Medical Policy Update for February 7, 2023

Policy Guidelines updated.  Specialty Matched Consultant Advisory Panel review 8/19/2022. 

Reviewed by Avalon 4th Quarter 2022 CAB. Medical Director Review 12/2022. Description, Policy Guidelines, and References updates. Related polices section removed. Update When Not Covered #4 to read as follows: “Reimbursement is not allowed for host antibody serology testing for all other situations not described above.” Remaining coverage criteria updated for clarity.

Specialty Matched Consultant Advisory Panel review 8/19/2022.

Off-cycle review by Avalon 4th Quarter 2022 CAB. Coverage criteria edited for clarity. Updates made to Policy Guidelines, Billing/Coding and References sections, removed Related Policies section. No change to policy statement. Medical Director review 1/2023.

Reviewed by Avalon 4th Quarter 2022 CAB.  Medical Director review 12/2022. Description, Policy Guidelines, and References updated. Related policy section removed. Coverage criteria updated for clarity. Added Note 2 to define first-degree relative “Note 2: First-degree relative include parents, full siblings, and children of the individual.” No changes to policy statement.

Updated Billing/Coding section to include codes 81329, 81333, 81336, 81337, 81442, 81470, 81471, 0232U, 0230U. Related Policies section removed.

Reviewed by Avalon 4th Quarter 2022 CAB. Description, Policy Guidelines and References sections updated. Related Policies section removed. When Covered section edited for clarity, no change to policy statement. Medical Director review 1/2023.

Reviewed by Avalon 4th Quarter 2022 CAB. Description, Policy Guidelines and References sections updated. Related Policies section removed. When Covered section received the following edits; Criteria 1 and 2 combined to now read “1. Reimbursement is allowed for genetic testing for the diagnosis of Fanconi Anemia (FA) for individuals who have received genetic counseling and who have clinical signs and symptoms of FA.”, previous item 3 edited to remove specific subcriteria which allowed for FA genetic testing and now reads “2. For pregnant individuals and those seeking pre-conceptive care, carrier screening for FA is considered medically necessary.”, removed subcriteria from previous item 4 and now reads “3. In situations where both biological parents are known carriers of a pathogenic FA mutation or where one biological parent is FA-affected and the other biological parent is a known carrier of a pathogenic FA mutation, preimplantation genetic testing for FA is considered medically necessary.” Not Covered section edited for clarity. Medical Director review 1/2023.

Reviewed by Avalon 4th Quarter 2022 CAB. Related policies section removed, When Covered section edited to combine previous coverage criteria 1 and 2 and now reads “Reimbursement is allowed for individuals who have received genetic counseling, diagnostic genetic testing for FMR1 gene CGG repeats and methylation status for any of the following conditions:”. Not Covered section edited for clarity, Policy guidelines, and References updated. No change to policy statement. Medical Director review 1/2023.

Reviewed by Avalon Q4 2022 CAB. Updated description, policy guidelines and reference sections. Clarified when covered section. Added new Note 1. Removed M2109 Molecular Panel Testing of Cancers to Identify Targeted Therapy from related policies section. Medical Director review 1/2023.

Reviewed by Avalon 4th Quarter 2022 CAB. Description, Policy Guidelines, and References updated with minor revisions, Related Policies section removed. Coverage criteria edited for clarity, no change in policy statement. Medical Director review 1/2023.

Reviewed by Avalon 4th Quarter 2022 CAB. Description, Policy Guidelines, and References updated with minor revisions, Related Policies section removed. Not Covered section edited for clarity, no change to policy statement.  Medical Director review 1/2023.

Reviewed by Avalon 4th Quarter 2022 CAB. Description, Policy Guidelines and References sections updated, Related Policies removed. When Covered section edited for clarity, no change to policy statement. Medical Director review 1/2023.

