| Medical Guidelines | Reason for Update |
|---|---|
| Biochemical Markers of Alzheimer Disease and Dementia AHS – G2048 | Added CPT code 0596U Billing/Coding section, effective 10/1/2025. |
| Continuous Monitoring of Glucose in the Interstitial Fluid | Updated When Covered Section B to remove the requirement for “multiple daily doses of insulin” per previous medical director review. |
| Genomic Testing for Hematopoietic Neoplasms AHS- M2182 | Added code 0592U to Billing/Coding section for effective date 10/1/25. |
Interferential Stimulation Archive Policy | Policy archived. |
| Laboratory Procedures Medical Policy AHS - R2162 | Codes 0575U, 0579U, 0581U, 0584U, 0586U, 0588U, 0589U, 0594U, and 0595U added to Billing/Coding section, effective 10/1/25. |
| Laboratory Testing for the Diagnosis of Inflammatory Bowel Disease AHS – G2121 | Code 0598U added to Billing/Coding section, effective 10/1/25. |
| Liquid Biopsy AHS - G2054 | Added code 0577U to Billing/Coding section for effective date 10/1/25. |
| Lyme Disease Testing AHS – G2143 | Added CPT code 0580U Billing/Coding section, effective 10/1/2025. |
| Microsatellite Instability and Tumor Mutational Burden Testing AHS - M2178 | Reviewed by Avalon Q3 2025 CAB. Medical Director review 9/2025. Updated TMB/MSI table, policy guidelines, guidelines and recommendations. Added and updated references. Added the following codes to Billing/Coding section: 0538U, 0539U, 0543U, 0585U effective 10/1/25. |
| Molecular Testing for Cutaneous Melanoma AHS - M2029 | Added code 0578U to Billing/Coding section for effective date 10/1/25. |
| Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers | References updated. When covered section updated to include under Single compartment or multichamber programmable lymphedema pumps applied to the limb may be considered medically necessary for the treatment of lymphedema when: “3. The individual has had an inadequate response to an initial course of treatment with a nonprogrammable pneumatic compression pump applied to the chest or trunk in addition to the limbs”. When covered section updated to include positive coverage criteria for chest and trunk, “Single-compartment or multichamber nonprogrammable pneumatic compression pumps applied to the chest or trunk in addition to the limbs may be considered medically necessary for the treatment of lymphedema that has failed to adequately respond to both conservative measures and nonprogrammable pneumatic compression to the limbs only. Single-compartment or multichamber programmable pneumatic compression pumps applied to the chest or trunk in addition to the limbs may be considered medically necessary for the treatment of lymphedema when: 1. The individual is otherwise eligible for nonprogrammable pneumatic pumps applied to the chest or trunk in addition to the limbs; and 2. There is documentation that the individual has unique characteristics (eg, significant scarring, recent surgery) that prevent satisfactory pneumatic compression with single-compartment or multichamber nonprogrammable compression pumps; or 3. The individual has had an inadequate response to an initial course of treatment with a nonprogrammable pneumatic compression pump applied to the chest or trunk in addition to the limbs.” When not covered section updated and removed the following statements, “Single compartment or multichamber lymphedema pumps applied to the limb are considered investigational in all situations other than those specified above” and “The use of lymphedema pumps to treat the trunk or chest in patients with lymphedema with or without involvement of the upper and/or lower limbs is considered investigational.” When not covered section updated to include Single-compartment or multichamber compression pumps are considered investigational in all situations other than those specified above. Policy guidelines updated to include clinical input statement. HCPCS codes E0658 and E0659 added to Billing/Coding section effective 10/01/2025. Specialty Matched Consultant Advisory Panel review 9/2025. Medical Director review 9/2025. |
| Prescription Medication and Illicit Drug Testing in the Outpatient Setting AHS - T2015 | Updated Billing/Coding section to add 0587U, effective 10/1/2025. |
| Proteogenomic Testing of Individuals with Cancer AHS - M2168 | Added code 0597U to Billing/Coding section for effective date 10/1/25 |
| Skin and Soft Tissue Substitutes | Updated Billing/Coding section to add A2036, A2037, A2038, A2039, Q4383, Q4384, Q4385, Q4386, Q4387, Q4388, Q4389, Q4390, Q4391, Q4392, Q4393, Q4394, Q4395, Q4396, and Q4397, effective 10/1/2025. |
| Transplant Rejection Testing AHS - M2091 | Code 0576U added to Billing/Coding section, effective 10/1/25. |
| Whole Genome and Whole Exome Sequencing AHS – M2032 | Codes 0582U and 0583U added to Billing/Coding section, effective 10/1/25. |
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