Medical Policy Update for December 17, 2024

References updated. Specialty Matched Consultant Advisory Panel review 11/2024. Medical Director review 11/2024.

References updated. Specialty Matched Consultant Advisory Panel review 11/2024.  Medical Director review 11/2024.

Reviewed by Avalon 3rd Quarter 2024 CAB. Updated References. Added CPT code 83884 to Billing/Coding section, effective 1/1/2025.  Medical Director review 10/2024.

Reviewed by Avalon 3rd quarter 2024 CAB.  Description, policy guidelines, and references updated. No change to policy statement. Medical Director review 10/2022.

Reviewed by Avalon 3rd Quarter 2024 CAB. Description, Policy Guidelines and References sections updated. No change to policy statement. Medical Director review 10/2024.

Policy Guidelines and References updated. Specialty Matched Consultant Advisory Panel 11/2024. Medical Director review 11/2024.

Description, Policy Guidelines and References updated. Specialty Matched Consultant Advisory Panel 11/2024. Medical Director review 11/2024.

Reviewed by Avalon 3rd Quarter 2024 CAB.  Policy Guidelines and References updated. No change to policy statement.  Medical Director review 10/2024.

Reviewed by Avalon 3rd Quarter 2024 CAB. Medial Director review 10/2024. Updated policy guidelines and added references. No change to policy statement.

Reviewed by Avalon 3rd Quarter 2024 CAB. Updated Policy Guidelines and Reference sections. When Covered and Not Covered sections edited for clarity, no change to policy statement. Medical Director review 10/2024.

Reviewed by Avalon 3rd Quarter 2024 CAB. Medical Director review 10/2024. Under “when covered” 1.f, added pre-operative to coverage criteria. Updated policy guidelines and references. Added related policies section: AHS-M2182 and AHS-2175.

References added. Description and Policy Guidelines updated to include irreversible electroporation. No changes to the coverage criteria. Specialty Matched Consultant Advisory Panel review 11/2024. Medical Director review 11/2024.

Reviewed by Avalon 3rd Quarter 2024 CAB. Updated Description and policy guidelines. Added references. No change to policy statement.  Medical Director review 10/2024.

Minor edits to the Description section, References updated. Specialty Matched Consultant Advisory Panel 11/2024. Medical Director review 11/2024.

Reviewed by Avalon 3rd Quarter 2024 CAB. Updated Description, Policy Guidelines, and Reference sections. Updated Note 1 in when covered section for clarity. No change to policy statement. Medical Director review 10/2024.

Reviewed by Avalon 3rd Quarter 2024 CAB. Description, Policy Guidelines, and References updated. Coverage criteria combined and edited for clarity on frequency. No changes to policy statement. Medical Director review 10/2024.

Reviewed by Avalon Q3 2024 CAB. Medical Director review 10/2024. Updated policy guidelines and references. No change to policy statement.

References added. Specialty Matched Consultant Advisory Panel review 11/2024. Medical Director review 11/2024.

Specialty Matched Consultant Advisory Panel review 11/2024. Medical Director review 11/2024.  No change to policy statement.

Policy archived with Avalon 3rd Quarter 2024 CAB.

Medical Director Review 11/2024. Specialty Matched Consultant Advisory Panel review 11/2024. No changes to policy statement.

Reviewed by Avalon 3rd Quarter 2024 CAB. Description, Policy Guidelines and References updated. Code 84433 added to Billing/Coding section. Medical Director review 10/2024.

Reviewed by Avalon 3rd Quarter 2024 CAB. References updated.  Medical Director review 10/2024.

Reference added. Updated Policy Guidelines. Specialty Matched Consultant Advisory Panel review 11/2024. Medical Director review 11/2024.

References added. Specialty Matched Consultant Advisory Panel review 11/2024. Medical Director review 11/2024.

Updated Billing/Coding section to remove PLA code 0396U.

Added PLA codes 0488U, 0489U, and 0494U to Billing/Coding section.

Reviewed by Avalon 3rd Quarter CAB. Related Policies updated. Policy Guidelines and References updated. No changes to coverage criteria. Medical Director review 11/2024.

Reference added. Policy Guidelines updated. When Covered section updated to change “prostate gland volume is estimated to be ≤80 cc” to read “Prostate gland volume is estimated to be ≤ 100 cc”, also removed “Prostate anatomy demonstrates normal bladder neck without an obstructive or protruding median lobe” from When Covered section.  Specialty Matched Consultant Advisory Panel review 11/2024. Medical Director review 11/2024.

