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Medical Policies

Medical policies express our determination of whether a health service (e.g., test, drug, device or procedure) is proven to be effective based on the published clinical evidence. They are also used to decide whether a given health service is medically necessary. Services determined to be experimental, investigational, unproven, or not medically necessary by the clinical evidence are typically not covered.

Medical policies do not certify benefits or authorization of benefits, which is designated by each individual policyholder contract. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and/or federal law. Medical technology is continuously evolving so medical policies are developed as needed, are regularly updated, and are subject to change without prior notice. The Technology Assessment Working Group (TAWG) reviews policies regularly.

Medical policies can be highly technical and complex and are provided here for informational purposes. The medical policies do not constitute medical advice or medical care. Treating health care providers are solely responsible for diagnosis, treatment and medical advice.

View our medical polices.


UPDATES FOR NOVEMBER 2018

POLICY

STATUS

REVISION

PG0311 Gender Reassignment Surgery

Revision
PENDING
Effective
01/25/19

11/28/18: Removed ICD-10 code F64.0 Transsexualism per CMS guidelines. Policy reviewed and updated to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0294 Transcranial Magnetic Stimulation

Revision
PENDING
Effective
01/25/19

11/28/18: Added ICD-10 codes F32.2 & F33.2 per CMS guidelines. Policy reviewed and updated to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0181 Topographic Genotyping  

Revision
PENDING
Effective
01/25/19

11/28/18: Policy reviewed and updated to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0038 Percutaneous Vertebroplasty, Kyphoplasty, and Sacroplasty

Revision
PENDING
Effective
01/25/19

11/28/18: Added ICD-10 code M85.88 as secondary dx for osteopenia under Group 3 Codes per CMS L34048 guidelines. Policy reviewed and updated to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0416 Lumbar Laminectomy, Hemi-Laminectomy, Laminotomy and/or Discectomy

Revision
PENDING
Effective
01/25/19

11/28/18: Policy reviewed and updated to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0363 CORUS® CAD

Revision
PENDING
Effective
01/25/19

11/28/18: Corus® CAD (81493) is non-covered for Elite per CMS guidelines. ICD-10 codes removed. Policy reviewed and updated to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0448 Joint Resurfacing

New
PENDING
Effective
01/25/19

11/28/18: Hip resurfacing does not require prior authorization. Appropriate ICD-10 diagnosis code (as listed in the policy) required for coverage. Any joint resurfacing procedure other than hip including, but may not be limited to, knee or shoulder is non-covered. Policy created to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0450 Positron Emission Tomography (PET) Oncology Applications

New
PENDING
Effective
01/25/19

11/28/18: PET scans for oncology applications do not require prior authorization. Non-Covered ICD-10 codes are listed in the policy for HMO, PPO, Individual Marketplace, & Advantage. PET scanning of the prostate is non-covered for HMO, PPO, Individual Marketplace, & Advantage. Policy created to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0449 Upper Gastrointestinal Endoscopy

New
PENDING
Effective
01/25/19

11/28/18: Upper gastrointestinal endoscopy does not require prior authorization. Appropriate ICD-10 diagnosis code (as listed in the policy) required for coverage. Policy created to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0196 Flu (Influenza) and Pneumonia Immunization Vaccines

Revision
PENDING
Effective
01/25/19

11/13/18: Fluzone high-dose (90662) vaccine is now covered for Advantage effective 11/01/2018 per ODM guidelines. Added effective 01/01/19 new code 90689 as covered for all product lines. Code 90664 (pandemic vaccine) is non-covered for HMO, PPO, Individual Marketplace, & Elite. Removed effective 12/31/15 deleted code 90669. Policy reviewed and updated to reflect most current clinical evidence per Medical Policy Steering Committee.

PG0445 Nurse Midwives, Nurse Practitioners and Physician Assistants

Revision
PENDING
Effective
01/25/19

11/13/18: The AS modifier should be reported by Nurse Midwives, Physician Assistants & Nurse Practitioners when performing surgical services as an Assistant Surgeon. Nurse Midwives should bill the SB modifier for non-surgical services. Policy created to reflect most current clinical evidence per Medical Policy Steering Committee.

PG0447 Pulmonary Rehabilitation (Outpatient)

Revision
PENDING
Effective
01/25/19

11/13/18: Outpatient pulmonary rehabilitation (G0237-G0239, G0424, S9473) does not require prior authorization. Code S9473 is Non-Medicare and therefore non-covered for Elite. Members are eligible for one series per lifetime consisting of one to two hour sessions three times a week for a maximum of six weeks (36 session limit). Policy created to reflect most current clinical evidence per Medical Policy Steering Committee.

PG0205 Hyperbaric Oxygen Therapy

Revision
PENDING
Effective
01/25/19

11/13/18: Added ICD-10 codes. Policy reviewed and updated to reflect most current clinical evidence per Medical Policy Steering Committee.

PG0013 Tobacco Cessation Counseling

Revision
PENDING
Effective
01/25/19

11/13/18: Policy reviewed and updated to reflect most current clinical evidence per Medical Policy Steering Committee.

