Medical Policy Updates

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Medical Policy Update November 16, 2021

Medical Guidelines Reason for Update
Allergen Testing AHS - G2031 Reviewed by Avalon 3rd Quarter 2021 CAB. Added item #6 to the When Not Covered section as follows: “ Reimbursement is not allowed for in-vitro testing of allergen non-specific IgE that does not identify a specific allergen using qualitative multi-allergen screen in the evaluation of suspected allergy and for any other indication.” Policy guidelines and references updated. Medical Director review 10.2021
Artificial Intervertebral Disc Specialty Matched Consultant Advisory Panel review 10/20/2021.
Βeta-Hemolytic Streptococcus Testing AHS – G2159 Reviewed by Avalon 3rd Quarter 2021 CAB. Description section updated. Regulatory section updated. Policy Guidelines updated. References updated.
Biochemical Markers of Alzheimer Disease and Dementia AHS - G2048 Specialty Matched Consultant Advisory Panel Review 10/20/2021. Reviewed by Avalon 3rd Quarter 2021 CAB. Description section updated. “…and/or any other tests not mentioned above” added to fourth non covered statement. Code 0207U added to Billing/Coding section. References updated.
Biomarker Testing for Multiple Sclerosis and Related Neurologic Diseases AHS - G2123 Specialty Matched Consultant Advisory Panel review 10/20/2021. Reviewed by Avalon 3rd Quarter 2021 CAB. Description section updated. Regulatory section updated. Policy Guidelines updated. References updated.
Bone Turnover Markers Testing AHS - G2051 Reviewed by Avalon 3rd quarter CAB. Background, policy guidelines, and references updated. Related Policies section added. Medical Director review 10/2021.
Cervical Cancer Screening AHS - G2002 Reviewed by Avalon Q3 CAB. No change to policy statement. Added Related Policies Diagnostic Testing of Sexually Transmitted Infections AHS - G2157. References updated. Added Rheumatoid arthritis not on immunosuppressive treatments and Type 1 diabetes mellitus to Risk Group Category table. Medical director review 10/2021.
Decompression of the Intervertebral Disc Using Laser Energy (Laser Discectomy) or Radiofrequency Coblation (Nucleoplasty) Reference added. Specialty Matched Consultant Advisory Panel review 10/20/2021.
Diagnosis and Treatment of Sacroiliac Joint Pain Correction made to Billing/Coding section. Added code 64625.
Diagnosis of Vaginitis including Multi-target PCR Testing AHS - M2057 Reviewed by Avalon 3rd Quarter 2021 CAB - off cycle review. Description, Policy Guidelines, and References updated. Updated when covered section “Reimbursement is allowed for screening for Trichomonas for women with risk factors including: new or multiple partners; history of sexually transmitted diseases (STDs), especially HIV; exchange of sex for payment; incarceration, or injection drug use” and “Reimbursement is allowed for Polymerase Chain Reaction (PCR) based identification of Candida for patients with complicated vulvovaginal candidiasis (VVC) to confirm clinical diagnosis and identify non-albicans Candida” and “Reimbursement is allowed for PCR testing and Multitarget polymerase chain reaction (PCR) testing for diagnosis of bacterial vaginosis” Medical Director review 10/2021.
Diagnostic Testing of Influenza AHS - G2119 Reviewed by Avalon 3rd Quarter 2021 CAB. Description section updated. Policy Guidelines updated. References updated.
Diagnostic Testing of Sexually Transmitted Infections AHS - G2157 Reviewed by Avalon 3rd Quarter 2021 CAB. Description section updated. When Covered section updated. When Not Covered section updated. Billing/Coding section updated with addition of the following codes: 82565, 82575, 84702, 84703, 86701, 86702, 86703, 86704, 86705, 86706, 86803, 86804, 87340, 0167U, G0432, G0433, G0435, G0472, G0475, G0499, and S3645. Policy Guidelines updated. References updated.
