Medical Policy Updates

Medical Policy Update September 13, 2022

Medical Guidelines	Reason for Update
Abdominoplasty and Panniculectomy	Related policy added. References updated. Specialty Matched Consultant Review 8/2022. Medical Director review 8/2022. No change to policy statement.
BCR-ABL 1 Testing AHS – M2027	Reviewed by Avalon 2nd Quarter 2022 CAB. Medical Director review 8/2022. Clarified When Covered section. Updated policy guidelines and references. Under Billing/Coding section, removed CPT code 81401.
Cardiac Biomarkers for Myocardial Infarction AHS – G2150	Reviewed by Avalon 2nd Quarter 2022 CAB. Background, policy guidelines, and references updated. No change to policy statement. Medical Director review 7/2022.
Carrier Screening for Genetic Disease	References updated. Specialty Matched Consultant Advisory Panel review 7/2022. Medical Director review 7/2022. No change to policy statement.
Chromosomal Microarray AHS – M2033	Reviewed by Avalon 2nd Quarter 2022 CAB. Related policies added. Description, policy guidelines, and references updated. Updated existing medical necessity language to reflect reimbursement language. When Covered section updated for clarity. Removed investigational statement and added coverage for low-pass whole genome sequencing (low-pass WGS). #3E updated to reflect “Due to family history or other indications as documented in the patient’s medical record, the fetus is at high risk for a chromosome abnormality, detectable by CMA”. Added #6 Reimbursement is allowed for CMA testing for central nervous system (CNS) tumors and pediatric solid and soft tissue tumors. Added following statements to When not covered: “Reimbursement is not allowed for co-testing CMA and low-pass WGS” and “Reimbursement is not allowed for all other CMA testing.” Removed 81479 from Billing/Coding section. Medical Director review 7/2022
Composite Allotransplantation of the Hand and Face	Minor updates in description section for clarity. References updated. Specialty Matched Consultant Advisory Panel 8/2022. Medical Director review 8/2022.
Diagnosis of Idiopathic Environmental Intolerance AHS – G2056	Reviewed by Avalon 2nd Quarter 2022 CAB-coding updates only. Added code 82705 to the Billing/Coding section. No change to policy statement. Medical Director review 7/2022.
DNA Ploidy Cell Cycle Analysis AHS – M2136	Policy archived and content merged into Flow Cytometry AHS-F2019.
Erectile Dysfunction AHS - G2132	Reviewed by Avalon 2nd Quarter 2022 CAB. Medical Director review 8/2022. Table of Terminology added. Federal Regulations updated. Code 84540 removed from Billing/Coding section. Medical Director review 8/2021.
Extracorporeal Photopheresis	Specialty Matched Consultant Advisory Panel review 8/24/2022. No change to policy statement.
Fecal Analysis in the Diagnosis of Intestinal Dysbiosis and Fecal Microbiota Transplant Testing AHS – G2060	Reviewed by Avalon 2nd Quarter 2022 CAB. Policy Guidelines and references updated. Added the following codes to the Billing/Coding section: 82705, S3708. Removed code 87623. No change to policy statement. Medical Director review 7/2022.
Flow Cytometry AHS–F2019	Reviewed by Avalon 2nd Quarter 2022 CAB. Updated description, policy guidelines and references. Medical Director review 8/2022. DNA Ploidy Cell Cycle Analysis AHS-M2136 has been archived and the policy content was merged into this policy Flow Cytometry AHS-F2019. Removed molar pregnancy item from When Covered section as this screening is no longer done by flow cytometry. Under Billing/Coding section, clarified reimbursement limitations and added new coverage criteria to address allowance of up to 2 specimens per date of service and reimbursed at one unit per specimen for CPT 88187-88189. Also clarified that CPT 88187-88189 should not be used together for a single specimen in any combination.
