Medical Policy and Coding Updates July 2019

  • Effective January 1, 2020

    Pilot Policy for Designated Centers of Excellence: Total Knee or Total Hip Replacement, 7.01.568
    Total knee or total hip replacement (arthroplasty) for the treatment of osteoarthritis may be considered medically necessary when criteria are met and the surgery is performed in a Designated Center of Excellence. This policy only applies to members whose plan includes the Total Joint Replacement Centers of Excellence Program.


    Effective November 10, 2019

    Updates to AIM Specialty Health® Clinical Appropriate Guidelines

    Effective for dates of service on and after November 10, 2019, the following updates will apply to the AIM Specialty Health® Advanced Imaging Clinical Appropriateness Guidelines.

    Cardiac Imagining Guideline contains updates to the following:
    Post-cardiac transplantation evaluation when any of the following applies: evaluation of new or worsening cardiac signs, symptoms or new EKG abnormalities; or, surveillance of a stable patient (no new or worsening cardiac signs or symptoms) within the first 6 months of transplant; or, surveillance of a stable patient (no new or worsening cardiac signs or symptoms) at 3-month intervals at 6 to 24 months post-transplant; or, annual surveillance of a stable patient (no new or worsening cardiac signs or symptoms) more than 24 months post-transplant.

    Head and Neck Imagining Guideline contains updates to the following:
    Sinusitis/rhinosinusitis (adult and pediatric): Defined a minimal treatment requirement for uncomplicated sinusitis prior to imaging. Defined indications for preoperative planning for image navigation following a clinical policy statement on appropriate use from the AAO-HNS. Removed CT screening for immunocompromised patients based on lack of evidence. Aligned pediatric and adult sinusitis guidelines and pediatric sinusitis guidelines with ACR and AAO-HNS.

    Trauma (adult and pediatric): Radiograph requirement added for suspected mandibular trauma. MRI TMJ in trauma for suspected internal derangement in surgical candidates.

    Neck mass: Align adult neck imaging guideline with a high-quality guideline from the American Academy of Otorhinolaryngology – Head and Neck Surgery (AAO-HNS) including mass size and feature requirements for advanced imaging.

    Parathyroid adenoma (adult and pediatric): Further defined the patient population that needs evaluation for parathyroid adenomas. Position CT as a diagnostic test after both ultrasound and parathyroid scintigraphy. Remove MRI as a modality to evaluate for parathyroid adenomas based on lack of evidence for diagnostic accuracy.

    Temporomandibular joint dysfunction (adult and pediatric): Added requirement for conservative treatment and planned intervention for suspected osteoarthritis.

    Hearing loss: More clearly delineated appropriate modalities based on types of hearing loss in pediatric patients.

    Oncologic Imagining Guideline contains updates to the following:
    Colorectal cancer: Removal of FDG-PET/CT for radiation planning to align AIM Appropriateness Criteria with NCCN: ACR appropriateness level 6 (may be appropriate) only for detection of distant metastases. Not addressed for locoregional staging; Low level evidence to support use of PET-CT imaging for radiation treatment planning; and NCCN states that PET-CT is not indicated for pre-operative staging of rectal cancer. PET-CT can also be considered for potentially curable M1.

    Germ cell tumors – testis and ovary: Align AIM Appropriateness Criteria with NCCN for PET-CT, evidence for PET-CT imaging to evaluate residual mass < 3 cm applies to seminoma ONLY. Removed this indication for nonseminoma and malignant ovarian germ cell cancer. Residual nonseminomatous germ cell tumors > 1 cm require surgery.

    Hepatobiliary cancer: Align AIM Appropriateness Criteria with NCCN for management, screening and surveillance.

    Kidney cancer: Align AIM Appropriateness Criteria with NCCN Kidney Cancer Guidelines and ACR Appropriateness Criteria for use of PET imaging in staging and management of Kidney Cancer/Renal Cell Carcinoma. ACR appropriateness level 3 (usually not appropriate) for use of PET imaging in staging of kidney cancer. NCCN states the value of PET in RCC remains to be determined.

