Medical Guidelines |
Reason for Update |
BCR-ABL 1 Testing AHS – M2027 |
Reviewed by Avalon Q2 2021 CAB. Reviewed by Medical Director 7/2021. Updated Description, Policy Guidelines, and References. Under “When Covered” section statement #4 a. edited “There is failure to reach response milestones.” Statement #4 b. edited “There is any sign of loss of response (defined as hematologic or cytogenic relapse).” Specialty Matched Consultant Advisory Panel review 8/18/2021. |
BRCA AHS - M2003 |
Specialty Matched Consultant Advisory Panel review 8/18/2021. No change to policy statement. |
Breast Surgeries |
Updated Related Policies section. References updated. Specialty Matched Consultant Advisory Panel review 8/2021. Medical Director review 8/2021. |
Carrier Screening for Genetic Disease |
Minor revisions. References updated. Specialty Matched Consultant Advisory Panel review 7/2021. Medical Director review 7/2021. |
Colorectal Cancer Screening AHS-B0001 |
Specialty Matched Consultant Advisory Panel review 8/18/2021. No changes to policy statement. |
Composite Allotransplantation of the Hand and Face |
References updated. Specialty Matched Consultant Advisory Panel 8/2021. Medical Director review 8/2021 |
Cosmetic and Reconstructive Surgery |
Specialty Matched Consultant Advisory Panel 8/2021. Medical Director review 8/2021. |
Esophageal Pathology Testing AHS – M2171 |
Minor wording revision for clarity to When Not Covered section item #5 (WATS-3D), policy guidelines updated with evidence summary for WATS-3D, and references updated. Medical Director review 8/2021. |
Extracorporeal Photopheresis |
Specialty Matched Consultant Advisory Panel review 8/18/2021. Reference added. No change to policy statement. |
Familial Adenomatous Polyposis and MUTYH-Associated Polyposis AHS-M2024 |
Specialty Matched Consultant Advisory Panel review 8/18/2021. No change to policy statement. |
Gene Expression Profiling and Protein Biomarkers for Prostate Cancer AHS - M2166 |
Specialty Matched Consultant Advisory Panel review 8/18/2021. No change to policy statement |
General Approach to Evaluating the Utility of Genetic Panels |
Specialty Matched Consultant Advisory Panel review 7/2021. Medical Director review 7/2021. |
General Genetic Testing, Germline Disorders AHS – M2145 |
Specialty Matched Consultant Advisory Panel review 7/2021. Medical Director review 7/2021 |
Genetic Testing for Acute Myeloid Leukemia AHS-M2062 |
Specialty Matched Consultant Advisory Panel review 8/18/2021. Reviewed by Avalon 2nd Quarter 2021 CAB. Updated policy guidelines and added references. Under “When Not Covered section: removed Item A: “Genetic testing for FLT3, NPM1, CEBPA, IDH ½, KIT and other mutations to detect minimal residual disease.” Please see CMP Minimal Residual Disease AHS-M2175. Medical Director review 7/2021. |
Genetic Testing for CHARGE Syndrome AHS – M2070 |
Specialty Matched Consultant Advisory Panel review 7/2021. Medical Director review 7/2021. |
Genetic Testing for Duchenne, Becker, Facioscapulohumeral, LimbGirdle Muscular Dystrophies AHS – M2074 |
Specialty Matched Consultant Advisory Panel review 7/2021. Medical Director review 7/2021. |
Genetic Testing for Familial Hypercholesterolemia AHS – M2137 |
Specialty Matched Consultant Advisory Panel review 7/2021. Medical Director review 7/2021. |
Hematopoietic Cell Transplantation |
Specialty Matched Consultant Advisory Panel review 8/18/2021. References added. Added Related Policies section. No change to policy statement. |
Infertility Diagnosis and Treatment – B0006 |
Added codes 0664T-0670T to Billing/Coding section effective 7/1/2021. Medical Director review 6/2021. Added investigational statement F. under “When Covered” section: “Uterine transplant is considered investigational as a treatment of infertility.” Notification given 7/1/21 for effective date 9/7/21. |