Folate Testing AHS – G2154	Reviewed by Avalon 2nd Quarter 2022 CAB. Description, Policy Guidelines, and References updated. Updated When Covered section to reflect: “Reimbursement for measurement of serum folate concentration is allowed for evaluation of patients when all of the following criteria have been met, patients who have been diagnosed with megaloblastic or macrocytic anemia; AND megaloblastic anemia and/or macrocytosis does not resolve after folic acid. When Not Covered section updated for clarity. Medical Director review 7/2022.
Gamma-glutamyl Transferase AHS – G2173	Reviewed by Avalon 2nd Quarter 2022 CAB. Background, policy guidelines and references updated. No change to policy statement. Medical Director review 7/2022.
General Approach to Evaluating the Utility of Genetic Panels	References updated. Specialty Matched Consultant Advisory Panel review 7/2022. Medical Director review 7/2022.
General Genetic Testing, Somatic Disorders AHS-M2146	Reviewed by Avalon 2nd Quarter 2022 CAB, coding updates only. Removed Related Policy “Molecular Panel Testing of Cancers for Diagnosis, Prognosis, and Identification of Targeted Therapy AHS – M2109” due to archival. Updated Billing/Coding section. No change to policy statement. Medical Director review 7/2022.
General Inflammation Testing AHS – G2155	Reviewed by Avalon 2nd Quarter 2022 CAB. Updated Description, Policy Guidelines and Reference sections. Related policies added. Updated When Covered Section to read as follows: “Reimbursement for measurement of erythrocyte sedimentation rate (ESR) and/or C-Reactive Protein (CRP) for patients for inflammatory conditions specified in Note 1.” Note 1 updated as follows: NOTE 1: Coverage of ESR, CRP, or both CRP and ESR is designated based on the diagnosed or suspected inflammatory condition.” Note also contains a table of inflammatory disorders and their corresponding allowed CRP/ESR testing and frequency when specified by societies. Removed following statement from When not Covered: “Reimbursement is not allowed for the measurement of both CRP and ESR, at the same visit, in the diagnosis, assessment and monitoring of inflammatory disorders, and/or undiagnosed conditions, and/or to detect acute phase inflammation.” Medical Director review 7/2021.
Genetic Testing for Acute Myeloid Leukemia AHS-M2062	Reviewed by Avalon 2nd Quarter 2022 CAB. Updated policy guidelines and references. Removed CPT code 81404 from Billing/Coding section.
Genetic Testing for Adolescent Idiopathic Scoliosis AHS – M2058	Reviewed by Avalon 2nd Quarter 2022 CAB. Medical Director review 8/2022. Policy Guidelines and References sections updated. Table of Terminology added. No change to policy statement.
Genetic Testing for Alpha- and Beta- Thalassemia AHS – M2131	Reviewed by Avalon 2nd Quarter 2022 CAB. Description, Policy guidelines, and Reference sections updated. No change to policy statement. Medical Director review 7/2022.
Genetic Testing for Cystic Fibrosis AHS – M2017	Reviewed by Avalon 2nd Quarter 2022 CAB. Updated background, guidelines, and references. Updated When Covered section 1, 3, 4b and for clarity. Added 1c “For gamete donors OR”, added “bronchiectasis” to 3d. Added C7 a-b. Not Covered section updated for clarity: “Genetic testing for mutations in the CFTR gene is considered not medically necessary for all other indications.” Medical Director review 7/2022.
Genetic Testing for Diagnosis of Inherited Peripheral Neuropathies AHS – M2072	Reviewed by Avalon 2nd Quarter 2022 CAB. Updated background, guidelines, and references. Billing/Coding section updated. Coverage criteria edited for clarity. No change to policy statement. Medical Director review 7/2022.
Genetic Testing for Familial Alzheimer’s Disease AHS – M2038	Reviewed by Avalon 2nd Quarter 2022 CAB. Table of Terminology added. Federal Regulations updated. Policy Guidelines updated. References updated. Medical Director review 8/2022.
