Medical Policy and Coding Updates July 2018

Special notice: Update to AIM Advanced Imaging clinical appropriateness guidelines

Effective October 29, 2018

CT Chest

• Expanded list of diagnostic testing abnormalities that may be followed up with CT to include endoscopy, fluoroscopy, and ultrasound in addition to specific chest radiography findings
• Lengthening of timeframe required prior to imaging for chronic cough from 3 to 8 weeks, and more specifics of preliminary workup required prior to imaging
• Lower threshold for defining unexplained weight loss, and more explicit definition of preliminary workup required prior to imaging
• Allowance for use of imaging in the staging of malignancy prior to biopsy confirmation
• Allowance for imaging of suspected pulmonary embolism in pregnancy
• New criteria for appropriate imaging of chest wall mass

CT Angiography (CTA) Chest

• Allowance for imaging of suspected pulmonary embolism in pregnancy

CT Abdomen/CT Pelvis/CT Abdomen & Pelvis

• Lower threshold for defining unexplained weight loss, and more explicit definition of preliminary workup required prior to imaging

MRI Chest

• New guideline for imaging of suspected pectoralis muscle tear
• New criteria for appropriate imaging of chest wall mass

MRI Abdomen

• Addition of hemochromatosis as an indication for imaging in pediatric patients

Special notice: New medical policies effective in October

Effective October 5, 2018

Orthoptic and Vision Therapy, Visual Perceptual Training, Vision Restoration Therapy, and Neurovisual Rehabilitation, 9.03.508
This policy replaces policy 9.03.03. These services are considered investigational:

• Orthoptic training or vision therapy for learning and reading disabilities, including dyslexia
• Orthoptic training or vision therapy for visual disorders other than convergence insufficiency
• Visual perceptual training
• Vision restoration therapy
• Neurovisual (optometric) rehabilitation

Special notice: Revised medical policies effective in October

Effective October 5, 2018

Orthognathic Surgery, 9.02.501
This policy is revised as follows:

• Removed the policy statement for orthognathic surgery for correction of articulation disorders and other impairments in the production of speech
• Added medical necessity criteria for the treatment of severe malocclusion contributing to TMJ syndrome symptoms
• Specified that the criteria for treatment of mandibular and maxillary deformities contributing to airway dysfunction and associated obstructive sleep apnea include report of AHI of ≥ 30, 90-day trial of PAP, and participation in PAP compliance program

Treatment of Hyperhidrosis, 8.01.519
Iontophoresis and radiofrequency ablation are considered investigational for all categories. Botulinum toxin is considered investigational for plantar, craniofacial, and secondary gustatory hyperhidrosis.
Note: This policy has been renumbered to 8.01.19, effective April 1, 2020.

Special notice: New medical policies effective in August

Effective August 3, 2018

Auditory Brainstem Implant, 7.01.83
When criteria are met, a unilateral auditory brainstem implant may be considered medically necessary for patients 12 years old and older whose total deafness was caused by surgery to treat neurofibromatosis type 2.

Special notice: Revised pharmacy policies effective in August

Effective August 3, 2018

Medical Necessity Criteria for Pharmacy Edits, 5.01.605
Testopel^® may be considered medically necessary when the patient has failed a trial of a generic testosterone gel (1%) and AndroGel^l® (1.62%).

Revised medical policies

Effective July 1, 2018

Artificial Intervertebral Disc: Cervical Spine, 7.01.108
Subsequent implantation of a second artificial cervical intervertebral disc at an adjacent level (contiguous to a previous placed artificial disc) may be considered medically when criteria are met.

Intraoperative Neurophysiologic Monitoring, 7.01.562
The investigational statement for intraoperative neurophysiologic monitoring of visual evoked potentials is removed.

Single Photon Emission Computed Tomography (SPECT) for Non-cardiac Indications, 6.01.502
Assessment of osteomyelitis may be considered medically necessary. Evaluation of degenerative joint disease/arthritis of the facet joints is considered not medically necessary.

