Medical Policy Updates

Medical Policy Update May 17, 2022

Medical Guidelines	Reason for Update
Allergen Testing AHS – G2031	Off-cycle review by Avalon 1st Quarter 2022 CAB. Description section updated and added Related Policies section. Under the When Covered section, removed the following statement from item #1a: “When in vitro testing is ordered, the medical record must clearly document the indication and why it is being used instead of skin testing.”, and added item #4. Under the When Not Covered section, added the following statement to the end of item #1: “except as specified in criteria 4 (above). Policy guidelines updated, added table of terminology. Removed code 83520 from the Billing/Coding section. References updated. Medical Director review 4/2022.
ANA/ENA Testing AHS – G2022	Reviewed by Avalon 1st Quarter 2022 CAB. Medical Director review 4/2022. Description, Policy Guidelines, and References updated. Added code 0312U to Billing/Coding section.
Cardiovascular Disease Risk Assessment AHS – G2050	Reviewed by Avalon 1st Quarter 2022 CAB. The following changes were made to the When Covered section: Item 1a-i: revised statement from “every 5 years” to “every 4 to 6 years’; reworded item 1a-ii for clarity; reworded item 1b as follows: “at increased risk of dyslipidemia due to the following conditions”; added the word “and” to item 1-f-ii for clarity; added items 2-v and vi; added “or elevated Lp(a)” to item 3a-i. Updated Note 1. The following changes were made to the When Not Covered section: reworded bullet referencing Homocysteine for clarity as follows: “Homocysteine testing for indications “other” than CVD…” Note 1 updated. Policy guidelines, updated and Table of Terminology added. Added codes 0308U and 0309U to Billing/Coding section. References updated. Medical Director review 4/2022.
Diagnosis of Idiopathic Environmental Intolerance AHS – G2056	Reviewed by Avalon 1st Quarter 2022 CAB. Policy Guidelines updated; added Table of Terminology. Removed code 88348 from Billing/Coding section. References updated. Medical Director review 4/2022.
Diagnosis of Vaginitis including Multi-target PCR Testing AHS – M2057	Reviewed by Avalon 1st Quarter 2022 CAB. Medical Director review 4/2022. Description, Policy Guidelines, and Reference section updated. No changes to policy statement.
Esophageal Pathology Testing AHS – M2171	Reviewed by Avalon 1st Quarter 2022 CAB. Minor revisions to the When Covered section under item 2, now reads as follows: “Mismatch repair (MMR)…”; no change to policy intent. Policy guidelines updated; added Table of Terminology. References updated. Medical Director review 4/2022.
Evaluation of Dry Eyes AHS - G2138	Reviewed by Avalon 1st Quarter 2022 CAB. Added related policies section. Updated policy guidelines and references.
Flow Cytometry AHS–F2019	Reviewed by Avalon 1st Quarter 2022 CAB. Expanded coverage criteria to include myeloproliferative. Removed Hypercellular Hematolymphoid Disorders, Chronic Lymphocytic Leukemia (CLL), and Chronic Myeloproliferative Disorders (CMPD) due to repetition. Updated policy guidelines and references. Removed CPT 88199 from Billing/Coding section. Medical Director review 4/2022.
General Genetic Testing, Somatic Disorders AHS-M2146	Reviewed by Avalon 1st Quarter 2022 CAB. Policy guidelines revised; added Table of Terminology. Reference updated. Medical Director review 4/2022.
Genetic Cancer Susceptibility Panels Using Next Generation Sequencing AHS-M2066	Reviewed by Avalon 1st Quarter 2022 CAB. Medical Director review 4/2022. Clarified coverage criteria statement #1 under “When Covered” section. Added CPT code 0022U to Billing/Coding section. Added BRCA AHS-M2003 and Lynch Syndrome AHS-M2004 to related policies section. Updated policy guidelines and references.
Genetic Testing and Genetic Expression Profiling in Patients with Cutaneous Melanoma AHS-M2029	Reviewed by Avalon Q1 2022 CAB. Medical Director review 4/2022. Removed reference to AHS-M2109. Edited Note to read “For 5 or more gene tests being run on the same platform, such as multi-gene panel next generation sequencing, please refer to AHS-R2162 Reimbursement Policy.” Updated policy guidelines and references.
Genetic Testing for Connective Tissue Disorders AHS – M2144	Reviewed by Avalon 1st Quarter 2022 CAB. Updated policy guidelines; adding Table of Terminology and references. Medical Director review 4/2022.
Genetic Testing for Familial Cutaneous Malignant Melanoma AHS – M2037	Reviewed by Avalon 1st Quarter 2022 CAB. Description section revised; removed policy “Molecular Panel Testing of Cancers for Diagnosis, Prognosis, and Identification of Targeted Therapy M2109 from Related Policies. Added item 1:a-g along with Notes 1-3 to When Covered section. Added “Any other” and “cutaneous” to When Not Covered section. Policy guidelines and references updated. Medical Director review 4/2022.