Genetic Testing for FMR1 Mutations AHS – M2028	Off-cycle review by Avalon 2nd Quarter 2022 CAB. Description, policy guidelines, and references updated. Billing/Coding section updated. The following updates made to the When Covered section: 2e updated and now reads “Fetuses and offspring of known FMR1 premutation or full mutation carriers”, 3 edited to remove family history requirements. removed all sub criteria. Not Covered section updated to include statement: “Genetic screening for FMR1 gene CGG repeat length more than once per lifetime is considered not medically necessary.” Medical Director review 7/2022.
Genetic Testing for Hereditary Hearing Loss AHS – G2148	Reviewed by Avalon 2nd Quarter 2022 CAB. Background, policy guidelines and references updated. No change to policy statement. Medical Director review 7/2022.
Genetic Testing for Hereditary Pancreatitis AHS – M2079	Reviewed by Avalon 2nd Quarter 2022 CAB. Description, policy guidelines, background and references updated. When Covered section edited for clarity. No change to policy statement. Medical Director review 7/2022.
Genetic Testing for Lactase Insufficiency AHS – M2080	Reviewed by Avalon 2nd Quarter 2022 CAB. Updated background, guidelines, and references. No change to policy statement. Medical Director review 7/2022.
Genetic Testing for Li_Fraumeni Syndrome AHS – M2081	Reviewed by Avalon 2nd Quarter 2022 CAB. Description, policy guidelines, background, and references updated. Billing/coding section updated. When Covered item 1 edited and reorganized for clarity and to match most recent NCCN guidelines, genetic counseling requirement added to item 2. Not Covered section edited for clarity. Medical Director review 7/2022.
Genetic Testing for Neurofibromatosis and Related Disorders AHS – M2134	Reviewed by Avalon 2nd Quarter CAB. Updated description, background, guidelines, and references. Coverage criteria edited for clarity. No change to policy statement. Medical Director review 7/2022.
Genetic Testing for Ophthalmologic Conditions AHS-M2083	Reviewed by Avalon 2nd Quarter 2022 CAB. Updated policy guidelines and references. Medical Director review 8/2022.
Genetic Testing for PTEN Hamartoma Tumor Syndrome AHS – M2087	Reviewed by Avalon 2nd Quarter 2022 CAB. Updated description, background, policy guidelines and references. Removed related policy titled Molecular Panel Testing of Cancers for Diagnosis, Prognosis, and Identification of Targeted Therapy AHS-M2109 due to archival. Billing/coding section updated. When Covered section edited for clarity and updated: Major and Minor criteria were moved from item 2 to Note 1, added item 2c, item 8 removed and added as sub criteria "a" to item 6. Medical Director review 7/2022.
Hematopoietic Cell Transplantation	Specialty Matched Consultant Advisory Panel review 8/24/22. No change to policy statement.
Hemoglobin A1c AHS – G2006	Reviewed by Avalon Q2 2022 CAB. Off cycle review. Description and policy guidelines updated. Removed “in individuals who have been transfused within the past 120 days;” from When Not Covered. Added “as the sole diagnostic test in children and adolescents except as previously described;” to When Not Covered. References updated. Medical Director review 7/2022.
Hepatitis C AHS – G2036	Reviewed by Avalon 2nd Quarter 2022 CAB. Medical Director review 8/2022. Related Policies added. Scientific Background updated. When Covered section updated. Table of Terminology added. Policy Guidelines updated. References updated.
HIV Genotyping and Phenotyping AHS – M2093	Reviewed by Avalon 2nd Quarter 2022 CAB. Scientific Background updated. Table of Terminology added. When covered section updated with two additional allowable indications. Policy Guidelines updated. References updated. Medical Director review 8/2022.
Identification of Microorganisms using Nucleic Acid Probes AHS – M2097	Reviewed by Avalon 2nd Quarter 2022 CAB. Updated background, policy guidelines and references. Policy and When Covered section edited for clarity. Billing/coding section updated. Medical Director review.
