Medical Policy and Coding Updates February 2018

Special notice: Revised policy effective in June

Effective June 1, 2018

Exondys 51^® (eteplirsen), 5.01.570
Exondys 51^® (eteplirsen) is subject to site of service administration effective June 1, 2018. Read the full policy.

New medical policy effective in April

Effective April 4, 2018

Cognitive (Neurologic) Rehabilitation, 8.03.504
This policy was previously archived but it is now being reinstated. Cognitive (neurologic) rehabilitation programs may be considered medically necessary for patients with cognitive impairment due to traumatic brain injury when criteria are met. It is considered investigational for other indications. Read the full policy.
Note: This policy has been renumbered to 8.03.10, effective April 1, 2020.

New benefit coverage guideline

Effective February 1, 2018

Preventive Care, 10.01.523
This benefit coverage guideline is published as a notification to providers and members describing how the health plan recognizes codes and diagnoses to pay for preventive services when the member's plan covers ACA-required preventive benefits. The processing system recognizes the first diagnosis only. Read the full guideline.

Revised medical policies

Effective February 1, 2018

Artificial Pancreas Device Systems, 1.01.30
The policy was revised to add a statement that the use of hybrid closed loop insulin delivery systems is investigational. (Policy replaced with InterQual® criteria, effective July 2, 2020.)

Measurement of Serum Antibodies to Infliximab and Adalimumab and Vedolizumab, 2.04.84
The policy was revised to include Anser™ VDZ test for Entyvio (vedolizumab) antibodies as investigational.
Note: Effective February 1, 2019, the services originally described in this policy are now found in policy 2.04.516 Measurement of Serum Antibodies to Infliximab, Adalimumab, and Vedolizumab

Molecular Markers in Fine Needle Aspirates of the Thyroid, 12.04.510
The policy was revised to add medical necessity statements for:

• ThyGenX
• Combined genetic variant analysis and microRNA gene expression classifiers (i.e., ThyGenX/ThyraMir)
• Afirma BRAF after Afirma Gene Expression Classifier
• Afirma MTC after Afirma Gene Expression Classifier

Note: Effective January 4, 2019, the services originally described in this policy are reviewed by AIM Specialty Health^®.

Patient Lifts, Seat Lifts, and Standing Devices, 1.01.519
The policy was revised to add a medical necessity statement for multi-positional lifts and replacement slings. A list of noncovered items was added for clarity. Read the full policy.

Physical Medicine and Rehabilitation - Physical Therapy and Medical Massage Therapy, 8.03.502
The policy was revised to add criteria for rehabilitation services to manage chronic pain and chronic conditions or diseases. The documentation requirements for medical massage therapy were clarified. Read the full policy.

Skilled Nursing Facility (SNF): Admission and Transition of Care Guideline, 11.01.510
The policy was revised to add medical necessity criteria for continued stay in a SNF and add statements related to admission. Medical necessity and transition of care statements were edited for clarity. Read the full policy.

Spinal Cord and Dorsal Root Ganglion Stimulation, 7.01.546
The investigational indications were revised. Axial back pain, failed cervical and thoracic surgery, post-herpetic neuralgia, occipital neuralgia, and peripheral neuropathy are removed as investigational indications. Added as investigational indications are treatment of cancer-related pain, heart failure, and pelvic pain. Read the full policy.

Temporomandibular Joint Dysfunction, 2.01.21
The investigational policy statement was revised to add botulinum toxin as an investigational treatment for TMJ. Note: Effective May 1, 2019, the services originally described in this policy are now found in policy 2.01.535 Temporomandibular Joint Disorder.

New pharmacy policies

Effective February 1, 2018

Antibody-Drug Conjugates, 5.01.582
When medical necessity criteria are met, Besponsa^® (inotuzumab ozogamicin) may be considered medically necessary for B-cell precursor ALL. Mylotarg^® (gemtuzumab ozogamicin) may be considered medically necessary for CD33-positive AML when criteria are met. Read the full policy.

Hemlibra (emicizumab-kxwh), 5.01.581
When medical necessity criteria are met, Hemlibra® (emicizumab-kxwh) may be considered medically necessary to treat hemophilia A (congenital factor VIII deficiency) in children and adults. Read the full policy.

Revised pharmacy policies

Effective February 1, 2018

IL-5 Inhibitors, 5.01.559
The policy was updated to include medical necessity criteria for Fasenra™ (benralizumab) as an add-on maintenance medication for patients with severe asthma with an eosinophilic phenotype. The policy title was changed from “Nucala^® (mepolizumab)” to “IL-5 Inhibitors.” Read the full policy.

Miscellaneous Oncology Drugs, 5.01.540
The policy was updated to add medical necessity criteria for Aliqopa™ (copanlisib) to treat relapsed/refractory follicular lymphoma when criteria are met. Read the full policy.

Trastuzumab and Other HER2 Inhibitors, 5.01.514
The medical necessity criteria for Nerlynx^® (neratinib) to treat breast cancer were updated to reflect the current NCCN guidelines. Read the full policy.

