Medical Policy Updates

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Blue Cross and Blue Shield of North Carolina Medical Policy Update May 4, 2021

Medical Guidelines Reason for Update
Allergy Immunotherapy (Desensitization) When Not Covered section for COVID-19 exception updated with “effective from March 6, 2020 through September 30, 2021. We will reevaluate if an additional extension is needed as we approach September 30.”
ANA/ENA Testing AHS – G2022 Specialty Matched Consultant Advisory Panel review 2/16/2021. Reviewed by Avalon 1st Quarter 2021 CAB. Medical Director review 4/2021. Reference added. No change to policy statement.
Cardiac Biomarkers for Myocardial Infarction AHS – G2150 Specialty Matched Consultant Advisory Panel review 4/2021. Medical Director review 4/2021.
Cardiovascular Disease Risk Assessment AHS – G2050 Reviewed by Avalon 1st Quarter 2021 CAB. The following changes were made to the When Covered section: Item 1-a: revised statement for adult age range starting at 18; item 1-b: removed “including but not limited” and added the following conditions listed in items v - x. Added the following statement under the When Not Covered section to the bullet noted for High-sensitivity Cardiac Troponin – “in the outpatient setting”. Policy guidelines and references updated. Specialty Matched Consultant Advisory Panel review 4/2021. Medical Director review 4/2021.
Dental Reconstructive Services Updated Policy Guidelines item 4 for clarification and added item 7. No change to policy statement.
Diagnosis and Treatment of Sacroiliac Joint Pain Updated Description and Policy Guidelines section. Code 64625 added to Billing/Coding section. Reference added. Specialty Matched Consultant Advisory Panel review 4/2021. Medical Director review 4/2021.
Diagnosis of Idiopathic Environmental Intolerance AHS – G2056 Reviewed by Avalon 1st Quarter 2021 CAB. References updated. Medical Director review 4/2021.
Diagnosis of Vaginitis including Multi-target PCR Testing AHS – M2057 Reviewed by Avalon 1st Quarter 2021 CAB. Description, Policy Guidelines, and References updated. Codes 81513 and 81514 added to Billing/Coding section. Medical Director review 4/2021.
Eculizumab (Soliris®) Added the following criteria within “When Covered” section for aHUS and PNH: “the patient has tried and had an inadequate response to ravulizumab (Ultomiris), OR the patient has a clinical contraindication or intolerance to ravulizumab (Ultomiris).” Policy notification given 2/23/2021 for effective date 5/4/2021
Erectile Dysfunction AHS - G2132 Specialty Matched Consultant Advisory Panel review 11/18/2020.
Esketamine (Spravato™) Nasal Spray Blue Cross NC Pharmacy and Therapeutics Committee 1/5/2021. Removed HCPCS code J3490 from Billing/Coding section for clarity.
Esophageal Pathology Testing AHS – M2171 Reviewed by Avalon 1st Quarter 2021 CAB. Policy guidelines and references updated. Medical Director review 4/2021.
Evaluation of Dry Eyes AHS - G2138 Reviewed by Avalon 1st Quarter 2021 CAB. Updated Description section, Policy Guidelines and References. Medical Director review 4/2021.
Familial Adenomatous Polyposis and MUTYH-Associated Polyposis AHS-M2024 Reviewed by Avalon 1st Quarter 2021 CAB. Medical Director review 4/2021. Under “When Covered” section item b. added: “there is a personal history of multifocal/bilateral congenital hypertrophy of the retinal pigment epithelium (CHRPE). Updated Policy Guidelines and references.
Flow Cytometry AHS–F2019 Reviewed by Avalon 1st Quarter 2021 CAB. Updated policy guidelines and references. Added related policy: Minimal Residual Disease under Description section.
General Genetic Testing, Somatic Disorders AHS-M2146 Reviewed by Avalon 1st Quarter 2021 CAB. Added item 5 as follows to When Covered section: “TMB testing is covered for all solid tumors for individuals being considered for pembrolizumab (Keytruda) therapy.” Description, policy guidelines, and references updated. Medical Director reviewed 4/2021.
Genetic Testing for Connective Tissue Disorders AHS – M2144 Reviewed by Avalon 1st Quarter 2021 CAB. Added the following statement to item 1 under the When Covered section: “the individual needs to consult cardiology specialist prior to genetic testing” for clarity; removed the following from item 2 “If FBN1 mutation testing is negative”; item 3 reworded about genetic testing (COL3A1 and COL1A1) for vascular Ehlers-Danlos syndrome (vEDS); reworded item 4 for clarity. Note 3 updated. Added 2nd statement to When Not Covered section: “Reimbursement is not allowed for genetic testing to confirm or establish a diagnosis of hypermobile Ehlers-Danlos syndrome (hEDS) in individuals with characteristics of hEDS (see Note 5).; and added Note 5. Description section, policy guidelines and references updated. Medical Director review 4/2021.
