Medical Policy Updates

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Medical Policy Update July 01, 2021

Medical Guidelines Reason for Update
Ambulatory Event Monitors The following code was added to the Billing/Coding section effective 7/1/21: 0650T.
Artificial Pancreas Device Systems References added. Specialty Matched Consultant Advisory Panel review 6/16/2021. Medical Director review. No change to policy statement.
Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions Reference added. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 6/16/2021.
Autologous Chondrocyte Implantation Description section updated. Related Policy removed. Specialty Matched Consultant Advisory Panel review 6/16/2021.
Capsule Endoscopy, Wireless References updated. The following code was added to the Billing/Coding section effective 7/1/21: 0651T. Specialty Matched Consultant Advisory Panel 5/2020. Medical Director review 5/2020.
Cardiac (Heart) Transplantation Minor updates to description section and policy guidelines. References updated. Specialty Matched Consultant Advisory Panel review 6/2021. Medical Director review 6/2021.
Carotid Artery Angioplasty/Stenting (CAS) Description section revised; replaced listed approved carotid artery stents and EPDs with Table 1 and Table 2 for updated listing of approved devices for clarity. Updated policy guidelines and references. No change to policy intent. Specialty Matched Consultant Advisory Panel review 6/2021. Medical Director review 6/2021.
Congenital Heart Defect, Repair Devices Minor revision to regulatory status. References updated. Specialty Matched Consultant Advisory Panel review 6/2021. Medical Director review 6/2021.
Continuous Monitoring of Glucose in the Interstitial Fluid Description, Policy Guidelines, References updated. Specialty Matched Consultant Advisory Panel review 6/16/2021. No change to policy statement.
Detection of Circulating Tumor Cells and Cell Free DNA in Cancer Management (Liquid Biopsy) AHS-G2054 Reviewed by Avalon 1st Quarter 2021 CAB. Medical Director review 4/2021, 6/2021. Added CPT codes 81162, 81163, 81164, 0011M, 0155U, 0177U, 0179U, 0229U, 0239U, 0242U to Billing/Coding section; removed CPT 81277. Updated Description and Policy Guidelines. Added Related Policies section under Description. Under “When Covered” section, added “Note: If the above criteria for medical necessity have been met (i.e., when tissue biopsy is contraindicated or quantity of tissue available is insufficient), panel testing using NGS for up to 50 genes may be performed.” Added references. No change to policy intent.
Focal Treatments for Prostate Cancer Added new code 0655T to the Billing/Coding section
Gender Affirmation Surgery and Hormone Therapy Medical necessity criteria added for facial surgery. Added specificity for which genital and chest procedures are covered. Tracheal shave and voice lessons added as medically necessary. Laryngoplasty added as investigational. Reversal surgery added as investigational. Several not medically necessary surgical and cosmetic services added as not medically necessary. Billing/Coding section updated.
Gene Expression Testing for Breast Cancer Prognosis AHS - M2020 Temporary expansion of benefit related to COVID-19 pandemic removed. Medical Director review 4/20/2021. Notification given 5/4/2021 for effective date 6/30/2021.

Reviewed by Avalon Q1 2021 CAB. Medical Director review 4/2021. Under “When Covered” section: added coverage statement for Breast Cancer Index (BCI). Updated Description and Policy Guidelines sections. Added references. Added PLA codes 0045U, 0153U to Billing/Coding section. (lpr)
General Genetic Testing, Germline Disorders AHS – M2145 Reviewed by Avalon 1st Quarter 2021 CAB. The following codes were added to the Billing/Coding section for PPA effective 7/1/21: 0230U, 0232U, 0236U; code 0129U was removed from this section. Medical Director review.
Genetic Cancer Susceptibility Panels Using Next Generation Sequencing AHS-M2066 Reviewed by Avalon 1st Quarter 2021 CAB. Medical Director review 4/2021. Updated Policy Guidelines and References. Under Billing/Coding section: added PLA code 0129U.
Genetic Testing for Cystic Fibrosis AHS – M2017 Off-cycle review by Avalon 1st Quarter 2021 CAB. CPT codes 81220 and 81221 added to Billing/Coding section for PPA effective date of 7/1/21. Medical Director review.
