| Medical Guidelines | Reason for Update |
|---|---|
| Ablation and Neural Therapy Procedures for Headache and Pain Management | Code G0571 added to Billing/Coding section effective 1/01/26. |
| Artificial Intervertebral Disc | Policy archived. |
| Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions | Policy archived. |
| Autologous Chondrocyte Implantation | Policy archived. |
| Automated Percutaneous and Endoscopic Discectomy | The following changes made to the Billing/Coding Section: deleted terminated code 0275T and added the following CPT codes: 62330 and 62331, effective 1/1/2026. |
| Bariatric Surgery | References updated. Under When Not Covered Section under Endoscopic procedures are investigational as a primary bariatric procedure or as a revision procedure, Endoscopic Sleeve Gastroplasty (ESG) added as another example. No changes to the coverage criteria or policy intent. Regulatory status updated to include FDA approval information on Apollo Endoscopic Sleeve Gastroplasty (ESG) System, Apollo ESG SX System, Apollo REVISE System and Apollo REVISE SX System. Added CPT code 43889 to the Billing/Coding section effective 01/01/2026. Added. |
| Baroreflex Stimulation Devices | Changes to the Billing/Coding section effective 1/1/26: codes 0266T, 0267T, 0268T, 0269T, 0270T, 0271T, 0272T, 0273T deleted. Codes 64654, 64655, 64656, 64657, 64658, 64659, 93145, 93146 added. |
| Cervical Spine Procedures | Policy archived. |
| Diagnosis and Treatment of Sacroiliac Joint Pain | Policy archived. |
| Durable Medical Equipment (DME) | Codes C9811, C9815 and C9816 added to the Billing/Coding section, effective 1/1/26. |
| Electronic Brachytherapy for Nonmelanoma Skin Cancer | Added CPT codes 77436, 77437, 77438, 77439 to Billing/Coding section effective 1/1/2026. |
| Facet Joint Denervation | Policy archived. |
| Focal Treatments for Prostate Cancer | References updated. Specialty Matched Consultant Advisory Panel review 11/2025. Medical Director review 11/2025. CPT code 55877 added to the Billing and Coding section effective 1/1/2026. |
| Gene Expression Profiling and Protein Biomarkers for Prostate Cancer AHS - M2166 | Added PLA code 0609U to Billing/Coding section effective 1/1/2026. |
| General Genetic Testing, Germline Disorders AHS - M2145 | Code 0605U added to Billing/Coding section, effective 1/1/26. |
| Image-Guided Minimally Invasive Decompression (IG-MLD) for Spinal Stenosis | The following changes made to the Billing/Coding Section: deleted terminated code 0275T and added the following CPT codes: 62330 and 62331, effective 1/1/2026. |
| Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence | References Updated. Specialty Matched Consultant Advisory Panel review 11/2025 Medical Director review 11/2025. |
| Intensity Modulated Radiation Therapy for Tumors of the Central Nervous System | Under Billing/Coding section: added CPT codes 77407, 77412; deleted 77385, 77386, G6015, G6016 effective 1/1/2026. |
| Intensity Modulated Radiation Therapy (IMRT) for Sarcoma of the Extremities | Under Billing/Coding section: added CPT codes 77407, 77412; deleted 77385, 77386, G6015, G6016 effective 1/1/2026. |
| Intensity Modulated Radiation Therapy (IMRT) of Abdomen and Pelvis | Under Billing/Coding section: added CPT codes 77407, 77412; deleted 77385, 77386, G6015, G6016 effective 1/1/2026. |
| Intensity Modulated Radiation Therapy (IMRT) of Head and Neck | Under Billing/Coding section: added CPT codes 77407, 77412; deleted 77385, 77386, G6015, G6016 effective 1/1/2026. |
| Intensity Modulated Radiation Therapy (IMRT) of the Chest | Under Billing/Coding section: added CPT codes 77407, 77412; deleted 77385, 77386, G6015, G6016 effective 1/1/2026. |
| Intensity Modulated Radiation Therapy (IMRT) of the Prostate | Under Billing/Coding section: added CPT codes 77407, 77412; deleted 77385, 77386, G6015, G6016 effective 1/1/2026. |
| Laboratory Procedures Medical Policy AHS - R2162 | Changes to Billing/Coding section effective 1/1/26: added codes 0601U, 0602U, 0604U, 0606U, 0607U, and 0608U. Removed code 0361U. |
| Liquid Biopsy AHS - G2054 | Added PLA codes 0611U and 0612U to Billing/Coding section effective 1/1/2026 |
| Lumbar Spine Procedures | Policy archived. |
| Neurostimulation, Electrical | Updated Billing/Coding section II to remove 0720T. Updated Billing/Coding section IV to add C9812 and C9814. |
| Pathogen Panel Testing AHS – G2149 | Codes 0600U and 0610U added to Billing/Coding section, effective 1/1/26. |
| Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence | References updated. Specialty Matched Consultant Advisory Panel review 11/2025. Medical Director review 11/2025. |
| Penile Prosthesis | Updated Related Policies from Gender Affirmation Surgery to Sex Trait Modification Procedures For Gender Affirming Care. References updated. Specialty Matched Consultant Advisory Panel review 11/2025. Medical Director review 11/2025. |
