CommercialNovember 1, 2019
Medical Policy and Clinical Guidelines Updates -- November 2019*
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.
PUBLICATIONS: November 2019 Anthem Provider News - Missouri
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