| Medical Guidelines | Reason for Update |
|---|---|
| Bariatric Surgery | References updated. Description section updated with to indicate updated endorsed procedures by the American Society for Metabolic and Bariatric Surgery. Policy Guidelines updated. No changes to policy intent. Specialty Matched Consultant Advisory Panel review 4/2026. Medical Director review 4/2026. |
| Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate, or Dermatologic Tumors | References updated. Specialty Matched Consultant Advisory Panel review 4/2026. Medical Director review 4/2026. |
| Cryosurgical Ablation of Primary or Metastatic Liver Tumors | References updated. Specialty Matched Consultant Advisory Panel review 4/2026. Medical Director review 4/2026. |
| Diagnosis of Idiopathic Environmental Intolerance AHS - G2056 | Reviewed by Avalon 1st Quarter 2026 CAB. Description, Policy Guidelines and References updated. The following edits were made for clarity and consistency: CC2 and CC3, replaced “In all circumstances” with “For asymptomatic individuals and/or during general encounters without abnormal findings,” for clarity. CC4, CC5, CC6, CC8 edited for consistency. CC7 edited for clarity and consistency, as breath hydrogen/methane testing is not allowed under any circumstances. Now reads: “7. Reimbursement is not allowed for breath hydrogen and/or breath methane testing.” Under Billing/Coding removed section titled "Reimbursement". Medical Director reviewed 1/2026. Notification given 2/25/26 for effective date 5/6/26. |
| Diagnostic Testing of Iron Homeostasis and Metabolism AHS - G2011 | Reviewed by Avalon 1st Quarter 2026 CAB. Medical Director review 1/2026. Description, Policy Guidelines, and References updated. Updated policy statement and headers to reflect previous title change. When Covered section updated as follows: Added “(no more than one test per month unless otherwise specified)” to #1. Updated 1.a for clarity. Updated #1. b for clarity and to add frequency “(no more than one test per month unless otherwise specified).” Updated #1.h to include frequencies for chronic kidney disease dependent on if the individual is or isn’t receiving hemodialysis. Added new statement #1. j “For individuals with restless leg syndrome or periodic limb movement disorder.” Added new statement #2. d “For individuals with restless legs syndrome or periodic limb movement disorder.” Updated Note 1 to align with symptoms of hemochromatosis (iron overload) and expand to allow arrhythmias, erectile dysfunction, pain in the knuckles, and provide specificity in the region of abdominal pain. Notification given on 2/25/2026 for effective date 5/6/2026. |
| General Genetic Testing, Germline Disorders AHS – M2145 | Reviewed by Avalon 1st Quarter 2026 CAB. Description, Policy Guidelines and References updated. Updates to When Covered section: New CC1 requiring genetic counseling: “1. Genetic counseling is required for individuals prior to and after undergoing genetic testing for diagnostic, carrier, and/or risk assessment purposes.” For clarity and consistency, “likely pathogenic or pathogenic variants” was changed to “pathogenic/likely pathogenic (P/LP) variants” (CC2) or “P/LP variants” (Note 1). Medical Director review 1/2026. |
| General Genetic Testing, Somatic Disorders AHS - M2146 | Reviewed by Avalon 1st Quarter 2026 CAB. Description, Policy Guidelines and References updated. Added code 0172U to Billing/Coding section. Medical Director review 1/2026. |
| Genetic Testing for CHARGE Syndrome AHS - M2070 | Reviewed by Avalon Quarter 1 2026 CAB. Description, Policy Guidelines and References updated. For clarity and consistency under when covered section “likely pathogenic or pathogenic variants” was changed to “pathogenic/likely pathogenic (P/LP) variants” or “P/LP variants” no change to coverage intent. Medical Director review 1/2026. |
| Genetic Testing for Fanconi Anemia AHS – M2077 | Reviewed by Avalon 1st Quarter 2026 CAB. Description, Policy Guidelines and References updated. Medical Director review 1/2026. |
| Genetic Testing for FMR1 Mutations AHS – M2028 | Reviewed by Avalon 1st Quarter 2026 CAB. Description, Policy Guidelines and References updated. Medical Director review 1/2026. |
| Genetic Testing for Germline Variants of the RET Proto-Oncogene AHS - M2078 | Reviewed by Avalon Q1 2026 CAB. References and policy guidelines updated. When covered section updated addition of genetic counseling requirement added to coverage criteria statement. Coverage criteria D updated to removal of “primary C-cell hyperplasia”, addition of “or clinical suspicion”. Coverage criteria D now reads “For individuals with a diagnosis of MTC or a clinical diagnosis or suspicion of multiple endocrine neoplasia type 2 (MEN2).” Medical Director review 1/2026. |
