Medical Policy and Coding Updates August 2017

  • New medical policies

    Effective August 1, 2017

    Molecular Testing in the Management of Pulmonary Nodules, 12.04.142
    Plasma-based proteomic testing (Xpresys® Lung) in patients with pulmonary nodules detected radiographically is investigational. Gene expression profiling (Percepta® Bronchial Genomic Classifier) on bronchial brushings in patients with indeterminate bronchoscopy results is investigational.
    Note: Effective January 4, 2019 the services originally described in this policy are reviewed by AIM Specialty Health®.

    Sphenopalatine Ganglion Block for Headache, 7.01.159
    Sphenopalatine ganglion blocks are investigational for all indications. Read the full policy.

    Revised medical policies

    Effective August 1, 2017

    Amniotic Membrane and Amniotic Fluid, 7.01.149
    The policy statement was revised to include a medically necessary statement for sutured human amniotic membrane grafts for specific eye indications. Human amniotic membrane without suture is investigational for eye indications. Read the full policy.

    Cardiac Rehabilitation in the Outpatient Setting, 8.03.08
    The policy statement was revised to include a statement that intensive cardiac rehabilitation with the Ornish Program for Reversing Heart Disease and the Pritikin Program are not medically necessary. Read the full policy.

    Genetic Testing for Mitochondrial Disorders, 12.04.117
    The policy statements were revised as follows: Genetic testing is no longer restricted to a set of specific mutations documented for a particular mitochondrial disorder. The medical necessity statement was revised to remove “female” for carrier testing of at-risk relatives.
    Note: Effective January 4, 2019 the services originally described in this policy are reviewed by AIM Specialty Health®.

    Genetic Testing for Rett Syndrome, 12.04.81
    The policy statement for genetic testing to diagnosis Rett syndrome in a child was revised to remove the word “female.” A medically necessary policy statement was added for targeted genetic testing to determine carrier status of a mother or sister of a person with Rett syndrome. All other genetic testing for Rett syndrome is investigational.
    Note: Effective January 4, 2019 the services originally described in this policy are reviewed by AIM Specialty Health®.

    Hematopoietic Cell Transplantation for Solid Tumors of Childhood, 8.01.511
    The policy statement was revised as follows: Hematopoietic cell transplantation (HCT) for metastatic retinoblastoma is medically necessary. HCT for retinoblastoma without metastases is investigational. HCT for late stage Wilms tumor is investigational. Tandem autologous HCT for high-risk or relapsed neuroblastoma is medically necessary. Read the full policy.

    Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Conditions, 1.01.15
    The policy was clarified to state that use of high-frequency chest wall compression devices and intrapulmonary percussive devices are considered not medically necessary rather than investigational for chronic lung conditions such as obstructive pulmonary disease or respiratory conditions associated with neuromuscular disorders. Read the full policy.

    Percutaneous Vertebroplasty and Sacroplasty, 6.01.25
    The policy statement was revised to include a medically necessary statement for vertebroplasty in vertebral fractures less than 6 weeks old when the fracture leads to hospitalization or prevents walking. Read the full policy.

    Archived policy

    An archived policy is no longer active and is not used for reviews.

    Archived on July 31, 2017

    Prostatic Urethral Lift, 7.01.151 (This service will now be covered.)

    Coding updates

    Added codes

    Effective August 1, 2017

    Amniotic Membrane and Amniotic Fluid, 7.01.149
    Reviewed for medical necessity; prior authorization required

    Q4131 - EpiFix, per square centimeter

    Q4132 - Grafix core, per square centimeter

    Q4133 - Grafix prime, per square centimeter

    Q4145 - EpiFix, injectable, 1 mg

    Q4154 - Biovance, per square centimeter

    Clinical Trials, 10.01.518
    Reviewed for medical necessity; prior authorization required

    S9990 - Services provided as part of a Phase II clinical trial

    S9991 - Services provided as part of a Phase III clinical trial

    Bronchial Thermoplasty, 7.01.127
    Prior authorization is required (currently reviewed for investigative)

    31660 - Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial thermoplasty, 1 lobe

    31661 - Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial thermoplasty, 2 or more lobes

    Genetic Testing for Mental Health Conditions, 12.04.515
    Reviewed for investigative; requires prior authorization

    0015U - Drug metabolism (adverse drug reactions), DNA, 22 drug metabolism and transporter genes, real-time PCR, blood or buccal swab, genotype and metabolizer status for therapeutic decision support

    JAK2 and MPL Mutation Analysis in Myeloproliferative Neoplasms, 12.04.60
    Reviewed for medical necessity; prior authorization required

    0017U - Oncology (hematolymphoid neoplasia), JAK2 mutation, DNA, PCR amplification of exons 12-14 and sequence analysis, blood or bone marrow, report of JAK2 mutation not detected or detected

    Quantitative Assay for Measurement of HER2 Total Protein Expression and HER2 Dimers, 12.04.76
    Reviewed for investigative; requires prior authorization

    0009U - Oncology (breast cancer), ERBB2 (HER2) copy number by FISH, tumor cells from formalin fixed paraffin embedded tissue isolated using image-based dielectrophoresis (DEP) sorting, reported as ERBB2 gene amplified or non-amplified

    Revised codes

    Effective August 1, 2017

    Amniotic Membrane and Amniotic Fluid, 7.01.149
    Revised from investigative review; now reviewed for medical necessity and requires prior authorization

    Q4137 - AmnioExcel or BioDExCel, per sq cm

    Q4139 - AmnioMatrix or BioDMatrix, injectable, 1 cc.

    Q4148 - Neox 1k, per sq cm

    Q4151 - AmnioBand or Guardian, per sq cm

    Q4155 - NeoxFlo or ClarixFlo, 1 mg

    Q4156 - Neox 100, per sq cm

    Q4162 - AmnioPro Flow, BioSkin Flow, BioRenew Flow, WoundEx Flow, Amniogen-A, Amniogen-C, 0.5 cc

    Q4163 - AmnioPro, BioSkin, BioRenew, WoundEx, Amniogen-45, Amniogen-200, per sq cm

    Q4168 - AmnioBand, 1 mg

    Lipid Apheresis, 8.02.04
    Revised from medical necessity review; now reviewed as investigative

    0342T - Therapeutic apheresis with selective HDL delipidation and plasma reinfusion

    Removed codes

    Effective August 1, 2017

    Bioengineered Skin and Soft Tissue Substitutes, 7.01.113
    Removed from investigative review

    Q4104 - Integra Bilayer Matrix Wound Dressing (BMWD), per square centimeter

    Q4108 - Integra Matrix, per square centimeter

    Prostatic Urethral Lift, 7.01.151
    Removed from investigative review; now covered as medically necessary

    52441 - Cystourethroscopy, with insertion of permanent adjustable transprostatic implant; single implant

  •    Email this article