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Medical Policy Update for December 29, 2023
| Medical Guidelines | Reason for Update |
|---|---|
| Ablative Techniques for the Myolysis of Uterine Fibroids | Updated Billing/Coding section to remove CPT code 0404T and added 58580, effective 1/1/2024. |
| Allergy Immunotherapy (Desensitization) | References updated. When Covered section edited for clarity, no change to policy statement. Specialty Matched Consultant Advisory Panel review 11/2023. Medical Director review 11/2023. |
| Allergy Skin and Challenge Testing | When Covered section edited for clarity, no change to policy statement. References updated. Specialty Matched Consultant Advisory Panel review 11/2023. Medical Director review 11/2023. |
| Bariatric Surgery | New CPT code 0813T added to the Billing/Coding section effective 01/01/2024. |
| Bone Mineral Density Studies | Updated Billing/Coding section to remove CPT code 0508T and add 0815T, effective 1/1/2024. |
| Charged Particle Radiotherapy | Off cycle review completed. Under “when covered” section, additional medical necessity indications added in bullets 4, 5, 6. Under “when not covered” section added the following statement: “BCBSNC considers the use of IMRT or other technologies appropriate to safely treat all other indications, and therefore, charged particle radiotherapy is not cost effective when compared to alternatives, such as IMRT. For the exceptional situations in which a provider feels that is not the case, a detailed explanation is required, and Blue Cross NC will consider whether charged particle radiotherapy will be covered on such exceptional circumstances.” Medical Director review 12/20/23. |
| Chromoendoscopy as an Adjunct to Colonoscopy | Description, Policy Guidelines and References updated. Specialty Matched Consultant Advisory Panel 11/2023. Medical Director review 11/2023. |
| Confocal Laser Endomicroscopy | Description, Policy Guidelines and References updated. Specialty Matched Consultant Advisory Panel 11/2023. Medical Director review 11/2023. |
| Cryoablation, Radiofrequency Ablation, and Laser Ablation for Treatment of Chronic Rhinitis | Added the following CPT codes to the Billing/Coding section: 31242, and 31243, effective 1/1/2024. Removed terminated HCPCS code C9771 from the Billing/Coding section. |
| Focal Treatments for Prostate Cancer | References added. Specialty Matched Consultant Advisory Panel review 11/2023. Medical Director review 11/2023. |
| Gastroesophageal Reflux Disease, Transendoscopic Therapies | Description, Policy Guidelines and References updated. Specialty Matched Consultant Advisory Panel 11/2023. Medical Director review 11/2023. |
| Gene Expression Profiling and Protein Biomarkers for Prostate Cancer AHS - M2166 | Added PLA codes 0424U and 0433U to Billing/Coding section for 1/1/2024 code update. |
| Implantable Bone Conduction Hearing Aids | Added the following CPT codes to the Billing/Coding section: 92622 and 92623, effective 1/1/2024. |
| In Vitro Chemoresistance and Chemosensitivity Assays AHS- G2100 | Added PLA code 0435U to Billing/Coding section for 1/1/2024 code update. |
| Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence | References added. Updated Regulatory Status. Specialty Matched Consultant Advisory Panel review 11/2023. Medical Director review 11/2023. |
| Islet Cell Transplantation | Added coverage criteria for donislecel-jujn (Lantidra™) to align with Corporate Pharmacy policy. Description, policy statement, and references updated. Related policy added. Billing/coding section updated with allogeneic islet transplantation infusion limit and added HCPCS codes: C9399, J3490, J3590. Medical Director review 12/2023. |
| Laboratory Procedures Medical Policy AHS - R2162 | Updates to Billing/Coding section: codes 0407U and 0418U added, effective 10/1/23 and codes 0421U, 0427U, 0430U, 0431U and 0432U added, effective 1/1/24. |
| Leadless Cardiac Pacemakers | Added codes 0823T, 0824T, 0825T and 0826T to Billing/Coding section, effective 1/1/24. |
| Liquid Biopsy AHS-G2054 | Added CPT code 81462 to Billing/Coding section for 1/1/2024 code update. |
| Magnetic Esophageal Sphincter Augmentation to Treat Gastroesophageal Reflux Disease (GERD) | Reference added. Removed from when covered “the individual is enrolled in the NC BEST (North Carolina Blue Cross Blue Shield Esophageal Therapeutics) registry that prospectively and uniformly collects prespecified clinical outcomes (see Policy Guidelines)”. Removed from when not covered “those individuals not enrolled in the NC BEST registry”. Removed paragraph in policy guidelines that references NC BEST registry. Specialty Matched Consultant Advisory Panel review 11/2023. Medical Director Review 11/2023. |