| Genetic Testing for Hereditary Hemochromatosis AHS – M2012 | Reviewed by Avalon 1st Quarter 2026 CAB. Description, Policy Guidelines and References updated. Medical Director review 1/2026. |
| Genetic Testing for Inherited Cardiomyopathies and Channelopathies AHS – M2025 | Reviewed by Avalon 1st Quarter 2026 CAB. Description, Policy Guidelines and References updated. Under When Covered section "likely pathogenic or pathogenic variants” was changed to “pathogenic/likely pathogenic (P/LP) variants" or “P/LP variants” throughout criteria. Added “(see Note 1)" to CC15. Under Not Covered section CC1 edited to change "likely pathogenic or pathogenic variant” to "P/LP variants" and added “(see Note 1)". No change to policy statement. Medical Director review 1/2026. |
| Genetic Testing for Lipoprotein A Variant(s) as a Decision Aid for Aspirin Treatment and/or CVD Risk Assessment AHS – M2082 | Reviewed by Avalon 1st Quarter 2026 CAB. Description, Policy Guidelines and References updated. Medical Director review 1/2026. |
| Genetic Testing for Muscular Dystrophies AHS – M2074 | Reviewed by Avalon Quarter 1 2026 CAB. Policy Guidelines and References updated. When Covered section updated for clarity and consistency. “Likely Pathogenic for Pathogenic Variants” was changed to “pathogenic/likely pathogenic (P/LP) variants” in coverage criteria #1 or “P/LP Variants” in coverage criteria #3 and #6. CPT code 81403 added to the Billing/Coding section. Medical Director review 1/2026. |
| Genetic Testing for Rett Syndrome AHS – M2088 | Reviewed by Avalon 1st Quarter 2026 CAB. Description, Policy Guidelines and References updated. Medical Director review 1/2026. |
| Genetic Testing of CADASIL Syndrome AHS – M2069 | Reviewed by Avalon Quarter 1 2026 CAB. Policy Guidelines and References sections updated. Under When Genetic Testing of CADASIL Syndrome is covered for clarity and consistency, “likely pathogenic or pathogenic variants” was changed to “pathogenic/likely pathogenic (P/LP) variants” (coverage criteria 2.A.) or “P/LP variants” (coverage criteria 2.B.). Medical Director review 1/2026. |
| Genetic Testing of Mitochondrial Disorders AHS – M2085 | Reviewed by Avalon 1st Quarter 2026 CAB. Description, Policy Guidelines and References updated. Medical Director review 1/2026. |
| Immune Cell Function Assay AHS-G2098 | Reviewed by Avalon 1st Quarter 2026 CAB. Title changed to align with Avalon. Updates made throughout to reflect title change. Policy Guidelines and References updated. No change to policy statement. Medical Director review 1/2026. |
| Immunohistochemistry AHS – P2018 | Reviewed by Avalon 1st Quarter 2026 CAB. Medical Director Review 1/2026. Policy Guidelines and References updates. No change to policy statement. |
| Intravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric Disorders | Description, Policy Guidelines, and References updated. No change to policy statement. Specialty Matched Consultant Advisory Panel review 4/2026. Medical Director review 4/2026. |
| Laboratory Procedures Medical Policy AHS - R2162 | Reviewed by Avalon 1st Quarter 2026 CAB. Updated section “Panel Reimbursement”; updated statement on concurrent ordering for clarity, added new bullet point and sub-bullet points on repeat multi-gene panel testing: “Repeat multi-gene panel testing is not allowed unless all of the following are true: a. The individual met all necessary criteria to receive genetic panel testing, b. The individual doesn’t have a previously identified mutation that is causative for the disorder being evaluated, c. The panel being requested contains one or more genes that were previously untested.” Updated 4th bullet point under section “Unit Threshold Met (Daily and Historical)” for clarity and now reads: “Scientific or statistical analyses demonstrate a reasonable limitation of the number of units that should be performed within a specified period of time.” Codes 0450U and 0451U deleted from Billing/Coding section. Codes 0614U, 0618U, 0619U, 0622U, 0623U, 0624U, 0625U, 0626U, 0627U, and 0629U added to Billing/Coding section, effective 4/1/26. Medical Director review 1/2026. Notification given 2/25/26 for effective date 5/6/26. |