KRAS, NRAS and BRAF Mutation Analysis in Colorectal Cancer	Reviewed by Avalon 2nd Quarter 2022 CAB. Medical Director review 8/2022. Removed related policy AHS-M2109 Molecular Panel Testing of Cancers to Identify Targeted Therapy. Updated policy guidelines and references. Under Billing/Coding section: removed CPT 81403 and 88363. Title changed from: Tumor Tissue Mutation Analysis in Colorectal Cancer to: KRAS, NRAS and BRAF Mutation Analysis in Colorectal Cancer.
Laser Treatment of Port Wine Stains	Billing/coding section updated for clarity. References updates. Specialty Matched Consultant Advisory Panel review 8/2022. Medical Director review 8/2022.
Microsatellite Instability and Tumor Mutational Burden Testing AHS-M2178	Reviewed by Avalon 2nd Quarter 2022 CAB. Medical Director review 8/2022. Updated policy guidelines and references. Table of solid tumors updated to match NCCN guideline updates. Removed related policy AHS-M2109. Under Billing/Coding section, removed CPT 0050U, added CPT 0326U.
Molecular Profiling for Cancers of Unknown Primary Origin AHS- M2065	Reviewed by Avalon 2nd Quarter 2022 CAB. Updated policy guidelines and references. Medical Director review 8/2022.
Multigene Expression Assay for Predicting Colon Cancer Recurrence AHS-M2111	Reviewed by Avalon 2nd Quarter 2022 CAB. Updated policy guidelines and references. Medical Director review 8/2022.
Oral Screening Lesion Identification Systems and Genetic Screening AHS – G2113	Reviewed by Avalon 2nd Quarter 2022 CAB. Description section, policy guidelines, and references updated. Removed “MOP™ testing” from When Not Covered section. Added code 0296U to Billing/Coding section. Medical Director review 7/2022.
Pancreatic Cancer Risk Testing Using Pancreatic Cyst Fluid AHS-M2114	Reviewed by Avalon 2nd Quarter 2022 CAB. Medical Director review 8/2022. Updated When Covered section: added medically necessary coverage criteria for full adoption of AHS policy. Removed AHS-M2109 Molecular Panel Testing of Cancers to Identify Targeted Therapy from related policies section. Updated the following sections: description, policy guidelines and references. Added CPT codes 82150, 82378, 0313U to Billing/Coding section. Title changed from: Pancreatic Cancer Risk Testing Using Molecular Classifier in Pancreatic Cyst Fluid to: Pancreatic Cancer Risk Testing Using Pancreatic Cyst Fluid.
Pancreatic Enzyme Testing for Acute Pancreatitis AHS – G2153	Reviewed by Avalon 2nd Quarter 2022 CAB. Policy background, guidelines and references updated. Added “(preferred)” after serum lipase in Covered and Not Covered sections, added “or urine” to 2b in Not Covered section, now reads: “b) serum or urine trypsin/trypsinogen/TAP (trypsinogen activation peptide)” Added item number 4 under Not covered section: “Reimbursement is not allowed for measurement of urinary amylase concentration for the initial diagnosis of acute pancreatitis in all patients presenting with signs and symptoms of acute pancreatitis” Billing/Coding section updated. Medical Director review 7/2022.
Pathogen Panel Testing AHS – G2149	Reviewed by Avalon 2nd Quarter 2022 CAB. Background, policy guidelines and references updated. Updated Billing/Coding section. No changes to policy statement. Medical Director review 7/2022.
Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention	Regulatory Status, References and Policy Guidelines updated. Added investigational statements regarding AtriClip device to Not Covered section. Medical Director review 8/2022.
Reconstructive Eyelid Surgery and Brow Lift	Specialty Matched Consultant Advisory Panel review 8/2022. Medical Director review 8/2022. References updated. No change to policy statement.
Serum Testing for Evidence of Mild Traumatic Brain Injury AHS – G2151	Reviewed by Avalon 2nd Quarter 2022 CAB. Table of Terminology added. Medical Director review 8/2022.
