Medical Policy Updates

Medical Policy Update November 02, 2021

Medical Guidelines	Reason for Update
Ambulatory Event Monitors	Minor update to Table 1 in Description section. References updated. Specialty Matched Consultant Advisory Panel review 10/2021. Medical Director review 10/2021.
Anesthesia Services	References updated. Specialty Matched Consultant Advisory Panel review 10/2021. Medical Director Review 10/2021. No change to policy statement.
Baroreflex Stimulation Devices	References updated. Specialty Matched Consultant Advisory Panel review 10/2021. Medical Director review 10/2021.
Cardiac Monitoring Devices in the Outpatient Setting	Policy guidelines and references updated. Specialty Matched Consultant Advisory Panel review 10/20201. Medical Director review 10/2021.
Carotid Intimal-Medial Thickness	Description section, policy guidelines, and references updated. Specialty Matched Consultant Advisory Panel review 10/2021. Medical Director review 10/2021.
Charged Particle Radiotherapy	Under “When Covered” section: added statement 3) Solid tumors in the pediatric population being treated with curative intent. Updated policy guidelines, reference added. Medical Director review 10/2021.
Chromosomal Microarray AHS – M2033	Reviewed by Avalon 2nd Quarter 2021 CAB. Medical Director review 7/2021. Under Billing/Coding section, added PLA code 0252U, deleted 0209U. Updated Policy Guidelines and References. Under “When Covered” section, added “for evaluation of 2nd consecutive clinical first trimester pregnancy loss” to statement #2. Under “When Covered” section for statement #3 also added: “When fetal growth restriction is detected and a fetal malformation, polyhydramnios, or both are also present regardless of gestational age, OR for item F and “When unexplained isolated fetal growth restriction is diagnosed at <32 weeks of gestation, OR” for item G. Notification given 8/24/21 for effective date 11/2/21.
Computed Tomography to Detect Coronary Artery Calcification	References updated. Specialty Matched Consultant Advisory Panel review 10/2021. Medical Director review 10/2021.
Dental Criteria for use of Hospital Inpatient or Outpatient Facility Services or Ambulatory Surgery Center Facility Services	Specialty Matched Consultant Advisory Panel review 10/2021. Medical Director Review 10/2021. No change to policy statement.
Dental Reconstructive Services	Specialty Matched Consultant Advisory Panel review 10/2021. Medical Director Review 10/2021. No change to policy statement.
Dermatologic Applications of Photodynamic Therapy	References updated. Specialty Matched Consultant Advisory Panel review 10/21/2020. Medical Director review. No change to policy statement.
Enhanced External Counterpulsation (EECP)	References updated. Specialty Matched Consultant Advisory Panel review 10/2021. Medical Director review 10/2021.
Epithelial Cell Cytology in Breast Cancer Risk Assessment AHS - G2059	Specialty Matched Consultant Advisory Panel review 3/17/21. No change to policy statement.
Hyperbaric Oxygen Therapy	References updated. Specialty Matched Consultant Advisory Panel review 10/2021. Medical Director review 10/2021. References updated. No change to policy statement.
Leadless Cardiac Pacemakers	References updated. Specialty Matched Consultant Advisory Panel review 10/2021. Medical Director review 10/2021.
Non-Pharmacologic Treatment of Rosacea	References updated. Description updated to remove related policy Light Therapy for Dermatologic Conditions – policy archived 2/2021. Specialty Matched Consultant Advisory Panel review 10/2021. Medical Direction review 10/2021. No change to policy statement.
Onychomycosis Testing AHS – M2172	References updated. Specialty Matched Consultant Advisory Panel review 10/2021. Medical Director review 10/2021. No changes to policy statement.
Orthodontics for Pediatric Patients	Specialty Matched Consultant Advisory Panel review 10/2021. Medical Director Review 10/2021. No change to policy statement.
Orthognathic Surgery	Specialty Matched Consultant Advisory Panel review 10/2021. Medical Director Review 10/2021. No change to policy statement.
Progenitor Cell Therapy for the Treatment of Damaged Myocardium Due to Ischemia	References updated. Specialty Advisory Consultant Advisory Panel review 10/2021. Medical Director review 10/2021.
Signal-Averaged ECG	Specialty Matched Consultant Advisory Panel review 10/2021. Medical Director review 10/2021.
Spinal Manipulation Under Anesthesia	References updated. Specialty Matched Consultant Advisory Panel Review 10/2021. Medical Director Review 10/2021. References updated. No change to policy statement.
Stem-cell Therapy for Peripheral Arterial Disease	Description section and references updated. Specialty Matched Consultant Advisory Panel review 10/2012. Medical Director review 10/2021.
Temporomandibular Joint Dysfunction (TMJD)	References updated. Specialty Matched Consultant Advisory Panel review 10/2021. Medical Director Review 10/2021. No change to policy statement.
TENS (Transcutaneous Electrical Nerve Stimulator)	Added 2021 HCPCS codes K1023 to the “Billing/Coding” section.
Urinalysis and Urine Culture Testing for Bacteria AHS – G2156	Reviewed per Avalon Q2 CAB. Medical Director review 8/2021. Removed 81007 from Billing/Coding section. Description, Policy Guidelines and References updated. Removed “urinalysis” from all statements in When Covered and When Not Covered sections. Notification given 8/24/2021 for policy effective date 11/2/2021.
Venous and Arterial Thrombosis Risk Testing AHS – M2041	Specialty Matched Consultant Advisory Panel review 10/2021. Medical Director review 10/2021.
Wearable Cardioverter Defibrillators	References updated. Specialty Matched Consultant Advisory Panel review 10/2021. Medical Director review 10/2021.