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Commercial Medical Policy Update for May 15, 2024
| Medical Guidelines | Reason for Update |
|---|---|
| Allergen Testing AHS – G2031 (PDF) | Reviewed by Avalon 1st Quarter 2024 CAB. Description, Policy Guidelines, and References updated. Related Policies section added to Description section. Table of Terminology removed. When Covered section edited for clarity. Under the Not Covered section, previous criteria 2 and 3 combined into new criteria 2 that now reads: “Reimbursement is not allowed for basophil activation flow cytometry testing (BAT) and in-vitro testing of IgG, IgA, IgM, and/or IgD for individuals with signs or symptoms of allergies.” Medical Director review 4/2024. |
| Biomarker Testing for Autoimmune Rheumatic Disease AHS – G2022 (PDF) | Reviewed by Avalon 1st Quarter 2024 CAB. Related policies added to Description section. Added the following statement to When Covered section: Reimbursement for testing for rheumatoid factor (RF) and/or anti-cyclic citrullinated peptide (anti-CCP) antibodies is allowed for individuals with painful and swollen joints and a clinical suspicion of rheumatoid arthritis: a) Once per lifetime in individuals with stable symptoms. b) Repeat testing only if a significant change in symptoms occurs. Updated When Not Covered section for clarity. Policy Guidelines updated. Added CPT codes 86200, 86430, and 86431 to Billing/Coding section. Medical director review 4/2024. |
| Colorectal Cancer Screening AHS - B0001 (PDF) | Reviewed by Avalon Q1 2024 CAB. No changes to policy statement. |
| Diagnosis of Idiopathic Environmental Intolerance AHS – G2056 (PDF) | Reviewed by Avalon 1st Quarter 2024 CAB. Description, Policy Guidelines and References updated. Related Policies added to Description section. Table of Terminology removed. Code 84999 removed from Billing/Coding section. No change to policy statement. Medical Director review 4/2024. |
| Diagnosis of Vaginitis AHS – M2057 (PDF) | Reviewed by Avalon 1st Quarter 2024 CAB. Medical Director review 4/2024. Description, Policy Guidelines, and Reference sections updated. No change to policy statement. |
| Evaluation of Dry Eyes AHS - G2138 (PDF) | Reviewed by Avalon Q1 2024 CAB. Medical Director review 4/2024. Updated policy guidelines and references. No change to policy statement. |
| Fibromyalgia Testing AHS - M2177 (PDF) | Reviewed by Avalon 1st Quarter 2024 CAB. Description, Policy Guidelines, and References updated. Related Policies added to Description section. No change to policy statement. Medical Director review 4/2024. |
| Genetic Testing for Connective Tissue Disorders AHS – M2144 (PDF) | Reviewed by Avalon 1st Quarter 2024 CAB. Updated Description, Policy Guidelines and References. Related Policies added to Description section. Removed Table of Terminology. Minor edits to Notes under When Covered and When Not Covered sections, no change to policy statement. Medical Director review 4/2024. |
| Helicobacter Pylori Testing AHS – G2044 (PDF) | Reviewed by Avalon 1st Quarter 2024 CAB. Description, Policy Guidelines, and References updated. Table of Terminology removed. No change to policy statement. Medical Director review 4/2024. |
| Human Immunodeficiency Virus AHS – M2116 (PDF) | Reviewed by Avalon 1st Quarter 2024 CAB. Updates to Description, Policy Guidelines, and References sections. No change to policy intent. Added Related Policies. Removed Table of Terminology. Added “AHS” to Policy Title, now reads Human Immunodeficiency Virus AHS - M2116. Medical Director review 4/2024. |
| Intracellular Micronutrient Analysis AHS – G2099 (PDF) | Reviewed by Avalon 1st Quarter 2024 CAB. Description, Policy Guidelines and References updated. Related Policies section added to the Description section. Table of Terminology removed. No change to policy statement. Medical Director review 4/2024. |
| Liquid Biopsy AHS - G2054 (PDF) | Reviewed by Avalon Q1 2024 CAB. Medical Director review 4/2024. Added related policies section. Updated policy guidelines and references. Under Billing/Coding section: added CPT codes 0388U and 0395U. No change to policy intent. |
| Lyme Disease Testing AHS – G2143 (PDF) | Reviewed by Avalon 1st Quarter 2024 CAB. Updates to Description, Policy Guidelines, and References sections. No change to policy intent. Added Related Policies. Removed Table of Terminology. Medical Director review 4/2024. |