Genetic Testing for Epilepsy AHS – M2075 Reviewed by Avalon 1st Quarter 2021 CAB. Policy Guidelines updated. Added code 81419. Medical Director review 4/2021. References added.
Genetic Testing for Lipoprotein A Variant(s) as a Decision Aid for Aspirin Treatment and/or CVD Risk Assessment AHS – M2082 Specialty Matched Consultant Advisory Panel review 4/2021. Medical Director review 4/2021.
Helicobacter Pylori Testing AHS – G2044 Reviewed by Avalon 1st Quarter 2021 CAB. Added the following statements to the When Covered sections: “xi. In patients with family history of gastric cancer xii. In patients who are first-generation immigrants from high prevalence areas”. Minor updates to policy guidelines and references. Medical Director review 4/2021.
Hemodialysis Treatment for ESRD References updated. Specialty Matched Consultant Advisory Panel review 4/2021. Medical Director review 4/2021.
Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence Reference added. Specialty Matched Consultant Advisory Panel review 11/18/2020.
Intracellular Micronutrient Analysis AHS – G2099 Reviewed by Avalon 1st Quarter 2021 CAB. Statement revised for clarity under the When Not Covered section by adding the following: “Cell Science Systems cell micronutrient assay”; no change to policy intent. Policy guidelines and references updated. Medical Director review 4/2021.
Intradialytic Parenteral Nutrition References updated. Specialty Matched Consultant Advisory Panel review 4/2021/ Medical Director review 4/2021.
Intravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric Disorders Description and Policy guidelines updated. References added. Specialty Matched Consultant Advisory Panel review 4/15/2020. Medical Director review 4/2021. No Change to policy statement.
Intravitreal Implant Policy archived. References added. Medical Director review 9/2020.
Laboratory Procedures Medical Policy AHS - R2162 Reviewed by Avalon 1st Quarter 2021 CAB. Title changed from Laboratory Procedures Reimbursement Policy to “Laboratory Procedures Medical Policy”. Changed “Policy Scope” to “Description”. The following statement was added to the section on reimbursement for genetic panel testing: “Concurrent ordering of multi-gene panel tests for a specific condition is strictly prohibited: only one multi-gene panel test may be ordered at a time for a specific condition. Medical Director review 4.2021.
Lipid Apheresis References updated. Specialty Matched Consultant Advisory Panel review 4/2021. Medical Director review 4/2021.
Lyme Disease AHS – G2143 Reviewed by Avalon 1st Quarter 2021 CAB. Description section updated. When Covered section updated. When Not Covered section updated. Policy Guidelines updated. Medical Director review 4/2021. References added.
Melphalan Flufenamide (Pepaxto®) New policy developed. Melphalan flufenamide (Pepaxto) is considered medically necessary for treatment of relapsed/refractory multiple myeloma, in combination with dexamethasone, in adults who have received at least four prior lines of therapy and whose disease is refractory to at least one proteasome inhibitor, one immunomodulatory agent, and one CD38-directed monoclonal antibody, when specified medical criteria and guidelines are met. Added HCPCS codes C9399, J3490, J3590, J9999, S0353, S0354 to Billing/Coding section. References added.
Melphalan Hydrochloride (Evomela) for Intravenous Use Policy archived. Medical Director review 3/2020.
Mutation Analysis in Myeloproliferative Neoplasms AHS - M2101 Reviewed by Avalon 1st Quarter 2021 CAB. Medical Director review 4/2021. Under “When Covered” section, removed statements: “Patients suspected to have polycythemia vera (PV) should first be tested for the most common finding JAK2V617F; and If testing for PV is negative, further testing to detect other JAK2 tyrosine kinase mutations, eg. in exon 12”; added CALR and MPL testing indication for Budd-Chiari Syndrome and PV. Under Billing/Coding section, removed CPT codes 81402, 81403; added CPT codes 81279, 81338, 81339. Updated Policy Guidelines and references.
Onychomycosis Testing AHS – M2172 Added Related Policies in description section. Policy guidelines updated. References updated. Specialty Matched Consultant Advisory Panel review 4/26/2021. Medical Director review 4/2020.
Parathyroid Hormone, Phosphorus, Calcium, and Magnesium Testing AHS – G2164 Description, Policy Guidelines, and Reference sections updated. Reviewed by Avalon for 1st Quarter 2021 CAB. No change to policy statement. Medical Director review 4/2021.
Pathogen Panel Testing AHS – G2149 Off-cycle review by Avalon 1st Quarter 2021 CAB. The following codes were deleted from the Billing/Coding section: 0098U, 0099U, 0100U. Medical Director review 4/2021
Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence Reference added. Specialty Matched Consultant Advisory Panel review 11/18/2020.
