The following Anthem Blue Cross and Blue Shield medical polices and clinical guidelines were reviewed on November 7, 2019 for Indiana, Kentucky, Missouri, Ohio and Wisconsin.

 

Below are new medical policies and/or clinical guidelines.

NOTE *Precertification required

 

Title

Information

Effective Date

*GENE.00052 Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling

• Outlines the Medical Necessity (MN) and Investigational and Not Medically Necessary (INV&NMN) criteria for whole genome sequencing, whole exome sequencing, gene panels, and molecular profiling

• Incorporated whole genome sequencing, whole exome sequencing, gene panel testing, and molecular profiling into single document

• Contains content from all other documents regarding whole genome/whole exome/mitochondrial DNA testing, all panel tests (defined as 5 or more genes, or gene mutation variants, same day, same member, same rendering provider) and molecular profiling:

o GENE.00001 Genetic Testing for Cancer Susceptibility

o GENE.00012 Preconception or Prenatal Genetic Testing of a Parent or Prospective Parent

o GENE.00025 Molecular Profiling and Proteogenomic Testing for the Evaluation of Malignancies

o GENE.00028 Genetic Testing for Colorectal Cancer Susceptibility

o GENE.00029 Genetic Testing for Breast and/or Ovarian Cancer Syndrome

o GENE.00030 Genetic Testing for Endocrine Gland Cancer Susceptibility

o GENE.00035 Genetic Testing for TP53 Mutations

o GENE.00043 Genetic Testing of an Individual’s Genome for Inherited Diseases

5/1/2020

 

The below current Clinical Guidelines and/or Medical policies were reviewed and updates were approved.

NOTE *Precertification required

 

Title

Change

Effective date

*CG-GENE-14 Gene Mutation Testing for Solid Tumor Cancer Susceptibility and Management

• Content moved from GENE.00001

• INV&NMN changed to NMN as a result of MP to CUMG transition

• Revised title

• Limited scope to gene mutation testing for solid tumor cancer susceptibility and management

• Added criteria for gene mutation testing to guide targeted cancer therapy in individuals with solid tumors

• Removed genetic panel testing from document.

 

Moved all codes except panel codes to this document with no changes; added codes 81307, 81308, 81403, 81408 and additional genes to other Tier 2 codes to pend for MN criteria; added 81242 as NMN for this indication.

 

WHOLE GENOME, WHOLE EXOME & GENE PANEL TESTING MOVED TO GENE.00052

2/5/2020

*CG-GENE-13 Genetic Testing for Inherited Diseases

• Content moved from GENE.00012 & GENE.00043

• INV&NMN changed to NMN as a result of MP to CUMG transition

• Title revised

• Removed whole genome, whole exome, and gene panel testing from document

• No other change to clinical indications

 

Moved all codes except whole genome/exome and panel codes to this document with no changes; added codes 81171, 81172, 81243, 81244 and Tier 2 genes previously addressed in CG-BEH-01 with no change; removed 0136U (not applicable)

 

WHOLE GENOME, WHOLE EXOME, & GENE PANELS MOVED TO GENE.00052

2/5/2020

*CG-GENE-20 Epidermal Growth Factor Receptor (EGFR) Testing

• Content moved from GENE.00006

• INV&NMN changed to NMN as a result of MP to CUMG transition

• Removed acronym and made minor wording change in Clinical Indications section

2/5/2020

*CG-GENE-15 Genetic Testing for Lynch Syndrome, Familial Adenomatous Polyposis (FAP), Attenuated FAP and MYH-associated Polyposis

• Content moved from GENE.00028

• INV&NMN changed to NMN as a result of MP to CUMG transition

• Revised title

• Removed genetic panel testing from document.

 

GENE PANEL TESTING MOVED TO GENE.00052

2/5/2020

*CG-GENE-16 BRCA Testing for Breast and/or Ovarian Cancer Syndrome

• Content moved from GENE.00029

• INV&NMN changed to NMN as a result of MP to CUMG transition

• Revised title

• Revised Clinical Indications to include recommendations from the USPSTF

• Added Note to refer to the NCCN testing criteria and BRCA1 or BRCA2 mutation assessment tools  listed in the Discussion/General Information section

• Removed gene panel testing from document.

