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Medical Policy Update for May 30, 2023
| Medical Guidelines | Reason for Update |
|---|---|
| Specialty Matched Consultant Advisory Panel review 2/15/2023. | |
Beta Amyloid Imaging With Positron Emission Tomography for Alzheimer’s Disease (PDF) | Regulatory status, policy guidelines, and references updated. Specialty Matched Consultant Advisory Panel review 5/2023. Medical Director review 5/2023. No change to policy statement. |
| When Covered, Not Covered and Policy Guidelines sections edited for clarity. References updated. No change to policy statement. Specialty Matched Consultant Advisory Panel 5/2023. Medical Director review 5/2023. | |
Chemoembolization of the Hepatic Artery, Transcatheter Approach (PDF) | Description updated. References added. Moved the following statement from policy guidelines to coverage criteria for clarity: “When using transcatheter arterial chemoembolization of the liver as a bridge to transplantation to prevent further tumor growth, the candidate should have the following characteristics: a single tumor less than 5 cm or no more than 3 tumors each less than 3 cm in size, absence of extrahepatic disease or vascular invasion, and Child-Pugh class A or B.” Specialty Matched Consultant Advisory Panel review 5/2023. Medical Director review 5/2023. |
Diagnostic Testing of Sexually Transmitted Infections AHS – G2157 (PDF) | Avalon off cycle policy review. Related Policies removed. Coverage for T. vaginalis outside of vaginitis restored to Policy. Added coverage criteria for screening for syphilis, chlamydia, and gonorrhea for sexually active individuals less than 18 years of age. Note 1 added. Codes 87660, 87661, and 87808 added to Billing/Coding section. Medical Director review. |
| References updated. Specialty Matched Consultant Advisory Panel 5/2023. Medical Director review 5/2023. | |
| When Covered section edited for clarity, no change to policy statement. References updated. Specialty Matched Consultant Advisory Panel 5/2023. Medical Director review 5/2023. | |
| Description, Policy Guidelines and References sections updated. When Covered section edited for clarity, no change to policy statement. Specialty Matched Consultant Advisory Panel 5/2023. Medical Director review 5/2023. | |
| Focal Treatments for Prostate Cancer (PDF) | Policy review. Reference added. Specialty Matched Consultant Advisory Panel review 11/16/2022. |
| Description and References sections updated. Specialty Matched Consultant Advisory Panel 5/2023. Medical Director review 5/2023. | |
HIV Genotyping and Phenotyping AHS – M2093 | Reviewed by Avalon 1st Quarter 2023 CAB. Policies titled Plasma HIV-1 and HIV-2 RNA Quantification for HIV Infection" and “HIV Genotyping and Phenotyping” combined to form new policy titled “Human Immunodeficiency Virus”. Policy archived. |
| Reviewed by Avalon 1st Quarter 2023 CAB. Policies titled Plasma HIV-1 and HIV-2 RNA Quantification for HIV Infection" and “HIV Genotyping and Phenotyping” combined to form new policy titled “Human Immunodeficiency Virus”. Scientific Background updated. Table of Terminology updated. Policy Guidelines updated. References updated and added. Codes 86689, 86701, 86702, 86703, 87389, 87390, 87391, 87534, 87535, 87537, 87538, 87806, 87900, 0219U, G0432, G0433, G0435, G0475, and S3645 added to Billing/Coding section. Medical Director review 4/2023 | |
| Lumbar Spine Fusion Surgery | References added. Specialty Matched Consultant Advisory Panel review 5/17/2023. |
| Reviewed by Avalon 1st Quarter 2023 CAB. Deleted Related Policies section. Description, Policy Guidelines, and References updated. Table of Terminology added. Policy title changed from Lyme Disease to Lyme Disease Testing. Medical Director review 4/2023. | |
| References added. Specialty Matched Consultant Advisory Panel review 5/2023. Medical Director Review 5/2023. No change to policy statement. | |
| References added. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 5/2023. Medical Director review 5/2023. No change to policy statement. | |
| References added. Policy Guidelines and description updated. Specialty Matched Consultant Advisory Panel review 5/2023. Medical Director review 5/2023. No change to policy statement. | |
| Pancreas Transplant (PDF) | Description section and References updated. Minor edits to When Covered section, no change to policy statement. Specialty Matched Consultant Advisory Panel 5/2023. Medical Director review 5/2023. |
Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence (PDF) | Policy review. Specialty Matched Consultant Advisory Panel review 11/16/2022. |
Peroral Endoscopic Myotomy for Treatment of Esophageal Achalasia (PDF) | Not Covered section updated to include statement: “Gastric peroral endoscopic myotomy (G-POEM) is considered investigational for all indications.” Description, Policy, Policy Guidelines and References sections updated. Specialty Matched Consultant Advisory Panel 5/2023. Medical Director review 5/2023 |
Plasma HIV-1 and HIV-2 RNA Quantification for HIV Infection AHS – M2116 | Reviewed by Avalon 1st Quarter 2023 CAB. Policies titled Plasma HIV-1 and HIV-2 RNA Quantification for HIV Infection" and “HIV Genotyping and Phenotyping” combined to form new policy titled “Human Immunodeficiency Virus”. Policy archived. |
| References added. Specialty Matched Consultant Advisory Panel review 5/2023. Medical Director review 5/2023. No change in policy statement. | |
| Policy review. Policy Guidelines updated. References updated. Specialty Matched Consultant Advisory Panel review 11/16/2022. | |
Sacral Nerve Neuromodulation/Stimulation for Pelvic Floor Dysfunction (PDF) | Policy review. Specialty Matched Consultant Advisory Panel review 11/16/2022. Regulatory Status updated with addition of new approvals. |
Screening for Vertebral Fracture with Dual X-ray Absorptiometry (DXA) (PDF) | Description and regulatory status updated. References added. Specialty Matched Consultant Advisory Panel review 5/2023. Medical Director review 5/2023. No change to policy statement. |
Small Bowel, Small Bowel with Liver, or Multivisceral Transplant (PDF) | Minor edits made to When Covered, Not Covered and Policy Guidelines sections. Billing/Coding and References sections updated. No change to policy statement. Specialty Matched Consultant Advisory Panel 5/2023. Medical Director review 5/2023. |
| References added. Specialty Matched Consultant Advisory Panel review 5/2023. Medical Director review 2023. No change to policy statement. |
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