Reviewed by Avalon 4th Quarter 2022 CAB. Description, Policy Guidelines and References sections updated. Related Policies section removed. When Covered section edited for clarity, no change to policy statement. Medical Director review 1/2023.

Reviewed by Avalon 4th Quarter 2022 CAB. Description, Policy Guidelines, Billing/Coding and References sections updated, removed Related Policies section. When Covered section edited for clarity, removed criteria "4. Genetic counseling for mitochondrial disorder genetic testing is considered medically necessary." Not Covered section also edited for clarity. Medical Director review 1/2023.

Reviewed by Avalon 4th Quarter 2022 CAB. Medical Director Review 12/2022. Description, Policy Guidelines, and References updates. No change to policy statement.

Reviewed by Avalon Q4 2022 CAB. Updated “when covered” section for clarity. Removed Note 2 and consolidated into coverage criteria. Table of solid tumors updated to match NCCN guidelines. Added College of American Pathologists table (CAP). Updated policy guidelines and references. Added PLA code 0334U to Billing/Coding section; removed PLA 0050U. Removed related policies section. Medical Director review 1/2023.

Reviewed by Avalon 4th Quarter 2022 CAB. Updated Description, Policy Guidelines, and References. Related policies section removed. The following bullets added When Covered section: “ • One biological parent is a known carrier of an early-onset, autosomal recessive disorder and the other biological parent is unavailable for testing” and “• One biological parent is a known carrier of an early-onset, autosomal recessive disorder and together, the biological parents have produced previous offspring affected with the disorder.” Added CPT code 81244 and removed CPT codes 89290 and 89291. Medical Director review 12/2022.

Policy titled changed to align with Avalon. Reviewed by Avalon 4th Quarter 2022 CAB.  Coding section updated – added 0341U. Description, Policy Guidelines, and References updated. Related policies section removed. Policy statement updated to reflect title change. Coverage criteria updated for clarity. Added the following statement to When Not Covered section: “Reimbursement for the diagnosis of fetal aneuploidy, the use of single cell genotyping in trophoblasts isolated from maternal serum (e.g., Luna Prenatal Test) is not allowed.” Medical Director review 12/2022.

Specialty Matched Consultant Advisory Panel review 8/19/2022. 

Specialty Matched Consultant Advisory Panel review 8/19/2022. 

Specialty Matched Consultant Advisory Panel review 8/19/2022. 

Reviewed by Avalon 4th Quarter 2022 CAB. Description, Policy Guidelines, and References updated with minor revisions, Related Policies section removed. Added code 0322U to the Billing/Coding section. Medical Director review 1/2023. When Covered section edited for clarity. Items 4 and 5 in Not Covered section removed and added as subcriteria to item 3. No change to policy statement. Medical Director review 1/2023.

Reviewed by Avalon 4th Quarter 2022 CAB. Description, Policy Guidelines, and References updated. Related policies section removed. Coverage criteria updated for clarity. Medical Director review 12/2022.

Policy re-titled, “Testosterone” for consistency with Avalon.  Reviewed by Avalon 4th Quarter 2022 CAB. Policy statement updated to reflect name change. Description, Policy Guidelines, and References updated. Coverage criteria, Note 1, and Note 2 updated for clarity. Added Note 3 and Note 4. Medical Director Review 12/2022.

Reviewed by Avalon 4th Quarter 2022 CAB Off-Cycle Review. Coding update only. Removed CPT codes 84437 and 84442 from Billing/Coding section.

Reference added.  Specialty Matched Consultant Advisory Panel review 8/19/2022. 

Reviewed by Avalon 4th Quarter 2022 CAB. Description, Policy Guidelines, and References updated. Related policies section removed. Added “Having undergone, or for those who have been scheduled for, bariatric procedures such as Roux-en-Y gastric bypass, sleeve gastrectomy, or biliopancreatic diversion with or without duodenal switch” to Note 1 and removed “Hypervitaminosis of Vitamin D” from Note 1. Medical Director review 12/2022.