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Notification of Policy Revisions Effective February 12, 2025 (Posted December 17, 2024)
Medical Policy | Revision |
|---|---|
| Βeta-Hemolytic Streptococcus Testing AHS – G2159 (PDF) | Reviewed by Avalon 3rd Quarter 2024 CAB. Policy Guidelines and References updated. Note 1 moved from Policy Guidelines to When Covered section. Bullet 2b under the When Not Covered Section updated and now states “As a follow-up test for individuals who have had either a bacterial culture test or a nucleic acid test for a streptococcal infection.” Added CPT code 86581 to the Billing/Coding section, effective 1/1/25. Medical Director review 10/2024. Notification 12/17/2024 for effective date 2/12/2025. |
| Cardiovascular Disease Risk Assessment AHS – G2050 (PDF) | Reviewed by Avalon 3rd Quarter 2024 CAB. Policy Guidelines and References updated. Code 84512 added to Billing/Coding section. The following edits were made to the When Covered section: coverage criteria 1). a). i). edited to remove previous phrase “to 6” and now reads “Every 4 years for individuals ages 18 to 79 years”. Added “annually” to coverage criteria 1). d). which now reads “Annually for individuals on a long-term drug therapy that requires lipid monitoring (e.g., Accutane, anti-psychotics).” Medical Director review 10/2024. Notification given 12/17/2024 for effective date 2/12/2025. |
| Diagnostic Testing of Sexually Transmitted Infections AHS – G2157 (PDF) | Reviewed by Avalon 3rd Quarter 2024 CAB. Updated policy title on one Related Policy. Policy Guidelines and References updated. When Not Covered section addition as follows: “Reimbursement is not allowed for nucleic acid testing to determine antimicrobial susceptibility in N. GONORRHOEAE or macrolide resistance in M. GENITALIUM.” Billing and Coding section updated as follows: removed PLA code 0167U and added PLA code 0484U. Medical Director review 10/2024. Notification given 12/17/2024 for effective date 2/12/2025. |
| Genetic Testing for Familial Alzheimer’s Disease AHS – M2038 (PDF) | Reviewed by Avalon 3rd Quarter 2024 CAB. Added one Related Policy. Removed the following statement from the When Covered section, “Reimbursement is allowed for genetic counseling for familial Alzheimer disease genetic testing” as this policy doesn’t address genetic counseling. Added Note 1 and 3 and reordered Note 2. When Not Covered section updated as follows: Added the following " Outside of situations addressed in Pharmacogenetic Testing AHS-M2021, testing of APOE is considered investigational". Under criterion 2b, defined children as individuals less than 18 years of age. Updated criterion 2c by removing APOE gene. Policy Guidelines and References updated. Removed the following CPT codes from the Billing/Coding section: 96040, S0265. Medical Director review 10/2024. Notification 12/17/2024 for effective date 2/12/2025. |
| Hepatitis Testing AHS – G2036 (PDF) | Reviewed by Avalon 3rd Quarter 2024 CAB. Updated policy title on one Related Policy. Policy Guidelines and References updated. Added criteria for Hepatitis A and Hepatitis D to When Covered and When Not Covered sections. Under the Hepatitis C subsection of the When Covered section, added the word “qualitative” to nucleic acid testing for clarity and also changed the age for the one-time screening for qualitative nucleic acid testing for HCV for perinatally exposed infants from 2-17 months of age to 2-6 months of age. Added the following CPT codes to the Billing and Coding section: 86692, 96708, 96709, 97380, 87516, 87523, and 87799. Medical Director review 10/2024. Notification given 12/17/2024 for effective date 2/12/2025. |
| Identification of Microorganisms using Nucleic Acid Probes AHS – M2097 (PDF) | Reviewed by Avalon 3rd Quarter 2024 CAB. Updated Description, Policy Guidelines and References. Removed Mycoplasma genitalium from table under When Covered section, as management of testing for M.genitalium is now contained within Diagnostic Testing of Common Sexually Transmitted Infections AHS - G2157. Removed direct probe for HHV6 code 87531 from table under When Covered section and placed in table under Not Covered section. Code 87563 removed from Billing/Coding section. Medical Director review 10/2024. Notification given 12/17/2024 for effective date 2/12/2025. |
| Pancreatic Enzyme Testing for Acute Pancreatitis AHS – G2153 (PDF) | Reviewed by Avalon 3rd Quarter 2024 CAB. Description, Policy Guidelines and References updated. Coverage criteria 1 under the Not Covered section edited for complete clarity on the disallowance of serum lipase or amylase for individuals who have already been diagnosed with acute pancreatitis or for those who have been diagnosed with chronic pancreatitis and now reads: “Reimbursement is not allowed for measurement of serum lipase and/or amylase concentration in any of the following situations: a. For individuals with an established diagnosis of acute or chronic pancreatitis. b. More than once per visit. c. For asymptomatic individuals during a general exam without abnormal findings.” Added new coverage criteria 5: “For all other situations or conditions not described above, reimbursement is not allowed for measurement of serum lipase and/or amylase.” Updated signs and symptoms of acute pancreatitis in Note 1. Medical Director review 10/2024. Notification given 12/17/2024 for effective date 2/12/2025. |
