Medical Policy Update for December 5, 2023

Reviewed by Avalon 3rd Quarter 2023 CAB.  Updates to Description, Policy Guidelines and References section. No change to policy intent. Removed Table of Terminology.  When Covered and Not Covered sections edited for clarity and specified testing criteria for individuals with ARF or PSGN.  Medical Director review 11/2023.

Reviewed by Avalon 3rd Quarter 2023 CAB.  Updates to Description, Policy Guidelines, and References sections. No change to policy intent.  Removed Table of Terminology. When Not Covered section updated for clarity with the addition of “dementia”. CPT Code 0393U added to Billing/Coding section.  Medical Director review 11/2023.

Reference added. Specialty Matched Consultant Advisory Panel review 11/2023. Medical Director Review 11/2023.

Reviewed by Avalon 3rd Quarter 2023 CAB.  Updates to Description, Policy Guidelines, and References sections. No change to policy intent. Removed Table of Terminology. When Covered section updated by removing ethnicity as an example of a high-risk population. Medical Director review 11/2023.

Reviewed by Avalon 3rd Quarter 2023 CAB. Description, Policy Guidelines and References updated. When Covered section edited to include new coverage criteria 2 regarding B-type natriuretic peptide (BNP) or N-terminal proBNP (NT-proBNP) testing. Billing Coding section updated to include CPT 83880. Medical Director review 11/2023.

Reviewed by Avalon 3rd quarter 2023 CAB. Description, policy guidelines, and references updated. Policy statement updated to reflect addition of coverage criteria. Reimbursement language added for measurement of bone turnover markers to assess an individual’s compliance with bisphosphonate therapy or for fracture risk prediction for individuals treated with bisphosphonates. Remaining coverage criteria updated for clarity. Medical Director review 10/2023.

Reviewed by Avalon 3rd Quarter 2023 CAB. Policy Guidelines and References sections updated. Under When Covered section, added items 1 and 2: “1. For individuals who have been diagnosed with celiac disease and who are IgA sufficient, reimbursement is allowed for serologic testing with IgA anti-tissue transglutaminase (TTG) at the following intervals: a. At the first follow-up visit 3-6 months after diagnosis. b. Every 6 months until normalization of anti-TTG levels has occurred. c. Every 12-24 months thereafter. 2. For individuals who have been diagnosed with celiac disease who are IgA deficient, reimbursement is allowed for testing for IgG endomysial antibodies, IgG deamidated gliadin peptide, or IgG TTG at the following intervals: a. At the first follow-up visit 3-6 months after diagnosis. b. Every 6 months until normalization of IgG levels has occurred. c. Every 12-24 months thereafter.” Added item 6 under Not Covered section: "6. Reimbursement is not allowed for testing for celiac disease for asymptomatic individuals not at an increased risk for developing celiac disease.”  Additional edits made to When Covered and Not Covered sections for clarity. Medical Director review 11/2023.

Updated Description, Policy Guidelines, and References updated. Updated coverage criteria to remove the following: Reimbursement for cervical cancer screening for individuals under 21 years of age is allowed only when one of the following criteria are met: a. There is a history of HIV and/or other non-HIV immunocompromised conditions, b. There is a previous diagnosis of cervical cancer, c. There is a previous diagnosis of cervical dysplasia, d. There is a history of an organ transplant. Remaining coverage criteria updated for clarity. Medical Director review 10/2023.

Reviewed by Avalon 3rd Quarter 2023 CAB.  Updates to Description, Policy Guidelines, and References sections. Removed Table of Terminology. Minor edits applied to When Covered and When Not Covered sections to provide clarity. No change to policy intent.  Medical Director review 11/2023.

Reviewed by Avalon 3rd Quarter 2023 CAB.  Updates to Description, Policy Guidelines, and References sections. No change to policy intent. Added Related Policies. Added criteria for antibody testing for syphilis infection (#4) to the When Covered section.  Added criteria for testing and screening for Mycoplasma genitalium to the When Not Covered and When Not Covered sections.  Note 3 updated with additional signs and symptoms of Syphilis Infection. Added Note 8.  Removed Table of Terminology.  Added CPT code 87563 to Billing/Coding section.  Medical Director review 11/2023.

Reference added. Specialty Matched Consultant Advisory Panel review 11/2023. Medical Director Review 11/2023.

Reviewed by Avalon 3rd Quarter 2023 CAB. Medical Director review 10/2023. Edited non-coverage statement for clarity. References added. Updated description and policy guidelines sections. Added CPT codes 88172, 88173, 88177 to Billing/Coding section.

