Medical Policy Updates

Medical Policy Update March 31, 2022

Medical Guidelines	Reason for Update
Bronchial Thermoplasty	Description and References updated. Specialty Matched Consultant Advisory Panel review 3/2022. Medical Director review 3/2022. No change to policy statement.
Computer Assisted Surgical Navigational Orthopedic Procedures	Specialty Matched Consultant Advisory Panel review 6/16/2021.
Cosmetic and Reconstructive Surgery	Removed “Hyperhidrosis, Treatment of” from related policies section. No change to policy statement.
Electromagnetic Navigation Bronchoscopy	Specialty Matched Consultant Advisory Panel review 3/2022. Policy guidelines updated. References added. Medical Director review 3/2022. No change to policy statement
Endobronchial Valves	Made the following updates to When Covered: Removed “Patient has completed a pulmonary rehabilitation program prior to valve placement”, “Body mass index (BMI) less than 35kg/m2”, and “There is little to no interlobar collateral ventilation as determined using the Chartis (Zephyr) or SeleCT (Spiration) systems”. Added “Provider attestation that the patient has attended or enrolled in a pulmonary rehabilitation program” and “There is little to no interlobar collateral ventilation as determined by ≥ 90% completeness of the fissure separating the target lobe and the adjacent lobe; fissure completeness scores can be obtained using quantitative CT analysis systems (StratX for Zephyr valves or SeleCT for Spiration valves); OR If the fissure separating the target lobe and the adjacent lobe is <90% complete on quantitative CT analysis systems, the lack of collateral ventilation must be confirmed by using the Chartis system (a measurement device used during bronchoscopy and prior to placement of the valves).” Updated Bullet #8 under When covered to read “Abstinence from smoking of any kind”. Made the following updates to When Not Covered: Removed “with diffuse homogenous emphysema”, updated bullet #5 to add “unless being treated by an allergist”. Specialty Matched Consultant Advisory Panel review 3/2022. References added. Medical Director review 3/2022
General Genetic Testing, Somatic Disorders AHS-M2146	Reviewed by Avalon 4th Quarter 2021 CAB. Removed items #4 and 5 from the When Covered section, as follows: “MSI testing for all solid tumors is considered medically necessary for individuals being considered for pembrolizumab (Keytruda) therapy, and TMB testing is covered for all solid tumors for individuals being considered for pembrolizumab (Keytruda) therapy.” Description, policy guidelines, and references updated with minor revisions. Added code 0268U and removed 81301 under the Billing/Coding section. Policy noticed 1/25/22 for effective date of 3/31/22. Medical Director review 1/2022.
Genetic Testing for Familial Alzheimer’s Disease AHS – M2038	Specialty Matched Consultant Advisory Panel review 10/20/2021.
Hormone Pellet Implantation for Treatment of Menopause Related Symptoms	Specialty Matched Consultant Advisory Panel review 3/2022. Medical Director Review 3/2022. No change to policy statement.
Lung and Lobar Lung Transplantation	Related policies updated. References added. Specialty Matched Consultant Advisory Panel review 3/2022. Medical Director review 3/2022. No change to policy statement.
Lung Volume Reduction Surgery	Related policy added. References added. Specialty Matched Consultant Advisory Panel review 3/2022. Medical Director review 3/2022. No change to policy statement.
Maternal and Fetal Diagnostics	References updated. Specialty Matched Consultant Advisory Panel review 3/2022. Medical Director review 3/2022. No change to policy statement.
Navigated Transcranial Magnetic Stimulation (nTMS)	Specialty Matched Consultant Advisory Panel review 10/20/2021.
Neurostimulation, Electrical	References added. Specialty Matched Consultant Advisory Panel review 10/20/2021.
Noninvasive Respiratory Assist Devices	Specialty Matched Consultant Advisory Panel review 3/2022. Medical Director review 3/2022. No change to policy statement.
Oscillatory Devices for the Treatment of Respiratory Conditions	References added. Specialty Matched Consultant Advisory Panel review 3/2022. Medical Director review 3/2022. No changes to policy statement.
Ovarian and Internal Iliac Vein Embolization, Ablation and Sclerotherapy	References updated. Specialty Matched Consultant Advisory Panel review 3/2022. Medical Director Review 3/2022. No change to policy statement
Percutaneous Electrical Nerve Stimulation (PENS) or Neuromodulation Therapy and Percutaneous Electrical Nerve Field Stimulation (PENFS)	Reference added. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 10/20/2021
Phrenic Nerve Stimulation for Central Sleep Apnea	Related policies added. References added. Specialty Matched Consultant Advisory Panel 3/2022. Medical Director review 3/2022. No changes to policy statement.
Progesterone Therapy in High Risk Pregnancies	References sections updated. Specialty Matched Consultant Advisory Panel review 3/2022. Medical Director review 3/2022. No change to policy statement
Quantitative Sensory Testing	Specialty Matched Consultant Advisory Panel review 10/20/2021.
Skin and Soft Tissue Substitutes	The following codes were added to the Billing/Coding section: A2011, A2012, A2013, A4100, Q4224, Q4225, Q4256, Q4257, Q4258 effective 4/1/2022.
Sleep Apnea: Diagnosis and Medical Management	Added new codes K1028 and K1029 to Billing/Coding section
Spinal Cord and Dorsal Root Ganglion Stimulation	Specialty Matched Consultant Advisory Panel review 10/20/2021.
Total Facet Arthroplasty	Reference added. Specialty Matched Consultant Advisory Panel review 10/20/2021.