Revised pharmacy policies

Effective July 1, 2018

Epidermal Growth Factor Receptor (EGFR) Inhibitors, 5.01.603
The policy is revised as follows:

• Gilotrif^® (afatinib) as second-line therapy for non-small-cell lung cancer (NSCLC) with EGFR common mutations is removed.
• Tagrisso^® (osimertinib) may be considered medically necessary for adults with metastatic NSCLC with any EGFR mutation.
• The policy statement for Erbitux^® (cetuximab) for NSCLC is removed.
• The policy statement for Vectibix^® (panitumumab) is revised for clarity.

Excessively High Cost Drug Products with Lower Cost Alternatives, 5.01.560
Medical necessity criteria are added for generic iodoquinol/hydrocortisone/aloe polysaccharides. Several additional drugs are added to the topical lidocaine medical necessity criteria.

Medical Necessity Criteria and Dispensing Quantity Limits for Exchange Formulary Benefits, 5.01.547
Emsam^® (selegiline transdermal system) requires trial and failure of two preferred medications.

Medical Necessity Criteria for Pharmacy Edits, 5.01.605
The policy is revised as follows:

• The preferred diabetic test strips are OneTouch^® (LifeScan). Medical necessity criteria are added for nonpreferred diabetic test strips.
• Step therapies for Amitiza^® (lubiprostone), Linzess^® (linaclotide), Movantik^® (naloxegol), and Trulance^® (plecanatide) are added for various indications.
• Branded, single-source hypnotic drugs require a trial of two generic hypnotic agents.
• Intranasal corticosteroids require a trial of at least two generic intranasal corticosteroids.

Pharmacotherapy of Multiple Sclerosis, 5.01.565
Zinbryta^® (daclizumab) is removed from the policy since it is no longer on the market.

A deleted policy is one whose number is no longer used but the content is either moved into another policy or replaced with a new policy and number.

To be deleted on October 5, 2018

Orthoptic Training for the Treatment of Vision or Learning Disabilities, 9.03.03 (replaced with 9.03.508, effective October 5, 2018)

Added codes

Effective July 1, 2018

Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast cancer, 12.04.36
Now requires review for investigative; now requires prior authorization

0045U - Oncology (breast ductal carcinoma in situ), mRNA, gene expression profiling by real-time RT-PCR of 12 genes (7 content and 5 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as recurrence score

Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions, 7.01.78
Now requires review for medical necessity including site of service; now requires prior authorization

29867 - Arthroscopy, knee, surgical; osteochondral allograft (eg, mosaicplasty)

Erythropoiesis-Stimulating Agents, 5.01.535
Now requires review for medical necessity; now requires prior authorization

Q5105 - Injection, epoetin alfa, biosimilar, (Retacrit) (for esrd on dialysis), 100 units

Q5106 - Injection, epoetin alfa, biosimilar, (Retacrit) (for non-esrd use), 1000 units

Expanded Molecular Panel Testing of Cancers to Identify Targeted Therapies, 12.04.115
Now requires review for investigative

0048U - Oncology (solid organ neoplasia), DNA, targeted sequencing of protein-coding exons of 468 cancer-associated genes, including interrogation for somatic mutations and microsatellite instability, matched with normal specimens, utilizing formalin-fixed paraffin-embedded tumor tissue, report of clinically significant mutation(s)

0050U -Targeted genomic sequence analysis panel, acute myelogenous leukemia, DNA analysis, 194 genes, interrogation for sequence variants or rearrangements

0057U - Oncology (solid organ neoplasia), MRNA, gene expression profiling by massively parallel sequencing for analysis of 51 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a normalized percentile rank

Gene Expression Profiling and Protein Biomarkers for Prostate Cancer Management, 12.04.111
Now requires review for investigative

0047U - Oncology (prostate), mRNA, gene expression profiling by real-time RT-PCR of 17 genes (12 content and 5 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a risk score

0053U - Oncology (prostate cancer), Fish analysis of 4 genes (ASAP1, HDAC9, CHD1 and PTEN), needle biopsy specimen, algorithm reported as probability of higher tumor grade

Genetic Testing for Mental Health Conditions, 12.04.515
Now requires review for investigative

