Medical Policy Updates

Medical Policy Update August 24, 2021

Medical Guidelines	Reason for Update
Ablative Techniques for the Myolysis of Uterine Fibroids	Added coverage Atrium registry for transcervical ultrasound guided radiofrequency ablation, “For Sonata™ transcervical ultra-sound guided radiofrequency ablation, the Individual is eligible for and enrolled in the ATRIUM Registry….” Policy Guidelines and References also updated.
Automated Percutaneous and Endoscopic Discectomy	Reference added.
Cardiac Biomarkers for Myocardial Infarction AHS – G2150	Reviewed by Avalon 2nd Quarter 2021 CAB. Background, policy guidelines, and references updated. Medical Director review 7/2021.
Erectile Dysfunction AHS - G2132	Reviewed by Avalon 2nd Quarter 2021 CAB. Policy Guidelines updated. Note added to When Not Covered section. References updated. Medical Director review 8/2021.
Gamma-glutamyl Transferase AHS – G2173	Reviewed by Avalon 2nd Quarter 2021 CAB. Policy guidelines and references updated. Medical Director review.
Genetic Testing for Adolescent Idiopathic Scoliosis AHS – M2058	Reviewed by Avalon 2nd Quarter 2021 CAB. Medical Director review 7/2021. Policy Guidelines and References sections updated. No change to policy statement.
Genetic Testing for Alpha- and Beta- Thalassemia AHS – M2131	Reviewed by Avalon 2nd Quarter 2021 CAB. Description, Policy guidelines, and Reference sections update. Specialty Matched Consultant Advisory Panel review 7/2021. Medical Director review 7/2021.
Genetic Testing for Cystic Fibrosis AHS – M2017	Reviewed by Avalon 2nd Quarter 2021 CAB review. Background, policy guidelines, and references updated. Reworded item 3, under the When Covered section for clarity, adding items b-d, and removed item d, under #4 pertaining to cascade testing, combining it within item c. Specialty Matched Consultant Advisory Panel review 7/2021. Medical Director review 7/2021.
Genetic Testing for Diagnosis of Inherited Peripheral Neuropathies AHS – M2072	Reviewed by Avalon 2nd Quarter 2021 CAB. The following statement was added to the When Not Covered section: “Genetic testing for CMT in asymptomatic individuals is considered investigational.” Background, policy guidelines, and references updated. Specialty Matched Consultant Advisory Panel review 7/2021. Medical Director review 7/2021.
Genetic Testing for Familial Alzheimer’s Disease AHS – M2038	Reviewed by Avalon 2nd Quarter 2021 CAB. Policy Guidelines updated. References updated. Medical Director review 7/2020.
Genetic Testing for Hereditary Hearing Loss AHS – G2148	Reviewed by Avalon 2nd Quarter 2021 CAB. Background, policy guidelines, and references updated. The following code was added to the Billing/Coding section: S3844. Specialty Matched Consultant Advisory Panel review 7/2021. Medical Director review 7/2021.
Genetic Testing for Hereditary Pancreatitis AHS – M2079	Reviewed by Avalon 2nd Quarter 2021 CAB. Policy guidelines and references updated. Specialty Matched Consultant Advisory Panel review 7/2021. Medical Director review 7/2021.
Genetic Testing for Lactase Insufficiency AHS – M2080	Reviewed by Avalon 2nd Quarter 2021 CAB. Policy guidelines updated. Specialty Matched Consultant Advisory Panel review 7/2021. Medical Director review 7/2021.
Genetic Testing for Li_Fraumeni Syndrome AHS – M2081	Reviewed by Avalon 2nd Quarter 2021 CAB. Policy guidelines and Billing/Coding section updated. Medical Director review 7/2021.
Genetic Testing for Neurofibromatosis and Related Disorders AHS – M2134	Reviewed by Avalon 2nd Quarter CAB. Policy guidelines and references updated. Specialty Matched Consultant Advisory Panel review 7/2021. Medical Director review 7/2021.
Hepatitis C AHS – G2036	Reviewed by Avalon 2nd Quarter 2021 CAB. Medical Director review 8/2021. Scientific Background and Applicable Federal Regulations updated. When Covered section updated. Policy Guidelines updated. References updated.
HIV Genotyping and Phenotyping AHS – M2093	Reviewed by Avalon 2nd Quarter 2021 CAB. Scientific Background updated. Policy Guidelines updated. New code 0219U added to Billing/Coding Section. References updated. Medical Director review 8/2021.
