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Medical Policy Update for December 13, 2022
| Medical Guidelines | Reason for Update |
|---|---|
| Βeta-Hemolytic Streptococcus Testing AHS – G2159 (PDF) | Reviewed by Avalon 3rd Quarter 2022 CAB. Description section updated. Table of Terminology added. Code 83789 removed from Billing/Coding section. Policy Guidelines updated. References updated. |
| Biochemical Markers of Alzheimer Disease and Dementia AHS – G2048 (PDF) | Reviewed by Avalon 3rd Quarter 2022 CAB. Description section updated. Table of Terminology added. Policy Guidelines updated. Deleted codes 81099 and 86849 from Billing/Coding section. Added codes 0289U and 0346U to Billing/Coding section. References updated. |
| Biomarker Testing for Multiple Sclerosis and Related Neurologic Diseases AHS – G2123 (PDF) | Reviewed by Avalon 3rd Quarter 2022 CAB. Description section updated. Regulatory section updated. Table of Terminology added. Policy Guidelines updated. Codes 86255 and 86256 removed from Billing/Coding section. References updated. |
| Bone Turnover Markers Testing AHS – G2051 (PDF) | Reviewed by Avalon 3rd quarter CAB. Background, policy guidelines, and references updated. Coverage criteria updated for clarity. Medical Director review 10/2022. |
| BRCA AHS - M2003 (PDF) | Reviewed by Avalon 3rd Quarter 2022 CAB. Medical Director review 11/2022. Updated description and policy guidelines sections for clarity and consistency with NCCN. Updated related policies section and references. Deleted previous *Note 4: Testing of Ashkenazi Jewish individuals without a known familial mutation should be initially limited to the three known founder mutations (185delAG and 518insC in BRCA1; 617delT in BRCA2) if the patient being tested has no personal or family history of BRCA-related cancers. (This would allow for members with cancer and strong family history to start with comprehensive testing over founder mutations). No changes to policy statement. |
| Breast Surgeries (PDF) | Removed 19304 from Billing/Coding section. |
| Celiac Disease Testing AHS - G2043 (PDF) | Reviewed by Avalon 3rd Quarter 2022 CAB. Background, Policy Guidelines, Billing/Coding and References sections updated. Minor edits made to When Covered section for clarity, no change to policy statement. Medical Director review 11/2022. |
| Cervical Cancer Screening AHS – G2002 (PDF) | Reviewed by Avalon Q3 CAB. Background, policies, and references updated. Coverage criteria updated for clarity. No change to policy intent. Medical director review 10/2022. |
| Coronavirus Testing in the Outpatient Setting AHS – G2174 (PDF) | Policy title updated to include “AHS-G2174” to align with Avalon. |
| Diagnostic Testing of Influenza AHS – G2119 (PDF) | Reviewed by Avalon 3rd Quarter 2022 CAB. Description section updated. Related policy added. Table of Terminology added. Policy Guidelines updated. References updated. |
| Diagnostic Testing of Sexually Transmitted Infections AHS – G2157 (PDF) | Reviewed by Avalon 3rd Quarter 2022 CAB. All information related to Trichomonas vaginalis removed as this is now addressed in policy Diagnosis of Vaginitis including Multi-target PCR Testing AHS – M2057. Description section updated. Related Policies updated. When Covered section updated. When Not Covered section updated. Billing/Coding section updated with deletion of the following codes: 87660, 87661, 87794, and 86808. Policy Guidelines updated. References updated. |
| Epithelial Cell Cytology in Breast Cancer Risk Assessment AHS - G2059 (PDF) | Reviewed by Avalon 3rd Quarter 2022 CAB. References updated. Medical Director review 11/2022. No change to policy statement. |
