Medical Policy and Coding Updates June 2018

  • 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.

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

    Special notice: Coding update

    Effective July 5, 2018

    Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease, 2.01.38
    The codes below have been reassigned to this more appropriate policy. These codes are now considered investigational for all uses. See this policy for details.

    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

    Revised benefit coverage guideline

    Effective June 1, 2018

    Preventive Care, 10.01.523
    The guideline was revised to add Bright Futures age guidelines to cholesterol section. Other additions include the addition of bilirubin to the screening section, vision screening criteria for amblyopia, clarification of age guideline for hearing loss screening, and all appropriate coding updates to be consistent with coverage of preventive benefits. View the benefit coverage guideline for full information.

    New pharmacy policies

    Effective June 1, 2018

    CGRP Inhibitors for Migraine Prophylaxis, 5.01.584
    When medical necessity criteria are met, Aimovig™ (erenumab) may be used to treat patients with an average of 4 migraine days per month.

    Revised pharmacy policies

    Effective May 21, 2018

    Chimeric Antigen Receptor (CAR) T Cell Therapies, 5.01.580
    When medical necessity criteria are met, Kymriah™ may now be used to treat adult patients with relapsed/refractory large B-cell lymphoma (DLBCL). Note: The services originally described in this policy are now found in policy 8.01.01 Adoptive Immunotherapy.

    Effective June 1, 2018

    Pharmacotherapy of Arthropathies, 5.01.550
    When medical necessity criteria are met, Tremfya®is now a first-line agent in treating patients with plaque psoriasis. Xeljanz®/Xeljanz XR is now considered medically necessary as a second-line agent in treating patients with plaque psoriasis when criteria are met.

    Pharmacotherapy of Inflammatory Bowel Disorder, 5.01.563
    Xeljanz® is no longer considered medically necessary to treat ulcerative colitis and is removed from the policy.

    Kalydeco® (ivacaftor), Orkambi® (lumacaftor/ivacaftor), and Symdeko™ (tezacaftor/ivacaftor), 5.01.539
    The policy statements were revised to remove the criterion that sputum cultures must be free of Burkholderia cenocepacia, dolosa, or mycobacterium abscessus.

    Miscellaneous Oncology Drugs, 5.01.540
    The criteria were updated to include the newly approved U. S. Food and Drug Administration labeled indications for Rubraca® (rucaparib) and combination therapy with Opdivo® (nivolumab) and Yervoy® (ipilimumab).

    Added codes

    Effective June 1, 2018

    Drugs for Rare Diseases, 5.01.576
    Now requires review for medical necessity, including for site of service administration; now requires prior authorization

    J0180 - Injection, agalsidase beta, 1 mg

    J0221 - Injection, alglucosidase alfa, (Lumizyme), 10 mg

    J1322 - Injection, elosulfase alfa, 1 mg

    J1743 - Injection, idursulfase, 1 mg

    J1786 - Injection, imiglucerase, 10 units

    J3385 - Injection, velaglucerase alfa, 100 units

    Intraoperative Neurophysiologic Monitoring, 7.01.562
    Now requires review for medical necessity

    95940 - Continuous intraoperative neurophysiology monitoring in the operating room, one on one monitoring requiring personal attendance, each 15 minutes (List separately in addition to code for primary procedure)

    95941 - Continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby) or for monitoring of more than one case while in the operating room, per hour (List separately in addition to code for primary procedure

    G0453 - Continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby), per patient, (attention directed exclusively to one patient) each 15 minutes (list in addition to primary procedure)

    Reconstructive Breast Surgery, 7.01.533
    Now requires review for medical necessity; now requires prior authorization

    S2067 - Breast reconstruction of a single breast with "stacked" deep inferior epigastric perforator (DIEP) flap(s) and/or gluteal artery perforator (GAP) flap(s), including harvesting of the flap(s), microvascular transfer, closure of donor site(s) and shaping the flap into a breast, unilateral

    S2068 - Breast reconstruction with deep inferior epigastric perforator (DIEP) flap or superficial inferior epigastric artery (SIEA) flap, including harvesting of the flap, microvascular transfer, closure of donor site and shaping the flap into a breast, unilateral

    Removed codes

    Effective June 1, 2018

    Intraoperative Neurophysiologic Monitoring, 7.01.562
    No longer requires investigational review

    95930 - Visual evoked potential (VEP) checkerboard or flash testing, central nervous system except glaucoma, with interpretation and report

    Intraoperative Neurophysiologic Monitoring, 7.01.562
    No longer requires review for medical necessity

    95925 - Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper limbs

    95926 - Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in lower limbs

    95927 - Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in the trunk or head

    95928 - Central motor evoked potential study (transcranial motor stimulation); upper limbs

    95929 - Central motor evoked potential study (transcranial motor stimulation); lower limbs

    95938 - Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper and lower limbs

    95939 - Central motor evoked potential study (transcranial motor stimulation); in upper and lower limbs

    Revised codes

    Effective June 1, 2018

    Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions, 7.01.78
    Currently requires prior authorization and medical necessity review. Now medical necessity criteria includes site of service.

