Medical policy and clinical guideline updates - April 2021*

Title

Information

Effective date

GENE.00056

Gene Expression Profiling for Bladder Cancer

• Gene expression profiling for diagnosing, managing and monitoring bladder cancer is considered INV&NMN -- Existing CPT codes 0012M, 0013M (Cxbladder GEP) moved from LAB.00011, still considered INV&NMN; CPT 0016M effective 01/01/2021 for Decipher TURBT® will be considered INV&NMN

7/1/2021

LAB.00038

Cell-free DNA Testing to Aid in the Monitoring of Kidney Transplants for Rejection

  • Cell-free DNA testing is considered INV&NMN as a non-invasive method of determining the risk of rejection in kidney transplant recipients

- Existing code 0118U for Vitacor TRAC will be considered INV&NMN for kidney transplant diagnoses; no specific codes for other tests, listed 81479, 81599 NOC codes

7/1/2021

LAB.00039

Pooled Antibiotic Sensitivity Testing

• Pooled antibiotic sensitivity testing is considered INV&NMN in the outpatient setting for all indications

- No specific codes for these tests (eg Guidance® assay for UTI [Pathnostics, Inc.]), considered INV&NMN; listed NOC codes 81479, 87999

7/1/2021

SURG.00159 

Focal Laser Ablation for the Treatment of Prostate Cancer

• Focal laser ablation is considered INV&NMN for the treatment of prostate cancer

- No specific code for focal laser ablation of prostate for cancer, considered INV&NMN; listed 55899 NOC and associated ICD-10-PCS code; also listed 0655T (will be effective 07/01/2021) considered INV&NMN

7/1/2021

*TRANS.00037

Uterine Transplantation

• Uterine transplantation is considered INV&NMN for all uses, including but not limited to the treatment of uterine factor infertility due to nonfunctioning or absent uterus

- No specific CPT code for uterine transplant services, considered INV&NMN; listed 58999 NOC and associated ICD-10-PCS codes, also listed 0664T-0670T (will be effective 07/01/2021) considered INV&NMN

7/1/2021

Title

Change

Effective date

*CG-GENE-22

Gene Expression Profiling for Managing Breast Cancer Treatment

• Content moved from GENE.00011

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

• Removed Insight DX test (no longer marketed) and added Insight TNBC type test as NMN

4/7/2021

*CG-GENE-23

Genetic Testing for Heritable Cardiac Conditions

• Content moved from GENE.00007 and GENE.00017

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

• No other change to clinical indications

4/7/2021

*ANC.00008

Cosmetic and Reconstructive Services of the Head and Neck

• Removed the word “physical” from the term “physical functional impairment” in Facial Plastic Surgery, Otoplasty, Rhinophyma, Rhinoplasty or Rhinoseptoplasty and Cranial Nerve Procedures position statements

• Added otoplasty using a custom-fabricated device, including but not limited to a custom fabricated alloplastic implant, as COS&NMN

- No specific code for implanted auricular prosthesis, added L8699 NOC, considered COS&NMN for specific implants

7/1/2020

*CG-OR-PR-04

Cranial Remodeling Bands and Helmets (Cranial Orthotics)

• Removed condition requirement from REC criteria

• Replaced current diagnostic REC criteria with criteria based on one of the following cephalometric measurements: the cephalic index, the cephalic vault asymmetry index, the oblique diameter difference index, or the cranioproportional index of plagiocephelometry

7/1/2021

*CG-SURG-82

Bone-Anchored and Bone Conduction Hearing Aids

• Reorganized Clinical Indications section

• Reorganized and clarified bilateral hearing loss MN criteria

• Clarified MN criteria for transcutaneously-worn bone conduction hearing aids for both bilateral and unilateral hearing loss

• Revised audiologic pure tone average bone conduction threshold criteria for unilateral implant for bilateral hearing loss

• Moved device-specific threshold information to the Discussion section

• Clarified MN criteria for transcutaneously worn and fully- or partially-implantable bone conduction hearing aids for unilateral hearing loss

• Added NMN statement for when MN criteria have not been met

• Clarified NMN statement regarding replacement parts or upgrades

• Added bone conduction hearing aids using an adhesive adapter behind the ear as NMN for all indications

7/1/2021

*CG-GENE-14

Gene Mutation Testing for Solid Tumor Cancer Susceptibility and Management

• Reorganizing genetic testing topics: Moved the content of the following topics into CG-GENE-14 Gene Mutation Testing for Solid Tumor Cancer Susceptibility and Management

   - CG-GENE-02 Analysis of RAS Status

   - CG-GENE-03 BRAF Mutation Analysis

   - CG-GENE-12 PIK3CA Mutation Testing for Malignant Condition

   - CG-GENE-20 Epidermal Growth Factor Receptor [EGFR] Testing)

• Added circulating tumor DNA (ctDNA) to guide targeted cancer therapy in individuals with solid tumor(s) as MN when criteria are met

• Added NMN criteria on circulating tumor DNA (ctDNA) when the medically necessary criteria are not met, including to detect the recurrence of a solid tumor, including ectal cancer, and to test for solid tumor cancer susceptibility

   - Content addressing ctDNA involving 4 or fewer genes or gene variants, moved from GENE.00049 Circulating Tumor DNA Panel Testing for Cancer (Liquid Biopsy) and added to this document (CG-GENE-14)

   - Content addressing ctDNA involving 5 or more genes or gene variants (gene panel), will continue to be addressed in GENE.00049

- Added PLA code 0229U (Colvera® 2-gene test) considered NMN (moved from GENE.00049, was considered INV&NMN); added specific codes from merged guidelines (PIK3CA 81309, 0155U, 0177U; RAS 81275, 81276, 81311, 0111U; BRAF 81210; EGFR 81235) and genes to Tier 2 codes, with no changes

4/1/2021