| Fecal Analysis in the Diagnosis of Intestinal Dysbiosis and Fecal Microbiota Transplant Testing AHS – G2060 (PDF) | Reviewed by Avalon 3rd Quarter 2022 CAB. Updated Description, Policy Guidelines, Billing/Coding and Reference sections. Minor edits made to When Covered section for clarity, no change to policy statement. Added Table of Terminology. Medical Director review 11/2022. |
| Fecal Calprotectin Testing in Adults AHS – G2061 (PDF) | Reviewed by Avalon 3rd Quarter 2022 CAB. Updated Description, Related Policies, Policy Guidelines and Reference sections. Minor edits made to When Covered section for clarity, no change to policy statement. Added Table of Terminology. Medical Director review 11/2022. |
| General Inflammation Testing AHS – G2155 (PDF) | Reviewed by Avalon 3rd Quarter 2022 CAB. Off-cycle review. Updated Policy Guidelines and References. Updated Table 1- “Irritable Bowel Disorders” changed to “Irritable Bowel Syndrome” and the frequency for IBS changed from “NS” to “During initial assessment to exclude other diagnoses”. Medical Director review 10/2022. |
| Genetic Testing and Genetic Expression Profiling in Patients with Cutaneous Melanoma AHS-M2029 (PDF) | Reviewed by Avalon Q3 2022 CAB. Medical Director review 11/2022. Updated the following sections: description, policy guidelines, guidelines/recommendations, and references. When covered section updated for clarity. No change to policy statement. |
| Genetic Testing and Genetic Expression Profiling in Patients with Uveal Melanoma AHS - M2071 (PDF) | Reviewed by Avalon 3rd Quarter 2022 CAB. Medical Director review 11/2022. Edited “when covered” section for clarity. No change to policy statement. Updated policy guidelines and references. Deleted AHS-M2109 from related policies section. |
| Genetic Testing for Connective Tissue Disorders AHS – M2144 (PDF) | Off-cycle review by Avalon 3rd Quarter 2022 CAB. Policy Guidelines and References updated. When Covered section edited for clarity and consistency. Added coverage criteria 2c “For individuals suspected of having Marfan Syndrome who have tested negative for FBN1”, removed coverage criteria 4 related to multi-gene testing outside of vEDS. Medical Director review 11/2022. |
| Genetic Testing for Inherited Cardiomyopathies and Channelopathies AHS – M2025 (PDF) | Off-cycle review by Avalon 3rd Quarter 2022 CAB. Related Policies, Policy Guidelines and References updated. When Covered and When Not Covered sections edited for clarity and consistency, no change to policy statement. Coverage criteria 16 removed due to redundancy with coverage criteria 14. These coverage criteria previously read: "14. Genetic testing for predisposition to hypertrophic cardiomyopathy (HCM) is considered medically necessary for patients who meet the diagnostic criteria for HCM in order to facilitate cascade screening of first-degree relatives. 16. Genetic testing for predisposition to hypertrophic cardiomyopathy (HCM) is considered medically necessary for individuals who meet the diagnostic criteria for HCM to assist treatment decisions or to facilitate cascade screening of their first-degree relatives." Coverage criteria 14 now reads "For patients who meet the diagnostic criteria for hypertrophic cardiomyopathy (HCM), genetic testing for predisposition to HCM is considered medically necessary." Added new Note 1 to define closer relatives: Note 1: Close blood relatives include 1st-degree relatives (e.g., parents, siblings, and children), 2nd-degree relatives (e.g., grandparents, aunts, uncles, nieces, nephews, grandchildren, and half-siblings), and 3rd-degree relatives (great-grandparents, great-aunts, great-uncles, great-grandchildren, and first cousins)." Medical Director review 11/2022. |
| Genetic Testing for Mental Health Disorders AHS – M2084 (PDF) | Policy title updated to include “AHS-M2084” to align with Avalon. |
