Medical Policy Updates

Medical Policy Update for December 30, 2021

Medical Guidelines	Reason for Update
Adaptive Behavioral Treatment for Autism Spectrum Disorders	Statement added to Policy Guidelines section Provider Qualifications, Providers performing services within North Carolina 8) Licensed Behavior Analyst. The General Assembly of North Carolina Session 2021, Senate Bill 103, Chapter 90 of the General Statues is amended by adding a new article (Article 43. Behavior Analyst Licensure. The newly established North Carolina Behavioral Analysis Board will issue a license to engage in the practice of behavior analyst if the applicant meets the qualifications set forth by the Board in accordance with G.S. 90-726.4(a) and provides satisfactory evidence to the Board that all criteria established are met. Update to Billing/Coding/Physician Documentation Information section for the number of number of units considered medically necessary. Notification given 10/1/2021 for effective date 1/1/2022
Allergy Immunotherapy (Desensitization)	When Not Covered section revised to remove COVID-19 exception as follows: “Subcutaneous immunotherapy performed in the home setting is considered investigational.” Medical Director review.
Aqueous Shunts and Devices for Glaucoma	Added CPT codes 66989, 66991 and deleted 0191T, 0376T in Billing/Coding section for effective date 1/1/2022.
Bariatric Surgery	Medical Director review. Added nonalcoholic steatohepatitis (NASH) to list of covered comorbidities.
Biomarker Testing for Multiple Sclerosis and Related Neurologic Diseases AHS – G2123	Added codes 86051, 86052, 86053, 86362, and 86363 to Billing/Coding section.
Bone Mineral Density Studies	The following codes were added to the Billing/Coding section: 77089, 77090, 77091, 77092, 0691T. Effective 1/1/2022.
Bone Morphogenetic Protein	Reference added. Policy Guidelines updated.
Capsule Endoscopy, Wireless	Under the Billing/Coding section, added code 91113 and removed code 0355T as it is being deleted. Both will be effective 1/1/22.
Cardiac Monitoring Devices in the Outpatient Setting	The following code was added to the Billing/Coding section: C1833 effective 1/1/22.
Celiac Disease Testing AHS – G2043	The following codes were added to the Billing/Coding section: 86231, 86258, 86364 effective 1/1/22.
Chromosomal Microarray AHS – M2033	The following code was added to the Billing/Coding section: 81349 effective 1/1/2022.
Cosmetic and Reconstructive Surgery	When Cosmetic and Reconstructive Surgery is covered section updated to state “Treatment of a keloid is considered medically necessary when there is documented evidence of significant functional impairment related to the keloid and the treatment can be reasonably expected to improve the functional impairment. Treatment of a keloid with superficial radiation therapy up to 3 fractions is considered medically necessary as adjunct therapy following surgical excision initiated within 3 days when the medically necessary criteria for keloid removal are met.” Billing/Coding section updated to include code 77401. Medical Director review 9/2021. Notification given 10/19/2021 for effective date 1/1/2022
Cryoablation for Chronic Rhinitis	New policy issued. Cryoablation for Chronic Rhinitis is considered investigational. Policy noticed 10/19/2021 for policy effective date 1/1/2022.
Durable Medical Equipment (DME)	The following code was added to the Billing/Coding section: E1629 effective 1/1/22.
Facet Joint Denervation	Updated Policy Guidelines item # 2c. Removed “and that documents the presence of facet disease;” Updated Policy Guidelines item #4.” A trial of two controlled medial branch block or facet injection with either a local anesthetic or combined local anesthetic and steroid under live fluoroscopic guidance that has resulted in at least a 70% reduction in pain for the duration of the expected injection”. Notification 10/19/2021 for effective date 1/1/2022.
Gene Expression Testing for Breast Cancer Prognosis AHS - M2020	Added CPT code 81523 to Billing/Coding section for effective date 1/1/22.
Growth Factors in Wound Healing	Code G0465 added to Billing/Coding section.
Hemodialysis Treatment for ESRD	The following code was added to the Billing/Coding section effective 1/1/22: 0692T.
Immune Cell Function Assay for Organ Transplant Rejection AHS-G2098	Added CPT code 81560 to Billing/Coding section for effective date 1/1/22.
Implantable Bone Conduction Hearing Aids	Reference added. Codes 69716, 69719, 69726, and 69727 added to Billing/Coding section.
Investigational (Experimental) Services	COVID-19 related changes removed for 12/31/2021 deadline. Medical Director review.
Lumbar Spine Fusion Surgery	Medical Director review. Reference added. The following note added to the When Covered section: “For non-emergent procedures that include fusion, it is required that the surgical candidate refrain from smoking/nicotine for at least six weeks prior to surgery and during the time of healing. Attestation from the performing provider is required”. NOTIFICATION GIVEN 10/19/2021 FOR POLICY EFFECTIVE DATE 1/1/2022
Microprocessor-Controlled Prostheses for the Lower Limb	Reference added.
MRI-guided Laser Interstitial Thermal Therapy for Neurological Indications	Specialty Matched Consultant Advisory Panel review 10/20/2021. Added codes 61736 and 61737 to Billing/Coding section.
Pathogen Panel Testing AHS – G2149	The following codes were added to the Billing/Coding section: 87154, 87636, 87637 effective 1/1/22.
Percutaneous Intradiscal and Intraosseous Radiofrequency Procedures of the Spine	Added codes 64628 and 64629 to Billing/Coding section.
Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention	The following codes were added to the Billing/Coding section effective 1/1/22: 33267, 33268, 33269.
Perirectal Spacer Use During Radiotherapy for Prostate Cancer	Under “When Not Covered” section: added “including use with brachytherapy monotherapy” to the investigational statement. Medical Director review 10/2021. Notification given 11/02/21 for effective date 1/1/22.
Peroral Endoscopic Myotomy for Treatment of Esophageal Achalasia	The following code was added to the Billing/Coding section effective 1/1/22: 43497.
Powered Exoskeleton for Ambulation in Patients with Lower Limb Disabilities	Reference added. Description section updated. Policy Guidelines updated. Code K1007 added to Billing/Coding section.
Screening for Vertebral Fracture with Dual X-ray Absorptiometry (DXA)	The following code was added to the Billing/Coding section: 0691T effective 1/1/2022.
Skin and Soft Tissue Substitutes	The following codes were added to the Billing/Coding section: A2001, A2002, A2003, A2004, A2005, A2006, A2007, A2008, A2009, A2010, Q4199 effective 1/1/2022.
Spinal Cord and Dorsal Root Ganglion Stimulation	Reference added. Policy Guidelines updated. Policy statement updated to add Dorsal Root Ganglion Stimulation trial to criteria for permanent coverage. Dorsal Root Ganglion Stimulation added to item B. in When Not Covered section. Policy noticed 10/19/2021 for effective date 1/1/2022
Surgery for Obstructive Sleep Apnea and Upper Airway Resistance Syndrome	Added codes 42975, 64582, 64583, and 64584 to Billing/Coding section. Deleted codes 0466T, 0467T, and 0468T from Billing/Coding section.
Treatment For Opioid Use Disorder in Opioid Treatment Programs (OTPs)	The following codes were added to the Billing/Coding section: G1028, G2067 through G2080, and G2215 to G2216 effective 1/1/2022.