Medical Policy Updates

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Medical Policy Update June 30, 2022

Medical Guidelines Reason for Update
Bariatric Surgery References added. Medical Director review. Amended statement 5 on page 2 by adding the words “one anastomosis gastric bypass (OAGB)” and removing the words “mini gastric bypass”. Code 43659 added. The following statements were added: “One anastomosis gastric bypass (OAGB) is a “combined procedure”, and it has both a “restrictive” and a “malabsorptive” component”, “The International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) issued a position statement on the role of one anastomosis gastric bypass (OAGB) in the field of bariatric/metabolic surgery in 2018. In order to avoid confusion between the Billroth II Gastrojejunostomy and the Roux en Y procedure, OAGB has been recommended as the preferred terminology”, and “The unlisted stomach code, CPT 43659, is most appropriate for the OAGB at this time”. On page 7 under When Bariatric Surgery is covered, added “One anastomosis gastric bypass (OAGB) using the Billroth II gastrojejunostomy with gastric partitioning”. On page 8 under When Bariatric Surgery is not covered, removed “Gastric bypass using a Billroth II type of anastomosis, popularized as the mini gastric bypass”.
Capsule Endoscopy, Wireless Policy title updated. Policy formatting updated to align with the new utilization management tool. No changes to policy statement or intent. Updated Regulatory Status under the Description section. Added investigational statement regarding magnetic capsule endoscopy to the When Not Covered section as follows: “Magnetic capsule endoscopy is considered investigational for the evaluation of patients with unexplained upper abdominal complaints and all other indications.” Policy guidelines updated. No change to policy intent. Specialty Matched Consultant Advisory Panel 5/2022. Medical Director review 5/2022.
Electrogastrography, Cutaneous Policy title updated. Policy formatting updated to align with the new utilization management tool. No changes to policy statement or intent. Specialty Matched Consultant Advisory Panel 5/2022. Medical Director review 5/2022.
Enteral Nutrition Policy title updated. Policy formatting updated to align with the new utilization management tool. No changes to policy statement or intent. Specialty Matched Consultant Advisory Panel 5/2022. Medical Director review 5/2022.
Esophageal Pathology Testing AHS – M2171 Off-cycle minor revision: added the following statement to the Description section, “For guidance concerning Tumor Mutational Burden Testing (TMB) and/or Microsatellite instability (MSI) analysis please refer to the AHS-M2178-Microsatellite Instability and Tumor Mutational Burden Testing policy.”; added AHS M2178 to the Related Policies section.
Esophageal pH Monitoring Policy title updated. Policy formatting updated to align with the new utilization management tool. No changes to policy statement or intent. Minor update to Description section. Specialty Matched Consultant Advisory Panel 5/2022. Medical Director review 5/2022.
Gastric Electrical Stimulation Policy title updated. Policy formatting updated to align with the new utilization management tool. No changes to policy statement or intent. Specialty Matched Consultant Advisory Panel 5/2022. Medical Director review 5/2022.
General Genetic Testing, Germline Disorders AHS – M2145 Reviewed by Avalon 1st Quarter 2022 CAB. Policy guidelines updated; added Table of Terminology. The following codes were added to Billing/Coding section: 0269U, 0270U, 0271U, 0272U, 0273U, 0274U, 0276U, 0277U, 0318U. Medical Director review 4/2022.
Growth Factors in Wound Healing Policy Guidelines updated.
Investigational (Experimental) Services COVID-19 related changes extended “effective from March 6, 2020, through September 30, 2022. We will reevaluate if an additional extension is needed as we approach September 30.” Medical Director review.
Laboratory Procedures Medical Policy AHS - R2162 The following PLA code was added to the Billing/Coding section: 0331U.
Molecular Markers in Fine Needle Aspirates of the Thyroid AHS - M2108 Reviewed by Avalon Q1 2022 CAB. Medical Director review 4/2022.Added PLA code 0287U to Billing/Coding section effective 7/1/22. Deleted Notes 1&2 for removal of 50 gene limit for cancer screening. Added new note for 5 or more gene tests run on the same platform. Updated policy guidelines and added references.
Non-Contact Ultrasound Treatment for Wounds Routine policy review.
Pancreas Transplant Policy title updated. Policy formatting updated to align with the new utilization management tool. No changes to policy statement or intent. Description section updated. Specialty Matched Consultant Advisory Panel 5/2022. Medical Director review 5/2022.
Pathogen Panel Testing AHS – G2149 The following PLA codes were added to the Billing/Coding section: 0323U, 0330U.
Peroral Endoscopic Myotomy for Treatment of Esophageal Achalasia Policy title updated. Policy formatting updated to align with the new utilization management tool. No changes to policy statement or intent.
Prenatal Screening for Fetal Aneuploidy AHS – G2055 Added 0327U to billing/coding section effective 7/1/2022.
Prescription Medication and Illicit Drug Testing in the Outpatient Setting AHS – T2015 Added code 0328U to billing/coding section. Effective 7/1/2022.
Small Bowel, Small Bowel with Liver, or Multivisceral Transplant Policy titled updated. Policy formatting updated to align with new utilization management tool. No changes to policy statement or intent. Specialty Matched Consultant Advisory Panel 5/2022. Medical Director review 5/2022.
Testosterone Testing AHS – G2013 Added the following, “For Policy Titled: Hormonal Testing in Adult Males” to implementation section for clarity.
Therapeutic Radiopharmaceuticals in Oncology When covered section updated to add “Radiopharmaceuticals are eligible for coverage for indications supported by an NCCN (National Comprehensive Cancer Network) 1 or 2A recommendation when all requirements, e.g. performance status, disease severity, previous failures, and mono- versus combination therapy, as well as the requested dose and treatment duration are met.” Policy Guidelines updated. References updated. Medical Director review 6/2022.
Whole Genome and Whole Exome Sequencing AHS – M2032 The following PLA code was added to the Billing/Coding section: 0329U.