Medical Policy and Clinical Guideline Updates - June 2020*

*DME.00041 Low Intensity Therapeutic Ultrasound for the Treatment of Pain

• The use of a low intensity therapeutic ultrasound device is considered Investigational and Not Medically Necessary (INV&NMN) for all indications

- HCPCS DME code K1004; considered INV&NMN

9/1/2020

GENE.00053 Metagenomic Sequencing for Infectious Disease in the Outpatient Setting

• Metagenomic sequencing for infectious diseases in the outpatient setting is considered Investigational and Not Medically Necessary (INV&NMN) for all indications

- Existing CPT codes 0112U, 0152U will be considered INV&NMN; also listed NOC code 87999

9/1/2020

GENE.00054 Paired DNA and Messenger RNA (mRNA) Genetic Testing to Detect, Diagnose and Manage Cancer

• Messenger RNA (mRNA) sequence analysis alone or in conjunction with DNA sequence analysis to aid in the classification of variations of uncertain significance or to otherwise detect, diagnose or manage cancer is considered INV&NMN

- Existing codes 0133U, 0136U, 0137U and 0138U (effective 10/01/19), 0157U, 0158U, 0159U, 0160U, 0161U and 0162U will be considered INV&NMN

9/1/2020

*SURG.00154 Microsurgical Procedures for the Treatment of Lymphedema

Microsurgery for the treatment of lymphedema (including lymphedema as a result of a mastectomy) is considered INV&NMN, including but not limited to the following:

1. Lymphaticolymphatic bypass;

2. Lymphovenous bypass;

3. Lymphaticovenular anastomosis;

4. Vascularized lymph node transfer;

5. Tissue/Flap transfer (for example, omental flap transfer)

9/1/2020

*SURG.00155 Cryoneurolysis for Treatment of Peripheral Nerve Pain

• Cryoneurolysis for treatment of peripheral nerve pain is considered INV&NMN for all indications, including osteoarthritis of the knee

9/1/2020

Title

Change

Effective date

DME.00011 Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices

Previous title: Electrical Stimulation as a Treatment for Pain and Related Conditions: Surface and Percutaneous Devices

• Revised title

• Revised scope of document to include other conditions and devices

• Added cranial electrical stimulation (CES) as INV&NMN for all indications

• Added remote electrical neuromodulation (REN) as INV&NMN for all indications

- Added HCPCS code K1002 for cranial electrotherapy stimulation systems, considered INV&NMN; no specific code for REN systems (E1399 NOC)

9/1/2020

LAB.00011 Analysis of Proteomic Patterns

• Revised INV&NMN statement to include management of disease

9/1/2020

MED.00120 Gene Therapy for Ocular Conditions

Previous title: Voretigene neparvovec-rzyl (Luxturna®)

• Revised title

• Expanded scope of document to include all gene therapies for ocular conditions

• Removed redundant language "gene therapy"

• Added the use of all other gene replacement therapies to treat any ocular condition as INV&NMN

- Added HCPCS code J3490 NOC

9/1/2020

*SURG.00032 Patent Foramen Ovale and Left Atrial Appendage Closure Devices for Stroke Prevention

Previous title: Transcatheter Closure of Patent Foramen Ovale and Left Atrial Appendage for Stroke Prevention

• Revised title

• Added left atrial appendage closure via surgical (non-percutaneous) implantation of a device as INV&NMN for all indications

- Added 33999 NOC; added ICD-10-PCS 02L70CK, 02L70DK, 02L73CK, 02L74CK, 02L74DK considered INV&NMN

9/1/2020

*SURG.00096 Surgical and Ablative Treatments for Chronic Headaches

Added existing CPT codes 14040, 14041, 14060, 14061, 64716, 64771, 64772, 64787 and diagnosis codes G50.1, M54.81, R51 based on inquiries and society guidelines; considered INV&NMN for headache diagnoses

9/1/2020

*CG-SURG-107 Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH)

• Content moved from SURG.00028

• INV&NMN changed to NMN as a result of Medical Policy (MP)  to Clinical UM Guideline (CUMG) transition

- Added examples of technologies for prostatic urethral lift, transurethral convective water vapor thermal ablation and waterjet tissue ablation

- Added NMN statement for prostatic urethral lift when the intent is to treat symptoms of conditions other than benign prostatic hyperplasia

9/1/2020