Identification of Microorganisms using Nucleic Acid Probes AHS – M2097	Reviewed by Avalon 2nd Quarter 2021 CAB. Policy guidelines and references updated. Medical Director review 7/2021.
Molecular Testing of Pulmonary Specimens AHS - M2160	Policy statement revised from “Reimbursement not allowed” to “not medically necessary”. No change to policy intent.
Oral Screening Lesion Identification Systems and Genetic Screening AHS – G2113	Reviewed by Avalon 2nd Quarter 2021 CAB. Description section, policy guidelines, and references updated. Medical Director review 7/2021.
Oscillatory Devices for the Treatment of Respiratory Conditions	References added. Volara™ System added to Regulatory Status. When not covered section updated with Volara System Oscillation and Lung Expansion is investigational. Specialty Matched Consultant Advisory Panel review 3/2021. Medical Director review 3/2021. Policy noticed 6/15/2021 for effective date 8/24/2021.
Pancreatic Enzyme Testing for Acute Pancreatitis AHS – G2153	Reviewed by Avalon 2nd Quarter 2021 CAB. Background, policy guidelines and references updated. Medical Director review 7/2021.
Pathogen Panel Testing AHS – G2149	Reviewed by Avalon 2nd Quarter 2021 CAB. Background, policy guidelines and references updated. Medical Director review 7/2021.
Percutaneous Electrical Nerve Stimulation (PENS) or Neuromodulation Therapy and Percutaneous Electrical Nerve Field Stimulation (PENFS)	Policy statement added that PENFS, including IB-stim, is considered investigational. Policy Guidelines updated. References added. Medical Director review. Title changed from Percutaneous Electrical Nerve Stimulation (PENS) or Neuromodulation Therapy to Percutaneous Electrical Nerve Stimulation (PENS) or Neuromodulation Therapy and Percutaneous Electrical Nerve Field Stimulation (PENFS). Notification given 6/15/2021 for policy effective date 8/24/2021.
Prescription Medication and Illicit Drug Testing in the Outpatient Setting AHS – T2015	Reviewed by Avalon Q2 CAB 2021, off-cycle review. Under the When Covered section, item B. Definitive Drug Testing, added “up to seven drug classes” to item #2. The following statements were added to the When Not Covered section as follows: “Reimbursement is not allowed for definitive drug testing when it is requested without prior presumptive screening test results.; Reimbursement is not allowed for panels larger than seven drug classes.; Reimbursement is not allowed for presumptive or definitive drug testing using proprietary tests such as RiskViewRx Plus because those tests have predetermined drug panels that are not based on the patient’s unique medical history, presumptive screening or current clinical presentation.” Under the Reimbursement section, revised item 2 and 6 removing “strictly prohibited” and adding “ not reimbursed”. The following PLA code was added to the Billing/Coding section: 0079U. Medical Director review 8.2021.
Serum Testing for Evidence of Mild Traumatic Brain Injury AHS – G2151	Reviewed by Avalon 2nd Quarter 2021 CAB. Policy Guidelines updated. References updated. Federal Regulations updated. Medical Director review 7/2021.
ST2 Assay for Chronic Heart Failure AHS – G2130	Reviewed by Avalon 2nd Quarter 2021 CAB. Policy guidelines and references updated. Medical Director review 7/2021.
Testing for Alpha-1 Antitrypsin Deficiency AHS-M2068	Reviewed by Avalon 2nd Quarter 2021 CAB. Description, Policy Guidelines and Reference sections updated. Medical Director review 7/2021.
Testing for Targeted Therapy of Non-Small-Cell Lung Cancer AHS - M2030	Reviewed by Avalon Q2 2021 CAB. Added Related Policies section, updated Policy Guidelines and References. Added CPT code 81479. Medical Director review 7/2021.
Whole Genome and Whole Exome Sequencing AHS – M2032	Reviewed by Avalon 2nd Quarter 2021 CAB. Background, policy guidelines and references updated. The following code was added to the Billing/Coding section: 0209U. Medical Director review 7/2021.
ZIKA Virus Risk Assessment AHS – G2133	Reviewed by Avalon 2nd Quarter 2021 CAB. Literature review updated. State and Federal Regulations updated. Policy Guidelines updated. References updated. Medical Director review 7/2021.