PG0069 Drug Testing

Revision
PENDING
Effective
01/25/19

11/13/18: Removed: All codes have a maximum allowed of 20 days per calendar year; 80305, 80306, 80307, 80320-80377, 83992, G0477, G0480, G0481, G0482, G0483, G0659. Added: Allow 30 dates of service per year (30 total tests per year) for Presumptive Drug Class Screening. Added: Allow 60 total tests per year for Definitive Drug Testing (12 dates of service per year & 5 tests within the code set listed per date of service). Removed codes G0478 and G0479. Removed effective 01/01/17 deleted codes 80300-80304. Policy reviewed and updated to reflect most current clinical evidence per Medical Policy Steering Committee.

UPDATES FOR OCTOBER 2018

POLICY

STATUS

REVISION

PG0351 The Implantable Miniature Telescope (IMT)

Revised
Effective
12/28/18

10/25/18: Added ICD-10 codes H35.3110, H35.3111, H35.3112, H35.3113, H35.3120, H35.3121, H35.3122, H35.3123, H35.3130, H35.3131, H35.3132, H35.3133, H35.3134 per CMS guidelines. Policy reviewed and updated to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0404 Laser Vitreolysis

Revised
Effective
12/28/18

10/25/18: Policy reviewed and updated to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0403 Therapeutic Contact Lenses

Revised
Effective
12/28/18

10/25/18: Policy reviewed and updated to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0415 Pancreatic Islet Cell Transplantation

Revised
Effective
12/28/18

10/25/18: Policy reviewed and updated to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0418 Retinal Prosthesis

Revised
Effective
12/28/18

10/25/18: Policy reviewed and updated to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0365 Bone Graft Substitutes

Revised
Effective
12/28/18

10/25/18/18: Policy reviewed and updated to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0337 Endovascular Repair of Visceral Aorta for Abdominal Aortic Aneurysm

NEW
PENDING
Effective
12/28/18

10/25/18: The use of FDA approved endovascular/endoluminal stent graft devices does not require prior authorization for all product lines. The use of fenestrated and branched endovascular/endoluminal stent graft devices (34839, 34841-34848) is non-covered for HMO, PPO, Individual Marketplace, & Elite. The use of fenestrated and branched endovascular/endoluminal stent graft devices (34839, 34841-34848) requires prior authorization for Advantage per odm guidelines. Policy created to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0004 Extracorporeal Shock Wave Therapy (ESWT)

Revised
Effective
12/28/18

10/25/18: Policy reviewed and updated to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0321 Subtalar Arthroereisis

Revised
Effective
12/28/18

10/25/18: Policy reviewed and updated to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0417 Proprietary Laboratory Analyses (PLA) Codes

Revised
Effective
12/28/18

10/25/18: Refer to PG0438 Next Generation Sequencing (NGS) Tests for Advanced Cancer for coverage determination for code 0022U. Policy reviewed and updated to reflect most current clinical evidence per the Technology Assessment Working Group (TAWG).

PG0228 Neuromuscular, Functional, & Therapeutic Electrical Stimulation Therapy

Revised
Effective
12/28/18

10/25/18: Effective 7/16/18 code E0770 is now covered without prior authorization for Advantage per ODM guidelines. Limits may apply. Policy reviewed and updated to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0446 Clinical Trials

NEW
PENDING
Effective
12/28/18

10/25/18: Clinical trials (S9988, S9990, S9991) are covered with prior authorization. Transportation (S9992), lodging (S9993), and meals (S9994) for clinical trials are non-covered. Codes G0293 & G0294 are non-covered. Policy created to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0371 Tumor Treatment Field Therapy for Glioblastoma

Revised
Effective
12/28/18

10/25/18: Tumor treatment field (TTF) therapy (i.e., Optune) (E0766) and treatment planning software (i.e., NovoTAL) for use with TTF therapy are non-covered for all product lines per administrative direction to follow CMS and ODM guidelines. Policy reviewed and updated to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0049 CT Screening for Lung Cancer in Heavy Smokers

Revised
Effective
12/28/18

10/09/18: Added ICD-10 diagnosis codes F17.210, F17.211, F17.213, F17.218, F17.219 per CMS guidelines. Prior authorization requirement removed for Elite for low dose CT scan (LDCT) for lung cancer screening in heavy smokers (G0296, G0297). These services (G0296, G0297) must be billed with ICD-10 diagnosis codes F17.210, F17.211, F17.213, F17.218, F17.219, Z87.891 per CMS guidelines. ICD-9 code removed. Removed effective 09/30/16 deleted code S8032. Policy reviewed and updated to reflect most current clinical evidence per Medical Policy Steering Committee.

PG0170 Prolotherapy

Revised
Effective
12/28/18

10/09/18: Prolotherapy (M0076) continues to be non-covered by all product lines. Policy reviewed and updated to reflect most current clinical evidence per Medical Policy Steering Committee.

PG0426 After Hours and Weekend Care Policy

Revised
Effective
12/28/18

10/09/18: Clarified when codes 99050 & 99051 will be separately reimbursed for Advantage. Policy reviewed and updated to reflect most current clinical evidence per Medical Policy Steering Committee.

