Medical Policy Update May 16, 2023
| Medical Guidelines | Reason for Update |
|---|---|
| Allergen Testing AHS – G2031 (PDF) | Reviewed by Avalon 1st Quarter 2023 CAB. Description, Policy Guidelines, and References updated. Related Policies section removed. Coverage criteria edited for clarity, no change in policy statement. Medical Director review 4/2023. |
| Diabetes Mellitus Testing AHS – G2006 (PDF) | Policy renamed and expanded to address additional testing beyond Hemoglobin A1c to align with Avalon. Reviewed by Avalon Q1 2023 CAB. Description and policy guidelines updated. Removed related policies. When covered section updated to include fasting plasma glucose testing. Added #1, #5, #6 and #9 to When Covered Section. When Not Covered section updated to read “Reimbursement is not allowed for measurement of hemoglobin A1c for all other situations not previously described (see Note 3)” with notes 1,2, and 3 added. Billing/Coding section updated to add 82951 and 82952. References updated. Medical Director review 4/2023. |
| Esophageal Pathology Testing AHS – M2171 (PDF) | Reviewed by Avalon 1st Quarter 2023 CAB. Description, Policy Guidelines and References updated. Related Policies section removed. The following edits were made to the When Covered section: previous items 1 and 2 combined for clarity to now read "For consideration of therapy with PD-1 inhibitors for individuals with locally advanced, recurrent, or metastatic esophageal, gastric, or esophagogastric junction cancer, reimbursement is allowed for any of the following testing: a. Tumor analysis of PD-L1 expression by immunohistochemistry. b. Mismatch repair (MMR) analysis. Remaining items renumbered (now items 2 and 3) with minor edits for clarity, new item 4 added "For the diagnosis and evaluation of Barrett’s esophagus, low-grade esophageal dysplasia, or high-grade esophageal dysplasia, wide-area transepithelial sampling (WATS) is considered medically necessary." Removed previous item 5 from Not Covered section: "Reimbursement is not allowed for wide-area transepithelial sampling (WATS-3D) for the determination of risk, the detection, or the prognosis of Barrett’s esophagus, esophageal cancers, and/or esophagogastric junction cancers." Remaining criteria under Not Covered section edited for clarity. Medical Director review 4/2023. |
| Evaluation of Dry Eyes AHS - G2138 (PDF) | Reviewed by Avalon 1st Quarter 2023 CAB. Medical Director review 4/2023. Deleted related policies section. Updated policy guidelines and references. No change to policy statement. |
| Fibromyalgia Testing AHS-M2177 (PDF) | New policy developed. Fibromyalgia testing is considered investigational for all applications. BCBSNC does not provide coverage for investigational services or procedures. Medical Director review 4/2023 |
| Flow Cytometry AHS–F2019 (PDF) | Reviewed by Avalon 1st Quarter 2023 CAB. Medical Director review 4/2023. Deleted related policies section. Updated references. No change to policy statement. |
| General Genetic Testing, Germline Disorders AHS – M2145 (PDF) | Reviewed by Avalon 1st Quarter 2023 CAB. Description, Policy Guidelines and References updated. When Covered and Not Covered sections edited for clarity, notes 1 and 2 added. No change to policy intent. Billing/Coding section updated. Medical Director review 4/2023. |
| General Genetic Testing, Somatic Disorders AHS-M2146 (PDF) | Reviewed by Avalon 1st Quarter 2023 CAB. Description, Policy Guidelines and References updated. Related Policies section removed. Coverage criteria edited for clarity, no change in policy statement. Medical Director review 4/2023. |
| Genetic Cancer Susceptibility Panels Using Next Generation Sequencing AHS-M2066 (PDF) | Reviewed by Avalon 1st Quarter 2023. Medical Director review 4/2023. Deleted related policies section. Updated “When Covered and When Not Covered” sections for clarity. Updated policy guidelines and references. Note 3 and 4 added. Under Billing/Coding section: deleted CPT codes 81449, 81451, 81456. No change to policy statement. |
| Genetic Testing for Connective Tissue Disorders AHS – M2144 (PDF) | Reviewed by Avalon 1st Quarter 2023 CAB. Removed Related Policies section, edited Note 4 under When Covered section for clarity. Updated policy guidelines and References. No change to policy statement. Medical Director review 4/2023. |
| Genetic Testing for Epilepsy AHS – M2075 (PDF) | Reviewed by Avalon 1st Quarter 2023 CAB. Policy Guidelines updated. Medical Director review 4/2023. References added. |
| Genetic Testing for Inherited Cardiomyopathies and Channelopathies AHS – M2025 (PDF) | Reviewed by Avalon 1st Quarter 2023 CAB. Related Policies section removed. Minor edits to When Covered section for clarity, no change in policy statement. Policy Guidelines and References updated. Medical Director review 4/2023. |
