Medical Policy Updates

Medical Policy Update for September 7, 2021

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.