Medical Policy Updates

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Medical Policy Update February 8, 2022

Medical Guidelines Reason for Update
Capsule Endoscopy, Wireless Under the Billing/Coding section, added code 91110.
Diagnosis of Vaginitis including Multi-target PCR Testing AHS – M2057 Reviewed by Avalon 4th Quarter 2021 CAB – off cycle review. Description, Policy Guidelines, and References updated. Updated when covered section “Reimbursement is allowed for Nucleic Acid Amplification Test (NAAT), PCR testing, and Multitarget polymerase chain reaction (PCR) testing for diagnosis of bacterial vaginosis.” Medical Director review 1/2022.
Diagnostic Testing of Iron Homeostasis and Metabolism AHS – G2011 Reviewed by Avalon 4th Quarter 2021 CAB. Medical Director review. Description, Policy Guidelines, and References updated. CPT codes 83540, 83550, and 0251U added to the Billing/Coding section. No changes to policy statement.
Gene Expression Profiling and Protein Biomarkers for Prostate Cancer AHS - M2166 Reviewed by Avalon Q4 2021 CAB. Removed PLA code 0244U from Billing/Coding section. Medical Director review 1/2022. No change to policy statement.
Genetic Testing and Genetic Expression Profiling in Patients with Cutaneous Melanoma AHS-M2029 Reviewed by Avalon Q4 2021 CAB. Policy Guidelines and references updated. Medical Director review 1/2022. No change to policy statement.
Genetic Testing for CHARGE Syndrome AHS – M2070 Reviewed by Avalon 4th Quarter 2021 CAB. Under the When Covered section, added the following to item #1 for clarity: “(Coloboma, Heart defects, Atresia choanae, Growth retardation, Genital abnormalities, and Ear abnormalities)”. Replaced the word “mutation” with “genetic” for clarity in both When Covered and When Not Covered sections. No change to policy intent. Description, policy guidelines, and references updated with minor revisions. Medical Director review 1/2022.
Genetic Testing for Duchenne, Becker, Facioscapulohumeral, Limb-Girdle Muscular Dystrophies AHS – M2074 Reviewed by Avalon 4th Quarter 2021 CAB. Under the When Covered section, added “BMD” and “OR” to item #1 and under the When Not Covered section, added “BMD” to item #1 for clarity; no change to policy intent. Description, policy guidelines, and references updated with minor revisions. Medical Director review 1/2022.
Genetic Testing for Epilepsy AHS – M2075 Specialty Matched Consultant Advisory Panel review 10/20/2021.
Genetic Testing for Familial Cutaneous Malignant Melanoma AHS – M2037 Reviewed by Avalon 4th Quarter 2021 CAB. Description, policy guidelines, and references updated with minor revisions. Medical Director review 1/2022.
Genetic Testing for Fanconi Anemia AHS – M2077 Reviewed by Avalon 4th Quarter 2021 CAB. Items B and C were removed from item #2 under the When Covered section as follows: “B. A definitive diagnosis of Fanconi Anemia cannot be made after standard workup, i.e., non-diagnostic results on chromosome breakage analysis, OR C. Diagnostic results on chromosome breakage test is positive”. Description, policy guidelines, and references updated with minor revisions. Medical Director review 1/2022.
Genetic Testing for FMR1 Mutations AHS – M2028 Reviewed by Avalon 4th Quarter 2021 CAB. Description, policy guidelines, and references updated with minor revisions. Medical Director review 1/2022.
Genetic Testing for Germline Mutations of the RET Proto-Oncogene AHS - M2078 Reviewed by Avalon Q4 2021 CAB. Policy Guidelines, guidelines and recommendations, references updated. No change to policy statement. Medical Director review 1/2022.
Genetic Testing for Hereditary Hemochromatosis AHS – M2012 Reviewed by Avalon 4th Quarter 2021 CAB. Description, policy guidelines, and references updated with minor revisions. Medical Director review 1/2022.
Genetic Testing for Lipoprotein A Variant(s) as a Decision Aid for Aspirin Treatment and/or CVD Risk Assessment AHS – M2082 Reviewed by Avalon 4th Quarter 2021 CAB. Description, policy guidelines, and references updated with minor revisions. Medical Director review 1/2022.
Genetic Testing for Rett Syndrome AHS – M2088 Reviewed by Avalon 4th Quarter 2021 CAB. Acronyms for CDKL5 and FOXG1 spelled out in item #1 under the When Covered section for clarity. No change to policy intent. Description, policy guidelines, and references updated with minor revisions. Medical Director review 1/2022.
Genetic Testing of CADASIL Syndrome AHS – M2069 Reviewed by Avalon 4th Quarter 2021 CAB. Under the When Covered section, added the following to item #1 for clarity: “cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy”; no change to policy intent. Description, policy guidelines, and references updated with minor revisions. Medical Director review 1/2022.