PG0396 Emergency Room Professional Services

Revised
Effective
12/28/18

10/09/18: Changed effective date to 01/01/19. The appropriate ICD-10 diagnosis code must be billed with CPT codes 99283-99285 to receive 100% reimbursement of the provider fee schedule. The ICD-10 code is no longer required in the first five diagnosis fields on the claim form. Title changed from Emergency Room Services to Emergency Room Professional Services. Policy reviewed and updated to reflect most current clinical evidence per Medical Policy Steering Committee.

PG0158 Physical Therapy (PT) and Occupational Therapy (OT)

Revised
Effective
12/28/18

09/25/18: Verbiage regarding Advantage limits removed per administrative direction.

10/09/18: Manual therapy (97140) no longer requires prior authorization for children 0-3 years of age for all product lines. Policy reviewed and updated to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0141 Hearing Aids

Revised
Effective
12/28/18

10/09/18: Effective 01/01/19 two TruHearing-branded hearing aids (one per ear) are covered per year for Elite. Removed code V5273 refer to PG0281 Cochlear and Auditory Brainstem Implants. Policy reviewed and updated to reflect most current clinical evidence per Medical Policy Steering Committee.

PG0343 Hip Surgery for Femoroacetabular Impingement (FAI)

Revised
Effective
12/28/18

10/09/18: Capsular repair, labral reconstruction, iliotibial band windowing, trochanteric bursectomy, abductor muscle repair, and/or iliopsoas tenotomy, when performed at the time of any FAI surgery, would be considered a component of and incidental to the FAI procedure. Policy reviewed and updated to reflect most current clinical evidence per Medical Policy Steering Committee.

 

 

UPDATES FOR SEPTEMBER 2018

POLICY

STATUS

REVISION

PG0224 Cardioverter Defibrillators

Revision
PENDING
Effective
11/23/18

09/27/18: Policy reviewed and updated to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0407 Frenectomy or Frenotomy for Ankyloglossia

Revised
Effective
11/23/18

09/27/18: Policy reviewed and updated to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0409 Ketamine for Treatment of Psychiatric Disorders and Pain Management

Revised
Effective
11/23/18

09/27/18: Policy reviewed and updated to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0411 Genetic Testing for Duchenne and Becker Muscular Dystrophy

Revised
Effective
11/23/18

09/27/18: Policy reviewed and updated to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0296 Comparative Genomic Hybridization (CGH) 

Revised
Effective
11/23/18

09/27/18: Comparative genomic hybridization (81228, 81229, S3870) is non-covered per CMS guidelines. Policy reviewed and updated to reflect the most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0232 Bone Growth Stimulating Services-Devices (Osteogenic Stimulators)

Revised
Effective
11/23/18

09/27/18: Clarified that code E0749 is non-covered for Advantage & Elite per ODM & CMS guidelines. Adjunct to cervical spinal fusion surgery is no longer a non-covered indication for Advantage per ODM guidelines. Policy reviewed and updated to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0367 Genetic and Protein Biomarkers for Diagnosis and Risk Assessment of Prostate Cancer

Revised
Effective
11/23/18

09/27/18: Added SelectMDx as non-covered for all product lines. Policy updated per CMS guidelines. Policy reviewed and updated to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0438 Next Generation Sequencing (NGS) Tests for Advanced Cancer

Revised
Effective
11/23/18

09/27/18: Added code 0022U as covered with prior authorization for Elite per CMS guidelines and non-covered for HMO, PPO, Individual Marketplace & Advantage. Code 81445 should be billed for Oncomine™ Dx Target Test for DOS 06/22/2017-09/30/2017. Code 0022U should be billed for Oncomine™ Dx Target Test for DOS after 10/01/2017. Policy created to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0065 Colorectal Cancer Screening

Revised
Effective
11/23/18

09/27/18: Colorectal cancer screening beginning at age 45 is considered a medically necessary preventive service for African Americans. For an average risk individual age 50 years and older, Paramount covers as medically necessary CT Colonography (74263) every 5 years (Refer to PG0182 Virtual Colonoscopy). Urine-based testing (e.g., PolypDx) is non-covered for colorectal cancer screening for all product lines. Policy reviewed and updated to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0443 Postoperative Sinus Debridement

NEW
Effective
11/23/18

09/27/18: Paramount considers postoperative sinus debridement (31237, S2342) to always be related to all the nasal and sinus procedure codes performed at the original surgical session. Code S2342 is non-Medicare and therefore non-covered for Elite. Policy created to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0444 Embolization of the Ovarian & Iliac Veins for Pelvic Congestion Syndrome

NEW
Effective
11/23/18

09/27/18: Embolization of the ovarian & iliac veins (37241, 75894) for pelvic congestion syndrome is non-covered. Policy created to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0371 Tumor Treatment Fields Therapy for Glioblastoma

Revised
Effective
11/23/18

09/27/18: Treatment planning software (i.e., NovoTAL) for use with TTF therapy is now covered with prior authorization for all product lines. Policy reviewed and updated to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0105 Benign Skin Lesion Removal

Revised
Effective
11/23/18

09/11/18: Verbiage removed regarding requirement for an ABN prior to performing the procedure for Elite members. Policy reviewed and updated to reflect most current clinical evidence per Medical Policy Steering Committee.

