Medical Policy | Revision |
---|---|
Adaptive Behavioral Treatment for Autism Spectrum Disorders | Description, policy guidelines, and references updated. Coverage criteria updated to reflect current standards care. Specialty Matched Consultant Advisory Panel Review 4/2025. Medical Director review 4/2025. Notification given 4/30/2025 for effective date 7/1/2025. |
Allergen Testing AHS – G2031 | Reviewed by Avalon 2nd Quarter 2025 CAB. Description, Policy Guidelines, and References updated. Removed previous coverage criteria 1 from the When Covered section and removed Notes from the Not Covered section as these were clinical guidance related to skin testing. Coverage criteria 2 under the Not Covered section edited to remove abbreviation “BAT” for clarity. Medical Director review 4/2025. |
Biochemical Markers of Alzheimer Disease and Dementia AHS – G2048 | Added CPT code 0568U Billing/Coding section, effective 7/1/2025. |
Biomarker Testing for Autoimmune Rheumatic Disease AHS - G2022 | Reviewed by Avalon for 2nd Quarter 2025 CAB. Updated description, policy guidelines, and reference. Updated coverage criteria for clarity on allowed frequency of biomarker testing. Added the following statement to When Not Covered section: “Reimbursement is not allowed for testing for serum biomarkers not discussed above, alone or in a panel (e.g., Seronegative Rheumatoid Arthritis Profile) for the diagnosis of RA.” Added “aisle® DX Disease Activity Index, Early Sjögren’s Syndrome Profile” to When Not Covered statement, now reads: “Reimbursement is not allowed for serum biomarker panel testing with proprietary algorithms and/or index scores (e.g., AVISE CTD, AVISE SLE Monitor, AVISE SLE Prognostic, aisle® DX Disease Activity Index, Early Sjögren’s Syndrome Profile) for the diagnosis, prognosis, or monitoring of SLE or connective tissue diseases.” Medial Director review 4/2025. Notification given 4/30/2025 for effective date 7/1/2025. |
BioZorb® | Specialty Matched Consultant Panel review 5/21/2025. Reference added. No change to policy statement. |
Brachytherapy, Intracavitary Balloon Catheter for Brain Cancer | Specialty Matched Consultant Advisory Panel review 5/21/2025. Updated Regulatory status and added references. No change to policy statement. |
Capsule Endoscopy, Wireless | References updated. Specialty Matched Consultant Advisory Panel 5/2025. Medical Director review 5/2025. Code 0977T added to the Billing/Coding section, effective 7/1/25. |
Colorectal Cancer Screening AHS - B0001 | Reviewed by Avalon Q2 2025 CAB. Reference added. No changes to policy statement. |
Diagnosis of Vaginitis AHS - M2057 | Reviewed by Avalon 2nd Quarter 2025 CAB. Updates made to coverage criteria for clarity and consistency. Added sialidase activity to CC1, as it is another appropriate diagnostic tool for vaginitis and does not require an independent coverage criteria, now reads: “Reimbursement is allowed for testing of pH, testing for the presence of amines, measurement of sialidase activity, saline wet mount, potassium hydroxide (KOH) wet mount and microscopic examination of vaginal fluids in individuals with signs and symptoms of vaginitis.” Resulting in removal of “Reimbursement is allowed for measurement of sialidase activity in vaginal fluid for the diagnosis of bacterial vaginosis in individuals with symptoms of vaginitis.” Description, Policy Guidelines, and Reference sections updated. Updated Billing/Coding section to remove 0352U and add 0557U. No change to policy intent. Medical Director review 4/2025. |
Electronic Brachytherapy for Nonmelanoma Skin Cancer | Specialty Matched Consultant Advisory Panel review 5/21/2025. Reference added. No change to policy statement. |
Esophageal Pathology Testing AHS - M2171 | Reviewed by Avalon 2nd Quarter 2025 CAB. Description, Policy Guidelines and References updated. Coverage criteria 3 under When Covered section edited to add “methodology” after “other in situ hybridization (ISH)”, no change to policy statement. Note edited to change “5” to “two” to align with guidance in Laboratory Procedures Medical Policy AHS-R2162. Code 81210 added to Billing/Coding section. Medical Director review 4/2025. |
