inflammatory Bowel Disease AHS – G2121 | Reviewed by Avalon 4th Quarter 2025 CAB. Description, Policy Guidelines and References updated. Contents of Fecal Calprotectin Testing in Adults AHS-G2061 combined with policy. Policy statement updated and now reads: “Reimbursement is allowed for laboratory testing for the diagnosis of inflammatory bowel disease when it is determined the medical criteria or reimbursement guidelines below are met.” Updates to the When Covered section: New coverage criteria 1. added “Reimbursement is allowed for fecal calprotectin or fecal lactoferrin testing (see Note 1) for any of the following situations: a. For the differential diagnosis between non-inflammatory gastrointestinal disease (e.g., IBS) and inflammatory gastrointestinal disease (e.g., IBD). b. To monitor individuals with IBD (e.g., assess for response to therapy or relapse).” Added new Note 1: “Fecal calprotectin is the preferred biomarker. If fecal calprotectin and fecal lactoferrin are ordered at the same time, only fecal calprotectin will be approved.” Updates to the Not Covered section: coverage criteria edited for clarity and now reads “2. Reimbursement is not allowed for the use of multianalyte serum biomarker panels (with or without algorithmic analysis) that are designed to distinguish between IBD and non-IBD or that are designed to diagnose or monitor IBD (e.g., ibs-smart™, IBSchek®, PredictSURE IBD™ Test, Prometheus® testing).” New coverage criteria 3 added “3. Reimbursement is not allowed for fecal calprotectin and fecal lactoferrin testing for all other situations not described above.” Codes 83630 and 83993 added to Billing/Coding section. Medical Director review 10/2025. |
| Lynch Syndrome AHS – M2004 | Reviewed by Avalon 4th Quarter 2025 CAB. Medical Director review 11/2025. Edited and clarified “when covered” section statements and Notes 1-4. No coverage changes. Updated policy guidelines, guidelines and recommendations, references. |
| Metabolite Markers of Thiopurines AHS – G2115 | References updated. Reviewed by Avalon 4th Quarter 2025 CAB. Policy Guidelines updated. No changes to coverage criteria. Medical Director review 11/2025. |
| Minimal Residual Disease (MRD) AHS – M2175 | Reviewed by Avalon 4th Quarter 2025 CAB. Medical Director review 11/2025. Under “when covered” section: added coverage criteria for individuals with B-cell lymphoma and Merkel cell carcinoma (see Items 4,5). Updated policy guidelines, guidelines/recommendations and added references. |
| Molecular Analysis for Gliomas AHS – M2139 | Reviewed by Avalon 4th Quarter 2025 CAB. Medical Director review 11/2025. Updated policy guidelines, guidelines and recommendations and references. |
| Molecular Testing for Pulmonary Disease AHS – M2160 | Reviewed by Avalon 4th Quarter 2025 CAB. Description, policy guidelines, and references updated. No change to policy statement. Medical Director review 10/2025. |
| Oral Cancer Screening and Testing AHS – G2113 | Reviewed by Avalon 4th Quarter 2025 CAB. Description, policy guidelines, and references updated. Updated When Covered section to add “or with metastatic squamous cell carcinoma of unknown primary origin in a cervical lymph node.” Updated When Not Covered to add “Detection of HPV from an oropharyngeal swab (e.g., OmniPathology Oropharyngeal HPV PCR Test).” Medical Director review 10/2025. |
| Pathogen Panel Testing AHS – G2149 | Off-cycle review by Avalon 4th Quarter 2025 CAB. Updates to the When Covered section: added new coverage criteria 3 which reads “3. Reimbursement is allowed for multiplex PCR-based panel testing of up to 25 respiratory pathogens for individuals who are immunocompromised and displaying signs and symptoms of a respiratory tract infection (see Note 1).” Updates to the Not Covered section: coverage criteria 2 edited and now reads “2. Reimbursement is not allowed for antigen panel testing or multiplex PCR-based panel testing of 6 or more respiratory pathogens for all situations not described above.” Added code 87812 to Billing/Coding section, effective 1/1/26. Medical Director review 10/2025. |
| Prenatal Screening (Genetic) AHS – M2179 | Reviewed with Avalon Q4 CAB 2025. Updated policy guidelines, and references. Updated when covered section to add CC #4 “For pregnant individuals who are alloimmunized or who are at risk for alloimmunization because of their antigen status (e.g., RHD negative), fetal genotyping for RHD (e.g., Prenatal Detect RhD) or other red blood cell antigens (e.g., UNITY Fetal Antigen™ NIPT) using maternal plasma is considered medically necessary when all the following conditions are met: The pregnant individual is at least 11 weeks gestation; Antigen typing of the pregnant individual’s reproductive partner is unavailable or the reproductive partner is heterozygous for an antigen that is of concern for the pregnant individual (e.g., pregnant individual is RHD negative and their reproductive partner is RHD heterozygous); Invasive diagnostic testing (i.e., amniocentesis or chorionic villus sampling [CVS]) is contradicted or has been declined.” Medical Director review 10/2025. |