Genetic Testing of Mitochondrial Disorders AHS – M2085 Reviewed by Avalon 4th Quarter 2021 CAB. Acronyms for MELAS, MERRF, CPEO. mtDNA, WES, and WGS spelled out in both covered and noncovered sections for clarity; no change to policy intent. Description, policy guidelines, and references updated with minor revisions. Medical Director review 1/2022.
Hormonal Testing in Adult Females AHS – G2161 Policy archived.
Immunohistochemistry AHS – P2018 Reviewed by Avalon 4th Quarter 2021 CAB. Medical Director Review 1/2022. Description, Policy Guidelines, and References updates. No change to policy statement.
In Vitro Chemoresistance and Chemosensitivity Assays AHS- G2100 Reviewed by Avalon Q4 2021 CAB. Added CPT code 0564T to Billing/Coding section. Medical Director review 1/2022. No change to policy statement.
Molecular Markers in Fine Needle Aspirates of the Thyroid AHS - M2108 Reviewed by Avalon Q4 2021 CAB. Removed PLA code 0208U from Billing/Coding section. Medical Director review 1/2022. No change to policy statement.
Myoelectric Prosthetic Components for the Upper Limb Reference added. Specialty Matched Consultant Advisory Panel review 6/16/2021.
Prenatal Screening for Fetal Aneuploidy AHS – G2055 Reviewed by Avalon 4th Quarter 2021 CAB. Coding section updated – removed 0168U. Description, Policy Guidelines, and References updated. No change to policy statement. Related policies added. Medical Director review 1/2022.
Prostate Biopsies AHS – G2007 Specialty Matched Consultant Advisory Panel review 11/17/2021.
Prostatic Urethral Lift Reference added. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 11/17/2021.
Proteogenomic Testing of Individuals with Cancer AHS-M2168 Reviewed by Avalon Q4 2021 CAB. Removed PLA code 0211U from Billing/Coding section. Medical Director review 1/2022. No change to policy statement.
Surgery for Groin Pain in Athletes Reference added. Specialty Matched Consultant Advisory Panel review 6/16/2021.
Temporomandibular Joint Dysfunction (TMJD) Billing/Coding/Physician Documentation information section updated. Added code 21299 to the following statement: Codes 21089 and 21299 should not be reported for orthotic to treat temporomandibular joint dysfunction. This is not an appropriate code because an orthotic or splint for treatment of temporomandibular joint disease is not an “unlisted maxillofacial prosthetic procedure.”. Medical Director review 1/2022.
Testing for Autism Spectrum Disorder and Developmental Delay AHS – M2176 Reviewed by Avalon 4th Quarter 2021 CAB. Description, policy guidelines, and references updated with minor revisions. Added code 0263U and removed 0139U under the Billing/Coding section. Medical Director review 1/2022.
Testing of Homocysteine Metabolism Related Conditions AHS – M2141 Reviewed by Avalon 4th Quarter 2021 CAB. Description, Policy Guidelines, and References updated. Related policies added. No change to policy statement. Medical Director review 1/2022.
Testosterone Testing AHS – G2013 Policy re-titled, “Testosterone Testing” for consistency with Avalon. Reviewed by Avalon 4th Quarter 2021 CAB, Medical Director Review 1/2022. Removed CPT codes: 82021, 83001, 83001, 83003, 84146, 84443. When covered criteria updated: removed language related to codes removed; Added Reimbursement is allowed for testing for serum total testosterone* (See Note 1) symptomatic females being evaluated for conditions associated with androgen excess (e.g., polycystic ovary syndrome and functional hypothalamic amenorrhea). The technology used for testing should be sensitive enough to detect the low concentrations normally found in females.” When not covered criteria updated: Changed “males” to “individuals” in item 4; Added Reimbursement is not allowed for testing for serum testosterone for the identification of androgen deficiency in women. Policy Guidelines and References updated. Description updated, changed “males” to “individuals”.
Vitamin B12 and Methylmalonic Acid Testing AHS – G2014 Reviewed by Avalon 4th Quarter 2021 CAB. Medical Director review 1/2022. Description, Policy Guidelines, and References updated. Related policies added. No change to policy statement.
Vitamin D Testing AHS – G2005 Reviewed by Avalon 4th Quarter 2021 CAB. Medical Director review 1/2022. Description, Policy Guidelines, and References updated. Related policy added. No change to policy statement.
Whole Gland Ablative Treatments of Prostate Cancer Medical Director review. Reference added. Policy updated and returned to active review. Policy statement updated to include both cryoablation and high intensity focused ultrasound as covered when criteria are met.