Evaluation of Dry Eyes AHS - G2138 | Reviewed by Avalon 2nd Quarter 2025 CAB. Medical Director review 4/2025. Updated policy guidelines, guidelines and recommendations and references. Added Related Policies section. No change to policy statement. |
Fibromyalgia Testing AHS - M2177 | Reviewed by Avalon 2nd Quarter 2025 CAB. Description, Policy Guidelines, and References updated. No change to policy statement. Medical Director review 4/2025. |
Flow Cytometry AHS - F2019 | Reviewed by Avalon 2nd Quarter 2025 CAB. Medical Director review 4/2025. Under “When covered” section, Item 1.h. edited for clarity, removed “and PIDs involving T, NK.” Updated policy guidelines and references. |
Gene Expression Profiling and Protein Biomarkers for Prostate Cancer AHS - M2166 | Added PLA codes 0558U, 0559U to Billing/Coding section for 7/1/25 code update. |
Genetic Testing for Connective Tissue Disorders AHS - M2144 | Reviewed by Avalon 2nd Quarter 2025 CAB. Updated Description, Policy Guidelines and References. Updates to the When Covered section: replaced “mutation” with pathogenic or likely pathogenic variant” in CC1.b. and CC2.b., with “variant” in CC3. New CC4 and 5. CC4. The following genetic testing for heritable thoracic aortic disease (HTAD) (see Note 5) is considered medically necessary: a. Multigene panel testing (see Note 6, Note 7) in the following situations: i. For individuals with thoracic aortic disease (TAD) and syndromic features of Marfan syndrome, Loeys-Dietz syndrome, or vascular Ehlers-Danlos syndrome. ii. For individuals presenting with TAD before 60 years of age. iii. For individuals with a family history of either TAD or peripheral/intracranial aneurysms in a first- or second-degree relative (see Note 2). iv. For individuals with a first- or second-degree relative (see Note 2) who had an unexplained sudden death at a relatively young age. b. Testing restricted to the known variant for individuals with a close blood relative (see Note 2) with a known pathogenic or likely pathogenic variant. CC5. The following genetic testing for epidermolysis bullosa (EB) are considered medically necessary: a. Single gene or multigene panel testing (see Note 6, Note 8) for individuals for whom there is a clinical suspicion of EB. b. Testing restricted to the known pathogenic or likely pathogenic variant in the following situations: i. For the biological parents of an individual who has been identified to have a pathogenic or likely pathogenic variant for EB. ii. For the prenatal diagnosis or PGD of EB in the offspring of individuals with known pathogenic or likely pathogenic variants. iii. COL7A1 testing for individuals being considered for beremagene geperpavec. Notes section updated with new notes added. New Note 2, defining first-degree relatives: “Note 2: First-degree relatives include parents, full siblings, and children of the individual.” “(see Note 2)” replaces description of first-degree relatives in CC1.b. and CC2.b. New Note 5, 7, and 8, to define HTAD and EB and to define rules for multigene panel testing. Note 2-5 numbers shifted with addition of new notes, adjusted within criterion to align. Former Note 4, now Note 6, edited to change “5” to “two” to align with guidance in R2162: “Note 6: For two or more gene tests being run on the same platform, please refer to Laboratory Procedures Medical Policy AHS-R2162.” Added codes 81403 and 81479 to the Billing/Coding section. Medical Director review 4/2025 |
Genetic Testing for Epilepsy AHS – M2075 | Reviewed by Avalon 2nd Quarter 2025 CAB. Updated policy title on one Related Policy. Policy Guidelines and References updated. Addition of criterion #1 to When Covered section as follows, “Genetic counseling IS REQUIRED for individuals prior to and after undergoing genetic testing for epilepsy and when whole exome sequencing (WES) or whole genome sequencing (WGS) is being considered, counseling must be provided by an ABMGG board-certified medical geneticist or an ABGC board-certified genetic counselor.” Criterion #2 updated by removing age restriction and added WES as allowed testing. Addition of criterion #3 as follows, “WGS is considered medically necessary when WES is unable to identify a causative variant, and the clinical suspicion of a genomic etiology remains in situations where any of the above criteria are met in their entirety.” Note 1 also updated by adding the following, “Panel testing for epilepsy must target 25 or more genes associated with epilepsy.” The word “mutation” changed to “variant” within the coverage criteria. Added the following CPT codes to the Billing and Coding section: 81415, 81416, 81425, and 81426. Medical Director review 4/2025. Notification given 4/30/2025 for effective date 7/1/2025. |
