Medical Policy Updates

Medical Policy Update for February 9, 2021

Medical Guidelines	Reason for Update
Belimumab (Benlysta)	Minor updates made to policy for clarity. Medical Director review 2/2021.
Bimatoprost Intracameral Implant (Durysta™)	Added medically necessary coverage criteria for Durysta for treatment of open angle glaucoma or ocular hypertension when specific medical criteria and guidelines are met. Medical Director review 2/2021.
BRCA AHS - M2003	Off-cycle review by Avalon. Under “When Covered” section added exocrine to statement 3.e.; reworded statement 3.l.; reworded Note 1 for clarity. Added CPT code 0172U to Billing/Coding section. Extensive updates to Policy Guidelines section. Updated references. Medical Director review 1/2021.
Diagnostic Testing of Iron Homeostasis and Metabolism AHS – G2011	Reviewed by Avalon 4th Quarter CAB. Medical Director review. Description, Policy Guidelines, and References updated. No changes to policy.
Eculizumab (Soliris®)	Removed the following criteria from “When Covered” section: “patient has a history of at least two relapses during the previous 12 months or three relapses during the previous 24 months (at least one of which has occurred within the previous 12 months).” Blue Cross NC Pharmacy and Therapeutics Committee 1/5/2021. Medical Director review 2/2021.
Esophageal Pathology Testing AHS – M2171	Annual review by Avalon 4th Qtr 2020 CAB. Minor revision to the description section and added the following under Related Policies: “Detection of Circulating Tumor Cells and Cell Free DNA in Cancer Management (Liquid Biopsy) AHS – G2054”. Item #4 under When Not Covered section changed from investigation to “Reimbursement is not allowed…”. Policy guidelines and references updated. Medical Director review 1/2020.
Gene Expression Profiling and Protein Biomarkers for Prostate Cancer Management AHS - M2166	Added PLA code 0005U to Billing/Coding section. Off-cycle review per Avalon, No change to policy statement.
Genetic Testing and Genetic Expression Profiling in Patients with Cutaneous Melanoma AHS-M2029	Reviewed by Avalon Q4 2020 CAB. Under “When Covered’ section: added NRAS and consolidated statements 1. and 2. into one statement addressing both stage III and IV melanoma. References and Description section updated. Extensive revisions/updates to Policy Guidelines section. Added related policies section. Added CPT codes 81311, 81529 to Billing/Coding section. Medical Director review 1/2021.
Genetic Testing for CHARGE Syndrome AHS – M2070	Annual review by Avalon 4th Quarter 2020 CAB. Minor update to policy guidelines; no change to policy intent. Medical Director review 1/2021.
Genetic Testing for Duchenne, Becker, Facioscapulohumeral, Limb-Girdle Muscular Dystrophies AHS – M2074	Annual review by Avalon 4th Quarter 2020 CAB. Added “Related Policies” to the Description section. Minor revision to When Covered section item #1-a.: changed “In a male” to “Individuals”. Minor revisions to policy guidelines and references. No change to policy intent. Medical Director review 1/2021.
Genetic Testing for Familial Cutaneous Malignant Melanoma AHS – M2037	Annual review by Avalon 4th Quarter 2020 CAB. Added “Related Policies” to Description section. Revised investigational statement as follows: “Genetic testing for inherited forms of melanoma is considered investigational.” Policy guidelines and references updated. No change to policy intent. The following codes were added to the Billing/Coding section: 81167, 81216, 81217, 81345; the following codes were removed: 81445 and 81455. Medical Director review 1/2021.
Genetic Testing for Fanconi Anemia AHS – M2077	Annual review by Avalon 4th Quarter 2020 CAB. Minor update to policy guidelines and references. Medical Director review 1/2021.
Genetic Testing for FMR1 Mutations AHS – M2028	Annual review by Avalon 4th Quarter 2020 CAB. Related Policy section added. Minor updates to policy guidelines. No change to policy intent. Medical Director review 1/2021.
Genetic Testing for Germline Mutations of the RET Proto-Oncogene AHS - M2078	Reviewed by Avalon 4th Quarter 2020 CAB. Under When Covered section: removed item C. (as an alternative to annual biochemical testing for C cell hyperplasia); added MTC to statement D.; added “diagnosis of MTC” to statement F. All revisions for clarification and due to 2020 NCCN guidelines. Added CPT codes 81406 and S3840 to Billing/Coding section. Extensive revisions to Policy Guidelines. Add related policies section. References updated. Medical Director review 1/2021.
Genetic Testing for Hereditary Hemochromatosis AHS – M2012	Annual review by Avalon 4th Quarter 2020 CAB. Description section updated. Added item #2 a-c and “NOTE 1” to the When Covered section. Policy guidelines updated. Added CPT code 81479 to the Billing/Coding section. References updated. Medical Director review 1/2021.
Genetic Testing for Lipoprotein A Variant(s) as a Decision Aid for Aspirin Treatment and/or CVD Risk Assessment AHS – M2082	Annual review by Avalon 4th Quarter 2020 CAB. Minor updates to description, policy guidelines and references. Medical Director review 1/2021.
Genetic Testing for Rett Syndrome AHS – M2088	Annual review by Avalon 4th Quarter 2020 CAB. Related Policies added to description section. Policy guidelines and references updated. Added PLA code 0234U to the Billing/Coding section, effective 4/1/21. Medical Director review 1/2021.