| Microsatellite Instability and Tumor Mutational Burden Testing AHS - M2178 (PDF) | Reviewed by Avalon Q1 2024 CAB--off cycle review. Medical Director review 4/2024. NCSCLC added to Table 2. No change to policy statement. |
| Molecular Diagnostics for Breast Cancer Prognosis AHS - M2020 (PDF) | Reviewed by Avalon Q1 2024 CAB. Medical Director review 4/2024. Added related policies section. “When covered” section edited for clarity and consistency, no change to intent and policy statement. Updated policy guidelines and references. |
| Molecular Markers in Fine Needle Aspirates of the Thyroid AHS - M2108 (PDF) | Reviewed by Avalon Q1 2024 CAB. Medical Director review 4/2024. Added related policies section. Updated policy guidelines and references. No change to policy statement. |
| Mutation Analysis in Myeloproliferative Neoplasms AHS - M2101 (PDF) | Reviewed by Avalon Q1 2024 CAB. Medical Director review 4/2024. Added related policies section. Under “when covered” section, added new coverage criteria #2 “To exclude a diagnosis of chronic myeloid leukemia (CML) for individuals with a suspected MPN, fluorescence in situ hybridization (FISH) or reverse transcriptase polymerase chain reaction (RT-PCR) testing on a peripheral blood sample to detect BCR: ABL1 transcripts is considered medically necessary.” Added additional genes to screen for in coverage criteria #3. Updated policy guidelines and references. Under Billing/Coding section, added CPT codes: 81206, 81207, 81208, 81273, 81275, 81276, 81311, 81347, 81351, 81352, 81353, 81357, 81403, 81405, 81432, 81442. Removed CPT code 81350. |
| Onychomycosis Testing AHS – M2172 (PDF) | Reviewed by Avalon for 1st Quarter 2024 CAB. Description, Policy Guidelines, and References updated. Related policies section added. When covered section updated to add “Reimbursement is allowed for nucleic acid amplification testing (NAAT) for individuals with onychomycosis and for whom anti-fungal therapy has failed to resolve infection.” Medical Director review 4/2024. |
| Parathyroid Hormone, Phosphorus, Calcium, and Magnesium Testing AHS – G2164 (PDF) | Reviewed by Avalon for 1st Quarter 2024 CAB. Description, Policy Guidelines, and Reference sections updated. Related policies added to Description section. No change to policy statement. Medical Director review 4/2024. |
| Pre-Implantation Genetic Testing AHS – M2039 (PDF) | Description, Policy Guidelines, and References updated. Related policies section added. When covered section edited for clarity to indicate that genetic counseling is required however medical necessity criteria is outside the scope of this policy. Updated Billing/Coding section to remove CPT codes 96040, S0265, 81251, 81255, 81257, 81260, 81290, 81326, 81330, 81331, 81332, 81413, 81414, 88245, 88248, 88249, 88261, 88262, 88263, 88264, 88271, 88272, 88273, 82274, 88275, 81161, 81200, 81201, 81202, 81203, 81205, 81209, 81220, 81221, 81240, 81242, 81243, 81244, 81250, 81252, 81253, 81288, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81301, 81303, 81304, 81310, 81321, 81322, 81323, 81324, 81325 and updated to add 81228, 81229, 81349, and 81479. Medical Director review 4/2024. |
| Prescription Medication and Illicit Drug Testing in the Outpatient Setting AHS – T2015 (PDF) | Reviewed by Avalon Q1 CAB 2024. Description, Policy Guidelines, and References updated. No changes to policy statement. Medical Director review 4/2024. |
| Prostate Specific Antigen (PSA) Testing AHS - G2008 (PDF) | Reviewed by Avalon Q1 2024 CAB. Medical Director review 4/2024. Added related policies section. Updated policy guidelines and references. Edit for clarity: removed reference to TRUS guided biopsy and digital rectal exam (DRE) from coverage criteria #5 in “when covered” section, as these are outside of Avalon’s scope. |
| Salivary Hormone Testing AHS – G2120 (PDF) | Reviewed by Avalon for 1st Quarter 2024 CAB. Updated Description, Policy Guidelines and References sections. Related Policies added to Description section. Coverage criteria updated for clarity. No change to policy statement. Medical Director review 4/2024. |
| Urinary Tumor Markers for Bladder Cancer AHS – G2125 (PDF) | Reviewed by Avalon 1st Quarter 2024 CAB. Updated the background, guidelines and recommendations. Updated table of terminology and references. Medical Director review. No changes in coverage criteria. Added CPT code 0420U to the billing section. |
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