Genetic Testing for Polyposis Syndromes AHS-M2024 | Reviewed by Avalon 2nd Quarter 2025 CAB. Medical Director review 4/2025. Updated description, policy guidelines, guidelines and recommendations, and references. Under “When covered” section, updated and edited Item 3 to reflect NCCN guideline updates. |
Genetic Testing of Mitochondrial Disorders AHS – M2085 | Code 0567U added to Billing/Coding section, effective 7/1/25. |
Helicobacter Pylori Testing AHS – G2044 | Reviewed by Avalon 2nd Quarter 2025 CAB. Description, Policy Guidelines and References updated. The following updates were made to the When Covered section: Clarity edits made to CC1, CC2, CC3, and CC4. CC1.a., changed “dyspeptic” to “dyspepsia (see Note 1)”. CC1.c., replaced “without H. pylori history” with “and who have had recurrent symptoms.” CC1.e., removed “endoscopic” Removed former CC1.g. due to repetition with CC1.a. Former CC1.h., now CC1.g., added “or who have been on a” and “aspirin”, now reads: “g) For individuals initiating chronic treatment with or who have been on a long-term aspirin or non-steroidal anti-inflammatory drug (NSAID) treatment.” Former CC1.j., change “chronic immune” to “idiopathic” and removed “and suspected H. pylori infection” Removed former CC2 (follow up testing now found in new CC5) Former CC4, now CC3, removed chronic ITP, follow up (now in CC5), added ulcers/erosions and family history. Now reads: 3. Reimbursement for urea breath testing or stool antigen testing to diagnose an H. pylori infection is allowed for individuals who are less than 18 years of age in any of the following situations: a. For individuals who have gastric or duodenal ulcers or erosions. b. For individuals who have a family history of gastric cancer.” Former CC5, now CC4, removed gastric ulcers (noninvasive testing now allowed in CC3), reworded criteria since it now only pertains to those with refractory IDA. Now reads: “4. For individuals who are less than 18 years of age and who have refractory iron deficiency anemia, reimbursement is allowed for a biopsy-based endoscopic histology test and either a rapid urease test or a culture with susceptibility testing to diagnose an H. pylori infection.” New CC5 and CC6: “5. Reimbursement is allowed for all individuals who have tested positive for H. pylori, urea breath testing or stool antigen testing to measure the success of eradication of H. pylori infection, with testing performed at least four weeks post-treatment. 6. For individuals with a refractory H. pylori infection, susceptibility testing (culture or nucleic acid based), reimbursement is allowed.” New Note 1 and Note 2: “Note 1: “Dyspepsia refers to bothersome upper abdominal symptoms that are often meal related. The predominant symptoms are fullness (or bloating) after meals, early satiety (inability to finish a normal-sized meal because of postprandial discomfort), or epigastric pain (or burning) that may or may not be related to meals. If dyspepsia is chronic, epigastric pain is a less common feature than postprandial fullness or satiety. Pain is not required to make a diagnosis of dyspepsia.” Note 2: Alarm features of dyspepsia: vomiting, gastrointestinal bleeding, unexplained iron deficiency, or weight loss.” Changes made to the Not Covered section: added “(i.e., heartburn, regurgitation)” to CC 1.b. Allowance of nucleic acid based susceptibility testing under When Covered section results in changes to CC6. Now reads: “6. For all other situations not described above, nucleic acid testing for H. pylori is considered investigational.” Medical Director review 4/2025. |