| Percutaneous Electrical Nerve Stimulation (PENS) or Neuromodulation Therapy and Percutaneous Electrical Nerve Field Stimulation (PENFS) | Updated Billing/Coding section to remove 0720T and add 64567, effective 1/1/2026. |
| Percutaneous Intradiscal and Intraosseous Radiofrequency Procedures of the Spine | Policy archived. |
| Percutaneous Tibial Nerve Stimulation for Voiding Dysfunction | References updated. Specialty Matched Consultant Advisory Panel review 11/2025. Medical Director review 11/2025. |
| Prescription Medication and Illicit Drug Testing in the Outpatient Setting AHS - T2015 | Updated Billing/Coding section to add 0603U, effective 1/1/2026. |
| Prostatic Urethral Lift | References updated. Specialty Matched Consultant Advisory Panel review 11/2025. Medical Director review 11/2025. |
| Proton Beam Therapy | Added medical necessity coverage criteria for head and neck cancers. Updated policy guidelines section. Added CMP “Medical Necessity” to related polices section. Medical Director review 11/2025. References added. |
| Radiosurgery, Stereotactic Approach | Deleted the following HCPCS codes under Billing/Coding section: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014 effective 1/1/2026 code update. |
| Remote Therapeutic and Physiologic Monitoring | Updated Billing/Coding section to add 98984, 98985, 98986, 98979, 99445, and 99470, effective 1/1/2026. |
| Sacral Nerve Neuromodulation/Stimulation for Pelvic Floor Dysfunction | References updated. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 11/2025. Medical Director review 11/2025. |
| Sacroiliac Joint Fusion/Stabilization | Policy archived. |
| Skin and Soft Tissue Substitutes | Updated Policy Guidelines and References. Updated When Covered section to include medical necessity criteria for use of processed nerve allografts and synthetic nerve conduits. Updated When Not Covered section as follows: Added "All other uses of processed nerve allografts and synthetic nerve conduits for individuals with peripheral nerve gaps are considered investigational for applications not specified above." Removed Avance™ Nerve Graft, AxoGuard® Nerve Connector (Axogen/AxioGuard®), NeuraGen™ Nerve Guide, NeuroMatrix™, NeuroMend™, NeuraWrap™ Nerve Protector from the list of investigational products. Updated Billing/Coding section to add HCPCS codes Q4398, Q4399, Q4400, Q4401, Q4402, Q4403, Q4404, Q4405, Q4406, Q4407, Q4408, Q4409, Q4410, Q4411, Q4412, Q4413, Q4414, Q4415, Q4416, Q4417, Q4420, Q4431, Q4432, Q4433 and to remove Q4100 and Q416, effective 1/1/2026. Medical Director review 11/2025. |
| Spinal Cord and Dorsal Root Ganglion Stimulation | Policy archived. |
| Testing for Targeted Therapy of Non-Small-Cell Lung Cancer AHS - M2030 | Reviewed by Avalon Q3 2025 CAB. Medical Director review 9/2025. Updated policy guidelines, guidelines and recommendations and references. Updated Note 1. Under Billing/Coding section: added CPT codes 81445, 81449, 81455, 81456, 0288U and deleted CPT 88342. Under “When Covered” section: clarified coverage statement and removed individual mutations listed. See Note 1 for mutations. Under “When Not Covered” section: added “single gene analysis for genetic alterations and broad molecular profiling panels that do not include the minimum genetic variants found in Note 1” are considered not medically necessary. Notification given 10/15/25 for effective date 12/31/25. |
| Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders | Updated Billing/Coding section to add 0997T and 0998T, effective 1/1/2026. |
| Transurethral Water Vapor Thermal Therapy and Transurethral Water Jet Ablation (Aquablation) for Benign Prostatic Hyperplasia | References updated. Description section updated. Specialty Matched Consultant Advisory Panel review 11/2025. Medical Director review 11/2025. Code 52597 added to Billing/Coding section effective 1/1/2026. |
| Tumor Treatment Fields Therapy | Added HCPCS code 1025T to Billing/Coding section effective 1/1/2026. |
| Urinary Tumor Markers for Bladder Cancer AHS - G2125 | Code 0613U added to Billing/Coding section effective 1/1/2026. |
| Vagus Nerve Stimulation | Added the following HCPCS code to the Billing/Coding section: C1607, effective 1/1/2026. |
| Vertebroplasty, Kyphoplasty, and Sacroplasty Percutaneous | Policy archived. |
| Vesicoureteral Reflux, Treatment with Periureteral Bulking Agents | References updated. Specialty Matched Consultant Advisory Panel review 11/2025. Medical Director review 11/2025. |
| Whole Gland Ablative Treatments of Prostate Cancer | Policy guidelines updated with (NCCN) Clinical Practice Guidelines (v.2.2026). References updated. Specialty Matched Consultant Advisory Panel review 11/2025. Medical Director review 11/2025. |
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