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Medical Policy Update for March 31, 2023
Medical GuidelinesReason for Update
Bronchial ThermoplastyDescription and References updated. Specialty Matched Consultant Advisory Panel review 3/2023. Medical Director review 3/2023. No change to policy statement.
Cardiovascular Disease Risk Assessment AHS – G2050Updated Billing/Coding section to add code 0377U effective 4/1/23.
Convection-Enhanced Delivery of Therapeutic Agents to the BrainSpecialty Matched Consultant Advisory Panel review 3/15/2023. Updated description section and references. No change to policy statement.
Cord Blood as a Source of Stem CellsSpecialty Matched Consultant Advisory Panel review 3/15/2023. Added reference for U.S. Food and Drug Administration (FDA). No change to policy statement.
Electromagnetic Navigation BronchoscopySpecialty Matched Consultant Advisory Panel review 3/2023. Policy guidelines and Regulatory status updated.  References added. Medical Director review 3/2023. No change to policy statement.
Endobronchial ValvesReferences updated. Specialty Matched Consultant Advisory Panel review 3/2023. Medical Director review 3/2023. No change to policy statement.
Esophageal Pathology Testing AHS – M2171Updated Billing/Coding section to add code 0386U effective 4/1/23.
Gene Expression Profiling and Protein Biomarkers for Prostate Cancer AHS - M2166Off cycle review by Avalon. Updated policy guidelines and references. Deleted related policies section. Clarified “when covered” section and added coverage criteria for 4Kscore. Clarified and edited notes 2-5. Added PLA codes 0339U, 0359U to Billing/Coding section. Medical Director review 1/2023.
Heart-Lung TransplantationMinor updates to description. Related policies added. References added. Specialty Matched Consultant Advisory Panel review 3/2023.  Medical Director review 3/2023.
Hormone Pellet Implantation for Treatment of Menopause Related SymptomsSpecialty Matched Consultant Advisory Panel review 3/2023. Medical Director Review 3/2023. Related Policies section updated. References updated. No change to policy statement. 
Laboratory Procedures Medical Policy AHS - R2162Updated Billing/Coding section to add codes 0372U, 0375U, 0376U, 0378U, 0381U, 0382U, 0383U, 0384U and 0385U effective 4/1/2023.
Liquid Biopsy  AHS-G2054Added PLA code 0368U to Billing/Coding section.
Lung and Lobar Lung TransplantationDescription and references updated. Specialty Matched Consultant Advisory Panel review 3/2023. Medical Director review 3/2023. No change to policy statement.
Lung Volume Reduction SurgeryReferences added. When covered section updated for clarity. Specialty Matched Consultant Advisory Panel review 3/2023. Medical Director review 3/2023. No change to policy statement.
Maternal and Fetal DiagnosticsReferences updated. Specialty Matched Consultant Advisory Panel review 3/2023. Medical Director review 3/2023. Related policies updated.  No change to policy statement. 
Microsatellite Instability and Tumor Mutational Burden Testing AHS-M2178Added PLA code 0379U to Billing/Coding section.
Minimal Residual Disease (MRD) AHS-M2175Added PLA code 0364U to Billing/Coding section.
Monoclonal Antibody Imaging for Prostate CancerSpecialty Matched Consultant Advisory Panel review 3/15/2023. Reference added. No change to policy statement.
Noninvasive Respiratory Assist DevicesDescription and Billing/coding sections updated for clarity. References added. Updated coverage criteria for Severe COPD for clarity. Specialty Matched Consultant Advisory Panel review 3/2023. Medical Director review 3/2023. No change to policy statement.
Oncologic Applications of Photodynamic Therapy, Including Barrett’s EsophagusSpecialty Matched Consultant Advisory Panel review 3/15/2023. References added. No change to policy statement.
Oscillatory Devices for the Treatment of Respiratory ConditionsRegulatory status and policy guidelines updated. References added. Specialty Matched Consultant Advisory Panel review 3/2023.  Medical Director review 3/2023. No changes to policy statement.
Ovarian and Internal Iliac Vein Embolization, Ablation and SclerotherapyDescription updated for clarity. References updated. Specialty Matched Consultant Advisory Panel review 3/2023. Medical Director Review 3/2023. No change to policy statement.
Pathogen Panel Testing AHS – G2149Updated Billing/Coding section to add codes 0369U, 0370U, 0371U, 0373U, and 0374U effective 4/1/2023.
Pharmacogenetics Testing AHS – M2021Updated Billing/Coding section to add code 0380U effective 4/1/23.
Phrenic Nerve Stimulation for Central Sleep ApneaDescription and policy guidelines updated. References added. Specialty Matched Consultant Advisory Panel 3/2023.  Medical Director review 3/2023. No changes to policy statement.
Progesterone Therapy in High Risk PregnanciesDescription, Regulatory Status, Policy Guidelines, and Reference sections updated.  Specialty Matched Consultant Advisory Panel review 3/2023. Medical Director review 3/2023. No change to policy statement.
Skin and Soft Tissue SubstitutesBilling/Coding section updated to add A2019, A2020, A2021, Q4265, Q4266, Q4267, Q4268, Q4269, Q4270, and Q4271, effective 4/1/2023.
Sleep Apnea: Diagnosis and Medical ManagementAdded new code A7049 to Billing/Coding section effective 4/1/2023. 

 

 

 

 

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