Genetic Testing for Inherited Cardiomyopathies and Channelopathies AHS – M2025 Reviewed by Avalon 1st Quarter 2021 CAB. Added the following to the When Covered section - item 5, a and b: “Patients have a” for clarity. Added CPT code 0237U to Billing/Coding section for PPA effective 7/1/21. Specialty Matched Consultant Advisory Panel review 4/2021. Medical Director review 4/2021.
Growth Factors in Wound Healing References added. Policy Guidelines updated.
Heart-Lung Transplantation Minor revisions to description section. Item #1 revised under When Covered section with current terminology as follows: replaced the term “primary” with “idiopathic pulmonary arterial hypertension.” References updated. Specialty Matched Consultant Advisory Panel review 6/2021. Medical Director review 6/2021
Hormonal Testing in Adult Males AHS – G2013 Specialty Matched Consultant Advisory Panel review 6/16/2021. Medical Director review. No change to policy statement.
Hormonal Testing in Adult Females AHS – G2161 Specialty Matched Consultant Advisory Panel review 06/16/2021. Medical Director review. No change to policy statement.
Implantable Cardioverter Defibrillator Specialty Matched Consultant Advisory Panel review 6/2021. Medical Director review 6/2021.
Insulin Therapy, Chronic Intermittent Intravenous (CIIIT) Policy Guidelines updated. References added. Specialty Matched Consultant Advisory Panel review 6/2021
Intensity Modulated Radiation Therapy (IMRT) of Head and Neck Under “When Covered” section: added coverage for epithelial head and neck cancer as well as locally advanced skin cancers with regional lymph node metastases. Medical Director review
Islet Cell Transplantation Guidelines and Recommendations added to Policy Guidelines. Reference added. Specialty Matched Consultant Advisory Panel review 6/2021. No change to policy statement.
Lipid Apheresis Policy archived. Medical Director review
Lynch Syndrome AHS-M2004 Reviewed by Avalon 1st Quarter 2021 CAB. Medical Director review 4/2021. Updated “When Covered” section: wording stating “in a tissue specimen of an” was removed from statement B; removed the following statements: if no known LS mutation AND colorectal or endometrial tumor tissue is available, then tumor testing with immunohistochemistry (IHC) and/or microsatellite instability (MSI) (for an individual meeting criteria in Note 1); LS-specific testing or multi-gene testing as a universal testing strategy without IHC or MSI for individuals if no known familial LS mutation and colorectal (or endometrial) tumor tissue is available; If no known LS mutation AND sufficient colorectal or endometrial tumor tissue is not available, then LS-specific testing—MLH1 , MSH2 , MSH6 , PMS2 , and EPCAM—OR multi-gene testing that includes concurrent testing of MLH1, MSH2, MSH6, PMS2 , and EPCAM for an individual meeting criteria in Note 2. Added the following statement C: If no known LS pathogenic variant in family, germline multi-gene testing OR tumor testing with immunohistochemistry (IHC) and/or microsatellite instability (MSI) is considered medically necessary in individuals meeting criteria in Note 1. Notes 1-2 clarified. Note 3 removed. Updated Policy Guidelines sections. Updated references. Under Billing/Coding section: added PLA code 0238U.
Margetuximab-cmkb (Margenza™) Added HCPCS code J9353 to Billing/Coding section effective 7/1/2021, deleted codes C9399, J3490, J3590, and J9999 termed 6/30/2021. Blue Cross NC Pharmacy and Therapeutics Committee 3/23/2021. Blue Cross NC Pharmacy and Therapeutics Committee 6/29/2021.
Melphalan Flufenamide (Pepaxto®) Added HCPCS code C9080 to Billing/Coding section effective 7/1/2021, deleted code C9399 termed 6/30/2021. Blue Cross NC Pharmacy and Therapeutics Committee 6/29/2021.