Human Immunodeficiency Virus AHS – M2116 | Reviewed by Avalon 2nd Quarter 2025 CAB. Updated to Description, Policy Guidelines and References. When Covered Section updated as follows: Updated appropriate testing for screening and follow up in criteria #1 and 2 by adding “antigen/antibody.” Also updated the frequency limit for repeat antigen/antibody screening for HIV infection in criterion #2. New criterion #3 added and reads, “Reimbursement for nucleic acid testing (qualitative or quantitative) for HIV-1 and HIV-2 (no more than one test every month) is allowed for any of the following situations: a. For individuals for whom initial screening was positive for HIV infection. b. For individuals for whom initial screening was indeterminate for HIV infection. c. For individuals for whom recent exposure is suspected or reported.” which then resulted in the following removal, “Reimbursement is allowed for a baseline HIV quantification when the risk of HIV infection is significant and the initiation of therapy is expected in any of the following situations: a) In an at-risk individual with persistence of borderline or equivocal serologic reactivity. b) In an at-risk individual with signs and symptoms of acute retroviral syndrome (characterized by fever, malaise, lymphadenopathy, and rash).” Added frequency limit to criterion #6. Medical Director review 4/2025. Notification given 4/30/2025 for effective date 7/1/2025. |
Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence | Code 0963T added to the to the Billing/Coding Section effective 7/1/25. |
Intensity Modulated Radiation Therapy (IMRT) for Sarcoma of the Extremities | Specialty Matched Consultant Advisory Panel review 5/21/2025. References added. No change to policy statement. |
Intensity Modulated Radiation Therapy (IMRT) of Abdomen and Pelvis | Specialty Matched Consultant Advisory Panel review 5/21/2025. References added. No change to policy statement. |
Intensity Modulated Radiation Therapy (IMRT) of Head and Neck | Specialty Matched Consultant Advisory Panel review 5/21/2025. References added. |
Intensity Modulated Radiation Therapy (IMRT) of the Chest | Specialty Matched Consultant Advisory Panel review 5/21/2025. Reference added. No change to policy statement. |
Intensity Modulated Radiation Therapy (IMRT) of the Prostate | Specialty Matched Consultant Advisory Panel review 5/21/2025. NCCN reference updated. No change to policy statement |
Intracellular Micronutrient Analysis AHS – G2099 | Reviewed by Avalon 2nd Quarter 2025 CAB. Description, Policy Guidelines and References updated. Medical Director review 4/2025. |
Laboratory Procedures Medical Policy AHS - R2162 | Code 0573U added to Billing/Coding section, effective 7/1/25. |
Liquid Biopsy AHS - G2054 | Reviewed by Avalon 2nd Quarter 2025 CAB. Medical Director review 4/2025. Added policies AHS-M2030 & AHS-M2175 to Related Polices section. Added screening test name GRAIL Galleri to Item 1 under “When not covered” section. Updated policy guidelines, guidelines and recommendations, and references. Added PLA codes 0539U, 0562U, 0565U, 0566U, 0569U and deleted PLA code 0356U in Billing/Coding section effective 7/1/25. |
Lyme Disease Testing AHS – G2143 | Reviewed by Avalon 2nd Quarter 2025 CAB. Policy Guidelines and References updated. No change to policy intent. Medical Director review 4/2025. |
Microsatellite Instability and Tumor Mutational Burden Testing AHS - M2178 | Added PLA code 0571U to Billing/Coding section for 7/1/25 code update. |
Minimal Residual Disease (MRD) AHS - M2175 | Added PLA codes 0560U, 0561U to Billing/Coding section for 7/1/25 code update. |
Molecular Diagnostics for Breast Cancer Prognosis AHS - M2020 | Reviewed by Avalon 2nd Quarter 2025 CAB. Medical Director review 4/2025. Updated policy guidelines, guidelines and recommendations, and references. No change to policy statement. |
Molecular Markers in Fine Needle Aspirates of the Thyroid AHS - M2108 | Reviewed by Avalon 2nd Quarter 2025 CAB. Medical Director review 4/2025. Updated related policies, policy guidelines, guidelines and recommendations, and references. Edited Note 1 to state “two or more gene tests.” |
Mutation Analysis in Myeloproliferative Neoplasms AHS - M2101 | Reviewed by Avalon 2nd Quarter 2025 CAB. Medical Director review 4/2025. Updated policy guidelines, guidelines and recommendations and references. Under “When covered” section, Item C.3. edited to state “BM fibrosis Grade <2.” Note 1 edited to two gene tests per AHS-R2162 Reimbursement policy. Onychomycosis Testing AHS - M2172 |