Genetic Testing of CADASIL Syndrome AHS – M2069	Annual review by Avalon 4th Quarter CAB 2020. Minor revisions; no change to policy intent. Medical Director review 1/2021.
Genetic Testing of Mitochondrial Disorders AHS – M2085	Annual review by Avalon 4th Quarter 2020 CAB. Related Policies added to description section. Item #3 added as follows to the When Covered section: “Quantification of mtDNA in tissue to diagnose mtDNA depletion syndrome is considered medically necessary.” The following statements were added to the When Not Covered section as follows: “Combination testing of mitochondrial genome testing with WES with intronic variants testing and regulatory variants testing, sometimes referred to as whole exome plus testing, including but not limited to Genomic Unity® Exome Plus Analysis is considered not medically necessary.”, and “Combination testing of mitochondrial genome testing with WGS with intronic variants testing and regulatory variants testing, sometimes referred to as Genomic Unity® Whole Genome Analysis is considered not medically necessary.” Policy guidelines and references updated. Removed code box and added codes 0212U-0215U to the Billing/Coding section. Medical Director review 1/2021.
Hormonal Testing in Adult Males AHS – G2013	Reviewed by Avalon 4th Quarter CAB, Medical Director Review 1/2021. “This policy only addresses coverage of hormonal testing in adult males (age 18 years and older)” added to Description section. When covered criteria updated for clarity by removing language referencing non-adult males from item 1 and 4. References to Notes updated with addition of Note 1 to coverage section. Added code 82681. Policy name changed from Hormonal Testing in Males AHS-G2013 to Hormonal Testing in Adult Males AHS-G2013. Description, Policy Guidelines, and References updated.
Immunohistochemistry AHS – P2018	Reviewed by Avalon 4th Quarter CAB. Medical Director Review 1/2021. Description, Policy Guidelines, and References updates. Coverage Criteria updated for clarity. No change to policy statement.
Inebilizumab-cdon (Uplizna™)	Removed the following criteria from “When Covered” section: “patient has a history of at least one relapse requiring rescue therapy during the previous 12 months OR at least two relapses requiring rescue therapy during the previous 24 months.” Blue Cross NC Pharmacy and Therapeutics Committee 1/5/2021. Medical Director review 2/2021.
Investigational (Experimental) Services - B0005	Last CAP Review date corrected from 2019 to 2020.
Light Therapy for Dermatologic Conditions	Medical Director Review 1/19/2021, policy archived.
Molecular Panel Testing of Cancers for Diagnosis, Prognosis, and Identification of Targeted Therapy AHS - M2109	Added the following CPT codes to the Billing/Coding section after code review by Avalon: 0017M, 81347, 81348, 81357, 81360. No change to policy statement.
Onasemnogene abeparvovec (Zolgensma®)	Added the following statement to “When Covered” section: “For certain identified gene and cellular therapies such as onasemnogene abeparvovec (Zolgensma), when coverage is available and the individual meets medically necessary criteria, distribution from a specialty pharmacy provider due to cost (distribution channel restriction) may be required in order for coverage to be provided. Please contact Care Management to coordinate this therapy.” Specialty Matched Consultant Advisory Panel review 10/21/2020. Medical Director review 11/2020. Policy notification given 12/8/2020 for effective date 2/9/2021.
Orthotics	References added. Specialty Matched Consultant Advisory Panel review 2/18/2020.
Prenatal Screening for Fetal Aneuploidy AHS – G2055	Reviewed by Avalon 4th Quarter 2020 CAB. Medical Director review 1/2021. "Reimbursement is not allowed for the use of the "penta" screen (hCG, AFP, uE3, DIA with NT, and hyperglycosylated hCG) to detect fetal aneuploidy" added to when not covered section. Billing/Coding/Physician Documentation Information sections updated: added codes 82106, 82677 and 0618U, removed code 0124U. Description, Policy Guidelines, and References updated. (bb)
Vitamin B12 and Methylmalonic Acid Testing AHS – G2014	Reviewed by Avalon 4th Quarter CAB. Medical Director review 1/2021. When Covered section updated with addition of bullet 3A4 – Risk Factors: "Patients that have undergone bariatric procedures such as Roux-en-Y gastric bypass sleeve gastrectomy, or biliopancreatic diversion/duodenal switch". Added code 83090. Description, Policy Guidelines, and References updated.
Vitamin D Testing AHS – G2005	Reviewed by Avalon 4th Quarter 2020 CAB. Medical Director review 1/2021. When covered section Guideline 1 updated for clarification: Part N “Lymphoma” was changed to read “Neoplastic hematologic disorders” and moved to become part Q. Description, Policy Guidelines, and References updated. No change to policy statement.
Voretigene Neparvovec-rzyl (Luxturna®)	Added the following statement to “When Covered” section: “For certain identified gene and cellular therapies such as voretigene neparvovec-rzyl (Luxturna), when coverage is available and the individual meets medically necessary criteria, distribution from a specialty pharmacy provider due to cost (distribution channel restriction) may be required in order for coverage to be provided. Please contact Care Management to coordinate this therapy.” Medical Director review 11/2020. Policy notification given 12/8/2020 for effective date 2/9/2021.