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Medical Policy Update for October 24, 2023
| Medical Guidelines | Reason for Update |
|---|---|
| Biomarkers for Myocardial Infarction and Chronic Heart Failure AHS – G2150 (PDF) | Reviewed by Avalon 2nd Quarter 2023 CAB. Title changed to Biomarkers for Myocardial Infarction and Chronic Heart Failure. Updated Description, Policy Guidelines and References. Policy expanded to include information for the ST2 analysis/assay moved (previously in G2130). When Covered section edited to include repeat troponin testing (moved from previous Note 1), now reads: “For individuals presenting with signs and symptoms of acute coronary syndrome (see Note 1), reimbursement is allowed for quantitative measurement of cardiac troponin (troponin T or I) for the diagnosis of myocardial infarction (MI) (when tested at an outpatient facility capable of performing an adequate clinical MI evaluation) up to four times within the first 72 hours following initial presentation.” Not Covered section edited to include new criteria 3 “For all situations, reimbursement is not allowed for qualitative measurement of cardiac troponin (troponin T or I).” and new criteria 5 “For all situations in the outpatient setting, reimbursement is not allowed for analysis of ST2 and/or its isoforms (e.g., Presage ST2).” CPT code 83006 added to Billing/Coding section. Medical Director review 7/2023. Notification given 8/15/23 for effective date 10/24/2023. |
| Chromosomal Microarray AHS – M2033 (PDF) | Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Reimbursement to Medical Necessity. |
| General Genetic Testing, Germline Disorders AHS – M2145 (PDF) | Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Reimbursement to Medical Necessity. Table of Terminology removed. |
| General Genetic Testing, Somatic Disorders AHS-M2146 (PDF) | Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Reimbursement to Medical Necessity. Table of Terminology removed. |
| General Inflammation Testing AHS – G2155 (PDF) | Reviewed by Avalon 2nd Quarter 2023 CAB. Updated Description, Policy Guidelines, Related Policies, and Reference sections. Updated when covered section for clarity. Added the following statement to when not covered section: “Reimbursement is not allowed for measurement of ESR for individuals without a diagnosed inflammatory condition.” Medical Director review 7/2023. Notification given 8/15/2023 for effective date 10/24/2023. |
| Genetic Testing for Fanconi Anemia AHS – M2077 (PDF) | Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Reimbursement to Medical Necessity. |
| Genetic Testing for FMR1 Mutations AHS – M2028 (PDF) | Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Reimbursement to Medical Necessity. |
| Genetic Testing for Hereditary Hearing Loss AHS – G2148 (PDF) | Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Reimbursement to Medical Necessity. |
| Genetic Testing for Li_Fraumeni Syndrome AHS – M2081 (PDF) | Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Reimbursement to Medical Necessity. |
| Genetic Testing for Neurodegenerative Disorders AHS – M2167 (PDF) | Wording in Policy Statement, When Covered, and/or Not Covered section(s) changed from Reimbursement to Medical Necessity. |
| Preimplantation Genetic Testing AHS – M2039 (PDF) | Wording in Policy Statement, When Covered, and/or Not Covered section(s) changed from Reimbursement to Medical Necessity. |
| Prenatal Screening (Nongenetic) AHS – G2035 (PDF) | Reviewed by Avalon 1st quarter 2023 CAB. Description, Policy Guidelines, and Reference section updated. Updated when covered section for clarity. Add the following to when not covered: “Reimbursement is not allowed for human chorionic gonadotropin (hCG) hormone testing for individuals with a normal pregnancy without complications.” Added 84702, 84703, 84704, and 0167U to Billing/Coding section. Medical Director Review 4/2023. Notification given 8/15/2023 for effective date 10/24/2023. |
| ST2 Assay for Chronic Heart Failure AHS – G2130 | Policy archived with 2023 Avalon Q2 CAB. See policy Biomarkers for Myocardial Infarction and Chronic Heart Failure AHS-G2150. |
| Testing for Vector-Borne Infections AHS – G2158 (PDF) | Reviewed by Avalon 2nd Quarter 2023 CAB. Policy retitled to Testing for Vector-Borne Infections. Information and coverage for Zika virus testing moved into policy. Description, Policy Guidelines, and References updated. Added the following to the When Covered section: 1) For the detection of dengue virus (DENV), reimbursement is allowed for the use of NAAT, IgM antibody capture ELISA (MAC-ELISA), or NS1 ELISA, as well as a confirmatory plaque reduction neutralization test for DENV in the following individuals: For individuals suspected of having DENV (see Note 4), or For non-pregnant individuals who are symptomatic for Zika virus infection (see Note 5). 2) For the detection of Zika virus, reimbursement is allowed for the use of NAAT in the following individuals: Up to 12 weeks after the onset of symptom for symptomatic (see Note 5) pregnant individuals who have either recently traveled to areas with a risk of Zika (see Note 12) or who have had sex with someone who either lives in or has recently traveled to areas with a risk of Zika (see Note 12), or For infants born from individuals who, during pregnancy, tested positive for Zika virus, or For infants born with signs and symptoms of congenital Zika syndrome (see Note 13) and who have a birthing parent who, during pregnancy, traveled to an area with a risk of Zika (see Note 12). 3) For pregnant individuals who have a fetus with prenatal ultrasound findings consistent with congenital Zika virus infection (see Note 13), reimbursement is allowed for Zika virus NAAT (maternal serum and maternal urine) and Zika virus IgM testing (maternal serum), as well as a confirmatory plaque reduction neutralization test for Zika. Added the following to the When Not Covered section: 1) For non-pregnant individuals symptomatic for Zika virus infection (see Note 5), reimbursement is not allowed for the use of NAAT and/or IgM testing for Zika detection. 2)For asymptomatic individuals, reimbursement is not allowed for testing for babesiosis, chikungunya virus, CTF, DENV, ehrlichiosis and/or anaplasmosis, malaria, rickettsial disease, TBRF, WNV, YFV, or Zika virus during a general exam without abnormal findings. Alphabetized When Covered and When Not Covered sections in addition to Notes according to infection name. Added CPT codes: 85060, 87254, and 87798 to Billing/Coding section. Notification given 8/15/2023 for effective date 10/24/2023. |
| ZIKA Virus Risk Assessment AHS – G2133 | Policy archived with Avalon 2nd Quarter 2023 CAB. Coverage criteria moved to retitled policy, Testing for Vector-Borne Infections AHS-G2158. |
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