*CG-MED-41 Moderate to Deep Anesthesia Services for Dental Surgery in the Facility Setting | - Revised formatting and hierarchy of MN statement
- Revised criteria regarding children
- Revised formatting of ASA criteria
- Added some diagnosis codes to two ranges
| 12/1/2023 |
*CG-MED-66 Cryopreservation of Oocytes or Ovarian Tissue | - Revised MN criteria for cryopreservation of mature oocytes to include: (1) medical and surgical treatment, gonadotoxic therapy and bilateral oophorectomy as possible causes of anticipated infertility; (2) Criterion which states “individual is a candidate based on ovarian reserve and likelihood for successful oocyte cryopreservation (for example, age 45 years or less)”
- Revised criteria so cryopreservation of ovarian tissue is considered MN when criteria are met
- Revised NMN statement to indicate cryopreservation of ovarian tissue is considered NMN when the criteria above are not met
- CPT codes 89398 (NOC) and non-specific codes 89344, 89354 when specified as cryopreservation of ovarian tissue or related services will be considered MN when criteria are met (were NMN for ovarian tissue)
| 12/1/2023 |
*CG-SURG-81 Cochlear Implants and Auditory Brainstem Implants | - Reformatted the MN criteria for cochlear implants
- Revised cochlear implantation criteria to include unilateral sensorineural deafness
- Revised unilateral implantation of a hybrid cochlear implant device criteria related to hearing loss in the contralateral ear
- Added diagnosis codes for single sided deafness, procedure codes will now be reviewed for MN criteria for these diagnoses
| 12/1/2023 |
DME.00011 Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices | - Added existing HCPCS code E0761 for electromagnetic treatment device considered INV&NMN
| 12/1/2023 |
*GENE.00010 Panel and other Multi-Gene Testing for Polymorphisms to Determine Drug-Metabolizer Status | - Added new CPT PLA code 0392U effective 07/01/2023 for panel test considered INV&NMN
| 12/1/2023 |
*GENE.00052 Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling | - Reformatted hierarchy for gene panel testing for inherited diseases, testing for cancer susceptibility, testing for cancer management, and molecular profiling for the evaluation of malignancies
- Revised panel testing criteria to remove 50 gene parameters
- Revised acute myeloid leukemia MN statement to include newly diagnosed or relapsed
- Added circulating tumor DNA to scope of document (moved content from GENE.00049 into this document and added new criteria for prostate cancer and advance non-small cell lung cancer)
- Revised molecular profiling criteria to remove progressed following prior treatment language
- Revised NMN statement for Whole Exome Sequencing to address repeat testing
- Code 81455 for panel over 50 genes to be reviewed for MN criteria (was NMN); added existing code 0022U MN in vitro diagnostic (IVD) criteria.
- Codes added from GENE.00049: 0326U molecular profiling MN criteria; 0239U IVD MN criteria; 0179U, 0242U ctDNA panels MN criteria (were INV&NMN); 0306U; 0307U; 0333U; 0356U; 0368U considered NMN (were INV&NMN);
- Added new 07/01/2023 CPT PLA codes: 0391U molecular profiling MN criteria; 0388U, 0397U ctDNA panels MN criteria; 0400U inherited disease panel considered NMN; 0401U risk panel considered INV&NMN
| 12/1/2023 |
*SURG.00121 Transcatheter Heart Valve Procedures | - Revised text and formatting in the MN statement for transcutaneous aortic valve replacement (TAVR)
- Revised MN statement for transcatheter pulmonary valve to remove right ventricular outflow tract (RVOT) conduit diameter criteria and added criteria for native and patched RVOT
- Added a new INV&NMN statement addressing TAVR cerebral protection devices
- Revised the INV&NMN statement regarding valve-in-valve repair to address replacement instead of repair
- CPT code 33370 add-on code for cerebral embolic protection will be considered INV&NMN (was being reviewed for TAVR criteria)
| 12/1/2023 |
CG-GENE-13 Genetic Testing for Inherited Diseases | - For Tier 2 code 81404, gene SOD1 was changed to review for MN criteria (was NMN)
| 12/1/2023 |
*CG-SURG-83 Bariatric Surgery and Other Treatments for Clinically Severe Obesity | - Added HCPCS codes C9784 for endoscopic sleeve gastroplasty and C9785 for outlet reduction TORE effective 07/01/2023, both considered NMN
| 12/1/2023 |
*SURG.00011 Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting | - Added HCPCS codes Q4272, Q4273, Q4274, Q4275, Q4276, Q4277, Q4278, Q4280, Q4281, Q4282, Q4283, Q4284 effective 07/01/2023 for products considered INV&NMN
