CommercialFebruary 1, 2020
Medical Policy and Clinical Guideline Updates - February 2020*
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.
PUBLICATIONS: February 2020 Anthem Provider News - Wisconsin
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