PG0104 Cosmetic and Reconstructive Surgery

Revised
Effective
11/23/18

09/11/18: Verbiage removed regarding requirement for an ABN prior to performing the procedure for Elite members. Removed ICD-9 codes. Policy reviewed and updated to reflect most current clinical evidence per Medical Policy Steering Committee.

PG0193 Treatment of Chronic Vertigo

Revised
Effective
11/23/18

09/11/18: Policy reviewed and updated to reflect most current clinical evidence per Medical Policy Steering Committee.

PG0244 Transcutaneous & Percutaneous Electrical Nerve Stimulators

Revised
Effective
11/23/18

09/11/18: Title changed from Transcutaneous Electrical Nerve Stimulator (TENS), Transcutaneous Electrical Acupoint Stimulation and Accessories to Transcutaneous & Percutaneous Electrical Nerve Stimulators (TENS, PENS). Codes A4556, A4558, E0740, E0746, E0748, E0749, E0755, E0760, E0762 removed from policy. Transcutaneous Electrical Nerve Stimulators (TENS) is covered without prior authorization. Limits may apply. Percutaneous electrical nerve stimulation (PENS) is non-covered. Codes A4630 & E0731 are non-covered for Advantage per ODM guidelines. Policy reviewed and updated to reflect most current clinical evidence per Medical Policy Steering Committee.

PG0245 Hospital Beds and Accessories

Revised
Effective 11/23/18

09/11/18: Codes E0275, E0276, E0325, E0326, E0350, E0352, E0370 removed from policy per CMS guidelines. Codes E0910, E0911, E0912, E0940, E1399 added to policy per CMS guidelines. Codes E0265, E0266, E0270, E0273, E0274, E0296, E0297, E0315 are non-covered for HMO, PPO, Individual Marketplace, Elite per CMS guidelines. Codes E0250, E0251, E0265, E0266, E0270, E0273, E0274, E0280, E0290, E0291, E0296, E0297, E0300, E0315, E0316, E0911 are non-covered for Advantage per ODM guidelines. Policy reviewed and updated to reflect most current clinical evidence per Medical Policy Steering Committee.

 

UPDATES FOR AUGUST 2018

POLICY

STATUS

REVISION

PG0237 Vagus Nerve Stimulation

Revised
Effective
10/26/18

08/23/18: Policy reviewed and updated to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0151 Total Ankle Replacement

Revised
Effective
10/26/18

08/23/18: Policy reviewed and updated to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0225 Implantable Testosterone Pellets

Revision
PENDING
Effective
10/26/18

08/23/18: Policy reviewed and updated to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0341 Measurement of Serum Antibodies to Infliximab, Adalimumab, & Vedolizumab

Revised
Effective
10/26/18

08/23/18: Added LabCorp ECLIA (electrochemiluminescence immunoassay) test as non-covered for all product lines. Policy reviewed and revised to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

 

PG0198 Actigraphy and Accelerometry

Revision
PENDING
Effective
10/26/18

08/23/18: Policy reviewed and updated to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0371 Tumor Treatment Fields Therapy for Glioblastoma

Revised
Effective
10/26/18

08/23/18: Policy reviewed and updated to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0358 Genetic Counseling

Revised
Effective
10/26/18

08/23/18: Policy reviewed and updated to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0357 Gene Expression Profiling for Colorectal Cancer

Revised
Effective
10/26/18

08/23/18:  Added ICD-10 codes per CMS guidelines for coverage of Oncotype DX® Colon. Policy reviewed and updated to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0367 Genetic and Protein Biomarkers for Diagnosis and Risk Assessment of Prostate Cancer

Revised
Effective
10/26/18

08/23/18: Added effective 07/01/2018 new code 0047U. Oncotype DX Prostate Cancer (0047U), Prolaris® (81541), Decipher® (81479), & ConfirmMDx® (81551) are now non-covered for HMO, PPO, Individual Marketplace, & Advantage. Policy reviewed and updated to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0041 Genetic and Experimental Lab Services