GENE PANEL TESTING MOVED TO GENE.00052

2/5/2020

*CG-GENE-17 RET Proto-oncogene Testing   for Endocrine Gland Cancer Susceptibility

• Content moved from GENE.00030

• INV&NMN changed to NMN as a result of MP to CUMG transition

• Revised title

• Removed gene panel testing from document.

GENE PANEL TESTING MOVED TO GENE.00052

2/5/2020

*CG-GENE-18 Genetic Testing for TP53 Mutations

• Content moved from GENE.00035

• INV&NMN changed to NMN as a result of MP to CUMG transition

• Removed gene panel testing from document

 

GENE PANEL TESTING MOVED TO GENE.00052

2/5/2020

*CG-GENE-19 Detection and Quantification of Tumor DNA Using Next Generation Sequencing in Lymphoid Cancers

• Content moved from GENE.00045

• INV&NMN changed to NMN as a result of MP to CUMG transition

• Clarified that “minimal residual disease” is also referred to as “measurable residual disease” in MN criteria

2/5/2020

CG-SURG-105 Corneal Collagen Cross-Linking

• Content moved from MED.00109

• INV&NMN changed to NMN as a result of MP to CUMG transition

• Clarified MN criteria addressing the time of diagnosis of progressive keratoconus ("over 24 consecutive months" changed to "within 24 months")

2/5/2020

CG-MED-87 Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications

 

• Content moved from RAD.00023

• INV&NMN changed to NMN as a result of MP to CUMG transition

• No other change to clinical indications

2/5/2020

*CG-SURG-106 Venous Angioplasty with or without Stent Placement or Venous Stenting Alone

• Content moved from SURG.00122

• INV&NMN changed to NMN as a result of MP to CUMG transition

• No other change to clinical indications

2/5/2020

*SURG.00028 Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH)

 

Previous title: Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) and Other Genitourinary Conditions

• Revised title

• Revised scope of document to only address benign prostatic hyperplasia (BPH)

• Combined surgical and minimally invasive treatments into one MN section

• Revised MN criteria for transurethral incision of the prostate by adding "prostate volume less the 30 mL

• Added transurethral convective water vapor thermal ablation in individuals with prostate volume less than 80 mL as MN indication

• Added waterjet tissue ablation as MN indication

• Moved transurethral radiofrequency needle ablation from MN to NMN section

• Changed INV&NMN indications to NMN

• Moved placement of prostatic stents from standalone statement to combined NMN statement

• Added 0421T, XV508A4 for AquaBeam waterjet as MN; changed TUIP 52450 and Rezum water vapor 53854  to pend for MN criteria; WIT 53899 (NOC) and RFNA 53852 changed to NMN; scope limited to specific BPH and related diagnosis codes

5/1/2020

*SURG.00037 Treatment of Varicose Veins (Lower Extremities)

• Added the anterior accessory great saphenous vein (AAGSV) as MN for ablation techniques when criteria are met

• Added language to the MN criteria for ablation techniques addressing variant anatomy

• Added limits to retreatment to the MN criteria for all procedures

5/1/2020

SURG.00047 Transendoscopic Therapy for Gastroesophageal Reflux Disease, Dysphagia and Gastroparesis

 

 

Previous title: Transendoscopic Therapy for Gastroesophageal Reflux Disease and Dysphagia

• Revised title

• Expanded scope to include gastroparesis

• Added gastric peroral endoscopic myotomy or peroral pyloromyotomy as INV&NMN.

• Added CPT 43999 (NOC) and ICD-10-PCS 0D878ZZ for G-POEM, considered INV&NMN

5/1/2020

SURG.00097 Vertebral Body Stapling and Tethering for the Treatment of Scoliosis in Children and Adolescents

 

 

Previous title: Vertebral Body Stapling for the Treatment of Scoliosis in Children and Adolescents

• Revised title

• Expanded scope of document to include vertebral body tethering

• Added vertebral body tethering as INV&NMN

 

5/1/2020

 

*New prior authorization requirements for providers may apply for new or updated reimbursement policies, medical policies, or prior authorization requirements.

 



Featured In:
February 2020 Anthem Provider News - Missouri