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Medical Policy Update for December 30, 2022
Medical Guidelines | Reason for Update |
|---|---|
Ambulatory Event Monitors (PDF) | Updated Billing/Coding section to delete 0497T and 0498T effective 1/1/2023. |
| Artificial Intervertebral Disc (PDF) | Policy update. Specialty Matched Consultant Advisory Panel review 10/19/2022. Added code 22860 to Billing/Coding section. Deleted code 0163T from Billing/Coding section. |
| Bariatric Surgery (PDF) | Medical Director review. Replaced code 43659 with code 43645 in paragraph describing OAGB. Deleted “The unlisted stomach code, CPT 43659, is most appropriate for the OAGB at this time” from the same paragraph. Deleted “There is no specific code describing the Mini-Gastric Bypass or OAGB (one anastomosis gastric bypass) procedures. Providers should bill the most appropriate unlisted code (i.e., CPT code 43659)” from the Billing/Coding section. Under Malabsorptive Procedures #2, replaced code 43999 with code 43659. Deleted codes 0312T, 0313T, 0314T, 0315T, 0316T, 0317T from Billing/Coding section. Added codes 43290, 43291 to Billing/Coding section. |
| Biochemical Markers of Alzheimer Disease and Dementia AHS – G2048 (PDF) | Added code 0358U to Billing/Coding section. |
| Bone Mineral Density Studies (PDF) | Added the following statements to When Not Covered section: “Bone mineral density measurement using Biomechanical Computed Tomography Analysis (BCT) is considered investigational.” and “Screening for osteoporosis using OsteoApp.ai is considered investigational.” Updated Billing/Coding section to add 0743T, 0749T, 0750T, effective 1/1/2023. Medical Director review 11/2022. |
| Bronchial Thermoplasty (PDF) | Added 0781T, 0782T to Billing/Coding section, effective 1/1/2023. |
| Continuous Monitoring of Glucose in the Interstitial Fluid (PDF) | Added the following statement to When Not Covered section, “The use of d-Nav technology for automated, intermittent glucose monitoring and insulin titration is considered investigational.” Updated Billing/Coding section to add 0740T, 0741T, A4239, and E2103, effective 1/1/2023; removed G0308 and G0309. Medical Director review 11/2022. |
| Cranial Electrotherapy Stimulation (CES) and Auricular Electrostimulation (PDF) | Added code 0783T to Billing/Coding section. |
| Electromagnetic Navigation Bronchoscopy (PDF) | Updated Billing/Coding section to add C7509, C7510, and C7511, effective 1/1/2023. |
| Epidural Steroid Injections for Back Pain (PDF) | Added the following statement to When Not Covered section, “The use of CompuFlo® for epidural spinal needle placement is considered investigational.” Updated Billing/Coding section to add 0777T, effective 1/1/2023. Medical Director review 11/2022 |
| Gene Expression Profiling and Protein Biomarkers for Prostate Cancer AHS - M2166 (PDF) | Added PLA code 0359U to Billing/Coding section for effective date 1/1/2023. |
| General Genetic Testing, Germline Disorders AHS – M2145 (PDF) | Updated Billing/Coding section to add 81441 effective 1/2023. |
| Genetic Cancer Susceptibility Panels Using Next Generation Sequencing AHS-M2066 (PDF) | Added CPT codes 81449, 81451, 81456 to Billing/Coding section for effective date 1/1/2023. |
| Genetic Testing for Familial Hypercholesterolemia AHS – M2137 (PDF) | Reviewed by Avalon 3rd Quarter 2022 CAB. Background, Policy Guidelines, and References updated. Related policies section revised. When Covered section, criteria 2 stating “Genetic testing of children of individuals with FH to determine future risk of disease is considered medically necessary when a known pathogenic mutation is present in a parent” removed and replaced with “Genetic testing for a known familial mutation associated with FH is considered medically necessary in asymptomatic close relatives (i.e., first-, second-, or third-degree relative) of an affected individual”. CPT code 81403 removed and 81479 added to the Billing/Coding section. Medical Director review 10/2022. |
| Implantable Bone Conduction Hearing Aids (PDF) | Added codes 69728, 69729, 69730 to Billing/Coding section. |
| Implantable Cardioverter Defibrillator (PDF) | Updated Billing/Coding section to add C7537, C7538, C7539, C7540 effective 1/1/2023. Removed duplicate code 33240. |
| Laboratory Procedures Medical Policy AHS - R2162 (PDF) | Updated Billing/Coding section to add 0355U, 0357U, 0361U effective 1/1/2023. |
| Liquid Biopsy AHS-G2054 (PDF) | Added PLA code 0356U to Billing/Coding section for effective date 1/1/2023. |
| Nerve Fiber Density Testing AHS – M2112 (PDF) | Reviewed by Avalon 3rd Quarter 2022 CAB. Policy Guidelines updated. Table of Terminology added. References updated. |
| Observation Room Services (PDF) | Removed the following codes from Billing/Coding section: 99217, 99218, 99219, 99220, 99224, 99225, 99226, effective 1/1/2023. |
| Pharmacogenetics Testing AHS – M2021 (PDF) | Updated Billing/Coding section to add 81418 effective 1/2023. |