Revised
Effective
10/26/18

08/23/18: Added reference to these genetic policies: PG0358 Genetic Counseling; PG0364 Gene Expression Profiling for Cancers of Unknown Primary Site (81504, 81540); PG0374 Verifi Prenatal Test (81420, 81507, 0009M); PG0387 Genetic Testing for Cystic Fibrosis (81220-81224); PG0391 UGT1A1 Targeted Mutation Analysis for Irinotecan Response (81350); PG0398 Genetic Testing for Spinal Muscular Atrophy (81400, 81401, 81403, 81405); PG0412 Genetic Testing for Macular Degeneration (81401, 81405, 81408); PG0436 CYP2C19 & CYP2D6 Pharmacogenetic Testing (81225, 81226); PG0437 HLA-B1502 & HLA-B5701 Pharmacogenetic Testing (81381); & PG0438 Next Generation Sequencing (NGS) Tests for Advanced Cancer (81455, 81479); PG0442 Carrier Screening for Genetic Diseases. Updated title PG0298 from Afirma® Thyroid FNA Analysis to Molecular Markers in Fine Needle Aspirates of Thyroid Nodules. Removed PG0334 ThyroSeq® v.2 Next Generation Sequencing (added to PG0298). Removed Proprietary Laboratory Analyses (PLA) Codes (0001U-0044U) from this policy, refer to PG0417 Proprietary Laboratory Analyses (PLA) Codes. Added effective 1/1/18 new Proprietary MAA code 0011M as non-covered for all product lines. Added effective 4/1/18 new Proprietary MAA codes 0012M & 0013M as non-covered for all product lines. Codes 81250 & 81255 are now non-covered for Elite per CMS guidelines. Code 81438 is now covered with prior authorization for Elite per CMS guidelines. Policy reviewed and updated to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0441 Genetic Testing for Alzheimer Disease

New
Effective
10/26/18

08/23/18: Genetic testing for Alzheimer Disease (e.g., APOE, APP, PSEN1, PSEN2) is non-covered for all product lines. Policy created to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0310 Sacroiliac Joint Fusion

Revised
Effective
10/26/18

08/23/18: Percutaneous or minimally invasive sacroiliac joint stabilization (e.g., iFuse Implant System™) for sacroiliac joint fusion (27279) is covered with prior authorization for Elite members per CMS guidelines. Policy reviewed and updated to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0442 Carrier Screening for Genetic Diseases

New
Effective
10/26/18

08/23/18: Direct-to-consumer (DTC) genetic testing is non-covered. Expanded carrier screening panels are non-covered. Policy created to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0277 Suction and Tracheal Supplies

Revised
Effective
10/26/18

08/14/18: Effective 7/16/18 added modifiers U2 & U3 for codes A7520 & A7521 as covered with limit of 2 per month for Advantage per ODM guidelines. Modifiers U1-U3 are N/A for HMO, PPO, Individual Marketplace, Elite. Policy reviewed and updated to reflect most current clinical evidence per Medical Policy Steering Committee.

PG0204 Viscosupplementation for Osteoarthritis of the Knee

Revised
Effective
10/26/18

08/14/18: Added new code effective 4/1/18 C9465 as non-covered for all product lines. Policy reviewed and updated to reflect most current clinical evidence per Medical Policy Steering Committee.

PG0263 Negative Wound Pressure Devices

Revised
Effective
10/26/18

08/14/18: Coverage increased from 3 to 10 canister sets (A7000) per month for HMO, PPO, Individual Marketplace, & Elite per CMS guidelines, and Advantage per ODM guidelines will continue with limit of 3 canister sets per month. Policy reviewed and updated to reflect most current clinical evidence per Medical Policy Steering Committee.

PG0152 Postoperative Continuous Local Delivery of Anesthesia

Revised
Effective
10/26/18

08/14/18: Policy reviewed and updated to reflect most current clinical evidence per Medical Policy Steering Committee.

PG0300 Immunohistochemistry (IHC)

Archived
Effective
10/26/18

08/14/18: The Medical Policy Steering Committee has determined this policy should be archived.

PG0114 Enteral and Parenteral Nutrition

Revised
Effective
10/26/18

08/14/18: Added CMS criteria from L33783 & A52493 for the HMO, PPO, Individual Marketplace, Elite product lines. Policy reviewed and updated to reflect most current clinical evidence per the Medical Policy Steering Committee.

PG0248 Breast Prosthesis and Mastectomy Bras

Revised
Effective
10/26/18

08/14/18: Codes A4280 & L8032 are now covered for HMO, PPO, Individual Marketplace, Elite per CMS guidelines. Policy updated to reflect most current clinical evidence per Medical Policy Steering Committee.

PG0241 Dressings and Wound Care

Revised
Effective
10/26/18

08/14/18: Updated per CMS & ODM guidelines. Code A6024 is now covered for HMO, PPO, Individual Marketplace, Elite per CMS guidelines. Policy reviewed and updated to reflect most current clinical evidence per Medical Policy Steering Committee.

 

UPDATES FOR JULY 2018

POLICY

STATUS

REVISION

PG0405 Doppler Studies of Ductus Venosus

Revised
Effective
09/28/18

07/26/17: Policy reviewed and updated to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0389 Occipital Nerve Block Therapy for the Treatment of Headache and Occipital Neuralgia

Revised
Effective
09/28/18

07/26/18: Verbiage “twice a month for three months” was removed from the criteria. Policy reviewed and updated to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0281 Cochlear and Auditory Brainstem Implants

Revised
Effective
09/28/18

07/26/18: Hybrid cochlear implants are now covered with prior authorization for all product lines. Added effective 01/01/18 new code L8625 as non-covered for Advantage & covered with prior authorization for HMO, PPO, Individual Marketplace, & Elite. Revised codes L8618, L8621, L8624. Policy reviewed and updated to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0119 Gene Expression Profiling of Melanomas