| Liquid Biopsy AHS - G2054 | Reviewed by Avalon 1st Quarter 2026 CAB. When Covered section updated as follows: 1a and 1b updated for clarity. To align with NCCN guidelines, 1d edited and 1e created. #2 edited to breast cancer types, allowed genes, and timing of testing to align with updated NCCN recommendations. New #4 created. When Not Covered section updated as follows: New #1 created. With changes to the biomarker list for cfDNA/ctDNA in Note 1, former 2, now 3, removed “for all other situations not addressed above,” as NCCN’s recommendations for PD-L1 analysis is by IHC, not liquid biopsy. #3 now reads: “Analysis of PD-L1 by liquid biopsy is considered investigational.” New Notes 1 (list of biomarkers from 1c in When Covered section) & 2 created. Policy Guidelines and References updated. Added CPT codes 0012M, 0013M, 0363U, 0420U, 0452U, 0465U, 0549U, and 0613U and deleted CPT code 0569U in Billing/Coding section. Medical Director review 4/2025. Notification given 2/25/2026 for effective date 5/6/2026. |
| Liver Transplant and Combined Liver-Kidney Transplant | References updated. Specialty Matched Consultant Advisory Panel review 4/2026. Medical Director review 4/2026. |
| Microsatellite Instability and Tumor Mutational Burden Testing AHS - M2178 | Reviewed by Avalon Q1 2026 CAB. Table of solid tumors updated to match NCCN guideline updates. Added indications for appendiceal neoplasms (new to policy) Cervical cancers, colon cancer, head and neck cancers, neuroendocrine/adrenal cancers, pancreatic cancer, testicular cancer, and culver cancer had updated indications for testing. Combining the three rows for thyroid cancers into a single row, updated to align with current recommendations for those thyroid cancer indications. Prostate cancer indications edited for clarity. Policy Guidelines updated. References updated. Medical Director review 1/2026. |
| Minimal Residual Disease (MRD) AHS - M2175 | Reviewed by Avalon Quarter 1 2026 CAB. References updated. Description section updated. When covered section updated to include 2 new indications for coverage. “For individuals with a diagnosis of diffuse large B-cell lymphoma, when end of treatment positron emission tomography is positive and biopsy is not feasible, testing for circulating tumor DNA (ctDNA) using a test with a detection limit of <1 part per million prior to additional therapy is considered medically necessary”, and “For individuals with a diagnosis of Merkel cell carcinoma (MCC), testing for ctDNA is considered medically necessary.” Policy guidelines updated. Added PLA code 0569U to Billing/Coding section effective 01/01/26. Medical Director review 1/2026. |
| Molecular Testing for Cutaneous Melanoma AHS - M2029 | Reviewed by Avalon Q1 2026 CAB. Updated Policy Guidelines and References without change policy intent. Removed CPT codes 81216 and 81217 from Billing/Coding section. Medical Director review 1/2026. |
| Nerve Fiber Density Testing AHS - M2112 | Reviewed by Avalon 1st Quarter 2026 CAB. Policy Guidelines updated without change to policy’s intent. References updated. Medical Director review 1/2026. |
| Neurostimulation, Electrical | Descriptions, related policies, regulatory statuses, and policy guidelines updated throughout policy. References added. Specialty Matched Consultant Advisory Panel review 4/2025. Medical Director review 4/2025. No change to policy statement. |
| Pancreatic Cancer Risk Testing Using Pancreatic Cyst Fluid AHS - M2114 | Reviewed by Avalon 1st Quarter 2026 CAB. Updated Policy Guidelines and References. Updated When Not Covered #1 to change example name of molecular classifier test from PancraGEN to PancreaSeq, as PancraGEN is no longer available on the market. Added the following statement to When Not Covered “Biomarker panels designed to classify pancreatic cyst lesions (e.g., PanCystPro™) using pancreatic cyst fluid are considered investigational.” Added 0573U to Billing/Coding section. Medical Director review 1/2026. |
| Percutaneous Electrical Nerve Stimulation (PENS) or Neuromodulation Therapy and Percutaneous Electrical Nerve Field Stimulation (PENFS) | Description, regulatory status, related policies, and policy guidelines updated. References added. Specialty Matched Consultant Advisory Panel review 4/2026. Medical Director review 4/206. No change to policy statement. |
| Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers | References updated. Related policies updated to include Surgical Treatment for Lipedema. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 4/2026. Medical Director review 4/2026. |
| Prenatal Testing for Fetal Aneuploidy AHS - G2055 | Reviewed by Avalon 1st Quarter 2026 CAB. Policy guidelines and references updated. No change to policy statement. Medical Director review 1/2026. |
