Medical Policy and Coding Updates August 2018

  • Special notice: New medical policies effective in November

    Effective November 2, 2018

    Ablation Procedures for Peripheral Neuromas, 7.01.147
    Minimally invasive ablation procedures such as radiofrequency ablation or cryoablation are considered investigational for the treatment of peripheral neuromas.

    Alcohol Injections for Treatment of Peripheral Neuromas, 2.01.97
    Alcohol injections are considered investigational for the treatment of peripheral neuromas (eg, Morton’s neuroma).

    Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting, 2.02.24
    This policy was previously archived and is being reinstated. Cardiac hemodynamic monitoring for the management of heart failure in the ambulatory care and outpatient setting using arterial pressure during the Valsalva maneuver, implantable direct pressure monitoring of the pulmonary artery, inert gas rebreathing, or thoracic bioimpedance is considered investigational.

    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

    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

    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

    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.

    New medical policies

    Effective August 1, 2018

    Ablative Procedures of Peripheral Nerves to Treat Pain, 7.01.565
    This replaces policy 7.01.154. Ablative procedures of peripheral nerves to treat pain for all indications are considered investigational for the following treatments: cooled radiofrequency ablation, cryoneuroloysis (cryoablation, cryotherapy, cryoanalgesia), or radiofrequency ablation.

    Gene Expression Profiling for Cutaneous Melanoma, 12.04.146
    Gene expression testing is considered investigational in the evaluation of patients with suspicious pigmented lesions, patients with melanocytic lesions with indeterminate histopathologic features, and patients with cutaneous melanoma.
    Note: Effective January 4, 2019, the services originally described in this policy are reviewed by AIM Specialty Health®.

    Three‐Dimensional Printed Orthopedic Implants, 7.01.161
    Three-dimensional printed implants are considered medically necessary for custom implants for patients with bone or joint deformity. They are considered investigational for standard and patient-matched implants.

    Revised medical policies

    Effective August 1, 2018

    Closure Devices for Patent Foramen Ovale and Atrial Septal Defects, 2.02.09
    The policy is modified to state that the percutaneous transcatheter closure of a patent foramen ovale using Amplatzer PFO Occluder may be considered medically necessary to reduce the risk of recurrent ischemic stroke if patient meets all of the specified criteria.

    Cranial Electrotherapy Stimulation and Auricular Electrostimulation, 8.01.58
    Electrical stimulation of the ear (also known as auricular neurostimulation) for opioid withdrawal is considered investigational.

    Drug Testing in Pain Management and Substance Use Disorder Treatment Settings, 2.04.513
    This policy is revised as follows:

    • The criteria for testing for pain management programs are differentiated from testing for substance use disorder treatment programs.
    • The specific criteria for testing for pain management programs are expanded and modified to be consistent with the Washington State AMDG guidelines.
    • The specific criteria for testing for substance use disorder treatment programs are expanded and modified to be consistent with ASAM guidelines.
    • All limits on the number and frequency of tests for pain management programs are modified to be consistent with the Washington State AMDG guidelines.
    • All limits on the number and frequency of tests for substance use disorder treatment programs are modified to be consistent with ASAM guidelines.
    • Policy title is changed.

    Electrical Stimulation Devices, 1.01.507
    The policy is modified to state that pulsed electrical stimulation and pulsed electromagnetic therapy are considered investigational for any indication including but not limited to the treatment of osteoarthritis, rheumatoid arthritis, neuropathic pain (diabetic peripheral neuropathy), post‐operative or non‐postoperative pain, or wounds.

    Transcatheter Pulmonary Valve Implantation, 7.01.131
    The policy is revised to state that transcatheter pulmonary valve implantation is considered medically necessary for patients with congenital heart disease and current right ventricular outflow tract obstruction or regurgitation when specified indications are met.

    Wearable Cardioverter Defibrillators as a Bridge to Implantable Cardioverter-Defibrillator Placement, 2.02.506
    The policy statements are edited for clarity. These indications are added as investigational: post coronary artery bypass graft (CABG) surgery patients, high-risk patients awaiting heart transplant, patients with newly diagnosed nonischemic cardiomyopathy, and women with peripartum cardiomyopathy.

    New pharmacy policies

    Effective August 1, 2018

    Intravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric Disorders, 5.01.586
    This replaces policy 5.01.16. The policy is expanded to include the statement that intravenous infusion of ketamine for psychiatric symptoms or disorders is considered investigational.

    Palynziq™ (pegvaliase-pqpz), 5.01.585
    Palynziq™ (pegvaliasepqpz) may be considered medically necessary to treat phenylketonuria (PKU) in adults when criteria are met.

    Revised pharmacy policies

    Effective August 1, 2018

    Drugs for Rare Diseases, 5.01.576
    The policy is revised to add criteria for Crysvita® (burosemab).

    Exondys 51® (eteplirsen), 5.01.570
    This policy is updated to reflect recently published long-term follow up from the clinical study.

    Migraine and Cluster Headache Medications, 5.01.503
    The policy is updated and simplified, and it consolidates previous updates. CGRP inhibitors are added to the discussion of prophylaxis.

    Monoclonal Antibodies for the Treatment of Lymphomas, 2.03.502
    The policy is revised to update the indications for Adcetris® (brentuximab vedotin).

    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.

    Deleted on August 1, 2018

    Intravenous Anesthetics for the Treatment of Chronic Pain, 5.01.16 (replaced with 5.01.586)

    Radiofrequency Ablations of Peripheral Nerves to treat Pain, 7.01.154 (replaced with 7.01.565)

    Added codes

    Effective August 1, 2018

    Ablative Procedures of Peripheral Nerves to Treat Pain, 7.01.565
    Now reviewed for investigative

    0441T - Ablation, percutaneous, cryoablation, includes imaging guidance; lower extremity distal/peripheral nerve

    Revised codes

    Effective August 1, 2018

    Expanded Molecular Panel Testing of Cancers to Identify Targeted Therapies, 12.04.115
    Now requires prior authorization; currently reviewed for investigative

    81455 - Targeted genomic sequence analysis panel, solid organ or hematolymphoid neoplasm, DNA analysis, and RNA analysis when performed, 51 or greater genes (eg, ALK, BRAF, CDKN2A, CEBPA, DNMT3A, EGFR, ERBB2, EZH2, FLT3, IDH1, IDH2, JAK2, KIT, KRAS, MLL, NPM1, NRAS, MET, NOTCH1, PDGFRA, PDGFRB, PGR, PIK3CA, PTEN, RET), interrogation for sequence variants and copy number variants or rearrangements, if performed

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