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Medical Policy Update July 26, 2022

Medical GuidelinesReason for Update
Amniotic Membrane and Amniotic Fluid Injections for Ophthalmic IndicationsSpecialty Matched Consultant Advisory Panel review 6/2022. Medical Director review 6/2022. No change to policy statement.
Aqueous Shunts and Devices for GlaucomaSpecialty Matched Consultant Advisory Panel review 6/2022. Updated policy guidelines and references added.
Autografts and Allografts in the Treatment of Focal Articular Cartilage LesionsReference added. Specialty Matched Consultant Advisory Panel review 6/29/2022.
Autologous Chondrocyte ImplantationPolicy Guidelines updated. Specialty Matched Consultant Advisory Panel review 6/29/2022.
BRCA AHS - M2003Reviewed by Avalon 1st Quarter 2022 CAB. Medical Director review 4/2022. Under “When Not Covered” section added new non-covered indication “genetic testing in minors < 18 years of age” is not medically necessary. Reformatted “When Covered” section. Note 5 removed. Updated policy guidelines and references. Notification 5/17/22 for effective date 7/26/22.
Capsule Endoscopy, WirelessWhen Covered section revised; moved Patient Selection criteria from the policy guidelines up under main bullet 1 and 3 for clarity, no change to policy intent.
Computer Assisted Surgical Navigational Orthopedic ProceduresReference added. Policy Guidelines updated. Expired code 0396T removed from Billing/Coding section. Specialty Matched Consultant Advisory Panel 6/29/2022.
Computerized Corneal TopographySpecialty Matched Consultant Advisory Panel review 6/2022. Medical Director review 6/2022. No change to policy statement.
Corneal Collagen Cross-linkingSpecialty Matched Consultant Advisory Panel review 6/2022. Updated policy guidelines and added reference.
Electrical Bone Growth StimulationDescription section updated. Regulatory Status updated. Specialty Matched Consultant Advisory Panel review 6/29/2022.
Epiretinal Radiation Therapy for Age-Related Macular DegenerationSpecialty Matched Consultant Advisory Panel review 6/2022. Removed CPT code 0190T from Billing/Coding section. Added CPT code 67299 to Billing/Coding section. Updated description section.
Extracorporeal Shock Wave Treatment for Musculoskeletal Conditions and Wound HealingSpecialty Matched Consultant Advisory Panel review 6/29/2022.
Eyelid Thermal Pulsation for the Treatment of Dry Eye SyndromeSpecialty Matched Consultant Advisory Panel review 6/2022. Updated description section and added references. Medical Director review 6/2022.
Fundus PhotographySpecialty Matched Consultant Advisory Panel review 6/2022. Medical Director review 6/2022. No change to policy statement.
Glaucoma, Evaluation by Ophthalmologic TechniquesSpecialty Matched Consultant Advisory Panel review 6/2022. Medical Director review 6/2022.
Immunopharmacologic Monitoring of Therapeutic Serum Antibodies AHS - G2105Reviewed by Avalon 1st Quarter 2022 CAB – off cycle review. Updated When not Covered section to add “Reimbursement is not allowed for drug and/or antibody concentration testing for anti-TNF therapies in patients with spondyloarthritis, rheumatoid arthritis, psoriatic arthritis, and psoriasis.” References updated. Medical Director review 4/2022. Notification given 5/17/2022 for policy effective date 7/26/2022.
KeratoprosthesisSpecialty Matched Consultant Advisory Panel review 6/2022. Medical Director review 6/2022. No change to policy statement.
Magnetic Esophageal Sphincter Augmentation to Treat Gastroesophageal Reflux Disease (GERD)Medical Director review. When Covered section updated to state that laparoscopic magnetic esophageal sphincter augmentation may be considered medically necessary when criteria are met. When Not Covered section updated with non-covered criteria. Policy Guidelines updated.
Meniscal Allografts and Other Meniscal ImplantsSpecialty Matched Consultant Advisory Panel review 6/29/2022.
Myoelectric Prosthetic Components for the Upper LimbSpecialty Matched Consultant Advisory Panel review 6/29/2022.
Optical Coherence Tomography (OCT) Anterior Segment of the EyeSpecialty Matched Consultant Advisory Panel review 6/2022. Updated description section. Updated policy guidelines section. Medical Director review 6/2022.
Patient-Specific Instrumentation (e.g., Cutting Guides) for Joint ArthroplastyReferences added. Specialty Matched Consultant Advisory Panel review 6/29/2022.
Refractive SurgerySpecialty Matched Consultant Advisory Panel review 6/2022. Medical Director review 6/2022.
Retinal ProsthesisSpecialty Matched Consultant Advisory Panel review 6/2022. Removed HCPCS code L8698 from Billing/Coding section. Medical Director review 6/2022.
Surgery for Femoroacetabular ImpingementPolicy Guidelines updated. Specialty Matched Consultant Advisory Panel review 6/29/2022.
Surgery for Groin Pain in AthletesSpecialty Matched Consultant Advisory Panel review 6/29/2022.
Thyroid Disease Testing AHS – G2045Reviewed by Avalon 1st Quarter 2022 CAB. Description, Policy Guidelines and References updated. When Covered section reorganized and updated for clarity. Added “Reimbursement is not allowed for testing for thyrotropin-releasing hormone (TRH) for the evaluation of the cause of hyperthyroidism or hypothyroidism.” to When Not Covered section. Medical Director review 4/2022 Notification given on 5/17/2022 for effective date 7/26/2022.
Vertebral Axial Decompression (VAD-X)Reference added. Specialty Matched Consultant Advisory Panel review 6/29/2022.
Viscocanalostomy and CanaloplastySpecialty Matched Consultant Advisory Panel review 6/2022. Updated description section and added references. Medical Director review 6/2022.