| Genetic Testing for Neurodegenerative Disorders AHS – M2167 (PDF) | Reviewed by Avalon 3rd Quarter 2022 CAB. When Covered section updated. Table of Terminology added. Codes 81177, 81186, 96040, 0231U, 0233U, 0236U, and S0265 added to Billing/Coding section. Policy Guidelines updated. References updated. |
| Identification of Microorganisms using Nucleic Acid Probes AHS – M2097 (PDF) | Off-cycle review by Avalon 3rd Quarter 2022 CAB. Policy Guidelines and References updated. Table 1 in When Covered section updated to include Orthopoxvirus and code 87593 added to Amplified Probe column. Coverage criteria 2 edited to remove specific list of organisms, as it was not all inclusive. Now reads “2. Reimbursement is allowed for PCR testing for any other microorganism without a specific CPT code.” When Not Covered section edited for clarity. Code 87593 added to Billing/Coding section. Medical Director review 11/2022. |
| Immune Cell Function Assay for Organ Transplant Rejection AHS-G2098 (PDF) | Reviewed by Avalon 3rd Quarter 2022 CAB. References updated. No change to policy statement. Medical Director review 11/2022. |
| Immunopharmacologic Monitoring of Therapeutic Serum Antibodies AHS - G2105 (PDF) | Reviewed by Avalon 3rd Quarter 2022 CAB. Description, policy guidelines, and references updated. When Not Covered # 2 updated as follows, “Reimbursement is not allowed for drug and/or antibody concentration testing for anti-TNF therapies in individuals without inflammatory bowel disease (including spondyloarthritis, rheumatoid arthritis, psoriatic arthritis, and psoriasis).” Medical Director review 10/2022. |
| In Vitro Chemoresistance and Chemosensitivity Assays AHS- G2100 (PDF) | Reviewed by Avalon Q3 2022 CAB. Added CPT codes 0249U, 0285U, 0324U, 0325U; deleted CPT 0564T in Billing/Coding section. References updated. Medical Director review 11/2022. No change to policy statement. |
| Laboratory Testing for the Diagnosis of Inflammatory Bowel Disease AHS–G2121 (PDF) | Reviewed by Avalon 3rd Quarter 2022 CAB. Minor revision to Related Policies section. Description, Policy Guidelines, Billing/Coding and References sections updated. When Not Covered section edited for clarity, no change to policy statement. Medical Director review 11/2022. |
| Lynch Syndrome AHS-M2004 (PDF) | Reviewed by Avalon 3rd Quarter 2022 CAB. Medical Director review 11/2022. Expanded related policies section. Updated policy guidelines and references. Deleted CPT codes 88341, 88342, 88344, 81288, 81292-81296 in Billing/Coding section. No change to policy statement. |
| Measurement of Thromboxane Metabolites for ASA Resistance AHS – G2107 (PDF) | Reviewed by Avalon 3rd Quarter 2022 CAB. Policy Guidelines, Coding/Billing and References sections updated. Medical Director review 10/2022. |
| Metabolite Markers of Thiopurines AHS – G2115 (PDF) | Reviewed by Avalon 3rd Quarter 2022 CAB. Description, Policy Guidelines and References updated. Item #1 under When Covered section divided into sub-criteria for clarity of coverage, item #3 edited for clarity. Removed statement “Reimbursement is not allowed for phenotypic analysis for the enzyme NUDT15 in all other situations” from When Not Covered section as there is no phenotypic test for NUDT15. No change to policy statement. Medical Director review 10/2022. |
| Minimal Residual Disease (MRD) AHS-M2175 (PDF) | Reviewed by Avalon 3rd Quarter 2022 CAB. Medical Director review 11/2022. Updated policy guidelines and references. Edited and reorganized “When Covered” section for clarity. No change to policy statement. Added CPT codes 0306U, 0307U to Billing/Coding section. |
| Molecular Analysis for Gliomas AHS - M2139 (PDF) | Reviewed by Avalon 3rd Quarter 2022 CAB. Medical Director review 11/2022. Updated policy guidelines and references. Deleted related policy section and AHS-M2109. “When Covered” section edited for clarity. No change to policy statement. |
