Medical Policy Updates

Medical Policy Update July 13, 2021

Medical Guidelines Reason for Update
Adaptive Behavioral Treatment for Autism Spectrum Disorders Specialty Matched Consultant Advisory Panel Review 6/2021. References added. No change to policy statement.
Amniotic Membrane and Amniotic Fluid Injections for Ophthalmic Indications Specialty Matched Consultant Advisory Panel review 6/16/2021. Reference added. Medical Director review. No change to policy statement.
Aqueous Shunts and Devices for Glaucoma Specialty Matched Consultant Advisory Panel review 6/16/2021. Reference added. Added CPT codes 0660T, 0661T to Billing/Coding section effective 7/1/2021. Medical Director review. No change to policy statement.
Balloon Dilation of the Eustachian Tube Specialty Matched Consultant Advisory Panel review 2/17/2021.
BRCA AHS - M2003 Reviewed by Avalon 1st Quarter 2021 CAB. Medical Director review 4/2021. Under “When Not Covered” section added two non-covered indications: c. Women diagnosed with breast cancer at age >65 years, with no close relative with breast, ovarian, pancreatic, or prostate cancer as there is a low probability that testing will have findings of documented clinical utility; d. Men diagnosed with localized prostate cancer with Gleason Score <7 and no close relative with breast, ovarian, pancreatic, or prostate cancer as there is a low probability that testing will have findings of documented clinical utility. Clarified items in “When Covered” section with no content changes. Updated Policy Guidelines section as well as References. Under Description section added related policy AHS-M2066 Genetic Cancer Susceptibility Using Next Generation Sequencing. Reordered and clarified *Notes 1-5. Notification 5/4/21 for effective date 7/13/21.
Computerized Corneal Topography Specialty Matched Consultant Advisory Panel review 6/16/2021. Reference added. Updated Description. Medical Director review. No change to policy statement.
Corneal Collagen Cross-linking Specialty Matched Consultant Advisory Panel review 6/16/2021. Reference added. Updated Description section. Medical Director review. No change to policy statement.
Dynamic Posturography Specialty Matched Consultant Advisory Panel review 2/17/2021.
Enteral Nutrition Policy updated to support coverage of Relizorb when the criteria indicated in the When Covered section are met. Description section, Policy statement, When Covered, When Not Covered, and policy guidelines revised in support of positive coverage of Relizorb. CPT code B4105 noticed for PPA 7/13/21, effective 10/1/21. References updated. Specialty Matched Consultant Advisory Panel 5/2021. Medical Director review 7/2021.
Epiretinal Radiation Therapy for Age-Related Macular Degeneration Specialty Matched Consultant Advisory Panel review 6/16/2021. Reference added. Medical Director review 6/2021. No change to policy statement.
Evaluation of Dry Eyes AHS - G2138 Specialty Matched Consultant Advisory Panel review 6/16/2021. Medical Director review 6/2021. No change to policy statement.
Eyelid Thermal Pulsation for the Treatment of Dry Eye Syndrome Specialty Matched Consultant Advisory Panel review 6/16/2021. Updated Description section. Reference added. Medical Director review 6/2021. No change to policy statement.
Fundus Photography Specialty Matched Consultant Advisory Panel review 6/16/2021. Medical Director review 6/2021. No change to policy statement.
Genetic Testing and Genetic Expression Profiling in Patients with Uveal Melanoma AHS - M2071 Specialty Matched Consultant Advisory Panel review 6/16/2021. Medical Director review 6/2021. No change to policy statement.
Glaucoma, Evaluation by Ophthalmologic Techniques Specialty Matched Consultant Advisory Panel review 6/16/2021. Reference added. Medical Director review 6/2021. No change to policy statement
Implantable Bone Conduction Hearing Aids Specialty Matched Consultant Advisory Panel review 2/17/2021.
Keratoprosthesis Specialty Matched Consultant Advisory Panel review 6/16/2021. Reference added. Medical Director review 6/2021. No change to policy statement.
Optical Coherence Tomography (OCT) Anterior Segment of the Eye Specialty Matched Consultant Advisory Panel review 6/16/2021. Reference added. Medical Director review 6/2021. No change to policy statement.
Quantitative Electroencephalography as a Diagnostic Aid for Attention Deficit/Hyperactivity Disorder Biofeedback for the evaluation and diagnosis for attention-deficit disorder was added as medically necessary to the policy statement and When Covered sections. Policy Guidelines updated with 2019 AAP practice guidelines. The following CPT codes were added to the Billing/Coding section applicable to biofeedback: 90875, 90876, 90901. References added. Specialty Matched Consultant Advisory Panel review 6/2021. Medical Director review 6/2021.
Refractive Surgery Specialty Matched Consultant Advisory Panel review 6/16/2021. Reference added. Medical Director review 6/2021. No change to policy statement.
Retinal Prosthesis Specialty Matched Consultant Advisory Panel review 6/16/2021. Reference added. Medical Director review 6/2021. No change to policy statement.
Sensory Integration Therapy and Auditory Integration Therapy Description updated. Specialty Matched Consultant Advisory Panel review 6/2021. Medical Director review 6/2021. No change to policy statement.
Temporomandibular Joint Dysfunction (TMJD) Billing/Coding/Physician Documentation information section updated- added codes D7880 and D7881, added the following: “Code 21089 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.”. Reference added. Medical Director review. Policy noticed 5/4/2021 for effective date 7/13/2021.
Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric /Neurologic Disorders References added. Specialty Matched Consultant Advisory Panel review 6/2021. Medical Director review. No change to policy statement
Treatment For Opioid Use Disorder in Opioid Treatment Programs (OTPs) Description section updated with “Related policies, Evaluation and Management Services”. Specialty Matched Consultant Advisory Panel review 6/2021. Medical Director review 6/2021.
Venous and Arterial Thrombosis Risk Testing AHS – M2041 Reviewed by Avalon 1st Quarter 2021 CAB. Specified “deep” venous thrombosis throughout policy for clarity. The following changes made to the When Covered section: Item 1 – added item i.- ” Pediatric arterial ischemic stroke”; item 2 – added statement “Assays for clotting inhibitors amount and function should be performed prior to any molecular testing.” And item k. “Pediatric arterial ischemic stroke”. The following changes were made to the When Not Covered section: Item 2 – added statement “Reimbursement is not allowed for venous thrombosis risk testing for superficial venous thrombosis (including superficial thrombophlebitis and varicosities).”; to item 3 – added h. “Testing more than once per lifetime”. Policy guidelines and references updated. Policy noticed 5/18/21; effective 7/13/21. Medical Director review 4/2021.
Viscocanalostomy and Canaloplasty Specialty Matched Consultant Advisory Panel review 6/16/2021. Reference added. Medical Director review 6/2021. No change to policy statement.