Medical Policy Update May 31, 2022
| Medical Guidelines | Reason for Update |
|---|---|
| Abdominoplasty and Panniculectomy (PDF) | Policy title changed from “Abdominoplasty, Panniculectomy, and Lipectomy” to “Abdominoplasty and Panniculectomy”. Description, Policy statement, and “When Not Covered” sections updated to remove reference to lipectomy. Billing/Coding section updated. Specialty Matched Consultant Advisory Panel review 8/2021. Medical Director review 5/2022. |
| Allergen Testing AHS – G2031 (PDF) | The following reimbursement policy was added to Related Policies section: Maximum Units of Service. |
| Allergy Immunotherapy (Desensitization) (PDF) | The following reimbursement policy was added to Related Policies section: Maximum Units of Service. |
| Ambulatory Event Monitors (PDF) | The following reimbursement policy was added to Related Policies section: Facility Billing Requirements. |
| Balloon Ostial Dilation (Balloon Sinuplasty) (PDF) | Medical Director review. Added “air fluid levels or opacification to support the diagnosis of sinusitis” to criteria 3 of the When Covered statement. Added “air fluid levels or opacification for” to the first Policy Guidelines sentence. Notification given March 31,2022 for policy effective date May 31, 2022. |
| Baroreflex Stimulation Devices (PDF) | The following reimbursement policy was added to Related Policies section: Facility Billing Requirements. |
| Beta Amyloid Imaging With Positron Emission Tomography for Alzheimer’s Disease (PDF) | References updated. Specialty Matched Consultant Advisory Panel review 5/2022. Medical Director review 5/2022. Related policy removed. No change to policy statement. |
| BioZorb® (PDF) | Specialty Matched Consultant Advisory Panel review 5/18/2022. No change to policy statement. |
| Brachytherapy, Intracavitary Balloon Catheter for Brain Cancer (PDF) | Specialty Matched Consultant Advisory Panel review 5/18/2022. Removed CPT codes 77785-77787 from Billing/Coding section since termed. No change to policy statement. |
| Charged Particle Radiotherapy (PDF) | Specialty Matched Consultant Advisory Panel review 5/18/2022. No change to policy statement. |
| Chemoembolization of the Hepatic Artery, Transcatheter Approach (PDF) | References added. Specialty Matched Consultant Advisory Panel review 5/2022. Medical Director review 5/2022. No change to policy statement. |
| Chiropractic Services (PDF) | The following reimbursement policy was added to Related Policies section: Maximum Units of Service |
| Congenital Heart Defect, Repair Devices (PDF) | The following reimbursement policy was added to Related Policies section: Facility Billing Requirements. |
| Cryoablation, Radiofrequency Ablation, and Laser Ablation for Treatment of Chronic Rhinitis (PDF) | New indications for radiofrequency ablation and laser ablation for chronic rhinitis added and are considered investigational. Title changed to Cryoablation, Radiofrequency Ablation, and Laser Ablation for Treatment of Chronic Rhinitis. Notification given 3/22/2022 for policy effective date 5/31/2022. |
| Durable Medical Equipment (DME) (PDF) | The following reimbursement policy was added to Related Policies section: Facility Billing Requirements. |
| Electronic Brachytherapy for Nonmelanoma Skin Cancer (PDF) | Specialty Matched Consultant Advisory Panel review 5/18/2022. No change to policy statement. |
| Epidural Steroid Injections for Back Pain (PDF) | The following reimbursement policy was added to Related Policies section: Maximum Units of Service. |
| Gene Expression Profiling and Protein Biomarkers for Prostate Cancer AHS - M2166 (PDF) | Reviewed by Avalon Q1 2022 CAB. Extensive revisions to policy. Added coverage criteria under “When Covered” section. Updated policy guidelines and references. Medical Director review 4/2022. |
| Implantable Cardioverter Defibrillator (PDF) | The following reimbursement policy was added to Related Policies section: Facility Billing Requirements. |
| Intensity Modulated Radiation Therapy for Tumors of the Central Nervous System (PDF) | Specialty Matched Consultant Advisory Panel review 5/18/2022. Added Radiation Therapy Services to related policies section. No change to policy statement. |
| Intensity Modulated Radiation Therapy (IMRT) for Sarcoma of the Extremities (PDF) | Specialty Matched Consultant Advisory Panel review 5/18/2022. Added Radiation Therapy Services to related policies section. No change to policy statement. |
| Intensity Modulated Radiation Therapy (IMRT) of Abdomen and Pelvis (PDF) | Specialty Matched Consultant Advisory Panel review 5/18/2022.Added Radiation Therapy Services to related policies section. No change to policy statement. |
| Intensity Modulated Radiation Therapy (IMRT) of Head and Neck (PDF) | Specialty Matched Consultant Advisory Panel review 5/18/2022. Added Radiation Therapy Services to related policies section. No change to policy statement. |
| Intensity Modulated Radiation Therapy (IMRT) of the Chest (PDF) | Specialty Matched Consultant Advisory Panel review 5/18/2022. Added Radiation Therapy Services to related policies section. No change to policy statement. |
| Intensity-Modulated Radiation Therapy (IMRT) of the Prostate (PDF) | Specialty Matched Consultant Advisory Panel review 5/18/2022. Added Radiation Therapy Services to related policies section. No change to policy statement. |