| Prenatal Screening (Nongenetic) AHS – G2035 | Reviewed by Avalon 4th quarter 2025 CAB. Minor updates made to policy guidelines. Added 87494 to Billing/Coding section, effective 1/1/2026. References updated. No change to policy statement. Medical Director review 10/2025. |
| Prostate Biopsy Specimen Analysis AHS – G2007 | Reviewed by Avalon 3rd Quarter CAB. References updated. Under When Covered The following changes were made for clarity and consistency: Note 1, added “Each vial, regardless of the number of cores enclosed, is considered a single specimen for billing purposes.” for clarity on unit restrictions for prostate biopsy. No changes to coverage criteria. Medical Director review 11/2025. |
| Serum Testing for Hepatic Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease AHS – G2110 | Reviewed by Avalon 4th Quarter 2025 CAB. Description, Policy Guidelines and References updated. Removed codes 88341 and 88342 from the Billing/Coding section. Coverage criteria under When Covered and Not Covered are now numbered. Updates to When Covered section: criteria 1 updated and now reads “In order to determine therapy, the use of multianalyte assay with algorithmic analysis for noninvasive assessment of hepatic fibrosis and necroinflammatory activity (e.g., FibroTest®, also known as FibroSURE®, ELF™(ELFTM)) in an individual with chronic liver disease secondary to metabolic dysfunction associated steatotic liver disease (MASLD) (including metabolic dysfunction-associated steatohepatitis [MASH]), or alcoholic hepatitis, or to rule out compensated advanced chronic liver disease (cACLD) for individuals with an elevated liver stiffness measurement, is considered medically necessary once every six months.”, new coverage criteria 2 added and reads “For individuals with a chronic hepatitis B (HBV) or chronic hepatitis C (HCV) viral infection, FibroSURE® (i.e., HBV FibroSURE®, HCV FibroSURE®), ELF™ (ELFTM), or FibroTest® testing once every six months is considered medically necessary.” Updates to Not Covered section: ELF™(ELFTM) testing added to criteria 1 and 2. Criteria 4 edited and now reads: “Except when included as a component of one of the multianalyte assays described above, the use of the following serum biomarkers in the diagnosis, prognosis, or monitoring of chronic liver disease is not covered: ….” Medical Director review 10/2025. Notification given 12/10/2025 for effective date 2/11/2026. |
| Testing for Alpha-1 Antitrypsin Deficiency AHS – M2068 | Reviewed by Avalon 4th Quarter 2025 CAB. Description, Policy Guidelines and References updated. Medical Director review 10/2025. |
| Testing for Diagnosis of Active or Latent Tuberculosis AHS – G2063 | Reviewed by Avalon 4th Quarter 2025 CAB. When Covered section updated as follows: Direct probe testing is no longer available. This resulted in consolidation of allowed tests for suspected TB infections into one criterion stating, “Reimbursement is allowed for the following tests for all suspected TB infections: Acid fast bacilli (AFB) smear/stain, Culture and culture-based drug susceptibility testing of Mycobacteria spp., and Qualitative nucleic acid amplification testing (NAAT) for Mycobacteria spp., M. tuberculosis, and M. avium complex.” Also updated “M. avium intracellulare” to “M. avium complex” to align with updated naming convention. Replaced “Hologic Amplified MTD” with “NAAT” for clarity in criterion 3. With removal of direct probes, there is no situation in which two types of NAAT would be allowed thus removed “Reimbursement is not allowed for simultaneous ordering of any combination of direct probe, amplified probe, and/or quantification for the same organism in a single encounter” due to redundancy. Policy Guidelines and References updated. Updated items 3, 6, and 7 in the When Not Covered section from medical necessity to reimbursement language. Added CPT codes 87182 and 87183, effective 1/1/2026 to the Billing/Coding section and removed the following CPT codes: 87149, 87550, 87555, and 87560. Medical Director review 10/2025. |
| Testing for Vector-Borne Infections AHS – G2158 | Reviewed by Avalon 4th Quarter 2025 CAB. Added “IgG or IgM indirect immunofluorescence antibody (IFA) assay for Babesia (initial testing and confirmatory testing should occur a minimum of two weeks apart)” which resulted in removal from the When Not Covered section. Additional updates to the When Covered section, include: “PCR testing” replaced with “NAAT testing” throughout. Replaced “serum sample” with “blood sample” related to the presence of chikungunya using NAAT. Minor editing changes made for clarity and consistency. Policy Guidelines and References updated. Medical Director review 10/2025. |
| Urine Culture Testing for Bacteria AHS – G2156 | Reviewed per Avalon Q4 2025 CAB. Description, Policy Guidelines and References updated. Updated when covered section to expand signs/symptoms of a UTI and added population specific signs/symptoms for children and elderly adults. No change to policy intent. Medical Director review 10/2025. |
| Use of Common Genetic Variants to Predict Risk of Non-Familial Breast Cancer AHS – M2126 | Reviewed by Avalon 4th Quarter 2025 CAB. Medical Director review 11/2025. Updated policy guidelines, guidelines and recommendations, and references. |
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