The following Anthem Blue Cross and Blue Shield medical polices and clinical guidelines were reviewed on August 22, 2019 for Indiana, Kentucky, Missouri, Ohio and Wisconsin.

 

Below are new medical policies or clinical guidelines

 

NOTE: *Precertification required

Title

Information

Effective Date

MED.00130 Surface Electromyography Devices for Seizure Monitoring

• The use of surface electromyography (sEMG) devices for seizure monitoring is considered Investigational and Not medically necessary (INV&NMN)

2/1/2020

CG-GENE-12 PIK3CA Mutation Testing

• Content moved from GENE.00044

• Revised title

• Revised medical necessity (MN) indications to include the use of a circulating tumor DNA (ctDNA) test to detect mutations of the PIK3CA gene

• INV&NMN changed to not medically necessary (NMN) as a result of Medical Policy (MP) to Clinical UM Guideline (CUMG) transition

11/20/2019

 

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

 

NOTE: *Precertification required

Title

Change

Effective Date

*CG-ANC-07 Inpatient Interfacility Transfers

• Added NMN statements regarding admission and subsequent care at the receiving facility

2/1/2020

*CG-GENE-02 Analysis of RAS Status

 

Previous title: Analysis of KRAS Status

• Revised MN criteria to include NRAS

• Revised NMN criteria to include all other indications for NRAS

-Added existing CPT code 81311 NRAS to pend for review of MN criteria; added PLA code 0111U effective 10/01/19 for Praxis test replacing 81479 NOC 

*Precertification will be required effective 2/1/2020

2/1/2020

*CG-SURG-83 Bariatric Surgery and Other Treatments for Clinically Severe Obesity

• Revised “gastric bypass, using a Billroth II type of anastomosis (also known as a “mini gastric bypass”)” to “One anastomosis gastric bypass, also known as mini gastric bypass" in NMN section

• Added TransPyloric Shuttle and bariatric arterial embolization as NMN indications

2/1/2020

*GENE.00023 Gene Expression Profiling of Melanomas

• Expanded Scope to include testing for the diagnosis of melanoma

• Updated INV&NMN statement to include suspicion of melanoma

-Added existing CPT codes 0089U Pigmented Lesion Assay and 0090U myPath Melanoma (considered INV&NMN)

*Precertification will be required effective 2/1/2020

2/1/2020

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

• Added MN indication for “Individual with a first-, second- or third-degree relative with metastatic prostate cancer”

• Clarified MN indications regarding “at least”

-Added ICD-10-CM diagnosis Z80.42 family history of prostate cancer to review for MN; added CPT PLA codes 0129U, 0131U, 0132U, 0134U, 0135U, 0138U eff 10/01/19

9/25/2019

*GENE.00046 Prothrombin (Factor II) Genetic Testing

 

Previous Title: Prothrombin G20210A (Factor II) Mutation Testing

• Revised title

• Expanded scope and position statement to include all prothrombin (factor II) variations

-Added Tier 2 code 81400 and NOC 81479 for additional F2 variants (considered INV&NMN)

*Precertification will be required effective 2/1/2020

2/1/2020

*MED.00110 Growth Factors, Silver-based Products and Autologous Tissues for Wound Treatment, Soft Tissue Grafting, and Regenerative Therapy

 

Previous title: Growth Factors, Silver-based Products and Autologous Tissues for Wound Treatment and Soft Tissue Grafting

• Revised title

• Added new INV&NMN statements addressing Autologous adipose-derived regenerative cell therapy and use of autologous protein solution

*Precertification will be required effective 2/1/2020

2/1/2020

RAD.00023 Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications

• Added dopamine transporter (DaT) scan to MN Position Statement

• Revised dopamine transporter (DaT) scan criterion in INV&NMN Position Statement

-Existing code for brain SPECT 78607 will pend for additional diagnosis codes for DaT scan; removed radiopharmaceutical code A9584

8/29/2019

*SURG.00052 Percutaneous Vertebral Disc and Vertebral Endplate Procedures

 

Previous title: Intradiscal Annuloplasty Procedures (Percutaneous Intradiscal Electrothermal Therapy [IDET], Percutaneous Intradiscal Radiofrequency Thermocoagulation [PIRFT] and Intradiscal Biacuplasty [IDB])

• Revised title

• Combined the three INV&NMN statements into a single statement

• Added Intraosseous basivertebral nerve ablation to the INV&NMN statement

-Added existing CPT 64999 (NOC), HCPCS C9752, C9753 & ICD-10-PCS 015B3ZZ, 015B4ZZ codes for basivertebral nerve destruction (considered INV&NMN)

*Precertification will be required effective 2/1/2020

2/1/2020

*TRANS.00035 Non-Hematopoietic Adult Stem Cell Therapy

 

Previous title: Mesenchymal Stem Cell Therapy for the Treatment of Joint and Ligament Disorders, Autoimmune, Inflammatory and Degenerative Diseases

• Revised title

• Expanded Position Statement to include non-hematopoietic adult stem cell therapy

2/1/2020

 

Below are coding updates and change to precertification requirements

 

NOTE: *Precertification required

Title

Change

Effective Date

*GENE.00009 Gene-Based Tests for Screening, Detection and Management of Prostate Cancer

Added CPT PLA code 0113U effective 10/01/19 for Mi-Prostate Score

*Precertification will be required effective 2/1/2020

2/1/2020

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

Added CPT PLA code 0136U effective 10/01/19 for ATM (pends for specific diagnoses)

*Precertification will be required effective 2/1/2020

2/1/2020

*GENE.00028 Genetic Testing for Colorectal Cancer Susceptibility

Added CPT PLA codes 0130U, 0134U for panels (considered INV&NMN)

*Precertification will be required effective 2/1/2020

2/1/2020

*GENE.00041 Genetic Testing to Confirm the Identity of Laboratory Specimens

Added 81265, 81266 when billed as provenance testing by dx  (considered NMN)

*Precertification will be required effective 2/1/2020

2/1/2020

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

Added CPT PLA code 0136U effective 10/01/19 for ATM (INV&NMN for diagnoses not on GENE.00012)

*Precertification will be required effective 2/1/2020

2/1/2020

*SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

Added HCPCS codes Q4205, Q4206, Q4208, Q4211, Q4212, Q4213, Q4214, Q4215, Q4216, Q4217, Q4218, Q4219, Q4220, Q4221, Q4222 effective 10/01/19 for new products (considered INV&NMN)

*Precertification will be required effective 2/1/2020

2/1/2020

*SURG.00132 Drug-Eluting Devices for Maintaining Sinus Ostial Patency

Added HCPCS code J7401 for Sinuva, Propel replacing S1090 10/01/19

*Precertification will be required effective 2/1/2020

2/1/2020

 

* Notice of Material Changes/Amendments to Contract and Changes to Prior Authorization Requirements may apply for new or updated reimbursement policies, medical policies, or prior authorization requirements.

 



Featured In:
November 2019 Anthem Provider News - Missouri