Medical Policy Update for February 21, 2024
Medical Guidelines | Reason for Update |
|---|---|
| Coronavirus Testing in the Outpatient Setting AHS – G2174 (PDF) | Reviewed by Avalon 4th Quarter 2023 CAB. Updated Description, Policy Guidelines, and References sections. No change to policy statement. Medical Director review 1/2024. |
| Diabetes Mellitus Testing – AHS G2006 (PDF) | Reviewed by Avalon Q4 2023 CAB. Description, policy guidelines, and references updated. Related policy added. Added the following statement to When Covered section, “Reimbursement is allowed for screening for prediabetes or type 2 diabetes once every three years with a fasting plasma glucose test for asymptomatic individuals who are 35 years of age or older and who have no risk factors for diabetes.” Added the following statement to When Not Covered section, “Reimbursement is not allowed for fasting plasma glucose testing at a wellness visit with no abnormal findings for all other situations not addressed above.” Edits to Note 3 to provide clarity on when hemoglobin A1c is not allowed. Remaining coverage criteria updated for clarity. Medical Director review 1/2024. |
| Diagnosis of Vaginitis AHS – M2057 (PDF) | Reviewed by Avalon 4th Quarter 2023 CAB. Policy title changed to align with Avalon. Add coverage criteria for NAAT panel testing designed to detect more than one type of vaginitis (VVC, BV, and/or trichomoniasis, e.g., BD MAX™ Vaginal Panel, NuSwab® VG, Xpert® Xpress MVP). Related policies added. Medical Director review 1/2024. |
| Diagnostic Testing of Iron Homeostasis and Metabolism AHS – G2011 (PDF) | Reviewed by Avalon 4th Quarter 2023 CAB. Medical Director review 1/2024. Description, Policy Guidelines, and References updated. Related policy section added. No changes to policy. |
| Gene Expression Profiling and Protein Biomarkers for Prostate Cancer AHS - M2166 (PDF) | Reviewed by Avalon Q4 2023 CAB. Medical Director review 1/2024. Updated policy guidelines and references. Added related policies section. Added coverage criteria for IsoPSA in “when covered” section. |
| Genetic Testing for CHARGE Syndrome AHS – M2070 (PDF) | Reviewed by Avalon 4th Quarter 2023 CAB. Description, Policy Guidelines and References sections updated. Related Policies added to Description section. New Note 1 added to When Covered section. Not Covered section edited for clarity, no change to policy statement. Medical Director review 1/2024. |
| Genetic Testing for Duchenne, Becker, Facioscapulohumeral, Limb-Girdle Muscular Dystrophies AHS – M2074 (PDF) | Reviewed by Avalon 4th Quarter 2023 CAB. Updated Description, Policy Guidelines and References sections. Related Policies added to Description section. No change to policy statement. Medical Director review 1/2024. |
| Genetic Testing for Fanconi Anemia AHS – M2077 (PDF) | Reviewed by Avalon 4th Quarter 2023 CAB. Description, Policy Guidelines and References sections updated. Related Policies added to Description section, Updates to Billing/Coding section: added codes 81403, 81443, removed codes 96040, S0265. No change to policy statement. Medical Director review 1/2024. |
| Genetic Testing for FMR1 Mutations AHS – M2028 (PDF) | Reviewed by Avalon 4th Quarter 2023 CAB. Related Policies added to Description section. The following statement was added to the Description section “For guidance on prenatal or preconception screening for FXS, please see Prenatal Screening (Genetic) AHS-M2179.” When Covered section updated as follows: coverage criteria 1 now reads: “For individuals who have received genetic counseling, diagnostic genetic testing for FMR1 gene CGG repeats (including AGG interruption testing) and methylation status is considered medically necessary for any of the following conditions”, removed previous coverage criteria 2 “For individuals seeking pre-conception or prenatal care, carrier screening for FMR1 gene CGG repeat length is considered medically necessary”. Policy Guidelines and References updated. Medical Director review 1/2024. |
| Genetic Testing for Germline Mutations of the RET Proto-Oncogene AHS - M2078 (PDF) | Reviewed by Avalon Q4 2023 CAB. Medical Director review 1/2024. Policy guidelines and references updated. No change to policy statement. |
| Genetic Testing for Hereditary Hemochromatosis AHS – M2012 (PDF) | Reviewed by Avalon 4th Quarter 2023 CAB. Added related policies section. Updated policy guidelines and references. Not Covered section edited for clarity, no changes in coverage criteria. Medical Director review 1/2024. |
| Genetic Testing for Lipoprotein A Variant(s) as a Decision Aid for Aspirin Treatment and/or CVD Risk Assessment AHS – M2082 (PDF) | Reviewed by Avalon 4th Quarter 2023 CAB. Description, Policy Guidelines, and References updated with minor revisions. Related Policies added to Description section. No change to policy statement. Medical Director review 1/2024. |
| Genetic Testing for Rett Syndrome AHS – M2088 (PDF) | Reviewed by Avalon 4th Quarter 2023 CAB. Policy Guidelines and References sections updated. Related Policies added to Description section. When Covered and Not Covered sections edited for clarity, no change to policy statement. Medical Director review 1/2024. |