Revised
Effective
09/28/18

07/26/18: Policy reviewed and updated to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0412 Genetic Testing for Macular Degeneration

Revised
Effective
09/28/18

07/26/18: Policy reviewed and updated to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0437 HLA-B1502 & HLA-B5701 Pharmacogenetic Testing

Revised
Effective
09/28/18

07/26/18: Code 81381 now requires prior authorization for all product lines. Policy created to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0440 Magnetic Resonance Image Guided High Intensity Focused Ultrasound (MRgFUS) for Essential Tremor

Revised
Effective
09/28/18

07/26/18: MRgFUS unilateral thalamotomy (0398T) is covered without prior authorization for Elite per CMS guidelines and non-covered for HMO, PPO, Individual Marketplace, & Advantage. Policy created to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0043 New Experimental Services

Revised
Effective
09/28/18

07/26/18: Added effective 07/01/18 new codes 0505T-0509T as non-covered for all product lines. Removed deleted codes effective 12/31/15 0099T, 0103T, 0123T, 0182T, 0223T, 0224T, 0225T, 0233T, 0240T, 0241T, 0243T, 0244T, 0262T, & 0311T. Refer to PG0440 Magnetic Resonance Image Guided High Intensity Focused Ultrasound (MRgFUS) for Essential Tremor for coverage determination for code 0398T. Refer to PG0344 Uterine Fibroid Surgical Treatments for coverage determination for codes 0071T, 0072T, 0336T in addition to 0404T. Refer to PG0026 Minimally Invasive Treatment of Back and Neck Pain for coverage determination for codes 0274T & 0275T. Refer to PG0386 Fractional Flow Reserve from Computed Tomography (FFRCT) for coverage determination for codes 0501T-0504T. Refer to PG0418 Retinal Prosthesis for coverage determination for codes 0100T, 0472T, & 0473T. Policy reviewed and updated to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0301 Genetic Expression Assays for Breast Cancer Prognosis

Revised
Effective
09/28/18

07/26/18: Added effective 07/01/2018 new code 0045U (The Oncotype DX® Breast DCIS Score™ Test) & as non-covered for all product lines. FoundationOne™ removed from policy. Refer to PG0438 Next Generation Sequencing (NGS) Tests for Advanced Cancer for coverage determination of FoundationOne CDx™ (F1CDx). Policy reviewed and updated to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0417 Proprietary Laboratory Analyses (PLA) Codes

Revised
Effective
09/28/18

07/26/18: Effective 07/01/18 new Proprietary Laboratory Analyses (PLA) codes 0045U-0046U, 0048U-0061U are non-covered for all product lines. Refer to PG0367 Genetic and Protein Biomarkers for Diagnosis and Risk Assessment of Prostate Cancer for coverage determination for code 0047U. Refer to PG0438 Next Generation Sequencing (NGS) Tests for Advanced Cancer for coverage determination for code 0037U.  Policy reviewed and updated to reflect most current clinical evidence per the Technology Assessment Working Group (TAWG).

PG0387 Genetic Testing for Cystic Fibrosis

Revised
Effective
09/28/18

07/26/18: Genetic testing (CFTR gene) for cystic fibrosis (CF) ( 81220-81224) does not require prior authorization when determined to be medically necessary as the medical criteria and guidelines in the policy are met. Policy created to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0391 UGT1A1 Targeted Mutation Analysis for Irinotecan Response

Revised
Effective
09/28/18

07/26/18: Genotyping to determine UGT1A1 genetic polymorphisms (81350) is non-covered for HMO, PPO, Individual Marketplace, & Elite per CMS guidelines. Genotyping to determine UGT1A1 genetic polymorphisms (81350) does not require prior authorization for Advantage per ODM guidelines. Policy reviewed and updated to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0364 Gene Expression Profiling for Cancers of Unknown Primary Site

Revised
Effective
09/28/18

07/26/18:  Changed title from PG0364 Cancer Type ID to Gene Expression Profiling for Cancers of Unknown Primary Site. Added code 81504. Added ResponseDX Tissue of Origin Test (81504) as covered without prior authorization for Elite per CMS guidelines, & non-covered for HMO, PPO, Individual Marketplace, & Advantage. Added ProOnc TumorSourceDX & RosettaGX Cancer Origin tests to policy as non-covered for all product lines. Added required ICD-10 diagnoses codes per CMS guidelines A54188 for CancerTYPE ID. Added required ICD-10 diagnoses codes per CMS guidelines A54198 for ResponseDX Tissue of Origin Test. Policy reviewed and updated to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0335 Children's Intensive Behavioral Service/Applied Behavioral Analysis (ABA)

Revised
Effective
09/28/18

07/10/18: Effective 07/01/18 codes 0359T, 0364T, 0365T, 0368T, & 0369T are now be covered with prior authorization for Advantage per ODM guidelines. Policy reviewed and updated to reflect most current clinical evidence per Medical Policy Steering Committee.

PG0105 Benign Skin Lesion Removal

Revised
Effective
09/28/18

07/10/18: Added ICD-10 codes per CMS guidelines. Policy reviewed and updated to reflect most current clinical evidence per Medical Policy Steering Committee.

