Medical Guidelines | Reason for Update |
|---|---|
| Allergy Immunotherapy (Desensitization) | References updated. Specialty Matched Consultant Advisory Panel review 11/2025. Medical Director review 11/2025. |
Allergy Skin and Challenge Testing | References updated. Specialty Matched Consultant Advisory Panel review 11/2025. Medical Director review 11/2025. |
References updated. Updated Regulatory Status to indicate The L-Dex U400 was discontinued by its manufacturer in November 2018. Specialty Matched Consultant Advisory Panel review 11/2025. Medical Director review 11/2025. | |
| Chromoendoscopy as an Adjunct to Colonoscopy | Minor edits made to the Description section; References updated. Specialty Matched Consultant Advisory Panel 11/2025. Medical Director review 11/2025. |
| Confocal Laser Endomicroscopy | Minor edits made to the Description section; References updated. Specialty Matched Consultant Advisory Panel 11/2025. Medical Director review 11/2025. |
References updated. Specialty Matched Consultant Advisory Panel review 11/2025. Medical Director review 11/2025. | |
Description, Policy Guidelines and References updated. Updated first coverage criteria under Not Covered section to include MUSE and GERDX, now reads: "Transoral incisionless fundoplication (TIF) (i.e., EsophyX, MUSE, GERDX) is considered investigational as a treatment of gastroesophageal reflux disease." Also corrected typo in first criteria. No change to policy intent. Specialty Matched Consultant Advisory Panel 11/2025. Medical Director review 11/2025. | |
| Growth Factors in Wound Healing | References updated. Description Section updated with current FDA information. Specialty Matched Consultant Advisory Panel review 11/2025. Medical Director review 11/2025. |
References updated. Specialty Matched Consultant Advisory Panel review 11/2025. Medical Director review 11/2025. | |
Reviewed by Avalon 3rd Quarter 2025 CAB. Updated Description, Policy Guidelines, and References. When Covered section updated as follows: Added additional high-risk situation for the triple panel testing for Hepatitis B and now reads as follows, “For individuals who are receiving immunosuppressant therapy.” Addition of once every three-month frequency to antibody testing for HCV. Addition of “for individuals who are immunocompromised” to qualitative nucleic acid testing for HCV. Billing and Coding section updated as follows: added HCPCS code G0567. Medical Director review 7/2025. Notification given 10/15/2025 for effective date 12/10/2025. | |
Identification of Microorganisms using Nucleic Acid Probes AHS – M2097 | Reviewed by Avalon 3rd Quarter 2025 CAB. Updated Description, Policy Guidelines and References. Changes to coverage criteria: Removed “Non-vaginal Candida species” and associated codes from the table under the Not Covered section. Direct probe testing for Chlamydia pneumoniae, Cytomegalovirus, Legionella pneumophila, and Mycoplasma pneumoniae all moved from the When Covered section to Not Covered. All direct probes in policy are now under the Not Covered section. Second coverage criteria under Not Covered section updated to remove phrase "any combination of direct probe" and "or" and now reads "Reimbursement is not allowed for simultaneous ordering of amplified probe and quantification for the same organism in a single encounter." Removed codes 87480, 87481 and 87482 from Billing/Coding section. Medical Director review 7/2025. Notification given 10/15/2025 for effective date 12/10/2025. |
| Specialty Matched Consultant Advisory Panel review 11/2025. Medical Director review 11/2025. No change to policy statement. | |
Magnetic Esophageal Sphincter Augmentation to Treat Gastroesophageal Reflux Disease (GERD) | References updated. Regulatory Status updated to include FDA revised labeling from February 2024. Specialty Matched Consultant Advisory Panel review 11/2025. Medical Director review 11/2025. |
| Medical Necessity | Medical Director Review 11/2025. Specialty Matched Consultant Advisory Panel review 11/2025. No changes to policy statement. |
| Non-Contact Ultrasound Treatment for Wounds | References updated. Specialty Matched Consultant Advisory Panel review 11/2025. Medical Director review 11/2025. |
| Pancreatic Enzyme Testing for Acute Pancreatitis AHS – G2153 | Reviewed by Avalon 3rd Quarter 2025 CAB. Description, Policy Guidelines and References updated. Removed amylase from coverage criteria 1 under the When Covered section. Updates to the Not Covered section: Removed amylase from coverage criteria 1 and 6 (formerly coverage criteria 5), added new coverage criteria 2 that reads "Reimbursement is not allowed for measurement of serum amylase when ordered for anything other than analysis of pancreatic cyst fluid." Medical Director review 7/2025. Notification given 10/15/2025 for effective date 12/10/2025. |
| Plugs for Fistula Repair | References updated. Specialty Matched Consultant Advisory Panel review 11/2025. Medical Director review 11/2025. |
| Postsurgical Home Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis | References updated. Policy guidelines updated. Specialty Matched Consultant Advisory Panel review 11/2025. Medical Director review 11/2025. |
| Surgical Treatments for Lymphedema | References updated. Policy guidelines update with current systemic reviews and RCT’s. Specialty Matched Consultant Advisory Panel review 11/2025. Medical Director review 11/2025. |
| Transanal Endoscopic Microsurgery (TEMS) | References updated. Specialty Matched Consultant Advisory Panel 11/2025. Medical Director review 11/2025. |
| Varicose Veins of the Lower Extremities, Treatment for | References updated. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 11/2025. Medical Director review 11/2025. |
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