Medical Policy Updates

Medical Policy Update July 26, 2022

Medical Guidelines	Reason for Update
Amniotic Membrane and Amniotic Fluid Injections for Ophthalmic Indications	Specialty Matched Consultant Advisory Panel review 6/2022. Medical Director review 6/2022. No change to policy statement.
Aqueous Shunts and Devices for Glaucoma	Specialty Matched Consultant Advisory Panel review 6/2022. Updated policy guidelines and references added.
Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions	Reference added. Specialty Matched Consultant Advisory Panel review 6/29/2022.
Autologous Chondrocyte Implantation	Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 6/29/2022.
BRCA AHS - M2003	Reviewed by Avalon 1st Quarter 2022 CAB. Medical Director review 4/2022. Under “When Not Covered” section added new non-covered indication “genetic testing in minors < 18 years of age” is not medically necessary. Reformatted “When Covered” section. Note 5 removed. Updated policy guidelines and references. Notification 5/17/22 for effective date 7/26/22.
Capsule Endoscopy, Wireless	When Covered section revised; moved Patient Selection criteria from the policy guidelines up under main bullet 1 and 3 for clarity, no change to policy intent.
Computer Assisted Surgical Navigational Orthopedic Procedures	Reference added. Policy Guidelines updated. Expired code 0396T removed from Billing/Coding section. Specialty Matched Consultant Advisory Panel 6/29/2022.
Computerized Corneal Topography	Specialty Matched Consultant Advisory Panel review 6/2022. Medical Director review 6/2022. No change to policy statement.
Corneal Collagen Cross-linking	Specialty Matched Consultant Advisory Panel review 6/2022. Updated policy guidelines and added reference.
Electrical Bone Growth Stimulation	Description section updated. Regulatory Status updated. Specialty Matched Consultant Advisory Panel review 6/29/2022.
Epiretinal Radiation Therapy for Age-Related Macular Degeneration	Specialty Matched Consultant Advisory Panel review 6/2022. Removed CPT code 0190T from Billing/Coding section. Added CPT code 67299 to Billing/Coding section. Updated description section.
Extracorporeal Shock Wave Treatment for Musculoskeletal Conditions and Wound Healing	Specialty Matched Consultant Advisory Panel review 6/29/2022.
Eyelid Thermal Pulsation for the Treatment of Dry Eye Syndrome	Specialty Matched Consultant Advisory Panel review 6/2022. Updated description section and added references. Medical Director review 6/2022.
Fundus Photography	Specialty Matched Consultant Advisory Panel review 6/2022. Medical Director review 6/2022. No change to policy statement.
Glaucoma, Evaluation by Ophthalmologic Techniques	Specialty Matched Consultant Advisory Panel review 6/2022. Medical Director review 6/2022.
Immunopharmacologic Monitoring of Therapeutic Serum Antibodies AHS - G2105	Reviewed by Avalon 1st Quarter 2022 CAB – off cycle review. Updated When not Covered section to add “Reimbursement is not allowed for drug and/or antibody concentration testing for anti-TNF therapies in patients with spondyloarthritis, rheumatoid arthritis, psoriatic arthritis, and psoriasis.” References updated. Medical Director review 4/2022. Notification given 5/17/2022 for policy effective date 7/26/2022.
Keratoprosthesis	Specialty Matched Consultant Advisory Panel review 6/2022. Medical Director review 6/2022. No change to policy statement.
Magnetic Esophageal Sphincter Augmentation to Treat Gastroesophageal Reflux Disease (GERD)	Medical Director review. When Covered section updated to state that laparoscopic magnetic esophageal sphincter augmentation may be considered medically necessary when criteria are met. When Not Covered section updated with non-covered criteria. Policy Guidelines updated.
Meniscal Allografts and Other Meniscal Implants	Specialty Matched Consultant Advisory Panel review 6/29/2022.
Myoelectric Prosthetic Components for the Upper Limb	Specialty Matched Consultant Advisory Panel review 6/29/2022.
Optical Coherence Tomography (OCT) Anterior Segment of the Eye	Specialty Matched Consultant Advisory Panel review 6/2022. Updated description section. Updated policy guidelines section. Medical Director review 6/2022.
Patient-Specific Instrumentation (e.g., Cutting Guides) for Joint Arthroplasty	References added. Specialty Matched Consultant Advisory Panel review 6/29/2022.
Refractive Surgery	Specialty Matched Consultant Advisory Panel review 6/2022. Medical Director review 6/2022.
Retinal Prosthesis	Specialty Matched Consultant Advisory Panel review 6/2022. Removed HCPCS code L8698 from Billing/Coding section. Medical Director review 6/2022.
Surgery for Femoroacetabular Impingement	Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 6/29/2022.
Surgery for Groin Pain in Athletes	Specialty Matched Consultant Advisory Panel review 6/29/2022.
Thyroid Disease Testing AHS – G2045	Reviewed by Avalon 1st Quarter 2022 CAB. Description, Policy Guidelines and References updated. When Covered section reorganized and updated for clarity. Added “Reimbursement is not allowed for testing for thyrotropin-releasing hormone (TRH) for the evaluation of the cause of hyperthyroidism or hypothyroidism.” to When Not Covered section. Medical Director review 4/2022 Notification given on 5/17/2022 for effective date 7/26/2022.
Vertebral Axial Decompression (VAD-X)	Reference added. Specialty Matched Consultant Advisory Panel review 6/29/2022.
Viscocanalostomy and Canaloplasty	Specialty Matched Consultant Advisory Panel review 6/2022. Updated description section and added references. Medical Director review 6/2022.