| Proteogenomic Testing of Individuals with Cancer AHS - M2168 | Reviewed by Avalon Q1 2026 CAB. Policy Guidelines updated with no change to policy intent. Under Billing/Coding section, removed PLA codes 0329U, 0362U, and 0413U. Medical Director review 1/2026. |
| Remote Electrical Neuromodulation for Migraines | Description and references updated. Policy statement updated to medically necessary when the criteria and guidelines have been met. Specialty Matched Consultant Review 4/2026. Medical Director Review 4/2026. |
| Sex Trait Modification Procedures For Gender Affirming Care | References updated. Specialty Matched Consultant Advisory Panel review 4/2026. Medical Director review 4/2026. |
| TENS (Transcutaneous Electrical Nerve Stimulator) | Description, Regulatory Status, Related Policies, Policy Guidelines, and References updated. Updated When Not Covered to remove “Chronic pain management with the use of Axon Therapy is considered investigational.” Updated Billing/Coding section to remove 0766T and 0767T. Removed language related to Axon Therapy throughout the policy. Specialty Matched Consultant Advisory Panel review 4/2024. Medical Director review 4/2024. |
| Testing for 5-Fluorouracil Use in Cancer Patients AHS - M2067 | Review by Avalon Quarter 1 2026 CAB. Policy Guidelines updated. Updated References. Medical Director review 1/2026. No change to coverage criteria. |
| Testing for Developmental Delay AHS - M2176 | Reviewed by Avalon 1st Quarter 2026 CAB. Description, Policy Guidelines and References updated. Not Covered section edited for clarity, CC1 split so that other uncovered genetic tests are addressed in CC1 and non-genetic tests are addressed in new CC2. CC1 now reads: "1. For the diagnosis of autism spectrum disorder (ASD) or non-syndromic developmental delay, all other genetic testing (e.g., multi-gene panels of 50 or more genes) outside of chromosomal microarray, whole exome sequencing, or whole genome sequencing or genetic testing for fragile X syndrome or Rett syndrome is considered not medically necessary." CC2 now reads: "2. All other laboratory tests designed to screen for, diagnose, or metabolically classify ASD/non-syndromic developmental delay (e.g., Clarifi™, NPDX ASD panels) are considered not medically necessary." Medical Director review 1/2026. |
| Testing of Homocysteine Metabolism Related Conditions AHS - M2141 | Reviewed by Avalon 1st Quarter 2026 CAB. Removed coverage criteria for the pyridoxine (B5) challenge test as it is not a laboratory test and is outside the scope of this policy. Policy Guidelines, and References updated. Removed 84207 from Billing/Coding section. Medical Director review 1/1/2026. |
| Testosterone AHS – G2013 | Reviewed by Avalon 1st Quarter 2026 CAB. Policy Guidelines and References updated. No changes to coverage criteria. Medical Director review 1/2026. |
| Topical Negative Pressure Therapy for Wounds | References updated. Policy guidelines updated. Specialty Matched Consultant Advisory Panel review 4/2026. Medical Director review 4/2026. |
| Trigger Point and Tender Point Injections | Related policies updated. References added. Specialty Matched Consultant Advisory Panel review 4/2026. Medical Director review 4/2026. No change to policy statement. |
| Urinary Tumor Markers for Bladder Cancer AHS - G2125 | Reviewed by Avalon Quarter 1 2026 CAB. Off-cycle review for coding changes. CPT codes 0012M, 0013M, 0363U, 0420U, 0452U, 0465U, 0549U, and 0613U removed from policy, these codes will now be managed under policy Liquid Biopsy AHS - G2054. Medical Director review in January 2026. |
| Vitamin B12 and Methylmalonic Acid Testing AHS - G2014 | Reviewed by Avalon 1st Quarter 2026 CAB. Policy Guidelines and References updated. No change to policy statement. Medical Director review 1/2026. |
| Vitamin D Testing AHS - G2005 | Reviewed by the Avalon 1st Quarter 2026 CAB. Updated the Description, Policy Guidelines, and References sections. Revised the When Covered section by removing item #3 and combining it with item #1, which now states: “Reimbursement for 25-hydroxyvitamin D serum testing is allowed for individuals with an underlying disease or condition specifically associated with vitamin D deficiency or decreased bone density (see Note 1), individuals suspected of hypervitaminosis D, or individuals with vitamin D deficiency (limited to no more than one test every six months).” Added “chemotherapy” to Note 1, item N, for clarification. |
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