| Liquid Biopsy AHS-G2054 (PDF) | Reviewed by Avalon 1st Quarter 2022 CAB. “When Covered” section reformatted and removed 50 gene limit sentences. Moved Note 1 & 2 and reformatted “When Not Covered” section. Updated policy guidelines, references. Added policy AHS- M2178 to related policies section and removed AHS-M2109 due to archival. Added CPT 0137U to Billing/Coding section. Medical Director review 4/2022. Policy title changed from “Detection of Circulating Tumor Cells and Cell Free DNA in Cancer Management (Liquid Biopsy)” to “Liquid Biopsy”. |
| Magnetic Resonance Spectroscopy (PDF) | References added. Specialty Matched Consultant Advisory Panel review 5/2022. Medical Director Review 5/2022. No change to policy statement. |
| Molecular Expression Testing for Breast Cancer Prognosis (PDF) | Reviewed by Avalon Q1 2022 CAB. Medical Director review 4/2022. Updated “When Covered” and “When Not Covered” sections. Updated policy guidelines and references. Added PLA codes 0067U, 0295U to Billing/Coding section. Policy title changed from “Gene Expression Testing for Breast Cancer Prognosis” to “Molecular Expression Testing for Breast Cancer Prognosis.” |
| MRI-Guided Focused Ultrasound (MRgFUS) (PDF) | Policy statement updated for clarity. Investigational statement added on tremor-dominant Parkinson disease to when not covered section. References added. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 5/2022. Medical Director review 5/2022. |
| Myocardial Sympathetic Innervation Imaging (PDF) | References added. Related policies updated. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 5/2022. Medical Director review 5/2022. No change to policy statement. |
| Neurostimulation, Electrical (PDF) | The following reimbursement policy was added to Related Policies section: Maximum Units of Service. |
| Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF) | The following reimbursement policy was added to Related Policies section: Facility Billing Requirements. |
| Perirectal Spacer Use During Radiotherapy for Prostate Cancer (PDF) | Specialty Matched Consultant Panel review 5/18/2022. No change to policy statement. |
| Positional Magnetic Resonance Imaging (MRI) (PDF) | References added. Specialty Matched Consultant Advisory Panel review 5/2022. Medical Director review 5/2022. No change in policy statement. |
| Radioembolization for Primary and Metastatic Tumors of the Liver (PDF) | Specialty Matched Consultant Advisory Panel review 5/18/2022. No change to policy statement. |
| Radiosurgery, Stereotactic Approach (PDF) | Under Policy Guidelines section, added Radiology Maximum Units guidelines for SBRT treatment course. Under Billing/Coding section, added CPT codes 77431 and 77470. Added Radiation Therapy Services Reimbursement Policy to Related Policies section. Medical Director review 3/2022. Notification given 3/22/22 for effective date 6/1/22. Specialty Matched Consultant Advisory Panel review 5/18/22. No change to policy statement. |
| Rehabilitative Therapies (PDF) | Added the following reimbursement policy to the Related Policies section: Modifier Guidelines. The following statement was added to the Billing/Coding section: “Any speech-language therapy service will require the GN modifier. Any occupational therapy service will require the GO modifier. Any physical therapy service will require the GP modifier. See Modifier Guidelines reimbursement policy.” |
| Screening for Vertebral Fracture with Dual X-ray Absorptiometry (DXA) (PDF) | Related policies updated. References added. Specialty Matched Consultant Advisory Panel review 5/2022. Medical Director review 5/2022. No change to policy statement. |
| Skin and Soft Tissue Substitutes (PDF) | The following reimbursement policy was added to related policies section: Facility Billing Requirements. Added the following statement to Billing/Coding section: “Billing for skin substitute application procedures required to also include the appropriate high cost or low- cost skin substitute products.” |
| Surgical Treatments for Lipedema (PDF) | New policy developed. Surgical Treatment for Lipedema is considered medically necessary when medical criteria and guidelines outlined in the policy are met. Medical Director review 5/2022. |
| Therapeutic Radiopharmaceuticals in Oncology (PDF) | The following reimbursement policy was added to related policies: Maximum Units of Service. Archived policies removed from related policies section. References added. The following statement added to When Covered Section: “Lutetium 177 (Lu 177) vipivotide tetraxetan (Pluvicto) is considered medically necessary for the treatment of adult patients with prostate-specific membrane antigen (PSMA)-positive metastatic castration-resistant prostate cancer when the following criteria are met: The patient has unresectable metastatic disease; AND; The patient had a PSMA-positive gallium-68-labeled PSMA-11 positron-emission tomographic-computed tomographic scan; AND; The patient has disease progression despite advanced androgen therapy, e.g., at least one androgen-receptor-pathway inhibitor, as demonstrated by prostate specific antigen (PSA) progression after at least four weeks; AND; The patient has disease progression after at least one taxane regimen. Billing/Coding section updated to add code A9699 – effective 10/1/2022; added ICD-10 code C61. Specialty Matched Consultant Advisory Panel review 5/2022. Medical Director review 2022 |
| Wearable Cardioverter Defibrillators (PDF) | The following reimbursement policy was added to Related Policies section: Facility Billing Requirements. |
| Wheelchairs (Manual and Power Operated) (PDF) | Off-cycle review. Under the Benefits Application section, revised the statement as follows: “Note: Power-operated wheelchairs do not require a rental period prior to purchase. All above criteria must be met for approval.” |
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