Intraoperative Neurophysiologic Monitoring |
Medical Director review. Removed “Intraoperative neurophysiologic monitoring for any other indication, including during routine cervical decompression, routine cervical fusion, cervical disc arthroplasty, and during lumbar spine surgery below L1/L2 is considered not medically necessary” from the When Not Covered section. |
Laboratory Procedures Medical Policy AHS - R2162 |
Specialty Matched Consultant Advisory Panel review 7/2021. Medical Director review 7/2021. |
Laser Treatment of Port Wine Stains |
Specialty Matched Consultant Advisory Panel review 8/2021. Medical Director review 8/2021. |
Lynch Syndrome AHS-M2004 |
Specialty Matched Consultant Advisory Panel review 8/18/2021. No change to policy statement. |
Minimal Residual Disease (MRD) AHS-M2175 |
Specialty Matched Consultant Advisory Panel review 8/18/2021. No change to policy statement. |
Molecular Markers in Fine Needle Aspirates of the Thyroid AHS - M2108 |
Specialty Matched Consultant Advisory Panel review 8/18/2021. No change to policy statement. |
Molecular Panel Testing of Cancers for Diagnosis, Prognosis, and Identification of Targeted Therapy AHS - M2109 |
Reviewed by Avalon 2nd Quarter 2021 CAB. Medical Director review 7/2021. Updated Description, Policy Guidelines, and References. Added Related Policies section. Under “When Covered” section: Added PLA code 0250U to Billing/Coding section. Specialty Matched Consultant Advisory Panel review 8/18/2021. |
Molecular Profiling for Cancers of Unknown Primary Origin AHS - M2065 |
Reviewed by Avalon 2nd Quarter 2021 CAB. Updated Description and Policy Guidelines. Added related policies section and references. Medical Director review 8/2021. Specialty Matched Consultant Advisory Panel review 8/18/2021. No change to policy statement. |
Mutation Analysis in Myeloproliferative Neoplasms AHS - M2101 |
Specialty Matched Consultant Advisory Panel review 8/18/2021. No change to policy statement. |
Professional Pathology Billing Requirements AHS – R2169 |
Specialty Matched Consultant Advisory Panel 7/2021. Medical Director review 7/2021. |
Prostate Specific Antigen (PSA) Testing AHS - G2008 |
Specialty Matched Consultant Advisory Panel review 8/18/2021. No change to policy statement. |
Reconstructive Eyelid Surgery and Brow Lift |
Specialty Matched Consultant Advisory Panel review 8/2021. Medical Director review 8/2021. |
Red Blood Cell Molecular Testing AHS-M2170 |
Specialty Matched Consultant Advisory Panel review 8/18/2021. References updated. No change to policy statement. |
Serum Tumor Markers for Malignancies AHS – G2124 |
Specialty Matched Consultant Advisory Panel review 8/18/2021. No change to policy statement. |
Skin and Soft Tissue Substitutes |
Removed Stratagraft from the When Not Covered section “for all indications”. References updated. Specialty Matched Consultant Advisory Panel 8/2021. Medical Director review 8/2021. |
Testing for 5-Fluorouracil Use in Cancer Patients AHS-M2067 |
Specialty Matched Consultant Advisory Panel review 8/18/2021. No change to policy statement. |
Testing for Autism Spectrum Disorder and Developmental Delay AHS – M2176 |
Specialty Matched Consultant Advisory Panel review 7/2021. Medical Director review 7/2021. |
Tumor Tissue Mutation Analysis in Colorectal Cancer AHS - M2026 |
Reviewed by Avalon 2nd Quarter 2021 CAB. Updated Policy Guidelines. References added. Specialty Matched Consultant Advisory panel review 8/18/2021. No change to policy statement. |
Tumor-Treatment Fields Therapy |
Specialty Matched Consultant Advisory Panel review 8/18/2021. Updated Description and Policy Guidelines. No change to policy statement. |