Reviewed by Avalon 3rd Quarter 2023 CAB. Updated Policy Guidelines and Reference sections. Removed Table of Terminology. No change to policy statement. Medical Director review 11/2023.

Reviewed by Avalon 3rd Quarter 2023 CAB. Updated Description, Policy Guidelines and Reference sections. When Covered and Not Covered sections edited for clarity, no change to policy statement. Removed Table of Terminology. Medical Director review 11/2023.

Reviewed by Avalon 3rd Quarter 2023 CAB. Medical Director review 10/2023. Updated policy guidelines and references.

Reviewed by Avalon 3rd Quarter 2023 CAB. Medical Director review 11/2023. Updated policy guidelines and added references. “When covered” section changes: edits for clarity for familial testing for unaffected individuals; expanded testing beyond just for BRCA 1/2; edits for clarity throughout section. Under Billing/Coding section, added CPT codes 81432, 81433, 81479, 0102U, 0103U, 0129U. 

Policy Title changed from: BRCA to: Genetic Testing for Breast, Ovarian, Pancreatic, and Prostate Cancers (BRCA).

Reviewed by Avalon 3rd Quarter 2023 CAB. Background, Policy Guidelines, and References updated. New Note 1 added to When Covered section, Not Covered section edited for clarity, no change to policy statement. CPT code 81403 added to Billing/Coding section. Medical Director review 11/2023.

Reviewed by Avalon 3rd Quarter 2023 CAB. Description, Policy Guidelines and References updated. The following changes were made to the When Covered section: former coverage criteria 2 and 3 combined, added new coverage criteria 2. b. “For an individual with a personal history of pediatric hypodiploid acute lymphoblastic leukemia.” Addition of new Note 1, former “Policy Guideline #1” is now Note 2. Not Covered section edited for clarity. Medical Director reviewed 11/2023.

Reviewed by Avalon 3rd Quarter 2023 CAB.  Policy Guidelines and References updated. When Covered section edited for clarity. Added Note 1.  Removed Table of Terminology.  No change to policy statement.  Removed CPT code 96040 and HCPCS code S0265 from the Billing/Coding section. Medical Director review 11/2023.

Reviewed by Avalon 3rd Quarter 2023 CAB. Updated Description, Policy Guidelines and References sections. The following changes were made to the When Covered section: Previous coverage criteria 1 regarding recommendation for genetic counseling moved into policy description. Previous coverage criteria 6 moved to coverage criteria 1 with coverage expanded to all members of a family with a known PTEN mutation. Former coverage criteria 2.c. was moved into coverage criteria 3 and adjusted to match NCCN language and now reads 3. “f. Two major and two or more minor criteria (for individuals without macrocephaly).” Not Covered section edited for clarity. Medical Director review 11/2023.

Updated related policies. References added. Updated Policy Guidelines. Removed deleted code 20926. Specialty Matched Consultant Advisory Panel review 11/2023. Medical Director review 11/2023.

References added. Specialty Matched Consultant Advisory Panel review 11/2023. Medical Director Review 11/2023.

Reviewed by Avalon 3rd Quarter 2023 CAB. Updated Description, Policy Guidelines, and References. When Covered section updated according to CDC updates for Hepatitis B screening and testing including triple panel testing in addition to minor edits for clarity.  Added Hepatitis B to the statement in the When Not Covered section.  Medical Director review 11/2023.

Reviewed by Avalon 3rd Quarter 2023 CAB. Medical Director review 10/2023. Updated policy guidelines; added references. Edited “when not covered” section for clarity; removed all bullets under this section.

Reviewed by Avalon 3rd Quarter 2023 CAB. Related Policies, Policy Guidelines, and References updated. Coverage criteria updated for clarity. No changes to policy statement. Medical Director review 10/2023. (tt)

Reviewed by Avalon Q3 2023 CAB. Medical Director review 10/2023. Added CPT code 0564T in Billing/Coding section. Removed statement “including but not limited to” in When not covered section. Updated policy guidelines; added references.

Specialty Matched Consultant Advisory Panel review 11/2023. Medical Director review 11/2023.  No change to policy statement.

Reviewed by Avalon 3rd Quarter 2023 CAB. Description, Policy Guidelines and References updated, Not Covered section edited for clarity, no change to policy statement. Medical Director review 11/2023.

Reviewed by Avalon 3rd Quarter 2023 CAB. Medical Director review 10/2023. Under when covered section #1, added “asymptomatic” to criteria for clarity that testing specified is for individuals without cancer. Updated policy guidelines; added references. Added the following CPT codes to Billing/Coding section: 81288, 81292, 81293-81296, 81435-81436, 81479, 0101U.