PG0238 Podiatry Shoes and Inserts (Orthotic Foot Inserts)

Revised
Effective
09/28/18

07/10/18: Added effective 4/1/18 new code K0903 as covered for all product lines. Codes L3031, L3160, & L3485 removed from non-covered list for HMO, PPO, Individual Marketplace, & Elite per CMS guidelines. Policy reviewed and updated to reflect most current clinical evidence per Medical Policy Steering Committee.

PG0439 Behavioral Health Integration Services

New
Effective
09/28/18

07/10/18: Psychiatric care management (99484, 99492-99494) is considered incidental and not eligible for separate reimbursement for HMO, PPO, & Individual Marketplace. Psychiatric care management (99484, 99492-99494) is separately reimbursed for treating (billing) practitioners without prior authorization for Elite & Advantage per CMS guidelines effective 01/01/18 & ODM guidelines effective 07/01/18. Policy created to reflect most current clinical evidence per Medical Policy Steering Committee.

PG0203 Skin Substitutes and Wound Repair Procedures

Revised
Effective
09/28/18

07/10/18: Code 46707 is non-covered for all product lines. Code Q4158 is now covered for Advantage per ODM guidelines. Codes Q4103, Q4104, Q4105, Q4108, Q4110, Q4111, Q4115, Q4117, Q4118, Q4122, Q4123, Q4124, Q4126, Q4128, Q4134, Q4135, Q4136, Q4137, Q4140, Q4141, Q4145, Q4146, Q4147, Q4148, Q4151, Q4152, Q4153, Q4154, Q4156, Q4157, Q4159, Q4160, Q4161, Q4163, Q4164, Q4165, Q4169, Q4172, Q4173, Q4174, Q4175, Q4177, Q4178 are now covered for HMO, PPO, Individual Marketplace, Elite per CMS guidelines. Code Q4182 is now non-covered for HMO, PPO, Individual Marketplace, Elite per CMS guidelines. Policy reviewed and updated to reflect most current clinical evidence per Medical Policy Steering Committee.

PG0215 Pneumatic Compression Devices

Revised
Effective
09/28/18

07/10/18: Unicompartmental (nonsegmented) or multicompartmental (segmented) pneumatic compression pump with gradient pressure (e.g., Flexitouch or LymphaPress Optimal) (E0652) are now covered without prior authorization for HMO, PPO, Individual Marketplace, Elite. Added as non-covered for all product lines: A-V Impulse System foot pump, Ambulatory, portable, battery powered intermittent or combination intermittent and sustained pneumatic compression devices (e.g., ActiveCare+SFT, Cirona 6400, Vasculaire, VenaPro Vascular Therapy System, VenoWave2 and VenoWave VW5), combination cold or heat therapy/intermittent pneumatic compression devices (e.g., Cothera VPULSE, Game Ready Accelerated Recovery System, Kinex ThermoComp Device, & NanoTherm, TEC System, Triple Play VT and the VascuTherm). Policy reviewed and updated to reflect most current clinical evidence per Medical Policy Steering Committee.

PG0013 Tobacco Cessation Counseling

Revised
Effective
09/28/18

07/10/18: Policy reviewed and updated to reflect most current clinical evidence per Medical Policy Steering Committee.

PG0177 Continuous Glucose Monitoring Systems and Insulin Pumps

Revised
Effective
09/28/18

07/10/18: Added Dexcom G6 to examples of FDA approved long-term CGM systems. Hybrid closed loop system (eg, MiniMed 670G) requires prior authorization for all product lines. Combined external insulin pumps and CGM with suspend on low feature (eg, MiniMed 530G, MiniMed 630G) are now covered with prior authorization. For Elite only, CGM system supplies and accessories are now covered if a non-DME de­vice (watch, smartphone, tablet, laptop computer, etc.) is used in conjunction with the durable CGM receiver (K0554) to display glucose data per CMS guidelines. Policy reviewed and updated to reflect most current clinical evidence per Medical Policy Steering Committee.

PG0114 Enteral and Parenteral Nutrition

Revised
Effective
09/28/18

07/10/18: Added effective 7/1/18 new code Q9994. Added modifier U1 for codes B4034, B4035, B4036, & B4100 per ODM guidelines. Food thickener (B4100, B4100-U1) is covered without prior authorization for Advantage. Food thickener (B4100, B4100-U1) is non-covered for HMO, PPO, Individual Marketplace, & Elite. Item B5200 is now covered for HMO, PPO, Individual Marketplace, Elite per CMS guidelines. Item B5200 remains non-covered for Advantage per ODM guidelines. Policy reviewed and updated to reflect most current clinical evidence per the Medical Policy Steering Committee.

PG0184 Salivia Hormone Testing

Revised
Effective
09/28/18

07/10/18: Added code 84999. Salivary cortisol testing (82530, 82533, 84999) collected in the evening for diagnosis of Cushing’s syndrome does not require prior authorization. Elite product line should bill unlisted code 84999 for salivary cortisol testing per CMS guidelines. All other salivary hormone testing (e.g., thyroid, testosterone, estrogen, parathyroid, growth hormone, etc.) is non-covered. Added ICD-10 codes per CMS guidelines. Policy reviewed and updated to reflect most current clinical evidence per The Medical Policy Steering Committee.

