Medical Policy Updates

Medical Policy Update November 30, 2021

Medical Guidelines	Reason for Update
Allergen Testing AHS – G2031	Specialty Matched Consultant Advisory Panel review 11/2021. Medical Director review 11.2021.
Allergy Immunotherapy (Desensitization)	Specialty Matched Consultant Advisory Panel review 11/2021. Medical Director review 11/2021.
Allergy Skin and Challenge Testing	Specialty Matched Consultant Advisory Panel review 11/2021. Medical Director review 11/2021.
Bioimpedance Devices for Detection of Lymphedema	Specialty Matched Consultant Advisory Panel review 11/17/2021.
Celiac Disease Testing AHS – G2043	Reviewed by Avalon 3rd Quarter 2021 CAB. Policy guidelines and references updated. Specialty Matched Consultant Advisory Panel review 11/2021. Medical Director review 11/2019.
Chromoendoscopy as an Adjunct to Colonoscopy	Specialty Matched Consultant Advisory Panel 11/2021. Medical Director review 11/2021.
Confocal Laser Endomicroscopy	Specialty Matched Consultant Advisory Panel 11/2021. Medical Director review 11/2021.
Diagnosis of Idiopathic Environmental Intolerance AHS – G2056	Specialty Matched Consultant Advisory Panel review 11/2021. Medical Director review 11/2021.
Electrostimulation and Electromagnetic Therapy for Wounds	Specialty Matched Consultant Advisory Panel review 11/17/2021.
Esophageal Pathology Testing AHS – M2171	Specialty Matched Consultant Advisory Panel review 11/2021. Medical Director review 11/2021.
Fecal Calprotectin Testing in Adults AHS – G2061	Reviewed by Avalon 3rd Quarter 2021 CAB. Title changed for clarity. Policy guidelines updated, added “Disease State/Recommendations” table. References updated. Specialty Matched Consultant Advisory Panel review 11/2021. Medical Director review 11/2021.
Gamma-glutamyl Transferase AHS – G2173	Specialty Matched Consultant Advisory Panel review 11/2021. Medical Director review 11/2021.
Gastroesophageal Reflux Disease, Transendoscopic Therapies	Minor revisions and updates to Description section and Policy Guidelines. No change to policy intente. References updated. Specialty Matched Consultant Advisory Panel 11/2021. Medical Director review 11/2021.
Growth Factors in Wound Healing	Specialty Matched Consultant Advisory Panel review 11/17/2021.
Handheld Radiofrequency Spectroscopy for Intraoperative Assessment of Surgical Margins during Breast-Conserving Surgery	Reference added. Specialty Matched Consultant Advisory Panel review 11/17/2021.
Investigational (Experimental) Services	Specialty Matched Consultant Advisory Panel review 11/2021. No change to policy statement.
Laboratory Testing for the Diagnosis of Inflammatory Bowel Disease AHS–G2121	Reviewed by Avalon 3rd Quarter 2021 CAB. Minor revision to Related Policies section. Policy guidelines and references updated. Specialty Matched Consultant Advisory Panel review 11/2021. Medical Director review 11/2021.
Magnetic Esophageal Sphincter Augmentation to Treat Gastroesophageal Reflux Disease (GERD)	Reference added. Specialty Matched Consultant Advisory Panel review 11/17/2021.
Medical Necessity	Medical Director Review 11/2021. Specialty Matched Consultant Advisory Panel review 11/2021. No changes to policy statement.
Non-Contact Ultrasound Treatment for Wounds	Specialty Matched Consultant Advisory Panel review 11/17/2021.
Plugs for Fistula Repair	Reference added. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 11/17/2021.
Postsurgical Home Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis	Reference added. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 11/17/2021.
Rehabilitative Therapies	Off-cycle review. Under When Rehabilitative Therapies are not covered section, removed from item D. Speech Therapy, 2. a-e as follows: “2. Speech therapy services are not covered for the following conditions: a. psychosocial speech delay, b. behavioral problems, c. attention disorders., d. conceptual handicap, e. mental retardation.” Medical Director review.
Surgical Treatments for Lymphedema	Reference added. Specialty Matched Consultant Advisory Panel review 11/17/2021.
Transanal Endoscopic Microsurgery (TEMS)	Specialty Matched Consultant Advisory Panel 11/2021. Medical Director review 11/2021.
Varicose Veins of the Lower Extremities, Treatment for	Reference added. Specialty Matched Consultant Advisory Panel review 11/17/2021.
Wheelchairs (Manual and Power Operated)	Under the When Covered section, Item III. Criteria for Specific Types of Power Wheechairs (PWC): item #1. Group 1 PWC - removed item c. as follows; “ The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the member.” Medical Director review. 11/2021.