| Microprocessor-Controlled Prostheses for the Lower Limb | New HCPCS codes L5615, and L5926 added to Billing/Coding section, effective 01/01/2024. |
| Microsatellite Instability and Tumor Mutational Burden Testing AHS-M2178 | Added PLA code 0428U and CPT codes 81457, 81458, 81459, 81463, 81464 to Billing/Coding section for 1/1/2024 code update. |
| Minimal Residual Disease (MRD) AHS-M2175 | Added PLA code 0422U to Billing/Coding section for 1/1/2024 code update. |
| Neurostimulation, Electrical | Added the following CPT codes to Peripheral Subcutaneous Field Stimulation Billing/Coding section: 64596, 64597, 64598, effective 1/1/2024. |
| Oral Cancer Screening and Testing AHS – G2113 | Added CPT code 0429U to Billing/Coding section, effective 1/1/2024. |
| Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence | Reference added. Minor edit to Description section added the words or Fecal to sentence Pelvic floor stimulation (PFS) is proposed as a nonsurgical treatment option for individuals with urinary or fecal incontinence. Specialty Matched Consultant Advisory Panel review 11/2023. Medical Director review 11/2023. |
| Percutaneous Tibial Nerve Stimulation for Voiding Dysfunction | References added. Updated title of related policies. Minor edits to Policy Guidelines. Specialty Matched Consultant Advisory Panel review. Medical Directory Review. |
| Pharmacogenetics Testing AHS – M2021 | Table of Terminology removed. Codes 0423U, 0434U, 0437U, and 0438U added to Billing/Coding section, effective 1/1/2024. |
| Phrenic Nerve Stimulation for Central Sleep Apnea | Removed the following CPT codes from Billing/Coding section: 0424T, 0425T, 0426T, 0427T, 0428T, 0429T, 0430T, 0431T, 0432T, 0433T, 0434T, 0435T, 0436T, Added the following CPT codes to Billing/Coding section, effective 1/1/2024: 33276, 33277, 33278, 33279, 33280, 33281, 33287, 33288, 93150, 93151, 93152, 93153. |
| Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers | Removed HCPCS code A6545 from Billing/Coding section. |
| Prenatal Testing for Fetal Aneuploidy AHS – G2055 | File name updated for consistency. |
| Prostatic Urethral Lift | Reference added. Minor edits to Description section. Specialty Matched Consultant Advisory Panel review 11/2023. Medical Director review 11/2023. |
| Proteogenomic Testing of Individuals with Cancer AHS-M2168 | Added PLA code 0436U to Billing/Coding section for 1/1/2024 code update. |
| Rehabilitative Therapies | Added code 97037 to Billing/Coding section, effective 1/1/2024. |
| Sacral Nerve Neuromodulation/Stimulation for Pelvic Floor Dysfunction | Reference added. Specialty Matched Consultant Advisory Panel Review 11/2023. Medical Director review 11/2023. |
| Sacroiliac Joint Fusion/Stabilization | Added the following CPT code to the Billing/Coding section: 27278, effective 1/1/2024 and removed terminated CPT codes 0775T and 0809T. |
| Serum Testing for Hepatic Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease AHS – G2110 | Updates to Billing/Coding section: code 0014M removed effective 12/31/23, code 81517 added effective 1/1/24. |
| Skin and Soft Tissue Substitutes | Added HCPCS codes Q4279, Q4287 - Q4299, and Q4300 - Q4304 to Billing/Coding section, effective 1/1/2024. |
| Sleep Apnea: Diagnosis and Medical Management | Removed the following HCPCS codes from Billing/Coding section: K1001, K1028, and K1029. |
| TENS (Transcutaneous Electrical Nerve Stimulator) | Removed HCPCS codes K1016-K1019, K1023 and CPT codes 0768T and 0769T from Billing/Coding section. Added CPT codes A4540, A4541, A4542, E0733, and E0734 to Billing/Coding section, effective 1/1/2024. |
| Transanal Endoscopic Microsurgery (TEMS) | Description, Policy Guidelines and References updated. Specialty Matched Consultant Advisory Panel 11/2023. Medical Director review 11/2023. |
| Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders | Added CPT code 0858T to Billing/Coding section, effective 1/1/2024. |
| Transurethral Water Vapor Thermal Therapy for Benign Prostatic Hyperplasia | Reference added. Specialty Matched Consultant Advisory Panel review 11/2023. Medical Director review 11/2023. |
| Vagus Nerve Stimulation | Added the following HCPCS code to the Billing/Coding section: E0735, effective 1/1/2024 and removed terminated HCPCS code K1020. |
| Vesicoureteral Reflux, Treatment with Periureteral Bulking Agents | References added. Specialty Matched Consultant Advisory Panel review 11/2023. Medical Director review 11/2023. |
| Whole Gland Ablative Treatments of Prostate Cancer | References added. Minor edits to description to update 2023 statistics. Specialty Matched Consultant Advisory Panel review 11/2023. Medical Director Review. |
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