Added codes

Effective February 1, 2018

Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer, 12.04.36
Now reviewed for medical necessity, now requires prior authorization

81520 - Oncology (breast), mRNA gene expression profiling by hybrid capture of 58 genes (50 content and 8 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a recurrence risk score

81521 - Oncology (breast), mRNA, microarray gene expression profiling of 70 content genes and 465 housekeeping genes, utilizing fresh frozen or formalin-fixed paraffin-embedded tissue, algorithm reported as index related to risk of distant metastasis

CYP450 Genotyping to Determine Drug Metabolizer Status, 12.04.517
Now reviewed for medical necessity, now requires prior authorization

81230 - CYP3A4 (cytochrome P450 family 3 subfamily A member 4) (e.g., drug metabolism), gene analysis, common variant(s) (e.g., *2, *22)

81231 - CYP3A5 (cytochrome P450 family 3 subfamily A member 5) (e.g., drug metabolism), gene analysis, common variants (e.g., *2, *3, *4, *5, *6, *7)

Gene Expression Profiling and Protein Biomarkers for Prostate Cancer Management, 12.04.111
Now reviewed for investigative, now requires prior authorization

81551 - Oncology (prostate), promoter methylation profiling by real-time PCR of 3 genes (GSTP1, APC, RASSF1), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a likelihood of prostate cancer detection on repeat biopsy

Genetic Testing for Developmental Delay/Intellectual Disability, Autism Spectrum Disorder, and Congenital Anomalies, 12.04.59
Now reviewed for medical necessity, now requires prior authorization

81258 - HBA1/HBA2 (alpha globin 1 and alpha globin 2) (e.g., alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis; known familial variant

81259 - HBA1/HBA2 (alpha globin 1 and alpha globin 2) (e.g., alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis; full gene sequence

81269 - HBA1/HBA2 (alpha globin 1 and alpha globin 2) (e.g., alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis; duplication/deletion variants

Genetic Testing for the Diagnosis of Inherited Peripheral Neuropathies, 12.04.89
Now reviewed for medical necessity, now requires prior authorization

81448 - Hereditary peripheral neuropathies (e.g., Charcot-Marie-Tooth, spastic paraplegia), genomic sequence analysis panel, must include sequencing of at least 5 peripheral neuropathy-related genes (eg, BSCL2, GJB1, MFN2, MPZ, REEP1, SPAST, SPG11, SPTLC1)

Genetic Testing for Mental Health Conditions, 12.04.515
Now reviewed for investigative, now requires prior authorization

81328 - SLCO1B1 (solute carrier organic anion transporter family, member 1B1) (e.g., adverse drug reaction), gene analysis, common variant(s) (e.g., *5)

Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer, 12.04.33
Now reviewed for investigative, now requires prior authorization

81541 - Oncology (prostate), mRNA gene expression profiling by real-time RT-PCR of 46 genes (31 content and 15 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a disease-specific mortality risk score

Non-Covered Services and Procedures, 10.01.517
Now viewed as a non-covered service, contract exclusions may apply

96161- Administration of caregiver-focused health risk assessment instrument (e.g., depression inventory) for the benefit of the patient, with scoring and documentation, per standardized instrument

Non-Covered Services and Procedures, 10.01.517
Now viewed as a non-covered service, contract exclusions may apply

96161- Administration of caregiver-focused health risk assessment instrument (e.g., depression inventory) for the benefit of the patient, with scoring and documentation, per standardized instrument

Sinus Surgery, 7.01.559
Now reviewed for medical necessity, now requires prior authorization

31253 - Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including frontal sinus exploration, with removal of tissue from frontal sinus, when performed

31257 - Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including sphenoidotomy

31259 - Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including sphenoidotomy, with removal of tissue from the sphenoid sinus

31298 - Nasal/sinus endoscopy, surgical; with dilation of frontal and sphenoid sinus ostia (e.g., balloon dilation)

Temporomandibular Joint Dysfunction, 2.01.21
Now reviewed for investigative

S3900 - Surface electromyography (EMG)

Transcatheter Mitral Valve Repair, 2.02.30
Now reviewed for medical necessity, now requires prior authorization

0483T - Transcatheter mitral valve implantation/replacement (TMVI) with prosthetic valve; percutaneous approach, including transseptal puncture, when performed

0484T - Transcatheter mitral valve implantation/replacement (TMVI) with prosthetic valve; transthoracic exposure (e.g., thoracotomy, transapical)

Treatment of Varicose Veins/Venous Insufficiency, 7.01.519
Now reviewed for medical necessity, now requires prior authorization

36465 - Injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance and monitoring; single incompetent extremity truncal vein (e.g., great saphenous vein, accessory saphenous vein)

36466 - Injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance and monitoring; multiple incompetent truncal veins (e.g., great saphenous vein, accessory saphenous vein), same leg

36482 - Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (e.g., cyanoacrylate) remote from the access site, inclusive of all imaging guidance and monitoring, percutaneous; first vein treated

36483 - Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (e.g., cyanoacrylate) remote from the access site, inclusive of all imaging guidance and monitoring, percutaneous; subsequent vein(s) treated in a single extremity, each through separate access sites. (List separately in addition to code for primary procedure.)

Revised codes

Effective February 1, 2018

Total Artificial Hearts and Implantable Ventricular Assist Devices, 7.03.11
No longer requires medical necessity review, now reviewed for investigative.

33990 - Insertion of ventricular assist device, percutaneous including radiological supervision and interpretation; arterial access only

33991 - Insertion of ventricular assist device, percutaneous including radiological supervision and interpretation; both arterial and venous access, with transseptal puncture

33993 - Repositioning of percutaneous ventricular assist device with imaging guidance at separate and distinct session from insertion

Removed code

Effective February 1, 2018

Occupational Therapy, 8.03.503
No longer reviewed for medical necessity

G0152 - Services performed by a qualified occupational therapist in the home health or hospice setting, each 15 minutes

S9129 - Occupational therapy, in the home, per diem

Physical Medicine and Rehabilitation - Physical Therapy and Medical Massage Therapy, 8.03.502
No longer reviewed for medical necessity

G0151 - Services performed by a qualified physical therapist in the home health or hospice setting, each 15 minutes

S9131 - Physical therapy; in the home, per diem

Speech Therapy, 8.03.505
No longer reviewed for medical necessity

G0153 - Services performed by a qualified speech-language pathologist in the home health or hospice setting, each 15 minutes

S9128 - Speech therapy, in the home, per diem