| Pathogen Panel Testing AHS – G2149 (PDF) | Reviewed by Avalon 3rd Quarter 2024 CAB. Description, Policy Guidelines and References updated. Removed phrase “in the outpatient setting” from coverage criteria in the When Covered and Not Covered sections. Additional changes made to the When Covered section: added statement “This policy is specific to testing in the outpatient setting. Criteria below do not apply to testing allowances in situations other than the outpatient setting”, removed previous coverage criteria 2 as up to 11 GIPs on a PCR-panel are now allowed for all individuals. Criteria 1 now reads “Reimbursement is allowed for multiplex PCR-based panel testing (up to 11 gastrointestinal pathogens [GIPs]) no more often than once every 7 days for individuals with persistent diarrhea or diarrhea with signs or risk factors for severe disease (i.e., fever, bloody diarrhea, dysentery, dehydration, severe abdominal pain).” Criteria 2 (previously criteria 3) edited to now read “Reimbursement is allowed for multiplex PCR-based panel testing (up to 5 respiratory pathogens) for individuals who are displaying signs and symptoms of a respiratory tract infection (i.e., temperature ≥ 102°F, pronounced dyspnea, tachypnea, tachycardia).” Added CPT code 0528U to Billing/Coding section, effective 1/1/2025. Medical Director review 10/2024. Notification given 12/17/2024 for effective date 2/12/2025. |
| Testing for Alpha-1 Antitrypsin Deficiency AHS - M2068 (PDF) | Reviewed by Avalon 3rd Quarter 2024 CAB. Description, Policy Guidelines and References updated. Updates to the When Covered section: added “once per lifetime” to coverage criteria 1 and now reads “For individuals who are suspected of having alpha-1 antitrypsin (AAT) deficiency, serum quantification of alpha-1 antitrypsin (AAT) protein and AAT phenotyping or AAT proteotyping or genetic testing for AAT deficiency (see Note 1) is considered medically necessary once per lifetime in any of the following situations…”, coverage criteria 1. b. edited to include examples of unexplained liver disease and now reads: “For individuals with unexplained liver disease (e.g., chronic hepatitis with or without cirrhosis, chronically elevated aminotransferase levels, portal hypertension, primary liver cancer).”, added new coverage criteria 1. h. “For individuals with neonatal cholestasis.” Medical Director review 10/2024. Notification given 12/17/2024 for effective date 2/12/2025. |
| Testing for Vector-Borne Infections AHS – G2158 (PDF) | Reviewed by Avalon 3rd Quarter 2024 CAB. Updated policy title on one Related Policy. Policy Guidelines and References updated. When Covered Section updated as follows: criteria have been reorganized to discuss the recommended testing for relapsing fevers caused by Borrelia spp, added PCR testing and updated IFA for clarity for those suspected of having Colorado tick fever, removed “non-pregnant” from cc 5b (DENV) detection, added PCR testing to confirm Plasmodium species in those with malaria, clarified test timing in those suspected of having rickettsial disease, added IgG antibodies to the use of IFA for those suspected of having WNV, added nucleic acid detection to confirm a WNV infection in immunocompromised individuals, updated Zika coverage criteria. When Not Covered Section updated as follows: added culture testing for individuals suspected of having a relapsing fever caused by a Borrelia spp., “immunocompetent” to individuals suspected of have WNV disease, clarified Zika detection testing by adding “who haven’t traveled outside of the US and its territories” for non-pregnant individuals who are symptomatic. Updated Notes numbering and added new Notes 2-4. Medical Director review 10/2024. Notification given 12/17/2024 for effective date 2/12/2025. |
| Whole Genome and Whole Exome Sequencing AHS – M2032 (PDF) | Reviewed by Avalon 3rd Quarter 2024 CAB. Description, Policy Guidelines and References updated. Billing/Coding section updated to remove codes 0297U, 0329U and 0036U and add codes 0214U, 0215U, 0425U, 0426U and 81479. Updates to When Covered section: coverage criteria 1, 2, and 3 edited for clarity, new coverage criteria 4 added: "When WES is unable to identify a causative mutation and the clinical suspicion of a genomic etiology remains in situations where any of the above criteria are met in their entirety, whole genome sequencing (WGS) is considered medically necessary." Updates to Not Covered section: new criteria added stating "Focused exome sequencing and targeted WGS is considered investigational", and previous criteria regarding all other testing situations edited to now read "For all other situations not described above, WGS is considered investigational." Medical Director review 10/2024. Notification 12/17/24 for effective date 2/12/25. |
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