Medical Policy Updates

Medical Policy Update October 1, 2021

Medical Guidelines	Reason for Update
Ablative Techniques for the Myolysis of Uterine Fibroids	References updated. Specialty Matched Consultant Advisory Panel review 9/2021. Medical Director review 9/2021. No change to Policy statement.
Allergy Immunotherapy (Desensitization)	When Not Covered section for COVID-19 exception updated with “effective from September 30, 2021 through December 31, 2021. We will reevaluate if an additional extension is needed as we approach December 31.”
Bone Mineral Density Studies	Description and references updated. Specialty Matched Consultant Advisory Panel review 9/2021. Medical Director review 9/2021. No change to Policy statement.
Bone Turnover Markers Testing AHS – G2051	Specialty Matched Consultant Advisory Panel review 9/2021. Medical Director review 9/2021. No change to Policy statement
Children’s Mobility and Positioning Equipment	Specialty Matched Consultant Advisory Panel review 9/2021. Medical Director review 9/2021.
Chiropractic Services	Specialty Matched Consultant Advisory Panel 9/2021. Medical Director review 9/2021.
Dry Needling of Myofascial Trigger Points	Minor update to policy guidelines. References updated. Specialty Matched Consultant Advisory Panel review 09/2021. Medical Director review 09/2021.
Durable Medical Equipment (DME)	Specialty Matched Consultant Advisory Panel 9/2021. Medical Director review 9/2021.
Functional Capacity Assessment and Work Hardening	Specialty Matched Consultant Advisory Panel 9/2021. Medical Director review 9/2021.
Gender Affirmation Surgery and Hormone Therapy	Medical Director review. Wording changes made throughout policy as follows: 1. Where policy wording stated, “new gender identity” changed to “affirmed gender identity”. 2. Where policy wording stated, “original gender” changed to “gender assigned at birth”. 3. Where policy wording stated, “desired gender role” changed to “their affirmed gender identity”. 4. Where policy wording stated, “the new role” changed to “their affirmed gender identity”.
Genetic Testing for PTEN Hamartoma Tumor Syndrome AHS – M2087	Reviewed by Avalon 2nd Quarter 2021 CAB. Added the following indication to item #5 under the When Covered section: “or Bannayan-Riley-Ruvalcaba syndrome (BRRS)”. Description, Policy Guidelines, and Reference sections updated. Added PLA code 0235U to Billing/Coding section effective 10/1/21. Specialty Matched Consultant Advisory Panel review 7/2021. Medical Director review 7/2021.
Microprocessor-Controlled Prostheses for the Lower Limb	New HCPCS code K1022 added to Billing/Coding section, effective 10/1/2021.
Non-Contact Ultrasound Treatment for Wounds	Reference added.
Patient Lifts	Specialty Matched Consultant Advisory Panel review 9/2021. Medical Director review 9/2021
Preimplantation Genetic Testing AHS – M2039	Specialty Matched Consultant Advisory Panel review 9/2021. Medical Director Review 9/2021. No change to Policy statement.
Pressure Reducing Support Surfaces	Specialty Matched Consultant Advisory Panel 9/2021. Medical Director review 9/2021.
Red Blood Cell Molecular Testing AHS-M2170	Reviewed by Avalon 2nd Quarter 2021 CAB. Medical Director review 8/2021. Added PLA codes 0221U, 0222U, 0246U to Billing/Coding section. Updated policy guidelines and references.
Rehabilitative Therapies	References updated. Specialty Matched Consultant Advisory Panel review 9/2021. Medical Director review 9/2021.
Sleep Apnea: Diagnosis and Medical Management	New HCPCS code K1027 added to Billing/Coding section effective 10/1/2021.
Wheelchairs (Manual and Power Operated)	Specialty Matched Consultant Advisory Panel 9/2021. Medical Director review 9/2021.