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Medical Policy Update for November 13, 2024
| Medical Guidelines | Reason for Update |
|---|---|
| Artificial Intervertebral Disc (PDF) | References updated. Specialty Matched Consultant Review 10/2024. Medical Director review 10/2024. |
| Autonomic Nervous System Testing (PDF) | References updated. Specialty Matched Consultant Review 10/2024. Medical Director review 10/2024. |
| Baroreflex Stimulation Devices (PDF) | Description and References updated. No change to policy statement. Specialty Matched Consultant Advisory Panel review 10/2024. Medical Director review 10/2024. |
| Cardiac Monitoring Devices in the Outpatient Setting (PDF) | Description, Regulatory Status, Policy Guidelines and References updated. No change to policy statement. Specialty Matched Consultant Advisory Panel review 10/2024. Medical Director review 10/2024. |
| Carotid Intimal-Medial Thickness (PDF) | Description and References updated. Specialty Matched Consultant Advisory Panel review 10/2024. Medical Director review 10/2024. |
| Computed Tomography to Detect Coronary Artery Calcification (PDF) | Description and References updated. Specialty Matched Consultant Advisory Panel review 10/2024. Medical Director review 10/2024. |
| Decompression of the Intervertebral Disc Using Laser Energy (Laser Discectomy) or Radiofrequency Coblation Nucleoplasty) (PDF) | References updated. Specialty Matched Consultant Advisory Panel review 10/2024. Medical Director review 10/2024. |
| Electrodiagnostic Studies (PDF) | Removed the following note from the Billing/Coding Sections: “Use of CPT code 95904 is incorrect coding for Quantitative Sensory Testing”. References updated. Specialty Matched Consultant Advisory Panel review 10/2024. Medical Director review 10/2024. |
| Enhanced External Counterpulsation (EECP) (PDF) | References updated. Specialty Matched Consultant Advisory Panel review 10/2024. Medical Director review 10/2024. |
| Genetic Testing for Breast, Ovarian, Pancreatic and Prostate Cancers (BRCA) AHS - M2003 (PDF) | Reviewed by Avalon 2nd Quarter 2024 CAB. Medical Director review 7/2024. Updated related policies, references, policy guidelines and recommendations. Added 3 Notes and renumbered all Notes 1-6. Under “when covered” section, several statements edited based on NCCN guidelines: close relatives are now first or second degree; exception in coverage statement #3. a. is now just for pancreatic cancer and does not include prostate cancer; only first-degree relatives of an individual affected with pancreatic cancer should be offered testing; clarified 5% probability cutoff; clarified testing for individuals of Ashkenazi Jewish ancestry. Under “when not covered” section, added new statement #3: “For all other purposes, including, but not limited to, testing of the general population, genetic testing for susceptibility to breast, ovarian, pancreatic, or prostate cancer is considered not medically necessary.” Added PLA codes 0474U and 0475U to Billing/Coding section. Notification 9/4/2024 for effective date 11/13/2024. |
| Injection Therapy for Headache (Migraine and Other) and Non-Spine Management (PDF) | Minor edits to Description section. Policy Guidelines updated. No change to policy intent. References updated. Specialty Matched Consultant Advisory Panel review 10/2024. Medical Director review 10/2024. |
| Interferential Stimulation (PDF) | References updated. Specialty Matched Consultant Advisory Panel review 10/2024. Medical Director review 10/2024. |
| MRI-guided Laser Interstitial Thermal Therapy for Neurological Indications (PDF) | Updated Regulatory Status and References. Specialty Matched Consultant Advisory Panel review 10/2024. Medical Director review 10/2024. |
| Prenatal Screening (Genetic) AHS – M2179 (PDF) | Reviewed with Avalon Q2 CAB 2024. Updated description, related policies, policy guidelines, and references. When covered #3 updated for clarification that screening in the reproductive partner is restricted to the genes for which their partner tested positive by carrier screening, not broad screening for themselves. When covered #5 updated for clarification that fetal testing must be a form of testing, not a form of screening (e.g., cfDNA screening), from an amnio or CVS sample. Added “Note 2: For 2 or more gene tests being run on the same platform, please refer to AHS-R2162 Reimbursement Policy” under when covered section. Added the following statement to when not covered: “Reimbursement is not allowed for the use of non-invasive prenatal screening (NIPS) to screen for single-gene mutations (i.e., autosomal recessive, autosomal dominant, X-linked) in the fetus." Added 0449U, 81479, 81599 to Billing/Coding section. Medical Director review 7/2024. Notification given 9/4/2024 for effective date 11/13/2024. |
| Quantitative Sensory Testing (PDF) | Updated references. Medical Director review 10/2024. Specialty Matched Consultant Advisory Panel review 10/2024. |
| Signal-Averaged ECG (PDF) | References updated. Specialty Matched Consultant Advisory Panel review 10/2024. Medical Director review 10/2024. |
| Spinal Cord and Dorsal Root Ganglion Stimulation (PDF) | Regulatory Status and References updated. Specialty Matched Consultant Panel review 10/2024. Medical Director review 10/2024. |
| Stem-cell Therapy for Peripheral Arterial Disease (PDF) | Description and References updated. Specialty Matched Consultant Advisory Panel review 10/2024. Medical Director review 10/2024. |
| Therapeutic Radiopharmaceuticals in Oncology (PDF) | Description, policy statement, coverage criteria, policy guidelines updated to remove reference iobenguane I 123 as the product has been withdrawn from the market by the manufacturer. Removed CPT code A9590 from Billing/Coding section. Medical Director review 10/2024. |
| Total Facet Arthroplasty (PDF) | Updated Regulatory Status. Policy Guidelines updated. No change to policy intent. References updated. Specialty Matched Consultant Advisory Panel review 10/2024. Medical Director review 10/2024. |
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