    Lung cancer – non-small cell: Use of MRI limited to scenarios where additional imaging would impact management.

    Lymphoma – Non-Hodgkin: The majority of mucosal melanomas originate from the head and neck. The qualifier added is intended to prevent inappropriate use of MRI head and neck when of other origin besides head and neck.

    Prostate cancer: Additional criteria for management to address active surveillance in reaction to NCCN recommending an annual limit on mpMRI for active surveillance.

    Suspected metastases not otherwise specified: New criteria for Sodium Fluoride PET.

    Vascular Imagining Guideline contains updates to the following:
    General vascular: Added diagnostic testing strategy for TAVI/TAVR carotid evaluation with initial ultrasound.

    Aneurysm – intracranial: Further define neurological signs and symptoms suggestive of intracranial aneurysm.

    Carotid stenosis or occlusion: Advanced imaging as an add on test for problem solving when ultrasound suggests a high-grade stenosis.

    Hemorrhage – intracranial or subarachnoid: Define use of vascular imaging as an add on test in patients following intracranial hemorrhage. Sequential diagnostic testing strategy for non-acute stroke or TIA with CTA or MRA as an add on test to change management in select circumstances for unexplained strokes.

    Venous thrombosis or compression – extracranial: Added requirement for nondiagnostic venous ultrasound. Further define isolated headache pattern that may require imaging to exclude venous sinus thrombosis. Adopt a sequential diagnostic testing strategy starting with CT or MRI for low risk groups (no risk factors and negative D-dimer).

    Aortic aneurysm or dissection: Annual evaluation of stable aneurysms (new for advanced imaging, aligns with echocardiography guidelines). New screening indication for high risk adults, annual screening for pediatrics.

    Other vascular indications: New criteria for PAH incorporating a diagnostic testing strategy. Annual evaluation of stable aneurysms (new for advanced vascular imaging) 6-month evaluation of newly diagnosed aneurysms. Further define diagnostic indications for suspected aneurysm for advanced imaging. Align pediatrics with adult guidelines. Added requirement that intra-abdominal bleeding be unexplained for advanced vascular imaging. Remove generalized atherosclerotic disease and follow up based solely on abnormal imaging, requirement for 4 or more antihypertensive medications. More specific clinical indications for CTA/MRA in the diagnosis of suspected stenosis. Duplex ultrasound guideline with CTA/MRA alignment in diagnosis, management, and surveillance for upper extremity. Ultrasound requirement for suspected DVT prior to advanced vascular imaging. Remove Raynaud’s syndrome based on low diagnostic yield and low diagnostic accuracy. Remove CTA/MRA for with ABI less than 0.9 alone for peripheral arterial disease.

    Effective for dates of service on and after November 10, 2019, the following updates will apply to the AIM Specialty Health® Clinical Appropriateness Guidelines: Radiation Oncology.

    Proton Beam Therapy Guideline contains updates to the following:
    Revised proton beam therapy considerations and indications for sinonasal cancer, melanoma of the uveal tract, and pediatric tumors.


    Effective August 2, 2019

    Pharmacologic Treatment of Osteoporosis, 5.01.596
    Forteo® (teriparatide), Tymlos® (abaloparatide), and Prolia® (denosumab) may be considered medically necessary when criteria are met. They are considered investigational when criteria are not met. The policy is revised to add medical necessity criteria for Evenity™ (romosozumab-aqqg) and update the criteria for Tymlos® (abaloparatide).

    Synthetic Cartilage Implants for Joint Pain, 7.01.160
    Synthetic cartilage implants are considered investigational for the treatment of articular cartilage damage.

    Revised medical policies

    Effective July 1, 2019

    Artificial Pancreas Device Systems, 1.01.30
    Use of an U.S. Food and Drug Administration (FDA) approved automated insulin delivery system (artificial pancreas device system) designated as hybrid closed-loop insulin delivery system (with low glucose suspend and suspend before low features) may be considered medically necessary in patients with type 1 diabetes when criteria are met.

