Medical Policy and Clinical Guideline Updates -- June 2019*

Title

Information

Effective Date

*GENE.00050 Gene Expression Profiling for Coronary Artery Disease

• The use of gene expression profiling for coronary artery disease is considered Investigational and Not Medically Necessary (INV&NMN)

• Moved the Corus CAD test from GENE.00043

o   CPT code 81493 moved from GENE.00043 to this new document

9/1/19

*SURG.00152 Wireless Cardiac Resynchronization Therapy for Left Ventricular Pacing

• Wireless CRT for left ventricular pacing is considered INV&NMN for all indications, including heart failure.

o   CPT Category III codes 0515T, 0516T, 0517T, 0518T, 0519T, 0520T, 0521T, 0522T will be considered INV&NMN

9/1/19

Title

Change

Effective Date

CG-GENE-06 Preimplantation Genetic Diagnosis Testing

• Content moved from GENE.00002

• INV&NMN changed to not medically necessary as a result of MP to CUMG transition

5/9/19

CG-GENE-07 BCR-ABL Mutation Analysis

• Content moved from GENE.00005

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

5/9/19

*CG-GENE-08 Genetic Testing for PTEN Hamartoma Tumor Syndrome

Content moved from GENE.00031

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

5/9/19

CG-GENE-09 Genetic Testing for CHARGE Syndrome

• Content moved from GENE.00040

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

5/9/19

*CG-SURG-97 Cardioverter Defibrillators

• Content moved from SURG.00033

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

CPT codes 33270, 33271 for subcutaneous ICD will be considered always NMN (were INV&NMN)

6/24/19

*CG-SURG-99 Panniculectomy and Abdominoplasty

• Content moved from SURG.00048

• Clarified that document only addresses liposuction when used for the removal of excess abdominal fat

• Clarified Cosmetic and Not medically necessary (COS&NMN) statement addressing repair of diastasis recti

5/9/19

CG-DME-44 Electric Tumor Treatment Field (TTF)

• Added the use of enhanced computer treatment planning software (such as NovoTal ) as NMN in all cases

No specific code for this software; part of code for treatment planning 77299 (NOC)

9/1/19

CG-MED-72 Hyperthermia for Cancer Therapy

• Clarified MN and NMN statements addressing frequency of treatment

9/1/19

*CG-SURG-09 Temporomandibular Disorders

• Clarified MN and NMN criteria and removed requirement for FDA approval of prosthetic implants

Added HCPCS codes D9130, D9920 for TMJ non-invasive therapies, behavior management as additional examples of TMJ procedures, removed D9940 (deleted)

9/1/19

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

• Removed INV&NMN statement and all other language and coding related to Corus CAD testing

• Corus CAD testing now addressed in GENE.00050

Removed CPT code 81493 for Corus CAD; added existing CPT codes 81205, 81250, 81302, 81303, 81304, 81331, 81332, S3850 and Tier 2 codes 81400, 81401, 81402, 81407 which will now be reviewed for MN or INV&NMN; also added applicable genes to Tier 2 code

9/1/19

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

Added existing CPT codes 81205, 81250, 81302, 81303, 81304, 81331, 81332, S3850 and Tier 2 codes 81400, 81401, 81402, 81407, 81408 which will now be reviewed for MN or INV&NMN; also added applicable genes to Tier 2 codes

9/1/19

*CG-GENE-01 Janus Kinase 2, CALR, and MPL Gene Mutation Assays

Previous title: Janus Kinase 2 (JAK2)V617F and JAK2 exon 12 Gene Mutation Assays

Revised title

• Reformatted MN clinical indications

• Added CALR and MPL gene mutation testing as MN when criteria are met

• Added CALR and MPL gene mutation testing as NMN when MN criteria are not met

Added CPT Tier 1 code 81219 and Tier 2 code 81402 for MPL and CALR genes to pend for review of criteria

9/1/19

MED.00101 Physiologic Recording of Tremor using Accelerometer(s) and Gyroscope(s)

Added CPT Category III codes 0533T, 0534T, 0535T, 0536T described as 'non-invasive kinetigraphy' (Note codes effective 01/01/19)

9/1/19

SURG.00139 Intraoperative Assessment of Surgical Margins During Breast-Conserving Surgery with Radiofrequency Spectroscopy or Optical Coherence Tomography

Added CPT Category III code 0546T which will be effective 07/01/19 for assessment of margins using radiofrequency spectroscopy

9/1/19