Electrodiagnostic Studies Specialty Matched Consultant Advisory Panel review 10/20/2021.
Epithelial Cell Cytology in Breast Cancer Risk Assessment AHS - G2059 Reviewed by Avalon 3rd Quarter 2021 CAB. Updated policy guidelines, references and added Related Policies section. Medical Director review 10/2021.
Fecal Analysis in the Diagnosis of Intestinal Dysbiosis and Fecal Microbiota Transplant Testing AHS - G2060 Reviewed by Avalon 3rd Quarter 2021 CAB. Policy guidelines and references updated. Medical Director review 10/2021.
Genetic Testing and Genetic Expression Profiling in Patients with Uveal Melanoma AHS - M2071 Reviewed by Avalon 3rd Quarter 2021 CAB. Updated policy description, policy guidelines, references. Added MLPA test to investigational for all other situations statement under When Not Covered. Added related policy section. Added CPT 81347 to Billing/Coding section. Medical Director review 10/2021.
Genetic Testing for Familial Hypercholesterolemia AHS - M2137 Reviewed by Avalon 3rd Quarter 2021 CAB. Policy guidelines and references updated. Medical Director review 10/2021.
Hemoglobin A1c AHS - G2006 Reviewed by Avalon Q3 CAB. No change to policy statement. Added Related Policies. Prenatal Screening AHS - G2035. References updated. Medical director review 10/2021.
Immune Cell Function Assay for Organ Transplant Rejection AHS-G2098 Reviewed by Avalon 3rd Quarter 2021 CAB. Updated policy guidelines and references. Medical Director review 10/2021.
Immunopharmacologic Monitoring of Therapeutic Serum Antibodies AHS - G2105 Reviewed by Avalon 3rd Quarter 2021 CAB. No change in policy statement. Related policies section added - Vectra DA Blood Test for Rheumatoid Arthritis AHS - G2127 and General Inflammation Testing AHS - G2155. References updated. Medical Director review 10/2021.
In Vitro Chemoresistance and Chemosensitivity Assays AHS- G2100 Reviewed by Avalon 3rd Quarter 2021 CAB. Updated policy guidelines and references. Added PLA code 0248U to Billing/Coding section. Medical Director review 10/2021.
Injection Therapy for Headache (Migraine and Other) and Non-Spine Management Reference added. Description section and Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 10/20/2021.
Interferential Stimulation Specialty Matched Consultant Advisory Panel review 10/20/2021.
Measurement of Thomboxane Metabolites for ASA Resistance AHS - G2107 Reviewed by Avalon 3rd Quarter 2021 CAB. Policy guidelines and references updated. Specialty Matched Consultant Advisory Panel review 10/2021. Medical Director review 10/2021.
Metabolite Markers of Thiopurines AHS - G2115 Reviewed by Avalon 3rd Quarter 2021 CAB. Removed item #2 from the When Covered section as follows: “Reimbursement is allowed for one-time phenotype analysis for the enzyme NUDT15 in patients prior to initiating treatment with azathioprine (AZA), mercaptopurine (6-MP) or thioguanine (6-TG) OR in patients on thiopurine therapy with abnormal complete blood count (CBC) results that do not respond to dose reduction.” Policy guidelines and references updated. Medical Director review 10/2021.
Minimal Residual Disease (MRD) AHS-M2175 Reviewed by Avalon 3rd Quarter 2021 CAB. Updated policy guidelines and references. Medical Director review 10/2021.
Molecular Analysis for Gliomas AHS - M2139 Reviewed by Avalon 3rd Quarter 2021 CAB. Under “When Covered” section added item e. H3F3A testing using a K27M histone antibody as medically necessary. Updated policy guidelines and references. Medical Director review 10/2021.
Molecular Testing of Pulmonary Specimens AHS - M2160 Description and references updated by Avalon Q3 CAB review. Added code 81554. Related policies section added. No change to policy statement. Medical Director review 10/2021.