Genetic Testing for Inherited Cardiomyopathies and Channelopathies AHS – M2025	Reviewed by Avalon 1st Quarter 2022 CAB. to the following revisions were made to the When Covered section, under item 2, wrote out “long QT syndrome (LQTS) for clarity along with item 7, wrote out “short QT syndrome”. Added items 14 and 17. Policy guidelines and references updated; added Table of Terminology. Medical Director review 4/2022.
Helicobacter Pylori Testing AHS – G2044	Reviewed by Avalon 1st Quarter 2022 CAB. Updated background, policy guidelines (added Table of Terminology) and references. Added “or” to several coverage criteria for clarity; no change to policy intent. Medical Director review 4/2022.
Immune Cell Function Assay for Organ Transplant Rejection AHS-G2098	Added CPT code 0018M to Billing/Coding section.
Intracellular Micronutrient Analysis AHS – G2099	Reviewed by Avalon 1st Quarter 2022 CAB. Policy guidelines updated and added “Table of Terminology”. References updated. No change to policy intent. Medical Director review.
Lyme Disease AHS – G2143	Reviewed by Avalon 1st Quarter 2022 CAB. Description section updated. Policy Guidelines updated. Code 0316U added to Billing/Coding section. Medical Director review 4/2022. References added.
Lynch Syndrome AHS-M2004	Reviewed by Avalon 1st Quarter 2022 CAB. Medical Director review 4/2022. Updated formatting in When Covered section and revised Note 1, removed Note 3. Updated policy guidelines and references. Added CPT code 0238U to Billing/Coding section. Removed AHS-M2109 from related policy section.
Molecular Panel Testing of Cancers for Diagnosis, Prognosis, and Identification of Targeted Therapy AHS - M2109	Archived per Avalon 1st Quarter 2022 CAB. See AHS-M2178 Microsatellite Instability and Tumor Mutational Burden Testing.
Mutation Analysis in Myeloproliferative Neoplasms AHS - M2101	Reviewed by Avalon 1st Quarter 2022 CAB. Medical Director review 4/2022. Under “When Covered” section: added coverage criteria #2 and #4-7. Added CPT codes 81120, 81121, 81236, 81237, 81348, 81479 to Billing/Coding section. Updated policy guidelines and references.
Onychomycosis Testing AHS – M2172	Reviewed by Avalon for 1st Quarter 2022 CAB. Policy description and guidelines updated. No change to policy statement. References added. Medical Director review 4/2022.
Oscillatory Devices for the Treatment of Respiratory Conditions	Updated When Covered Section for clarity on rental versus purchase of device. Added the following statement to Billing/Coding section: “Please refer to Durable Medical Equipment policy for information regarding rental versus purchase of device.” Related policies added. Medical Director review 5/2022.
Parathyroid Hormone, Phosphorus, Calcium, and Magnesium Testing AHS – G2164	Description, Policy Guidelines, and Reference sections updated. Reviewed by Avalon for 1st Quarter 2022 CAB. Added “in patients with hypercalcemia” to 1a in When Covered section. Medical Director review 4/2022.
Pathogen Panel Testing AHS – G2149	Off-cycle code review by Avalon 1st Quarter 2022 CAB. The following codes were deleted from the Billing/Coding section: 0097U and 0151U and code 0321U was added to this section.
Peroral Endoscopic Myotomy for Treatment of Esophageal Achalasia	Description section revised; added the 3 types of achalasia based on the Chicago Classification. Policy statement revised as follows: “Peroral endoscopic myotomy is considered medically necessary as a treatment for esophageal achalasia when it is determined to be medically necessary because the criteria and guidelines show below are met.” When Covered section revised with medically necessary criteria for POEM. When Not Covered section revised as follows: “Peroral endoscopic myotomy is considered investigational when the above criteria are not met.” Policy guidelines and references updated. Medical Director review 4/2022.
Pharmacogenetics Testing AHS – M2021	Reviewed by Avalon 1st Quarter 2022 CAB. Description section with minor revisions. When covered section extensively revised as follows: Item #1revised to include a-ii; item #2 revised to include a-e; item #3 added for testing for the CYP2C19 genotype, including a-l; item #4 added for testing for the CYP2C9 genotype, including a-i; item # 6 added for testing for the TPMT and NUDT15 genotype, including a-c; item #7 added for testing for the DPYD genotype, including a-d; item #8 for testing for the following Human Leukocyte Antigens (HLAs) genotypes, including a-d; item #9 for added for testing for the CYP2C9 and HLA-B*15:02 genotype, including a; item #10 added for testing for the G6PD genotype, including a-d; item #11 added for testing for the following genotypes, including a-g; item #12 added. Under the When Not Covered section, item 2-b and item 4 were removed. Policy guidelines and references updated. Added code 0286U to the Billing/Coding section. Medical Director review 4/2022.