| Genetic Testing for Polyposis Syndrome AHS – M2024 (PDF) | Reviewed by Avalon 1st Quarter 2023 CAB. Medical Director review 4/2023. “When covered” section edited for clarity and criteria expanded. Edited both “when covered” and “when not covered” sections for clarity. Added Notes 1, 2. Updated description, policy guidelines, references. Deleted related policies section. Under Billing/Coding section, added CPT code 81479. Policy title changed from “Familial Adenomatous Polyposis and MUTYH-Associated Polyposis” to “Genetic Testing for Polyposis Syndromes" |
| Helicobacter Pylori Testing AHS – G2044 (PDF) | Reviewed by Avalon 1st Quarter 2023 CAB. Description, Policy Guidelines, and References updated. Coverage criteria edited for clarity, no change in policy statement. Medical Director review 4/2023. |
| Hemodialysis Treatment for ESRD (PDF) | Specialty Matched Consultant Advisory Panel review 4/2023. References updated. Medical Director review 4/2023. |
| Hepatitis AHS – G2036 (PDF) | Reviewed by Avalon 1st Quarter 2023. Director review 4/2023. Policy name changed from Hepatitis C to Hepatitis Testing. Coverage criteria broadened to include coverage on Hepatitis B. Guidance on HCV testing in pregnant individuals moved to note in the Description section. Specified antibody screening as the allowed test for initial HCV screening. Reflex NAT testing allowed. Removed “Reimbursement for patients with acute HCV infection, monitoring HCV RNA to determine spontaneous clearance of HCV infection versus persistence of infection is allowed. Testing can be performed every 4 to 8 weeks for 6 to 12 months” because of updates to ASSLD-ISDA guidelines that now recommend HCV treatment begin without awaiting spontaneous resolution. Added “forty-eight weeks” to statement “Twelve, twenty-four, and forty-eight weeks after completion of treatment.” Added Note 1: “Note 1: The CDC defines HBsAg prevalence by geographic region: https://wwwnc.cdc.gov/travel/yellowbook/2020/travel-related-infectious-diseases/hepatitis-b.” Added CPT codes 86704, 86705, 86706, 87340, 87341, 87517, G0499 to Billing/Coding section. |
| In Vitro Chemoresistance and Chemosensitivity Assays AHS- G2100 (PDF) | Deleted CPT codes 0324U and 0325U from Billing/Coding section per Avalon Q1 2023 CAB. No change to policy statement. |
| Intracellular Micronutrient Analysis AHS – G2099 (PDF) | Reviewed by Avalon 1st Quarter 2023 CAB. Policy Guidelines and References updated. Related Policies section removed. Not Covered section edited for clarity, no change to policy statement. Medical Director reviewed 4/2023. |
| Intradialytic Parenteral Nutrition (PDF) | Minor edits made to When Covered section for clarity, no change to policy statement. References updated. Specialty Matched Consultant Advisory Panel review 4/2023. Medical Director review 4/2023. |
| Investigational (Experimental) Services (PDF) | COVID-19 related changes removed due to PHE expiration on 5/11/2023. Medical Director review 3/2023. Notification given 3/7/2023 for effective date 5/16/2023. |
| Liquid Biopsy AHS-G2054 (PDF) | Reviewed by Avalon 1st Quarter 2023 CAB. Medical Director review 4/2023. Expanded medical necessity criteria under “When Covered” section. Updated policy guidelines, description, and references. Removed Notes 1, 2. Deleted related policies section. Under Billing/Coding section, added CPT codes: 81194, 81210, 81275, 81276, 81405, 81406, 0332U, 0333U, 0337U, 0338U, 0343U, 0356U, 0368U; deleted CPT codes: 81301, 81404, 0239U, 0242U, 0346U. |
| Minimal Residual Disease (MRD) AHS-M2175 (PDF) | Updated last review date to 3/2023. No change to policy statement. |
| Molecular Diagnosis for Breast Cancer Prognosis AHS - M2020 (PDF) | Reviewed by Avalon Q1 2023 CAB. Medical Director review 4/2023. Updated the following sections: description, policy guidelines and references. Deleted related policies section. Added new Note 3. Edited “When covered and when not covered” sections for clarity and reordered criteria coverage. Deleted CPT code 84999 from Billing/Coding section. Policy title changed from “Molecular Expression Testing for Breast Cancer Prognosis” to Molecular Diagnostics for Breast Cancer Prognosis.” |
| Molecular Markers in Fine Needle Aspirates of the Thyroid AHS - M2108 (PDF) | Reviewed by Avalon 1st Quarter 2023 CAB. Medical Director review 4/2023. Deleted related policies section. Edited “When covered and When not covered” sections for clarity. Updated the following sections: description, policy guidelines, references. |
| Mutation Analysis in Myeloproliferative Neoplasms AHS - M2101 (PDF) | Reviewed by Avalon 1st Quarter 2023 CAB. Medical Director review 4/2023. Deleted related policies section. Updated policy guidelines and references. Edited “When covered” section for clarity. Added Note 1. |
| Occipital Nerve Stimulation (PDF) | Codes C1897 and L8695 added to Billing/Coding section. |
