Medical Policy Updates

Medical Policy Update for April 20, 2021

Medical Guidelines	Reason for Update
Advanced Illness / Advance Directives	Policy format update. No changes to policy statement.
Ana/Ena Testing AHS – G2022	Reviewed by Avalon 4th Quarter CAB. Medical Director Review 1/2021. Description, Policy Guidelines, and References updates. When not covered section updated to include “ The use of cell- bound activation products (e.g. AVISE Lupus) for the diagnosis of systemic lupus erythematosus (SLE) is considered investigational” and clarification of item six. Added code 81599. Policy noticed 2/9/2021 for effective date 4/20/2021.
CAR-T Therapy	Added new indication for Yescarta for relapsed/refractory follicular lymphoma with specific medical necessity criteria. Added newly approved Abecma (idecabtagene vicleucel) to policy to be considered medically necessary for the treatment of patients with relapsed or refractory multiple myeloma when specified medical criteria and guidelines are met. Updated Description and Policy Guidelines sections to include information relevant to idecabtagene vicleucel. Added HCPCS codes C9399, J3490, J3590, and J9999 to Billing/Coding section for Abecma. Reference added.
Co-Surgeon, Assistant Surgeon, Team Surgeon And Assistant-At-Surgery Guidelines	Policy format update. No changes to policy statement.
Consistency Guidelines	Policy format update. No changes to policy statement.
Developmental Delay Screening And Testing Guidelines	Policy format update. No changes to policy statement.
Documentation Requirements For Treatment Of End Stage Renal Disease	Policy format update. No changes to policy statement.
ECG Reimbursement	Policy format update. No changes to policy statement.
Evinacumab-dgnb (Evkeeza™)	New policy developed. Evinacumab-dgnb (Evkeeza) is considered medically necessary in patients (12 years of age or older) with homozygous familial hypercholesterolemia (HoFH) when specified medical criteria and guidelines are met. Added HCPCS codes C9399, J3490, and J3590 to Billing/Coding section. References added.
Fosdenopterin (Nulibry™)	New policy developed. Fosdenopterin (Nulibry) is considered medically necessary in patients with molybdenum cofactor deficiency (MoCD) Type A when specified medical criteria and guidelines are met. Added HCPCS codes C9399, J3490, and J3590 to Billing/Coding section. References added.
General Genetic Testing, Somatic Disorders AHS-M2146	Specialty Matched Consultant Advisory Panel review 3/2021. Medical Director review 3/2021.
Genetic Testing For Connective Tissue Disorders AHS – M2144	Specialty Matched Consultant Advisory Panel review 3/2021. Medical Director review 3/2021.
Group Visit (Shared Medical Appointment) Guidelines	Policy format update. No changes to policy statement.
Hormonal Testing In Adult Females AHS – G2161	Annual review by Avalon 4th Quarter 2020 CAB. Title changed from Hormonal Testing in Females to Hormonal Testing in Adult Females. Items 2a-c and 6 added to Not Covered section. Note 1 moved to Note 2 and Note 1 added to not covered section. “This policy only addresses coverage of hormonal testing in adult females (age 18 years and older)” added to Description section. CPT codes 82397, 82681, and 86636 added. Description, Policy Guidelines, and References updated. Medical Director review 1/2021. Notification given 02/09/2021 for effective date 04/20/2021.
Immunization Guidelines	Policy format update. No changes to policy statement.
Maximum Units Of Service	Policy format update. No changes to policy statement.
Modifier Guidelines	Policy format update. No changes to policy statement.
Multiple Surgical Procedure Guidelines For Professional Providers	Policy format update. No changes to policy statement.
Nonpayment For Serious Adverse Events	Policy format update. No changes to policy statement.
Preadmission And Preoperative Services	New policy developed. Blue Cross Blue Shield North Carolina (BCBSNC) will limit reimbursement for preadmission and preoperative services according to the criteria outlined in this policy. Medical Director review 3/2021.
Pricing And Adjudication Principles For Professional Providers	Policy format update. No changes to policy statement.
Removal Of Impacted Cerumen	Policy format update. No changes to policy statement.
Semi-Implantable And Fully Implantable Middle Ear Hearing Aid	Specialty Matched Consultant Advisory Panel review 2/17/2021.
Testing For Autism Spectrum Disorder And Developmental Delay AHS – M2176	New policy developed. BCBSNC will provide coverage for testing for autism spectrum disorder and developmental delay when it is determined to be medically necessary because the medical criteria and guidelines are met. Policy noticed 2/9/21, effective 4/20/21. Medical Director review 1/2021.
Trilaciclib (Cosela™)	New policy developed. Trilaciclib (Cosela) is considered medically necessary to decrease incidence of chemotherapy-induced myelosuppression in adults when administered prior to a platinum/etoposide-containing regimen or topotecan-containing regimen for extensive-stage small cell lung cancer, when specified medical criteria and guidelines are met. Added HCPCS codes C9399, J3490, J3590, J9999, S0353, S0354 to Billing/Coding section. References added.