Reference added. Description section updated. Specialty Matched Consultant Advisory Panel Review 11/2024. Medical Director review 11/2024.

Reviewed by Avalon 3rd Quarter 2024 CAB. Updated Policy Guidelines and Reference sections. No change to policy statement. Medical Director review 10/2024.

Reviewed by Avalon 3rd Quarter 2024 CAB. Description, Policy Guidelines and References updated. Updated the name of NAFLD in coverage criteria 1 to MASLD and now reads “In order to determine therapy, the use of multianalyte assay with algorithmic analysis for noninvasive assessment of hepatic fibrosis and necroinflammatory activity (e.g., FibroTest, also known as FibroSure, ELF) in a patient with chronic liver disease secondary to hepatitis B or C or metabolic dysfunction associated steatotic liver disease (MASLD) is considered medically necessary.” No change to policy statement. Medical Director review 10/2024.

Reviewed by Avalon 3rd Quarter 2024 CAB. Policy Guidelines and References updated. No change to policy intent.  Updated items 3, 6, and 7 in the When Not Covered section from medical necessity to reimbursement language.  Added CPT code 87564 to Billing/Coding section, effective 1/1/2025.  Medical Director review 10/2024.

Reviewed by Avalon 3rd Quarter 2024 CAB Review. Description, Policy Guidelines, and References updated. Related policies added. Coverage criteria #1 edited to address appropriate type of thyroid function testing for all sub criteria. Updated Coverage criteria #1. A to add appropriate fT4 monitoring for those diagnosed with secondary hypothyroidism. Updated coverage criteria #1.C for clarity and added that TSH is the appropriate screening test. Coverage criteria #1.C now reads “For asymptomatic individuals who have been prescribed drugs that can interfere with thyroid function and thus who are at an increased risk for thyroid disease, TSH testing at the following intervals: i) Annually. ii) When dosage or medication changes. iii) If symptoms consistent with thyroid dysfunction develop”. Updated Coverage criteria #1. D to clarify that TSH is the appropriate marker. Added new coverage criteria #1. E that reads “One-time TSH screening: i) For asymptomatic individuals at high risk for thyroid disease due to: (a) Personal or family history of thyroid dysfunction. (b) Personal or family history of type 1 diabetes or other autoimmune disease. ii) For individuals with disease or neoplasm of the thyroid or other endocrine glands. iii) For individuals with chronic or acute urticaria. iv) For pediatric individuals diagnosed with short stature. v) For pediatric individuals with a clinical finding of failure-to-thrive.” Updated coverage criteria #1. F to add TSH with reflex fT4 and fT3 when initial result is abnormal, as appropriate marker testing. Added new Coverage criteria #1. G that reads “For individuals with hypothalamic-pituitary disease, monitoring of TSH and fT4: i) Biannually for individuals less than 18 years of age. ii) Annually for individuals 18 years of age or older.” Remaining coverage criteria updated for clarity and consistency. Added CPT code 83520 to Billing/Coding section. Medical Director review 10/2024.

Policy Guidelines and References updated. Specialty Matched Consultant Advisory Panel 11/2024. Medical Director review 11/2024.

Minor wording edits to description section. Reference added. Specialty Matched Consultant Advisory Panel review 11/2024. Medical Director Review 11/2024.

Reviewed per Avalon Q3 2024 CAB. Description, Policy Guidelines and References updated.  No change to policy statement. Medical Director review 10/2024.

Reviewed by Avalon 3rd Quarter 2024 CAB. Description, Policy Guidelines and References updated. Related Policies section added. Removed Table of Terminology. Changes made to the When Covered section: added "or pulmonary embolism" to coverage criteria 1a, added new coverage criteria 3 that reads "For individuals with a first-degree relative (see Note 2) with a known Factor V Leiden or prothrombin gene G20210A mutation, reimbursement is allowed for genetic testing for the known familial mutation in any of the following situations:  a. For individuals who are considering the use of oral contraceptives. b. For individuals who were assigned female at birth and who are considering hormone replacement therapy. " Added CPT code 0529U to Billing/Coding section, effective 1/1/2025. Medical Director review 10/2024.

Reference added. Specialty Matched Consultant Advisory Panel review 11/2024. Medical Director review 11/2024.

References updated. Specialty Matched Consultant Advisory Panel review 10/2024. Medical Director review 10/2024.