    Intraoperative Neurophysiologic Monitoring, 7.01.562
    Intraoperative neurophysiologic monitoring may be considered medically necessary when there is significant risk of nerve, recurrent laryngeal nerve or spinal cord injury during anterior cervical spine surgery and parathyroid surgery when criteria are met.

    Reconstructive Breast Surgery/Management of Breast Implants, 7.01.533
    Explantation (removal) of a silicone gel or saline-filled breast implant may be considered medically necessary if the original implant was placed for medically necessary reconstructive purposes – and not for cosmetic purposes – in patients with breast implant-associated anaplastic large cell lymphoma.

    Spinal Cord and Dorsal Root Ganglion Stimulation, 7.01.546
    A dorsal root ganglion neurostimulation trial is considered medically necessary for the treatment of severe and chronic pain of the trunk or limbs that is refractory to all other pain therapies when criteria are met. Placement of a permanent dorsal root ganglion neurostimulator may be considered medically necessary when the medical necessity criteria for a trial dorsal root ganglion neurostimulator are met, along with all other criteria.

    Surgical Treatments for Lymphedema, 7.01.567
    Surgical treatments for lymphedema of the genitalia are considered investigational.

    New pharmacy policies

    Effective July 1, 2019

    Spravato™ (esketamine) Nasal Spray, 5.01.609
    Spravato™ (esketamine) may be considered medically necessary for the treatment of depression when criteria are met.

    Revised pharmacy policies

    Effective July 1, 2019

    Medical Necessity Criteria for Pharmacy Edits, 5.01.605.

    Duobrii™ (halobetasol propionate and tazarotene), a topical brand corticosteroid, may be considered medically necessary when criteria are met. Xenazine® (tetrabenazine) may be considered medically necessary for the treatment of chorea associated with Huntington’s disease when criteria are met. Inbrija™ (levodopa inhalation powder) may be considered medically necessary for the intermittent treatment of OFF episodes in patients with Parkinson’s disease when criteria are met.The policy is revised to add medical necessity criteria for Xospata® (gilteritinib).

    Pharmacotherapy of Spinal Muscular Atrophy (SMA), 5.01.574
    Zolgensma® (onasemnogene abeparvovec-xioi) may be considered medically necessary for the treatment of spinal muscular atrophy (SMA) when criteria are met.

    Use of Vascular Endothelial Growth Factor Receptor (VEGF) Inhibitors and Other Angiogenesis Inhibitors in Oncology Patients, 5.01.517
    Mvasi™ (bevacizumab-awwb) may be considered medically necessary for treatment of cancer when criteria are met.

    An archived policy is one that's no longer active and is not used for reviews.

    Archived June 30, 2019

    Corneal Collagen Cross-Linking, 9.03.28.

    Added codes

    Effective July 1, 2019

    Herceptin® (trastuzumab) and Other HER2 Inhibitors, 5.01.514
    Now requires review for medical necessity, now requires prior authorization

    J9356 - Injection, trastuzumab, 0mg and hyaluronidase-oysk

    Q5112 - Injection, trastuzumab-dttb, biosimilar, (ontruzant), 10 mg

    Q5113 - Injection, trastuzumab-pkrk, biosimilar, (herzuma), 10 mg

    Q5114 - Injection, trastuzumab-dkst, biosimilar, (ogivri), 10 mg

    Q5115 - Injection, rituximab-abbs, biosimilar, (truxima), 10mg

    Non-Covered Services and Procedures, 10.01.517
    Now considered noncovered

    0552T - Low-level laser therapy, dynamic photonic and dynamic thermokinectic energies, provided by a physician or other qualified health care professional

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

    0544T - Transcatheter mitral valve annulus reconstruction, with implantation of adjustable annulus reconstruction device, percutaneous approach including transseptal puncture