Onychomycosis Testing AHS - M2172 | Reviewed by Avalon for 2nd Quarter 2025 CAB. Policy description and guidelines updated. When covered section updated to add “signs of onychomycosis” for clarity. References updated. Medical Director review 4/2025. |
Parathyroid Hormone, Phosphorus, Calcium, and Magnesium Testing AHS - G2164 | Reviewed by Avalon for 2nd Quarter 2025 CAB. Updated description, policy guidelines, and references. Updated coverage criteria to describe all appropriate testing indications for PTH which now reads as follows: Reimbursement is allowed for serum intact parathyroid (PTH) testing in any of the following situations: a. For individuals with abnormal calcium levels; b. One time testing for the diagnosis of hypoparathyroidism for individuals with signs of hypoparathyroidism (see Note 1); c. One test every year for individuals diagnosed with hyperparathyroidism and who have not undergone parathyroidectomy; d. For at least six months following parathyroidectomy; e. At the following frequency for individuals with chronic kidney disease (CKD): o For individuals with Grade 3 CKD: One test every twelve months. O For individuals with Grade 3 CKD: One test every twelve months; f. For individuals with osteoporosis or low bone mass; g. One time testing for individuals with multiple endocrine neoplasia type 2A (MEN2A) or familial medullary thyroid carcinoma; h. During the initial assessment and diagnosis of pseudohypoparathyroidism and related disorders (see Note 2); i. One test every three months for individuals who have pseudohypoparathyroidism or related disorders (see Note 2) and who are less than 18 years of age; j. One test every year for individuals who have pseudohypoparathyroidism or related disorders (see Note 2) and who are 18 years of age or older. Updated Note 1 to define signs of hypoparathyroidism. Removed “hypoparathyroidism” from Note 1 and created Note 2 to define conditions of pseudohypoparathyroidism and related disorders. Medical Director review 4/2025. Notification given 4/30/2025 for effective date 7/1/2025 |
Pathogen Panel Testing AHS – G2149 | Codes 0556U, 0563U, 0564U added to Billing/Coding section, effective 7/1/25. |
Percutaneous Intradiscal and Intraosseous Radiofrequency Procedures of the Spine | Description, Policy Guidelines, and Reference sections updated. Policy statement revised as follows: “BCBSNC will provide coverage for Percutaneous Intraosseous Radiofrequency Procedures of the Spine when it is determined to be medically necessary and when the medical criteria and guidelines shown below are met.” When Covered section revised with medically necessary criteria for intraosseous radiofrequency ablation of the basivertebral nerve. When Not Covered section revised to include when intraosseous radiofrequency ablation of the basivertebral nerve is investigational and not covered. Medical Director review 5/2025. Specialty Matched Consultant Advisory Panel review 5/2025. |
Perirectal Spacer Use During Radiotherapy for Prostate Cancer | Specialty Matched Consultant Panel review 5/21/2025. Updated Description and added references. No change to policy statement. |
Pharmacogenetics Testing AHS - M2021 | Description, Policy Guidelines and References sections updated. Minor edits to When Covered section for clarity, no change to policy statement. Medical Director review 4/2025. |
Pre-Implantation Genetic Testing AHS - M2039 | Reviewed by Avalon 2nd Quarter 2025 CAB. Updated description, policy guidelines, and references. Added the following statement to when covered: “One biological parent is a known carrier of one of the following adult-onset, autosomal dominant disorders: Huntington Disease (HTT); Autosomal dominant polycystic kidney disease (PKD, PKD2). Updated Billing/Coding section to include 0552U, 0553U, 0554U, and 0555U, effective 7/1/2025. Medical Director review 4/2025. |
Prenatal Screening (Nongenetic) AHS - G2035 | Reviewed by Avalon 2nd quarter 2025 CAB. Minor updates made throughout policy. Updated Billing/Coding section to remove 87592. No change to policy statement. Medical Director review 4/2025. |