Nerve Fiber Density Testing AHS - M2112 Specialty Matched Consultant Advisory Panel review 10/20/2021. Reviewed by Avalon 3rd Quarter 2021 CAB. Regulatory section updated. Policy Guidelines updated. References updated.
Pre-Operative Testing AHS - G2023 Medical Director review. Archive policy.
Prostate Biopsies AHS - G2007 Reviewed by Avalon 3rd Quarter CAB. Policy Guidelines section updated. References updated.
Proteogenomic Testing of Individuals with Cancer AHS-M2168 Reviewed by Avalon 3rd Quarter 2021 CAB. Added PLA codes 0260U, 0262U, 0264U, 0266U, 0267U to Billing/Coding section. Added two investigational statements to When “Not Covered” section: 2)Tumor gene expression profiling with algorithmic analysis providing gene pathway activity scores is considered investigational and 3)Optical genome mapping with or without whole genome sequencing and transcriptome analysis is considered investigational. Updated policy guidelines and references. Medical Director review 10/2021.
Serum Testing for Hepatic Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease AHS - G2110 Reviewed by Avalon 3rd Quarter 2021 CAB. References updated. Medical Director review 10/2021.
Testing for 5-Fluorouracil Use in Cancer Patients AHS-M2067 Reviewed by Avalon 3rd Quarter 2021 CAB. Updated policy guidelines and references. Medical Director review 10/2021.
Testing for Diagnosis of Active or Latent Tuberculosis AHS - G2063 Reviewed by Avalon 3rd Quarter CAB. Description section updated. Regulatory section updated. When Covered section updated with removal of “5 years or older” from criteria 1A. When Not Covered section updated with removal of “Reimbursement is not allowed for a gamma interferon blood test to diagnose latent tuberculosis infection in healthy children <5 years of age for whom it has been decided that diagnostic testing is warranted. Tuberculosis Skin Test is recommended”. Policy Guidelines section updated. Scientific Background/References updated.
Testing for Mosquito or Tick-Related Infections AHS - G2158 Reviewed by Avalon 3rd Quarter 2021 CAB. Description section updated. When Covered section updated. Change from one to two units of IFA for rickettsial diseases per CDC. Change for IgG as meeting coverage criteria for Borrelia testing per CDC. Removed “or IgG” from “IFA for WNV-specific IgM or IgG antibodies in either serum or CSF; AND”. When Not Covered section updated. Change for IgG as does not meet criteria for WNV testing per CAB decision: Added “IFA for WNV-specific IgG antibodies in either serum or CSF” to “The following DOES NOT MEET COVERAGE CRITERIA: NAAT, including PCR, for WNV; IFA for WNV-specific IgG antibodies in either serum or CSF”. Addition of “nausea and/or vomiting” to DENV signs and symptoms per CDC. Policy Guidelines updated. References updated. Medical Director review 10/2021.
Thyroid Disease Testing AHS - G2045 Reviewed by Avalon 3rd Quarter 2021 CAB Off-Cycle Review. Medical Director review 10/2021. Description, Policy Guidelines and References updated. When covered section updated 1→J with Pediatric individuals diagnosed with short stature.
Transplant Rejection Testing AHS - M2091 Reviewed by Avalon 3rd Quarter 2021 CAB. Added 2nd statement to the When Not Covered section as follows: “The use of peripheral blood microarray-based genomic test that analyzes gene expression profiles to rule out kidney transplant rejection (e.g. TruGraf) in individuals with stable renal function as an alternative to surveillance biopsies in considered investigational.” Added code 0018M to the Billing/Coding section. Policy guidelines and references updated. Medical Director review 10/2021.
Use of Common Genetic Variants to Predict Risk of Non-Familial Breast Cancer AHS-M2126 Reviewed by Avalon 3rd Quarter 2021 CAB. Updated policy guidelines and references. Medical Director review 10/2021.