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.

Added CPT code 0568U Billing/Coding section, effective 7/1/2025.

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.

Specialty Matched Consultant Panel review 5/21/2025. Reference added. No change to policy statement.

Specialty Matched Consultant Advisory Panel review 5/21/2025. Updated Regulatory status and added references. No change to policy statement.

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.

Reviewed by Avalon Q2 2025 CAB. Reference added. No changes to policy statement.

Specialty Matched Consultant Advisory Panel review 5/21/2025. Reference added. No change to policy statement.

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.

Reviewed by Avalon 2nd Quarter 2025 CAB.  Description, Policy Guidelines, and References updated. No change to policy statement. Medical Director review 4/2025.

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.

Added PLA codes 0558U, 0559U to Billing/Coding section for 7/1/25 code update.

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

Code 0567U added to Billing/Coding section, effective 7/1/25.

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.

Code 0963T added to the to the Billing/Coding Section effective 7/1/25.

Specialty Matched Consultant Advisory Panel review 5/21/2025. References added. No change to policy statement.

Specialty Matched Consultant Advisory Panel review 5/21/2025. References added. No change to policy statement.

Specialty Matched Consultant Advisory Panel review 5/21/2025. References added.

Specialty Matched Consultant Advisory Panel review 5/21/2025. Reference added. No change to policy statement.

Specialty Matched Consultant Advisory Panel review 5/21/2025. NCCN reference updated. No change to policy statement

Reviewed by Avalon 2nd Quarter 2025 CAB. Description, Policy Guidelines and References updated. Medical Director review 4/2025.

Code 0573U added to Billing/Coding section, effective 7/1/25.

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.

Reviewed by Avalon 2nd Quarter 2025 CAB. Policy Guidelines and References updated. No change to policy intent.  Medical Director review 4/2025.

Added PLA code 0571U to Billing/Coding section for 7/1/25 code update.

Added PLA codes 0560U, 0561U to Billing/Coding section for 7/1/25 code update.

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.

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.”

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.

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

Codes 0556U, 0563U, 0564U added to Billing/Coding section, effective 7/1/25.

Specialty Matched Consultant Panel review 5/21/2025. Updated Description and added references. No change to policy statement.

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.

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.

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.

Specialty Matched Consultant Advisory Panel review 5/21/2025. Reference added. No change to policy statement.

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.

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.

Added the following CPT codes to the Billing/Coding section: 0951T, 0952T, 0953T, 0954T, and 0955T effective 7/1/2025. 

Added PLA codes 0558U, 0559U to Billing/Coding section for 7/1/25 code update.

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.

Updated Billing/Coding section to add 0964T, 0965T, and 0966T, effective 7/1/2025.

7/01/25 Added CPT code 0574U Billing/Coding section, effective 7/1/2025. 

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.

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.