Medical Policy Updates

Medical Policy Update for May 18, 2021

Medical Guidelines	Reason for Update
Bariatric Surgery	References added. Policy guidelines updated. Specialty Matched Consultant Advisory Panel review 4/21/2021.
Bronchial Thermoplasty	Description and References updated. Specialty Matched Consultant Advisory Panel review 3/2021. Medical Director review 4/2021. No change to policy statement.
Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate, or Dermatologic Tumors	Reference added. Regulatory Status updated. Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors removed from list of Related Policies. Specialty Matched Consultant Advisory Panel review 4/21/2021.
Cryosurgical Ablation of Primary or Metastatic Liver Tumors	Reference added. Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors removed from list of Related Policies. Specialty Matched Consultant Advisory Panel review 4/21/2021.
Electromagnetic Navigation Bronchoscopy	Specialty Matched Consultant Advisory Panel review 3/2021. Regulatory Status and Policy guidelines updated. Reference added. Medical Director review 4/2021. No change to policy statement.
Endobronchial Valves	Description, When Covered, When Not Covered, and Policy Guidelines sections updated to reflect coverage criteria. References added. Policy statement changed to medically necessary for emphysema with criteria and persistent air leaks. Specialty Matched Consultant Advisory Panel review 3/2021. Medical Director review 4/2021.
Eptinezumab-jjmr (Vyepti™)	Updated initial authorization length to 6 months. Added the following criteria to initial and continuation sections of “When Covered” section: “If Vyepti 300 mg is requested, the patient has tried and had an inadequate response to the 100 mg strength.” Notification given 3/9/2021 for effective date 5/18/2021. Blue Cross NC Pharmacy and Therapeutics Committee 1/5/2021.
Focal Treatments for Prostate Cancer	Added new code 55880 to the Billing/Coding section.
Gene Expression Profiling and Protein Biomarkers for Prostate Cancer AHS - M2166	Reviewed by Avalon 1st Quarter 2021 CAB. Medical Director review 4/2021. Revised “When Covered” section to include tests to assess and/or monitor prostate cancer which were relocated from AHS-G2008 Prostate Specific Antigen (PSA) Testing policy. These tests remain investigational. Updated Policy Guidelines, Billing/Coding sections as well as References. Changed related policy AHS-G2008 Prostatic Specific Antigen (PSA) Testing title. Policy Title changed from: Gene Expression Profiling and Protein Biomarkers for Prostate Cancer Management to: Gene Expression Profiling and Protein Biomarkers for Prostate Cancer.
Liver Transplant and Combined Liver-Kidney Transplant	Reference added. Description section updated. Specialty Matched Consultant Advisory Panel 4/21/2021.
Lung and Lobar Lung Transplantation	References added. Specialty Matched Consultant Advisory Panel review 3/2021. Medical Director review 4/2021. No change to policy statement.
Lung Volume Reduction Surgery	Reference added. Specialty Matched Consultant Advisory Panel review 3/2021. Medical Director review 4/2021. No change to policy statement.
Molecular Testing of Pulmonary Specimens AHS - M2160	Specialty Matched Consultant Advisory Panel 3/2021. Medical Director review 4/2021. No change to policy statement.
Neural Therapy	References added. Specialty Matched Consultant Advisory Panel review 4/2021. Medical Director review 4/2021. No change to policy statement.
PD-1 Inhibitors	Added additional FDA approved indications to “When Covered” section for Keytruda and Opdivo to be consistent with FDA labeling. Removed indication for metastatic small cell lung cancer for Keytruda and Opdivo to be consistent with FDA labeling. Additional minor updates made throughout “When Covered” section for clarity. Blue Cross NC Pharmacy and Therapeutics Committee 1/5/2021. References added.
Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers	Specialty Matched Consultant Advisory Panel review 4/21/2021.
Pre-Operative Testing AHS – G2023	Specialty Matched Consultant Advisory Panel review 4/21/2021.
Prolotherapy	References added. Specialty Matched Consultant Advisory Panel review 4/2021. Medical Director review 4/2021. No change to policy statement.
Prostate Biopsies AHS – G2007	Specialty Matched Consultant Advisory Panel review 11/18/2020.
Prostate Specific Antigen (PSA) Testing AHS - G2008	Reviewed by Avalon 1st Quarter 2021 CAB. Medical Director review 4/2021. Under “When Covered” section: revised and updated to include total PSA testing for average risk individuals aged 45-75 with African ancestry, germline mutations that increase risk for prostate cancer, suspicious family history. Updated Description and Policy Guidelines sections as well as References. Revised and updated Billing/Coding section. Policy title changed from: Prostate Cancer Screening to: Prostate Specific Antigen (PSA) Testing.
Prostatic Urethral Lift	Reference added. Regulatory Status updated. Specialty Matched Consultant Advisory Panel review 11/18/2020.
Sacral Nerve Neuromodulation/Stimulation for Pelvic Floor Dysfunction	Specialty Matched Consultant Advisory Panel review 11/18/2020.
TENS (Transcutaneous Electrical Nerve Stimulator)	Reference added. Specialty Matched Consultant Advisory Panel review 4/2021. Medical Director review 4/2021. No change to policy statement.
Topical Negative Pressure Therapy for Wounds	Reference added. Regulatory status updated. Specialty Matched Consultant Advisory Panel review 4/21/2021.
Transurethral Water Vapor Thermal Therapy for Benign Prostatic Hyperplasia	Reference added. Specialty Matched Consultant Advisory Panel review 11/18/2020.
Vestibular Function Testing	Specialty Matched Consultant Advisory Panel review 2/17/2021. Medical Director review. When Covered section updated with medically necessary statement for Vestibular Evoked Myogenic Potentials (VEMP).