Molecular Markers in Fine Needle Aspirates of the Thyroid AHS - M2108 Reviewed by Avalon 1st Quarter 2021 CAB. Medical Director review 4/2021. Under “When Not” covered statement 2: added nondiagnostic or unsatisfactory Bethesda I or benign Bethesda II reference. Updated Note 1 for clarity: added statement “except for genomic expression classifiers.” Table in Note 2 updated. Updated Policy Guidelines, Description and References. Added Related Policies section. Under Billing/Coding section: added CPT code 81546, PLA codes: 0204U, 0208U, 0245U.
Monoclonal Antibodies for Non-Hodgkin Lymphoma and Acute Myeloid Leukemia In the Non-Hematopoietic Stem Cell Transplant Setting Added HCPCS code Q5123 to Billing/Coding section effective 7/1/2021, deleted codes C9399, J3490, J3590, and J9999 termed 6/30/2021. Blue Cross NC Pharmacy and Therapeutics Committee 1/5/2021. Blue Cross NC Pharmacy and Therapeutics Committee 3/23/2021.
Naxitamab-gqgk (Danyelza®) Added HCPCS code J9348 to Billing/Coding section effective 7/1/2021, deleted codes C9399, J3490, J3590, and J9999 termed 6/30/2021. Blue Cross NC Pharmacy and Therapeutics Committee 3/23/2021.
Parathyroid Hormone, Phosphorus, Calcium, and Magnesium Testing AHS – G2164 Specialty Matched Consultant Advisory Panel review 6/2021.
Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention Specialty Matched Consultant Advisory Panel review 6/2021. Medical Director review 6/2021.
Phrenic Nerve Stimulation for Central Sleep Apnea Description section updated. References added. Specialty Matched Consultant Advisory Panel 3/2021. Medical Director review 4/2021. No changes to policy statement.
Preimplantation Genetic Testing AHS – M2039 Reviewed by Avalon 1st Quarter 2021 CAB. Updated Description, Policy Guidelines, and References. No change to policy statement. Medical Director review 4/2021.
Professional Pathology Billing Guidelines AHS – R2169 Replaced the term “Blue Cross NC” with “Blue Cross and Blue Shield of North Carolina (BCBSNC) throughout the policy. Minor revisions to Description section. Replaced the term “guidelines with “requirements” within the policy statement. Removed the following statement from under the heading – Billing Guidelines: “INFORMATION IN THIS CHART HIGHLIGHTS THE MOST FREQUENTLY USED PLACED OF SERVICE SCENARIOS” and replaced with “The chart below is how pathology claims must be filed in order to process and pay appropriately.” Moved the term “Reference Laboratory” and corresponding definition under the “DEFINITIONS” table. Under the Billing/Coding section, replaced the statement “This policy may apply to the following codes” with “Applicable codes for this policy are for reference only and may not be all inclusive”; added the Clinical pathology code ranges. Paragraph under the Policy Implementation/Update Information section revised for policy cohesion and clarity. Notification given 4/20/21 for effective date 7/1/21 Medical Director review 4/2021.
Skilled Nursing Services When covered section criteria 6->e) removed. Medical Director review 4/20/2021. Notification given 5/4/2021 for effective date 6/30/2021
Surgical Management of Transcatheter Heart Valves Minor update to policy guidelines and references updated. Added the following to the policy statement under the When Covered section for Transcatheter Pulmonary Valve Implantation - may be considered medically necessary “with a Food and Drug Administration-approved valve”. No change to policy intent. The following code was added to the Billing/Coding section effective 7/1/21: 0646T. Specialty Matched Consultant Advisory Panel review 6/2021. Medical Director review 6/2021.
Surgical Ventricular Restoration Minor update to policy guidelines and references updated. Specialty Matched Consultant Advisory Panel review 6/2021. Medical Director review 6/2021.
Thyroid Disease Testing AHS – G2045 Specialty Matched Consultant Advisory Panel review 06/17/2021.
Transcatheter Closure of Ventricular Septal Defects Specialty Matched Consultant Advisory Panel review 6/2021. Medical Director review 6/2021.
Trilaciclib (Cosela™) Added HCPCS code C9078 to Billing/Coding section effective 7/1/2021, deleted code C9399 termed 6/30/2021. Blue Cross NC Pharmacy and Therapeutics Committee 6/29/2021.