Plasma HIV-1 and HIV-2 RNA Quantification for HIV Infection AHS – M2116	Reviewed by Avalon 1st Quarter 2022 CAB. Medical Director review 4/2022. Description section updated. Policy Guidelines updated. Guidelines and Recommendations updated. References updated and added.
Preimplantation Genetic Testing AHS – M2039	Reviewed by Avalon 1st Quarter 2022 CAB. Updated Description, Policy Guidelines, Related Policies, and References. When Covered section updated as follows: Reimbursement is allowed for preimplantation genetic testing when ALL of the conditions below are met: 1) Specific mutation(s) or chromosomal changes have been defined to be associated with a specific disorder, AND 2) One of the following conditions are met: Both biological parents are known carriers of an autosomal recessive disorder with early onset, OR, One biological parent is a known carrier of an autosomal dominant early onset disorder, OR, One biological parent is a known carrier of an X-linked early onset disorder, OR One biological parent carries a balanced or unbalanced chromosomal translocation. When not Covered section updated as follows: 1) Reimbursement is not allowed for Preimplantation genetic testing for sex selection, in the absence of a sex-linked early onset disease; Reimbursement is not allowed for preimplantation genetic testing in the following situations: -Preimplantation genetic testing for adult-onset disorders. - Preimplantation HLA genotyping for purposes of identifying potential tissue or organ donors. -Routine preimplantation screening for chromosomal abnormalities including testing based on advanced maternal age. Reimbursement is not allowed for preimplantation genetic testing for all other indications. Medical Director review 4/2022
Prenatal Screening AHS – G2035	Reviewed by Avalon 1st quarter 2022 CAB. Description, Policy Guidelines, and Reference section updated. Changed woman/women to individual/individuals throughout coverage criteria. Eliminated ethnicity specific phrases in coverage criteria. Billing/Coding section updated. Medical Director Review 4/2022.
Prescription Medication and Illicit Drug Testing in the Outpatient Setting AHS – T2015	Reviewed by Avalon Q1 CAB 2022. Description, Policy Guidelines, and References updated. When covered section updated for clarity, no changes to policy statement. Medical Director review 4/2022.
Prostate Specific Antigen (PSA) Testing AHS - G2008	Reviewed by Avalon 1st Quarter 2022 CAB. Medical Director review 4/2022. Updated guidelines/recommendations and references.
Salivary Hormone Testing AHS – G2120	Reviewed by Avalon for 1st Quarter 2022 CAB. Updated Description and Policy Guidelines section. Updated related policies. Updated references. No change to policy statement. Medical Director review 4/2022.
Surgery for Obstructive Sleep Apnea and Upper Airway Resistance Syndrome	Added the following statement to the When Covered section: “An individual being evaluated for hypoglossal nerve stimulation may be evaluated with a home sleep test if the individual does not meet criteria for supervised polysomnography”. Replaced the word “patient(s)” with the word “individual(s)” throughout the policy. Medical Director review.
Transplant Rejection Testing AHS – M2091	Off-cycle review by Avalon 1st Quarter 2022 CAB. Under the When Covered section: added item 2. a-b and removed this indication from the When Not Covered section. The following codes were added to the Billing/Coding section: 0319U, 0320U, and 84999. Code 0085T and 0018M were removed from this section.
Urinary Tumor Markers for Bladder Cancer AHS – G2125	Reviewed by Avalon 1st Quarter 2022 CAB. Medical Director review 4/2022. References updated and added. Description section updated. Removed the following statement from the When Not Covered section; “The use of all other urinary biomarkers, including but not limited to quantitative mRNA (Cxbladder) is investigational.” Policy Guidelines updated.
Vectra DA Blood Test for Rheumatoid Arthritis AHS – G2127	Reviewed by Avalon for 1st Quarter 2022 CAB. Updated Description, Policy Guidelines, and References. Related policies added. No change to policy statement. Medical Director review 4/2022.
Venous and Arterial Thrombosis Risk Testing AHS – M2041	Reviewed by Avalon 1st Quarter 2022 CAB. Under the When Covered section: reworded item 1, adding “mutations” and removed criteria “Recurrent deep vein thrombosis” from both item 1 and 2. Added item 2 to When Not Covered section as follows: “Reimbursement is not allowed for genetic testing for Factor V Leiden and Prothrombin gene G20210A mutations in patients with recurrent thrombotic events who are receiving a lifelong anticoagulation regimen”. Policy guidelines and references updated. Added code 0278U to the Billing/Coding section. Medical Director review 4/2022.
ZIKA Virus Risk Assessment AHS – G2133	Reviewed by Avalon 1st Quarter 2022 CAB. When Covered section and When Not Covered section updated. References updated. Medical Director review 3/2022.