    Removed codes

    Effective July 1, 2019

    Corneal Collagen Cross-Linking, 9.03.28
    No longer requires review for Medical Necessity

    0402T - Collagen cross-linking of cornea (including removal of the corneal epithelium and intraoperative pachymetry when performed)

    Corneal Collagen Cross-Linking, 9.03.28
    No longer requires review for Medical Necessity; No longer requires Prior Authorization

    J2787 - Riboflavin 5'-phosphate, ophthalmic solution, up to 3 mL

    Granulocyte Colony-Stimulating Factor (G-CSF) Use in Adult Patients, 5.01.551
    No longer requires review for Medical Necessity; No longer requires Prior Authorization

    Q5110 - Injection, filgrastim-aafi, biosimilar, (Nivestym), 1 mcg

    Home Enteral Nutrition, 8.01.502
    No change made to claims processing; Updated Plan Review requirements

    B9002 - Enteral nutrition infusion pump – with alarm

    B9004 - Parenteral nutrition infusion pump, portable

    B9006 - Parenteral nutrition infusion pump, Stationary

    B9998 - NOC for enteral supplies

    B9999 - NOC for parenteral supplies

    S9340 - Home therapy; enteral nutrition; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (enteral formula and nursing visits coded separately), per diem

    S9341 - Home therapy; enteral nutrition via gravity; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (enteral formula and nursing visits coded separately), per diem

    S9342 - Home therapy; enteral nutrition via pump; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (enteral formula and nursing visits coded separately), per diem

    S9343 - Home therapy; enteral nutrition via bolus; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (enteral formula and nursing visits coded separately), per diem

    Added codes

    Effective July 1, 2019

    Codes will now be reviewed by AIM Specialty Health
    0087U - Cardiology (heart transplant), mrna gene expression profiling by microarray of 1283 genes, transplant biopsy tissue, allograft rejection and injury algorithm reported as a probability score

    0088U - Transplantation medicine (kidney allograft rejection) microarray gene expression profiling of 1494 genes, utilizing transplant biopsy tissue, algorithm reported as a probability score for rejection

    0089U - Oncology (melanoma), gene expression profiling by rtqpcr, prame and linc00518, superficial collection using adhesive patch(es)

    0090U - Oncology (cutaneous melanoma) mrna gene expression profiling by rt-pcr of 23 genes (14 content and 9 housekeeping), utilizing formalin-fixed paraffin embedded tissue, algorithm reported as a categorical result (ie, benign, indeterminate, or malignant)

    0094U - Genome (eg, unexplained constitutional or heritable disorder or syndrome), rapid sequence analysis

    0101U - Hereditary colon cancer disorders (eg, lynch syndrome, pten hamartoma syndrome, cowden syndrome, familial adenomatosis polyposis); genomic sequence analysis panel utilizing a combination of ngs, sanger, mlpa and array cgh, with mrna analytics to resolve variants of unknown significance when indicated [15 genes (sequencing and deletion/duplication), epcam and grem1 (deletion/duplication only)

    0102U - Hereditary breast cancer-related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer); genomic sequence analysis panel utilizing a combination of ngs, sanger, mlpa and array cgh, with mrna analytics to resolve variants of unknown significance when indicated [17 genes (sequencing and deletion/duplication)

    0103U - Hereditary ovarian cancer (eg, hereditary ovarian cancer, hereditary endometrial cancer); genomic sequence analysis panel utilizing a combination of ngs, sanger, mlpa and array cgh, with mrna analytics to resolve variants of unknown significance when indicated [24 genes (sequencing and deletion/duplication); epcam (deletion/duplication only)

    0104U - Hereditary pan cancer (eg, hereditary breast and ovarian cancer, hereditary endometrial cancer, hereditary colorectal cancer); genomic sequence analysis panel utilizing a combination of ngs, sanger, mlpa and array cgh, with mrna analytics to resolve variants of unknown significance when indicated [32 genes (sequencing and deletion/duplication); epcam and grem1 (deletion/duplication only)

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