Percutaneous Tibial Nerve Stimulation for Voiding Dysfunction Reference added. Specialty Matched Consultant Advisory Panel review 11/18/2020.
Pharmacogenetics Testing AHS – M2021 Reviewed by Avalon 1st Quarter 2021 CAB. Policy guidelines and references updated. CPT code 81220 requires PPA and code 81346 was added to the Billing/Coding section. Medical Director review 4/2021.
Plasma HIV-1 and HIV-2 RNA Quantification for HIV Infection AHS – M2116 Reviewed by Avalon 1st Quarter 2021 CAB. Medical Director review 4/2021. Related Policy added. When Covered section updated. When Not Covered section updated. Policy Guidelines updated. Background section updated. State and Federal Regulations section updated. Guidelines and Recommendations updated. References updated and added.
Prenatal Screening AHS – G2035 Reviewed by Avalon 1st quarter 2021 CAB. Description, Policy Guidelines, and Reference section updated. When covered items 1h, 1m, 3f, 3h updated for clarity. Code 81220 added to Billing/Coding section.
Prescription Medication and Illicit Drug Testing in the Outpatient Setting AHS – T2015 Reviewed by Avalon Q3 CAB. Removed “urine” from when covered section, added “or oral fluid” to #3 under Reimbursement. Policy Guidelines and References updated. Medical Director review 10/2020.
Radiofrequency Ablation of the Renal Nerves as a Treatment of Hypertension Minor revisions to regulatory status and policy guidelines. References updated. Specialty Matched Consultant Advisory Panel review 4/2021. Medical Director review 4/2021.
Renal (Kidney) Transplantation References updated. Specialty Matched Consultant Advisory Panel review 4/2021. Medical Director review 4/2021.
Salivary Hormone Testing AHS – G2120 Reviewed by Avalon 1st Quarter 2021 CAB. Updated Description and Policy Guidelines section. Billing/Coding section updated: codes 82530 and 82533 corrected due to typographical error, code 2681 added. Updated references. No change to policy statement. Medical Director review 4/2021.
Serum Tumor Markers for Malignancies AHS – G2124 Reviewed by Avalon 1st Quarter 2021 CAB. Medical Director review 4/2021. Under “When Covered” section F. (g) (Cancer Antigen 19-9) and H.(g) (Carcinoembryonic Antigen CEA), added covered indication: epithelial ovarian cancer, fallopian tube cancer, or primary peritoneal cancer workup and monitoring; Under section K. (a) removed word “histopathologies” for clarity. Also under “When Covered” section, removed language in sections M. (PSA) and moved to AHS-G2008 Prostate Cancer Screening; and N. (Thyroglobulin TG) and moved to AHS-G2045 Thyroid Disease Testing. Under “When Not Covered” section, deleted the following tests since they have been removed from the market: EPCA-2, Advise MCV, Advise PG, ConfirmMDx, DCIS Recurrence Score, Postop Px(Prostate PX), Previstage GCC, ProOnc Tumor Source Dx test, Prostate Px and Proveri Prostate cancer assay, Response Dx colon, UroCor cytology panels. Under Billing/Coding section: removed CPT codes 81551, 84152, 84153, 84154, 84432, 86800, 0021U, 0045U. Updated Policy Guidelines and references.
ST2 Assay for Chronic Heart Failure AHS – G2130 Specialty Matched Consultant Advisory Panel review 4/2021. Medical Director review 4/2021.
Thyroid Disease Testing AHS – G2045 Reviewed by Avalon 1st Quarter 2021 CAB. Medical Director review 4/2020. Description, Policy Guidelines and References updated. Item 1->i and Item 3 added to When Covered section
Transplant Rejection Testing AHS – M2091 Specialty Matched Consultant Advisory Panel review 4/2021. Medical Director review 4/2021.
Treatment for Severe Primary IGF-1 Deficiency Policy archived. Blue Cross NC Pharmacy and Therapeutics Committee 1/5/2021. Medical Director review 1/2021.
Urinary Tumor Markers for Bladder Cancer AHS – G2125 Specialty Matched Consultant Advisory Panel review 11/18/2020. Reviewed by Avalon 1st Quarter 2021 CAB. Medical Director review 4/2021. References updated and added. Description section updated. Related Policies updated. State and Federal Regulations section updated. Policy Guidelines updated.
Vectra DA Blood Test for Rheumatoid Arthritis AHS – G2127 Reviewed by Avalon for 1st Quarter 2021 CAB. Updated Description, Policy Guidelines, and References. No change to policy statement. Medical Director review 4/2021.
Vesicoureteral Reflux, Treatment with Periureteral Bulking Agents Reference added. Description section updated. Specialty Matched Consultant Advisory Panel review 11/18/2020.