| Private Duty Nursing Services (PDF) | Description updated. When Private Duty Nursing services are covered updated to reflect: “The services are ordered by a licensed physician (MD, doctor of medicine; or DO, doctor of osteopathic medicine) as part of a treatment plan for a covered medical condition, and The attending physician must approve a written treatment plan with short and long term goals specified, and The services provided are reasonable and necessary for care of a patient’s illness or injury or particular medical needs, and are within the accepted standards of nursing practice, and Provide care needed by the member when their condition stabilize and The services are performed by a licensed nurse (i.e., Registered Nurse, RN; or Licensed Practical Nurse, LPN), and The services provided are within the scope of practice of a licensed nurse (RN or LPN), and The services require the professional proficiency and skills of a licensed nurse (RN or LPN), and The services are provided in the patient’s private residence, and The patient’s condition is such that a licensed professional is required to reinforce/educate and teach the caregiver the technical as well as basic care needs of the member. The length and duration of skilled nursing services in the home is considered intermittent and temporary in nature and not intended to be provided on a permanent ongoing basis. The member’s condition requires frequent nursing assessments and changes in the plan of care with MD collaboration. The member and caregivers must accept and be engaged in the Blue Cross Blue Shield of North Carolina Case Management process.” When Private Duty Nursing Services are not covered updated to reflect: “When the conditions above are not met, the nurse providing care must not be the patient’s spouse, natural or adoptive child, parent, or sibling, grandparent or grandchild. This also includes any person with an equivalent step or in-law relationship to the patient. PDN is not considered medically necessary if a caregiver is unavailable to assume the care needs of the member. PDN is not covered if the patient is in an acute inpatient hospital, inpatient rehabilitation hospital, skilled nursing facility, intermediate care facility or a resident of a licensed residential care facility. PDN is not covered for the convenience of the member/caregiver or to allow respite/sleep for caregivers or patient’s family. PDN is not covered to allow the patient’s family or caregiver to work or go to school. The time the nurse spends traveling to and from a patient’s home is included in the cost for providing the service. It is not covered separately. Maintenance care or custodial care is not considered PDN. (See Policy Guidelines below.) PDN in the home is not covered when provided at the same time as other home healthcare nursing services. Policy Guidelines and Medical Definitions updated for clarity. Specialty Matched Consultant Advisory Panel review 2/2022. Medical Director review 5/2022. Notification given on 7/1/22 for effective date 1/1/2023. |
| Proteogenomic Testing of Individuals with Cancer AHS-M2168 (PDF) | Added PLA code 0362U to Billing/Coding section for effective date 1/1/2023. |
| Retinal Prosthesis (PDF) | Deleted CPT codes C1841, C1842 from Billing/Coding section effective 1/1/2023. |
| Sacroiliac Joint Fusion/Stabilization (PDF) | Added code 0775T to Billing/Coding section. |
| Skin and Soft Tissue Substitutes (PDF) | Billing/Coding section updated to add Q4236, Q4262, Q4263, Q4264; and remove C1849, effective 1/1/2023. |
| TENS (Transcutaneous Electrical Nerve Stimulator) (PDF) | Added the following statement to When Not Covered section, “Chronic pain management with the use of Axon Therapy is considered investigational.” Updated Billing/Coding section to add 0766T, 0767T, 0768T, 0769T, effective 1/1/2023. Medical Director review 11/2022. |
| Testing for 5-Fluorouracil Use in Cancer Patients AHS-M2067 (PDF) | Reviewed by Avalon 3rd Quarter 2022 CAB. Medical Director review 11/2022. Added medically necessary coverage criteria to “When Covered” section. Policy statement updated with coverage criteria. Updated policy guidelines and references. |
| Testing for Diagnosis of Active or Latent Tuberculosis AHS – G2063 (PDF) | Reviewed by Avalon 3rd Quarter 2022 CAB. Description section updated. Regulatory section updated. When Covered and When Not Covered sections updated for clarity. Table of Terminology added. Policy Guidelines section updated. Scientific Background/References updated. |
| Testing for Mosquito or Tick-Related Infections AHS – G2158 (PDF) | Reviewed by Avalon 3rd Quarter 2022 CAB. Description section updated. Related policy added. When Covered section updated. When Not Covered section updated. Table of Terminology added. Added codes 86382, 87468, 87469, 87478, and 87484 to Billing/Coding section. Deleted codes 87798, 85060, and 87254 from Billing/Coding section. Policy Guidelines updated. References updated. |
| Urinary Tumor Markers for Bladder Cancer AHS – G2125 (PDF) | Added code 0363U to Billing/Coding section. |
| Vertebroplasty, Kyphoplasty, and Sacroplasty Percutaneous (PDF) | Added new codes C7504, C7505, C7507, and C7508 to Billing/Coding section. |
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