Reviewed by Avalon 3rd Quarter 2023 CAB. Description, Policy Guidelines, and References sections updated. Medical Director review 10/2023.

Medical Director Review 11/2023. Specialty Matched Consultant Advisory Panel review 11/2023. No changes to policy statement.

Reviewed by Avalon 3rd Quarter 2023 CAB. Description, Policy Guidelines and References updated. Coverage criteria updated for clarity. No change to policy statement. Medical Director review 10/2023.

Reviewed by Avalon 3rd Quarter 2023 CAB. Medical Director review 10/2023. Updated policy guidelines and added references.

Reviewed by Avalon 3rd Quarter 2023 CAB. Medical Director review 10/2023. Under when covered section #1a, removed PCR testing based on updated NCCN guidelines; edited other criteria 1b, f, 2a, b for clarity. Updated policy guidelines; added references.

Reviewed by Avalon 3rd Quarter 2023 CAB. Description, policy guidelines, and references updated. Coverage criteria updated for clarity. No change to policy statement. Medical Director review 10/2023.

Reviewed by Avalon 3rd Quarter 2023 CAB. Minor edits made for clarity to When Covered and When Not Covered sections.  No change to policy intent.  Removed Table of Terminology.  Removed CPT codes 88305 and 88314 from Billing/Coding section. References updated.

References added. Specialty Matched Consultant Advisory Panel review 11/2023. Medical Director review 11/2023.

Reference added. Specialty Matched Consultant Advisory Panel review 11/2023. Medical Director review 11/2023.

References added. Specialty Matched Consultant Advisory Panel review 11/2023. Medical Director review 11/2023

Reviewed by Avalon 3rd Quarter 2023 CAB. Description, policy guidelines, and references updated. Related policies section added. Removed “who are adequately counseled” from When Covered section #1. Combined former When Covered #1f and #2 into a new #2. Updated When Not Covered section “b” to read as follows: For the screening of pregnant individuals with higher order multiple gestation pregnancies. Changed “chorionic villa sampling (CVS) or amniocentesis” to “karyotyping to confirm fetal aneuploidy” in When Covered #3. Removed “For screening in egg donor pregnancies” from When Not Covered. Medical Director review 10/2023.

Reviewed by Avalon 3rd Quarter CAB.  Policy Title change to “Prostate Biopsy Specimen Analysis”. For clarity  the words “pathological examination of tissue obtained from a” where added  before prostate biopsy in the When covered and Not Covered sections. No changes to coverage criteria.  Policy Guidelines and  References updated. Medical Director review 11/2023.

Reviewed by Avalon 3rd Quarter 2023 CAB. Medical Director review 10/2023. Edited “when not covered” section for clarity. Updated policy guidelines and references.

Reviewed by Avalon 3rd Quarter 2023 CAB. Description, Background, Related Policies, Policy Guidelines, and References updated. No change to policy statement. Medical Director review 10/2023.

Reference added. Specialty Matched Consultant Advisory Panel review 11/2023. Medical Director review 11/2023.

Reviewed by Avalon 3rd Quarter 2023 CAB. Medical Director review 10/2023. Coverage criteria edited to allow therapeutic drug monitoring (TDM) in anyone receiving 5-FU as toxicity from 5-FU is not specific to a cancer type. Updated policy guidelines and references added.

Reviewed by Avalon 3rd Quarter 2023 CAB. Description, Policy Guidelines, and References sections updated.  When Covered section updated for clarity.  Table of Terminology removed.  No change to policy intent.  Medical Director review 11/2023.

Reviewed by Avalon 3rd Quarter 2023 CAB. Description, Policy Guidelines and References updated. The following changes were made to the When Covered section: edited coverage criteria 1 to address appropriate frequency for AlloMap usage and coverage criteria 2 to address appropriate frequency for usage of dd-cfDNA. Added coverage criteria 4 to Not Covered section "To assess for rejection and injury in transplanted organs, mRNA expression profiling of biopsied tissue from a transplanted organ (e.g., MMDx Heart, MMDx Kidney) is considered investigational." Codes 0087U and 0088U added to Billing/Coding section. Medical Director review 11/2023.

Reviewed by Avalon 3rd Quarter 2023 CAB. Medical Director review 10/2023. Updated description, policy guidelines and references.

Reference added. Specialty Matched Consultant Advisory Panel review 11/2023. Medical Director review 11/2023.