| 12/1/2023 |
*SURG.00150 Leadless Pacemaker | - Added new CPT Category III codes 0795T, 0796T, 0797T, 0798T, 0799T, 0800T, 0801T, 0802T, 0803T, 0804T effective 07/01/2023 for dual chamber leadless pacemaker considered INV&NMN; added existing ICD-10-PCS code 02PA3NZ for removal considered INV&NMN
| 12/1/2023 |
TRANS.00035 Therapeutic use of Stem Cells, Blood, and Bone Marrow Products | - Revised descriptors for HCPCS codes G0460, G0465
| 6/28/2023 |
CG-DME-31 Powered Wheeled Mobility Devices | - Revised hierarchy and formatting in the MN statement addressing power seating systems
- Added new MN and NMN criteria to address power seat elevation systems when individuals meet criteria for (uneven) transfers
| 12/1/2023 |
CG-GENE-10 Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability and Congenital Anomalies | - Removed aCGH and replaced it with CMA in the *notation in the Clinical Indications section
| 6/28/2023 |
CG-GENE-16 BRCA Genetic Testing | - Revised Clinical Indications to include homologous recombination deficiency pathways to PARP inhibitor criteria
| 12/1/2023 |
CG-MED-59 Upper Gastrointestinal Endoscopy in Adults | - Revised Clinical Indications section to remove references to life-limiting comorbidities
| 6/28/2023 |
CG-MED-73 Hyperbaric Oxygen Therapy (Systemic/Topical) | - Added continuation criteria to each section on chronic non-healing wounds in MN statement
- Revised formatting and hierarchy in the Clinical Indications sections
- Removed continuation criteria from the NMN statement
- Added Stroke to NMN statement
| 12/1/2023 |
CG-SURG-12 Penile Prosthesis Implantation | - Revised hierarchy and formatting of Clinical Indications section
- Removed intra-urethral medications from the MN criteria
| 6/28/2023 |
CG-SURG-82 Bone-Anchored and Bone Conduction Hearing Aids | - Removed code 69799 NOC, no longer applicable
| 6/28/2023 |
CG-SURG-95 Sacral Nerve Stimulation and Percutaneous or Implantable Tibial Nerve Stimulation for Urinary and Fecal Incontinence; Urinary Retention Previously titled: Sacral Nerve Stimulation and Percutaneous Tibial Nerve Stimulation for Urinary and Fecal Incontinence, Urinary Retention | - Revised title
- Added MN criteria for temporary SNS for urinary and fecal conditions
- Reformatted MN criteria for permanent SNS for urinary and fecal conditions
- Revised the Clinical Indications section IV for percutaneous or implantable tibial nerve stimulation (PTNS) to include implantable devices
| 12/1/2023 |
DME.00011 Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices | - Added existing HCPCS code E0761 for
electromagnetic treatment device considered INV&NMN | 12/1/2023 |
MED.00004 Noninvasive Imaging Technologies for the Evaluation of Skin Lesions Previously Titled: Technologies for the Evaluation of Skin Lesions (including Dermatoscopy, Epiluminescence Microscopy, Video microscopy and Ultrasonography) | - Revised title
- Added additional technologies to INV&NMN section
| 12/1/2023 |
*SURG.00121 Transcatheter Heart Valve Procedures | - Revised text and formatting in the MN statement for transcutaneous aortic valve replacement (TAVR)
- Revised MN statement for transcatheter pulmonary valve to remove right ventricular outflow tract (RVOT) conduit diameter criteria and added criteria for native and patched RVOT
- Added a new INV&NMN statement addressing TAVR cerebral protection devices
- Revised the INV&NMN statement regarding valve-in-valve repair to address replacement instead of repair
- CPT code 33370 add-on code for cerebral embolic protection will be considered INV&NMN (was being reviewed for TAVR criteria)
| 12/1/2023 |
TRANS.00025 Laboratory Testing as an Aid in the Diagnosis of Heart Transplant Rejection | - Revised MN criteria regarding the time frame for AlloMap testing post HT
- Removed the word, Noninvasive from the INV&NMN statement about AlloSource Heart, AlloSeq cell-free DNA, MMDx Heart and myTAIHeart
| |
GENE.00009 Gene Expression Profiling and Genomic Biomarker Tests for Prostate Cancer | - Removed CPT PLA code 0053U
| 6/28/2023 |
MED.00135 Gene Therapy for Hemophilia | - Revised MN statement on etranacogene dezaparvovec-drlb
- Added MN statement on valoctocogene roxaparvovec-rvox
- Revised first INV&NMN statement and deleted second INV&NMN statement
- No changes to coding
- Codes that may be used for Roctavian (NOC C9399, J3490, J3590) already listed
| 12/1/2023 |
