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Notification of Policy Revisions Effective April 30, 2025 (Posted February 26, 2025)
| Medical Policy | Revision |
|---|---|
| Coronavirus Testing in the Outpatient Setting AHS – G2174 | Reviewed by Avalon 4th Quarter 2024 CAB. Updated Description, Policy Guidelines, and References sections. Updated When covered #4 to reflect nucleic acid amplification testing as an acceptable test option for MIS-C and MIS-A. Updated When Covered #5 to include a frequency of once every 48 hours. Removed “Reimbursement for individuals with signs and symptoms of a respiratory tract infection, antigen panel testing of up to 5 antigens is allowed” from When Covered and “Reimbursement is not allowed for multiplex PCR-based panel testing of 6 or more respiratory pathogens” from When Not Covered due to redundancy with G2149-Pathogen Panel Testing. Updated Note 1 with updated CDC signs and symptoms of COVID-19. Updated Note 2 and Note 3 with updated CDC clinical requirements for suspected MIS-C and MIS-A. Updated Billing/Coding section to remove CPT codes 87631, 87632, 87633, 0115U, 0202U, 0223U, 0225U, and C9803. Medical Director review 1/1/2025. Notification given on 2/26/2025 for Effective Date 4/30/2025. |
| Diabetes Mellitus Testing - AHS G2006 | Reviewed by Avalon Q4 2024 CAB. Description, policy guidelines, and references updated. Updated When Covered section #2 to add 2.e: “Quarterly for individuals who are pregnant” and #5 to add 5.i: “For individuals with metabolic dysfunction-associated steatotic liver disease (MASLD)”. Removed Note 1 and updated Note 2 and 3 to support note number changing and references. Medical Director review 1/2025. Notification given on 2/26/2025 for effective date 4/30/2025. |
| Diagnostic Testing of Iron Homeostasis and Metabolism AHS - G2011 | Reviewed by Avalon 4th Quarter 2024 CAB. Medical Director review 1/2025. Description, Policy Guidelines, and References updated. Updated When covered #2 to remove “(using serum iron and serum iron binding capacity measurements)”. Updated When Not Covered section to clarify that testing outside of conditions addressed above is not allowed, including the testing of asymptomatic individuals (individuals should be symptomatic for indications provided in criteria, not just symptomatic in general). Notification given on 2/26/2025 for effective date 4/30/2025. |
| Testing for Developmental Delay AHS - M2176 | Reviewed by Avalon 4th Quarter 2024 CAB. Title changed to Testing for Developmental Delay AHS-M2176. Description, Policy Guidelines and References updated. When Covered section criteria 1 edited for clarity and now reads “For individuals less than 18 years of age who have had a physical examination suggestive of syndromic developmental delay or developmental delay due to a metabolic disorder (e.g., dysmorphology, growth parameters {including head circumference}, skin examination), targeted genetic testing is considered medically necessary.” Updates to Not Covered section: previous criteria 1, 2, and 3 removed. New criteria 1 reads “For the diagnosis of autism spectrum disorder (ASD) or non-syndromic developmental delay, all other testing outside of chromosomal microarray, whole exome sequencing, or whole genome sequencing or genetic testing for fragile X syndrome or Rett syndrome is considered not medically necessary.” Note 1 updated and now reads “For two or more gene tests being run on the same platform, please refer to Laboratory Procedures Medical Policy AHS-R2162.” Medical Director review 1/2025. Notification given 2/26/25 for effective date 4/30/25. |
| Testing of Homocysteine Metabolism Related Conditions AHS - M2141 | Reviewed by Avalon 4th Quarter 2024 CAB. Description, Policy Guidelines, and References updated. Updated When Covered #2 to read as follows: “Genetic testing for variants of MTHFR known to cause homocystinuria, is considered medically necessary if either of the following conditions are met: For symptomatic individuals that have tested negative for classic homocystinuria due to CBS deficiency; For individuals with a first-degree relative (see Note 1) positive for known variants of MTHFR that cause homocystinuria.” Added the following statement to When Covered section: “Note 1: First-degree relatives include parents, full siblings, and children of the individual.” Added the following statement to When Not Covered section: “Genetic testing for MTR, MTRR, and MMADHC genes is considered not medically necessary.” Medical Director review 1/1/2025. Notification given 2/26/2025 for effective date 4/30/2025. |
| Vitamin B12 and Methylmalonic Acid Testing AHS - G2014 | Reviewed by Avalon 4th Quarter 2024 CAB. Policy Guidelines. Related Policies, and References updated. Updated When Covered section to add a three-month testing frequency for all vitamin B testing/screening. Added the following statement to When Not Covered section: “Reimbursement is not allowed for total vitamin B12 (serum cobalamin) testing for all other situations not described above”. Medical Director review 1/2025. Notification given on 2/26/2025 for effective date 4/30/2025. |
| Vitamin D Testing AHS - G2005 | Reviewed by Avalon 4th Quarter 2024 CAB. Updated Description, Policy Guidelines, and References. Updated When Covered #3 for clarity and consistency. Updated When Covered Note 1 to remove obesity as an indication for serum measurement of 25-hydroxyvitamin. Updated Note 1 and 2 to remove “medical necessity” language. Medical Director review 1/2025. Notification given 2/26/2025 for effective date 4/30/2025 |
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