| Molecular Testing for Pulmonary Disease AHS - M2160 (PDF) | Reviewed by Avalon 3rd Quarter CAB. Policy title changed to Molecular Testing for Pulmonary Disease. Description, Related Policies, and Policy Guidelines updated. When Covered section updated to reflect the following changes: “For individuals who have been adequately counseled on the interpretation of positive and negative results, risk assessment of a pulmonary nodule using Nodify XL2 proteomic analysis is considered medically necessary when all of the following criteria are met: The pulmonary nodule size is 8-30 mm; The patient is 40 years of age or older; The pre-test risk of cancer is less than 50% based on the Solitary Pulmonary Nodule Malignancy Risk Score (Mayo Clinic Model). When Not Covered updated as follows: “The use of molecular testing for pulmonary disease is considered not medically necessary for all other indications.” Billing/Coding section updated to add 0080U and 0360U. Medical Director review 10/2022. |
| Prostate Biopsies AHS – G2007 (PDF) | Reviewed by Avalon 3rd Quarter CAB. Related Policies updated. Table of Terminology added. “Reimbursement is allowed for followup biopsy (excluding prostate saturation biopsy) when the clinical suspicion of prostate cancer remains in an individual for whom an initial biopsy was negative for prostate cancer” added to When Covered section. Policy Guidelines updated. References updated. |
| Proteogenomic Testing of Individuals with Cancer AHS-M2168 (PDF) | Reviewed by Avalon 3rd Quarter 2022 CAB. Medical Director review 11/2022. Deleted related policy AHS-M2109. Updated policy guidelines and references. Removed Caris MI Cancer seek from “When Not Covered” section as this test is used for TMB/MSI detection and is addressed under AHS-M2178. No changes to policy statement. Added CPT codes: 0298U, 0299U, 0300U to Billing/Coding section. |
| Serum Testing for Hepatic Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease AHS – G2110 (PDF) | Reviewed by Avalon 3rd Quarter 2022 CAB. Description, Background, Policy Guidelines, and References updated. No change to policy statement. Medical Director review 10/2022. |
| Thyroid Disease Testing AHS – G2045 (PDF) | Reviewed by Avalon 3rd Quarter 2022 CAB Off-Cycle Review. Medical Director review 10/2022. Description, Policy Guidelines, Related Policies. and References updated. When covered section updated to reflect 1.D.ii “Have experienced two or more pregnancy losses.”; 1.J “For individuals diagnosed with primary mitochondrial disease, annual screening of TSH and fT”; 1.L “For pediatric individuals with a clinical finding of failure-to-thrive.” Remaining coverage criteria updated for clarity. |
| Transplant Rejection Testing AHS – M2091 (PDF) | Reviewed by Avalon 3rd Quarter 2022 CAB. Description, Policy Guidelines and References sections updated. When Covered and When Not Covered sections edited for clarity, no change to policy statement. Codes 0887U and 0088U removed from Billing/Coding section. Medical Director review 11/2022. |
| Use of Common Genetic Variants to Predict Risk of Non-Familial Breast Cancer AHS-M2126 (PDF) | Reviewed by Avalon 3rd Quarter 2022 CAB. Medical Director review 11/2022. Updated policy guidelines and references. Deleted CPT codes 81307, 81308 from Billing/Coding section. No change to policy statement. |
| Vitamin B12 and Methylmalonic Acid Testing AHS – G2014 (PDF) | Reviewed by Avalon 3rd Quarter 2022 CAB. Off-cycle review. Medical Director review 10/2022. Description, Policy Guidelines, and References updated. Related policies added. Updated When Covered Section #3.A.4 as follows, “Having undergone, or for those who have been scheduled for, bariatric procedures such as Roux-en-Y gastric bypass, sleeve gastrectomy, or biliopancreatic diversion/duodenal switch.” Remaining coverage criteria updated for clarity. |
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