| Genetic Testing of CADASIL Syndrome AHS – M2069 (PDF) | Reviewed by Avalon 4th Quarter 2023 CAB. Description, Policy Guidelines and References sections updated. Related Policies added to Description section. New Note 1 added to When Covered section. Not Covered section edited for clarity, no change to policy statement. Medical Director review 1/2024. |
| Genetic Testing of Mitochondrial Disorders AHS – M2085 (PDF) | Reviewed by Avalon 4th Quarter 2023 CAB. Description, Policy Guidelines and References sections updated. Related Policies added to Description section. Codes 96040 and S0265 removed from Billing/Coding section. No change to policy statement. Medical Director review 1/2024. |
| Hepatitis Testing AHS – G2036 (PDF) | Reviewed by Avalon Q4 CAB 2023, off-cycle review. Criteria for NAT for HCV screening for perinatally exposed infants ages 2-17 months added to When Covered Section. Guideline Section and References also updated. Medical Director review 01/2023. |
| Immunohistochemistry AHS – P2018 (PDF) | Reviewed by Avalon 4th Quarter 2023 CAB. Medical Director Review 1/2024. Description, Policy Guidelines, and References updates. No change to policy statement. |
| Microsatellite Instability and Tumor Mutational Burden Testing AHS - M2178 (PDF) | Reviewed by Avalon Q4 2023 CAB. Medical Director review 1/2024. Updated policy guidelines and references. Table of solid tumors updated to match NCCN guideline updates. |
| Molecular Testing for Cutaneous Melanoma AHS - M2029 (PDF) | Reviewed by Avalon Q4 2023 CAB. Medical Director review 1/2024. References updated. No change to policy statement. |
| Prenatal Testing for Fetal Aneuploidy AHS – G2055 (PDF) | Reviewed by Avalon 4th Quarter 2023 CAB. Description, policy guidelines, and references updated. Upper gestational age limitation removed from When Covered #2. Updated When Not Covered “d” for consistency. Medical Director review 1/2024. |
| Proteogenomic Testing of Individuals with Cancer AHS - M2168 (PDF) | Reviewed by Avalon Q4 2023 CAB--off cycle review. Medical Director review 1/2024. Under “when covered” section, added medical necessity coverage criteria for OncoExTra, Caris MI Tumor Seek, and Caris MI Profile comprehensive testing. Added AHS - M2178 Microsatellite Instability and Tumor Mutational Burden Testing to related policies section. Under Billing/Coding section, added PLA codes 0329U and 0019U. |
| Serum Tumor Markers for Malignancies AHS – G2124 (PDF) | Reviewed by Avalon Q4 2023 CAB. Medical Director review 1/2024. Updated description, policy guidelines and references. Reformatted coverage table in “when covered” section from listing by condition to listing by tumor marker for ease of reference. No change to policy statement. |
| Testing for Autism Spectrum Disorder and Developmental Delay AHS – M2176 (PDF) | Reviewed by Avalon 4th Quarter 2023 CAB. Description, Policy Guidelines and References updated. Related Policies added to Description section. When Covered and Not Covered sections edited for clarity, no change to policy statement. Previous Notes 2, 3, 4 removed from When Covered section. Medical Director review 1/2024. |
| Testing of Homocysteine Metabolism Related Conditions AHS – M2141 (PDF) | Reviewed by Avalon 4th Quarter 2023 CAB. Description, Policy Guidelines, and References updated. Related policies section added. Removed the following statement from When Covered, “Reimbursement is allowed for genetic counseling and is recommended prior to genetic testing for Homocystinuria.” Removed 96040 and S0265 from billing/coding section. Medical Director review 1/2024. |
| Testosterone AHS – G2013 (PDF) | Reviewed by Avalon 4th Quarter 2023 CAB. Minor grammar changes to Policy Guidelines. References updated. Medical Director review 1/2024. No changes to coverage criteria. |
| Transplant Rejection Testing AHS – M2091 (PDF) | Reviewed by Avalon 4th Quarter 2023 CAB. When Covered section updated to include new coverage criteria 2: “For heart transplant recipients who are 28 or more days post-transplant, the use of donor-derived cell-free DNA tests (e.g., AlloSure Heart, Prospera™ Heart) is considered medically necessary at the following frequency: a) Every month for individuals who are 1-12 months post-transplant b) Every 3 months for individuals who are 12-36 months post-transplant c) Every 6 months for individuals who are greater than 36 months post-transplant.” Not Covered section updated to include new criteria 2: “For heart transplant recipients, testing for heart transplant rejection with simultaneous gene ex-pression testing and donor-derived cell-free DNA testing (e.g., HeartCare®) is considered investigational.” Policy Guidelines and References updated. Medical Director review 1/2024. |
| Vitamin B12 and Methylmalonic Acid Testing AHS – G2014 (PDF) | Reviewed by Avalon 4th Quarter 2023 CAB. Policy Guidelines and References updated. No change to policy statement. Medical Director review 1/2024. |
| Vitamin D Testing AHS – G2005 (PDF) | Reviewed by Avalon 4th Quarter 2023 CAB. Description, Policy Guidelines and References updated. Added Related Policies section: AHS - G2164. Medical Director review 1/2024. |
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