UPDATES FOR JUNE 2018

POLICY

STATUS

REVISION

PG0128 Computer Assisted Surgery

Revised
Effective
08/24/18

06/12/18: Policy reviewed and updated to reflect most current clinical evidence per The Medical Policy Steering Committee.

 

PG0382 Acupuncture

Revised
Effective
08/24/18

06/12/18: Policy reviewed and updated to reflect most current clinical evidence per Medical Policy Steering Committee.

 

PG0432 Temporomandibular Joint Disorders

New
Effective
08/24/18

04/26/18: Treatment of temporomandibular joint (TMJ) disorders does not require prior authorization when determined to be medically necessary as the medical criteria and guidelines are met. Policy created to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

06/12/18: Policy reviewed and updated to reflect most current clinical evidence per Medical Policy Steering Committee.

PG0120 Cranial Orthotic Devices & Protective Helmets

Revised
Effective
08/24/18

06/12/18: For Advantage, protective helmets (A8002, A8003) are now allowed one per year per ODM guidelines versus per medical event. Policy reviewed and updated to reflect most current clinical evidence per Medical Policy Steering Committee.

PG0142 Telehealth Services

Revised
Effective
08/24/18

06/12/18: Per CMS as of January 1, 2018, the GT modifier is only allowed on institutional claims billed under CAH Method II. CMS eliminated the requirement to use the GT modifier (via interactive audio and video telecommunications systems) on professional claims for telehealth services. Use of the telehealth Place of Service (POS) Code 02 certifies that the service meets the telehealth requirements. Only the Elite product line will follow this CMS guideline. Policy reviewed and updated to reflect most current clinical evidence per Medical Policy Steering Committee.

UPDATES FOR MAY 2018

POLICY

STATUS

REVISION

PG0108 Transcatheter Valve Replacement

Revised
Effective
07/27/18

05/24/18: Removed ICD-9 codes. Removed deleted code 0262T effective 12/31/15. Policy reviewed and updated to reflect most current clinical evidence per the Technology Assessment Working Group (TAWG).

PG0027 Artificial Intervertebral Disc Replacement

Revised
Effective
07/27/18

05/24/18: Lumbar artificial disc replacement at one level (22857) is now covered with prior authorization for Advantage per ODM guidelines effective 07/01/18. Policy reviewed and updated to reflect most current clinical evidence per the Technology Assessment Working Group (TAWG).

PG0111 VeriStrat® Testing

Revised
Effective
07/27/18

05/24/18: Policy reviewed and updated to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0433 Vitamin D Testing

New
Effective
07/27/18

05/24/18: Testing of vitamin D levels may be considered medically necessary to monitor therapy when vitamin D deficiency is diagnosed. Routine testing and general population screening is considered not medically necessary. The ICD-10 diagnosis codes that are appropriate for vitamin D, 25-hydroxy testing (82306) and vitamin D, 1,25-dihydroxy testing (82652) are listed in this policy. Sensieva™ Droplet 25OH Vitamin D2/D3 Microvolume LC/MS Assay (0038U) is non-covered. Policy created to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0434 Microwave Tumor Ablation

New
Effective
07/27/18

05/24/18: Microwave tumor ablation is non-covered. Policy created to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0435 Hyperthermia for Cancer Treatment

New
Effective
07/27/18

05/24/18: Hyperthermia for cancer treatment does not require prior authorization when determined to be medically necessary because the medical criteria and guidelines in this policy are met. Policy created to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0158 Physical Therapy (PT) and Occupational Therapy (OT)

Revised
Effective
07/27/18

05/24/18: Added Miscellaneous Services (Non-covered) per CMS guidelines that includes Interactive metronome therapy (Brain Bright Therapy). Policy reviewed and updated to reflect most current clinical evidence per Medical Policy Steering Committee.

PG0438 Next Generation Sequencing (NGS)Tests for Advanced Cancer

New
Effective
07/27/18

05/24/18: Effective 03/16/18 Next Generation Sequencing (NGS) tests may be covered with prior authorization for Elite per CMS guidelines. Next Generation Sequencing (NGS) tests for advanced cancer are non-covered for HMO, PPO, Individual Marketplace & Advantage. Policy created to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0163 Bariatric Services

Revised
Effective
07/27/18

05/24/18: Added non-covered procedures and documentation requirements. Policy reviewed and updated to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0177 Continuous Glucose Monitoring Systems and Insulin Pumps

Revised
Effective
07/27/18

05/24/18: Hybrid closed loop system (eg, MiniMed 670G) is now covered without prior authorization for all product lines. Policy reviewed and updated to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).

PG0436 CYP2C19 & CYP2D6 Pharmacogenetic Testing

New
Effective
07/27/18

05/24/18: CYP2C19 (81225) and CYP2D6 (81226) genotyping requires prior authorization for all product lines. Policy created to reflect most current clinical evidence per The Technology Assessment Working Group (TAWG).