Medical Policy Update for September 29, 2023

Medical Guidelines	Reason for Update
Ablative Techniques for the Myolysis of Uterine Fibroids	Policy guidelines updated. References updated. Specialty Matched Consultant Advisory Panel review 9/2023. Medical Director review 9/2023. No change to policy statement.
Biochemical Markers of Alzheimer Disease and Dementia AHS – G2048	Added code 0412U to Billing/Coding section, effective 10/1/2023.
Bone Mineral Density Studies	Related policies updated. References updated. Specialty Matched Consultant Advisory Panel review 9/2023. Medical Director review 9/2023. No change to Policy statement.
Cardiovascular Disease Risk Assessment AHS – G2050	Updated Billing/Coding section to add codes 0019M and 0415U, effective 10/1/23.
Coronavirus Testing in the Outpatient Setting AHS – G2174	Added CPT code 0408U to Billing/Coding section, effective 10/1/2023.
Dermatologic Applications of Photodynamic Therapy	Related policies added. References updated. Specialty Matched Consultant Advisory Panel review 9/2023. Medical Director review 9/2023. No change to policy statement.
Diagnostic Testing of Sexually Transmitted Infections AHS – G2157	Added CPT code 0402U to Billing/Coding section, effective 10/1/23.
Gene Expression Profiling and Protein Biomarkers for Prostate Cancer AHS - M2166	Added PLA code 0403U to Billing/Coding section for 10/1/23 code update.
Genetic Cancer Susceptibility Panels Using Next Generation Sequencing AHS-M2066	Added PLA code 0405U to Billing/Coding section for 10/1/23 code update.
Genetic Testing of Mitochondrial Disorders AHS – M2085	Added code 0417U to Billing/Coding section for effective date 10/1/23.
Infertility Diagnosis and Treatment – B0006	References updated. Specialty Matched Consultant Advisory Panel review 9/2023. Medical Director review 9/2023. No change to policy statement.
Injection Therapy for Headache (Migraine and Other) and Non-Spine Management	Added the following ICD 10 codes to the Billing/Coding section: G43.E01, G43.E09, G43.E11, and G43.E19, effective 10/1/2023.
Liquid Biopsy AHS-G2054	Added PLA code 0410U to Billing/Coding section for 10/1/23 code update.
Lumbar Spine Procedures	Policy updated for effective date 10/1/2023. Updated the Note under the Lumbar Spine Procedures procedure in the When Covered section. Now reads: “For non-emergent procedures that include fusion, it is strongly recommended that the surgical candidate refrain from smoking/nicotine for at least six weeks prior to surgery and during the time of healing”. Removed requirement of 6 week tobacco cessation and associated provider attestation.
Microsatellite Instability and Tumor Mutational Burden Testing AHS-M2178	Added PLA code 0409U to Billing/Coding section for 10/1/23 code update.
Molecular Testing for Pulmonary Disease AHS - M2160	Added CPT code 0406U to Billing/Coding section, effective 10/1/2023.
Non-Pharmacologic Treatment of Rosacea	Regulatory status and references updated. Specialty Matched Consultant Advisory Panel review 9/2023. No change to policy statement. Medical Director review 9/2023.
Occipital Nerve Stimulation	Added the following ICD 10 codes to the Billing/Coding section: G43.E01, G43.E09, G43.E11, and G43.E19, effective 10/1/2023.
Orthotics	Added HCPCS code L1681 to Billing/Coding section, effective 10/1/2023.
Pathogen Panel Testing AHS – G2149	Updated Billing/Coding section to add code 0416U, effective 10/1/2023.
Pharmacogenetics Testing AHS – M2021	Codes 0411U and 0419U added to Billing/Coding section, effective 10/1/23.
Proteogenomic Testing of Individuals with Cancer AHS-M2168	Added PLA code 0413U to Billing/Coding section for 10/1/23 code update.
Serum Tumor Markers for Malignancies AHS – G2124	Added PLA code 0404U to Billing/Coding section for 10/1/23 code update.
Skin and Soft Tissue Substitutes	Added HCPCS codes A2002, A2023, A2024, A2025, Q4285, Q4286 to Billing/Coding section, effective 10/1/2023.
Surgical Treatment of Sinus Disease	Description updated. Removed terminated CPT codes 0406T and 0407T and added CPT codes 31237 and 31299. Added related policy. Changed patient to individual throughout policy. Updated references. Added Fungal Sinusitis to list of covered indications. When covered section updated as follows: added names of additional examples of mometasone furoate sinus implants. The use of a mometasone furoate sinus implant: Bullet 1 subsection to now read “individual is ≥ 18 years of age”. Bullet 2 subsection to now read: “Ethmoid or frontal sinus surgery is planned”. Policy guidelines updated in reference to oral antibiotic use. Medical Director review 8/2023. Specialty Matched Consultant Advisory Panel review 8/2023.
Testing for Targeted Therapy of Non-Small-Cell Lung Cancer AHS - M2030	Added PLA code 0414U to Billing/Coding section for 10/1/23 code update.

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