Prescription Medication and Illicit Drug Testing in the Outpatient Setting AHS - T2015 | Reviewed by Avalon Q2 CAB 2025. Description, Policy Guidelines, and References updated. Updated Documentation Requirements in Billing/Coding section to read as follows: “The laboratory must obtain documentation that fully supports the medical necessity for drug testing. This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures. The laboratory must have a signed order by the ordering provider with the specific test documented on the order.” No changes to policy statement. Medical Director review 4/2025. |
Prostate Specific Antigen (PSA) Testing AHS - G2008 | Reviewed by Avalon 2nd Quarter 2025 CAB. Medical Director review 4/2025. Updated policy guidelines, guidelines and recommendations and references. Under “When covered” section, Item 1 edited age range for average risk annual screening from 45-75 to 45 years of age and older; Item 2 edited age range for annual screening from 40-75 to 40 years of age and older. Repeat screening edited from 4 years to 3 year intervals. |
Proton Beam Therapy | Specialty Matched Consultant Advisory Panel review 5/21/2025. Medical Director/CAP review 5/2025. Under “When covered” section, edited Item #1for clarity: Primary ocular tumors, including intraocular/uveal melanoma. Reference added. |
Radioembolization for Primary and Metastatic Tumors of the Liver | Specialty Matched Consultant Advisory Panel review 5/21/2025. Reference added. No change to policy statement. |
Radiosurgery, Stereotactic Approach | Specialty Matched Consultant Advisory Panel review 5/21/2025. Under “when covered” section A. #5, added coverage criteria for meningiomas in the postoperative setting for grades II-III. References added. |
Salivary Hormone Testing AHS - G2120 | Reviewed by Avalon for 2nd Quarter 2025 CAB. Updated Description and Policy Guidelines section. Updated references. No change to policy statement. Updated Billing/Coding section to remove 82626, 82627, 82670, 82671, 82672, 82677, 82679, 82681, 84144, 84402, 84403, 84410. Medical Director review 4/2022. |
Semi-Implantable and Fully Implantable Middle Ear Hearing Aid | Added the following CPT codes to the Billing/Coding section: 0951T, 0952T, 0953T, 0954T, and 0955T effective 7/1/2025. |
Serum Tumor Markers for Malignancies AHS - G2124 | Added PLA codes 0558U, 0559U to Billing/Coding section for 7/1/25 code update. |
Skin and Soft Tissue Substitutes | Updated Billing/Coding section to add HCPCS codes Q4368, Q4369, Q4370, Q4371, Q4372, Q4373, Q4375, Q4376, Q4377, Q4378, Q4379, Q4380, Q4381, and Q4382, effective 7/1/2025. |
Sleep Apnea: Diagnosis and Medical Management | Updated Billing/Coding section to add 0964T, 0965T, and 0966T, effective 7/1/2025. |
Testing for Diagnosis of Active or Latent Tuberculosis AHS - G2063 | 7/01/25 Added CPT code 0574U Billing/Coding section, effective 7/1/2025. |
Thyroid Disease Testing AHS – G2045 | Reviewed by Avalon 2nd Quarter 2025 CAB Review. Description, Policy Guidelines, and References updated. Updated coverage criteria 1.D to remove “are undergoing evaluation for infertility.” Now reads: “TSH testing for individuals capable of becoming pregnant who have experienced two or more pregnancy losses.” Added “TSH testing for individuals with a thyroid nodule.” to When Covered section. Added specific thyroid antibodies to coverage criteria #4. Medical Director review 4/2025. |
Transplant Rejection Testing AHS - M2091 | Reviewed by Avalon 2nd Quarter 2025 CAB. Description, Policy Guidelines and References sections updated. When Covered section edited for clarity, no change to policy statement. Medical Director review 4/2025. |
Urinary Tumor Markers for Bladder Cancer AHS - G2125 | Reviewed by Avalon 2nd Quarter 2025 CAB. Updated the background, guidelines and recommendations. Updated references. Medical Director review in April 2025. No changes in coverage criteria. |
Venous and Arterial Thrombosis Risk Testing AHS - M2041 | Reviewed by Avalon 2nd Quarter 2025 CAB. Description, Policy Guidelines and References sections updated. Minor edit to When Covered section for clarity, no change to policy statement. Medical Director review 4/2025. |