| Onychomycosis Testing AHS – M2172 (PDF) | Reviewed by Avalon for 1st Quarter 2023 CAB. Policy description and guidelines updated. Related policies removed. No change to policy statement. References added. Medical Director review 4/2023. |
| Parathyroid Hormone, Phosphorus, Calcium, and Magnesium Testing AHS – G2164 (PDF) | Reviewed by Avalon for 1st Quarter 2023 CAB. Description, Policy Guidelines, and Reference sections updated. Related policies removed. Updated coverage criteria for clarity. No change to policy statement. Medical Director review 4/2023. |
| Pharmacogenetics Testing AHS – M2021 (PDF) | Reviewed by Avalon 1st Quarter 2023 CAB. Description section, Policy Guidelines and References updated. Related Policies section removed. When Covered section revised as follows: Added Abrocitinib (item a) and Mavacamten (item j) to coverage criteria #3, added Nateglinide (item g) to coverage criteria #4, item #12 added "To aid in therapy selection and/or dosing for individuals being considered for therapy or who are in their course of therapy with belzutifan, testing for the CYP2C19 and UGT2B17 genotype once per lifetime (see Note 1) is considered medically necessary." Under the Not Covered section, previous item 2-b removed and item c edited to state "Pharmacogenetic testing (e.g., single nucleotide polymorphism [SNP] testing or SNP panel testing; single gene or multi-gene panel testing [see Note 3]) for all other situations not addressed above.", item 3 removed as all other testing types are now addressed in the edit of item #2-c. Added notes 1, 2, 3. Medical Director review 4/2023. |
| Prescription Medication and Illicit Drug Testing in the Outpatient Setting AHS – T2015 (PDF) | Reviewed by Avalon Q1 CAB 2023. Description, Policy Guidelines, and References updated. When covered section updated for clarity, no changes to policy statement. Medical Director review 4/2023. |
| Radiofrequency Ablation of the Renal Nerves as a Treatment of Hypertension (PDF) | Description, Policy Guidelines and References updated. Specialty Matched Advisory Panel review 4/2023. Medical Director review 4/2023. |
| Renal (Kidney) Transplantation (PDF) | Minor edits made to When Covered section for clarity, no change to policy statement. References updated. Specialty Matched Specialty Advisory Panel review 4/2023. Medical Director review 4/2023. |
| Salivary Hormone Testing AHS – G2120 (PDF) | Reviewed by Avalon for 1st Quarter 2023 CAB. Updated Description and Policy Guidelines section. Related policies removed. Coverage criteria updated for clarity. Updated references. No change to policy statement. Medical Director review 4/2023. |
| Thyroid Disease Testing AHS – G2045 (PDF) | Reviewed by Avalon 1st Quarter 2023 CAB Review. Description, Policy Guidelines, and References updated. Added Note 1, 2, and 3 to Policy Guidelines. Related policies section removed. Billing/coding section updated to add 84442. When covered section updated as follows: #1 edited for clarity. #1.A.iv. frequency for hypothyroidism follow up changed from “6-12” to “every 6 weeks”. #1B.v.a., frequency for hyperthyroidism follow up changed from “6-12” to “every 8 weeks”. Replaced #1E with coverage criteria #2 and #3. Thyroid antibody testing expanded beyond autoimmune thyroiditis, now allowing testing in hypothyroidism or hyperthyroidism, with testing restricted to once every 3 years. TBG added as not covered under any circumstances. Medical Director review 4/2023 |
| Urinary Tumor Markers for Bladder Cancer AHS – G2125 (PDF) | Reviewed by Avalon 1st Quarter 2023 CAB. Medical Director review 4/2023. Related References updated and added. Description section updated. Policy Guidelines updated. |
| Vectra DA Blood Test for Rheumatoid Arthritis AHS – G2127 | Archive policy. |
| Venous and Arterial Thrombosis Risk Testing AHS – M2041 (PDF) | Reviewed by Avalon 1st Quarter 2023 CAB. Description, Policy Guidelines and References updated. Related Policies section removed. The following changes were made to the When Covered section: For genetic and plasma testing, shared risk factors now fall under single coverage criteria (item #1), however protein C and protein S deficiency (but NOT antithrombin III deficiency) are now specific to warfarin-induced skin necrosis and in infants who develop neonatal purpura fulminans. Based on this, item #2 edited to read: “Reimbursement for individuals with warfarin-induced skin necrosis or for infants who develop neonatal purpura fulminans, plasma testing for protein C deficiency and protein S deficiency (see Note 1) is allowed.”, notes 1 and 2 added. Item #4 added to Not Covered section: “For all situations, reimbursement is not allowed for activated protein C (aPC) resistance assay.” Medical Director review 4/2023. |
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