Serum Tumor Markers for Malignancies AHS – G2124	Reviewed by Avalon 2nd Quarter 2022 CAB. Medical Director review 8/2022. Updated When Covered section: added medically necessary coverage criteria for full adoption of AHS policy. Updated policy guidelines and references. Under Billing/Coding section, removed CPT 82397, 0067U and added CPT 83521, 83880, G0327, 81479.
Skin and Soft Tissue Substitutes	References updated. Specialty Matched Consultant Advisory Panel review 8/2022. Medical Director review 8/2022. No changes to policy statement.
ST2 Assay for Chronic Heart Failure AHS – G2130	Reviewed by Avalon 2nd Quarter 2022 CAB. Policy guidelines and references updated. No change to policy statement. Medical Director review 7/2022.
Surgical Treatment for Lipedema	When covered section updated. When not covered section updated. Policy Guidelines updated. Billing/Coding section updated. References updated. Medical Director review 8/2022. Specialty Matched Consultant Advisory Panel Review 8/2022.
Surgical Treatment of Chest Wall Deformities (Congenital or Acquired)	Specialty Matched Consultant Advisory Panel 8/2022. Medical Director review 8/2022. References updated. No change to policy statement.
Testing for Alpha-1 Antitrypsin Deficiency AHS-M2068	Reviewed by Avalon 2nd Quarter 2022 CAB. Description, Background, Policy Guidelines and Reference sections updated. Items 2, 4, 5 under the When Covered section updated for clarity. No change to policy statement. Medical Director review 7/2022.
Testing for Targeted Therapy of Non-Small-Cell Lung Cancer AHS - M2030	Reviewed by Avalon 2nd Quarter 2022 CAB. Medical Director review 8/2022. Updated policy guidelines and references. Updated When Covered section for full adoption of AHS policy. Under Related policies section, removed AHS-M2109 Molecular Panel Testing of Cancers to Identify Targeted Therapy and added AHS-M2178 Microsatellite Instability and Tumor Mutational Burden Testing. Under Billing/Coding section, added CPT codes 81194, 81405, 81406, 81479; removed CPT codes 81301, 81401, 88271, 88272, 88273.
Tumor-Treatment Fields Therapy	Specialty Matched Consultant Advisory Panel review 8/24/22. No change to policy statement.
Urinalysis and Urine Culture Testing for Bacteria AHS – G2156	Reviewed per Avalon Q2 2022 CAB. Description, Policy Guidelines and References updated. Related policy added. When covered section updated for clarity. Following statement removed from When not Covered section: “Reimbursement is not allowed for urine culture testing (with isolate identification and antibiotic susceptibilities if applicable) in all other situations, including for asymptomatic bacteriuria or asymptomatic urinary tract infection in all other instances not outlined by the above criteria.” Medical Director review 7/2022.
Urinary Tumor Markers for Bladder Cancer AHS – G2125	Reviewed by Avalon 2nd Quarter 2022 CAB. Medical Director review 8/2022. Related policy “Molecular Panel Testing of Cancers for Diagnosis, Prognosis, and Identification of Targeted Therapy” removed. Table of Terminology added. References updated and added. Description section updated. Added codes 88346 and 88350 to Billing/Coding section. Policy Guidelines updated.
Vitamin D Testing AHS – G2005	Reviewed by Avalon 2nd Quarter 2022 CAB. Off cycle review. Description, Policy Guidelines, and References updated. Added inflammatory bowel disease (Crohn’s disease and ulcerative colitis) to Guideline 1: Indications that support medical necessity for serum measurement of 25-hydroxyvitamin D. Medical Director review 7/2022.
Whole Genome and Whole Exome Sequencing AHS – M2032	Reviewed by Avalon 2nd Quarter 2022 CAB. Background, policy guidelines and references updated. Billing/Coding section updated. No change to policy statement. Medical Director review 7/2022.