0032U - COMT (catechol-O-methyltransferase)(drug metabolism) gene analysis, c.472G>A (rs4680) variant

0033U - HTR2A (5-hydroxytryptamine receptor 2A), HTR2C (5-hydroxytryptamine receptor 2C) (eg, citalopram metabolism) gene analysis, common variants (ie, HTR2A rs7997012 [c.614-2211T>C], HTR2C rs3813929 [c.-759C>T] and rs1414334 [c.551-3008C>G])

Genetic Testing for Warfarin Dose, 12.04.48
Now requires review for investigative

0030U - Drug metabolism (warfarin drug response), targeted sequence analysis (ie, CYP2C9, CYP4F2, VKORC1, rs12777823)

Hemlibra^® (emicizumab-kxwh), 5.01.581
Now requires review for medical necessity; now requires prior authorization

Q9995 - Injection, emicizumab-kxwh, 0.5 mg

Noninvasive Prenatal Screening for Fetal Aneuploidies and Microdeletions Using Cell-Free Fetal DNA, 4.01.21
Now requires review for investigative; now requires prior authorization

0060U - Twin zygosity, genomic targeted sequence analysis of chromosome 2, using circulating cell-free DNA in maternal blood

Revised codes

Effective June 18, 2018

Site of Service: Select Surgical Procedures, 11.01.524
Now requires review for investigative; now requires prior authorization

No longer requires site of service review; currently reviewed for medical necessity; currently requires prior authorization

L8679 - Implantable neurostimulator, pulse generator, any type

L8680 - Implantable neurostimulator electrode, each

L8682 - Implantable neurostimulator radiofrequency receiver

L8683 - Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver

L8685 - Implantable neurostimulator pulse generator, single array, rechargeable, includes extension

L8686 - Implantable neurostimulator pulse generator, single array, nonrechargeable, includes extension

L8687 - Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension

L8688 - Implantable neurostimulator pulse generator, dual array, nonrechargeable, includes extension

Effective July 1, 2018

Artificial Intervertebral Disc: Cervical Spine, 7.01.108
No longer requires medical necessity review including site of service; now requires review for investigative; currently requires prior authorization

0375T - Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection), cervical, three or more levels

Lumbar Spine Decompression Surgery: Discectomy, Foraminotomy, Laminotomy, Laminectomy, 7.01.551
Now requires review for site of service; currently requires review for medical necessity; currently requires prior authorization

62380 - Endoscopic decompression of spinal cord, nerve root(s), including laminotomy, partial facetectomy, foraminotomy, discectomy and/or excision of herniated intervertebral disc, 1 interspace, lumbar

Proteomic Testing for Targeted Therapy in Non-Small Cell Lung cancer, 2.04.125
Now requires prior authorization; currently reviewed for investigative

81538 - Oncology (lung), mass spectrometric 8-protein signature, including amyloid A, utilizing serum, prognostic and predictive algorithm reported as good versus poor overall survival

Effective July 5, 2018

Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease, 2.01.38
Now requires review for investigative; no longer reviewed for medical necessity; no longer requires prior authorization

43201- Esophagoscopy, flexible, transoral; with directed submucosal injection(s), any substance

43236 - Esophagogastroduodenoscopy, flexible, transoral; with directed submucosal injection(s), any substance

43257- Esophagogastroduodenoscopy, flexible, transoral; with delivery of thermal energy to the muscle of lower esophageal sphincter and/or gastric cardia, for treatment of gastroesophageal reflux disease

Removed codes

Effective July 1, 2018

Epidermal Growth Factor Receptor (EGFR) Inhibitors, 5.01.603
No longer reviewed for medical necessity; no longer requires prior authorization

J8565 - Gefitinib, oral, 250 mg

J8999 - Prescription drug, oral, chemotherapeutic, NOS

Sacral Nerve Neuromodulation/Stimulation, 7.01.69
No longer requires medical necessity review; no longer requires prior authorization

64585 - Revision or removal of peripheral neurostimulator electrode array

64590 - Insertion or replacement of peripheral or gastric neurostimulator pulse generator or receiver, direct or inductive coupling