    27415 - Osteochondral allograft, knee, open

    27416 - Osteochondral autograft(s), knee, open (eg, mosaicplasty) (includes harvesting of autograft[s])

    28446 - Open osteochondral autograft, talus (includes obtaining graft[s])

    29866 - Arthroscopy, knee, surgical; osteochondral autograft(s) (eg, mosaicplasty) (includes harvesting of the autograft[s])

    Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions, 7.01.48
    Currently requires prior authorization and medical necessity review. Now medical necessity criteria includes site of service.

    27412 - Autologous chondrocyte implantation, knee

    29877 - Arthroscopy, knee, surgical; debridement/shaving of articular cartilage (chondroplasty)

    29879 - Arthroscopy, knee, surgical; abrasion arthroplasty (includes chondroplasty where necessary) or multiple drilling or microfracture

    29880 - Arthroscopy, knee, surgical; with meniscectomy (medial AND lateral, including any meniscal shaving)

    29881 - Arthroscopy, knee, surgical; with meniscectomy (medial OR lateral, including any meniscal shaving)

    29882 - Arthroscopy, knee, surgical; with meniscus repair (medial OR lateral)

    29883 - Arthroscopy, knee, surgical; with meniscus repair (medial AND lateral)

    J7330 - Autologous cultured chondrocytes, implant

    S2112 - Arthroscopy, knee, surgical for harvesting of cartilage (chondrocyte cells)

    Artificial Intervertebral Disc: Cervical Spine, 7.01.108
    Currently requires prior authorization and medical necessity review. Now medical necessity criteria includes site of service.

    0095T - Removal of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, cervical (List separately in addition to code for primary procedure

    0098T - Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, cervical (List separately in addition to code for primary procedure)

    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

    22856 - Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection), single interspace, cervical

    22858 - Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); second level, cervical (List separately in addition to code for primary procedure)

    22861 - Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervical

    Coronary Angiography for Known or Suspected Coronary Artery Disease, 2.02.507
    Currently requires medical necessity review. Now requires prior authorization and medical necessity criteria now includes site of service.

    93454 - Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation

    93455 - Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation with catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) including intraprocedural injection(s) for bypass graft angiography

    93456 - Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right heart catheterization

    93457 - Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) including intraprocedural injection(s) for bypass graft angiography and right heart catheterization

    93458 - Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed

    93459 - Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography

    93460 - Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed

    93461 - Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography

    Exondys® 51, 5.01.570
    Currently requires prior authorization and medical necessity review. Now medical necessity criteria includes site of service.

    J1428 - Injection, eteplirsen, 10 mg

    Knee Arthroscopy in Adults, 7.01.549
    Currently requires prior authorization and medical necessity review. Now medical necessity criteria includes site of service.

    29871 - Arthroscopy, knee, surgical; for infection, lavage and drainage

    29873 - Arthroscopy, knee, surgical; with lateral release

    29874 - Arthroscopy, knee, surgical; for removal of loose body or foreign body (eg, osteochondritis dissecans fragmentation, chondral fragmentation)

    29875 - Arthroscopy, knee, surgical; synovectomy, limited (eg, plica or shelf resection) (separate procedure)

    29876 - Arthroscopy, knee, surgical; synovectomy, major, 2 or more compartments (eg, medial or lateral)

    29877 - Arthroscopy, knee, surgical; debridement/shaving of articular cartilage (chondroplasty)

    29879 - Arthroscopy, knee, surgical; abrasion arthroplasty (includes chondroplasty where necessary) or multiple drilling or microfracture

    29880 - Arthroscopy, knee, surgical; with meniscectomy (medial AND lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed

    29881 - Arthroscopy, knee, surgical; with meniscectomy (medial OR lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed

    29882 - Arthroscopy, knee, surgical; with meniscus repair (medial OR lateral)

    29883 - Arthroscopy, knee, surgical; with meniscus repair (medial AND lateral)

    29884 - Arthroscopy, knee, surgical; with lysis of adhesions, with or without manipulation (separate procedure)

    29888 - Arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction

    29889 - Arthroscopically aided posterior cruciate ligament repair/augmentation or reconstruction

    Lumbar Spine Decompression Surgery: Discectomy, Foraminotomy, Laminotomy, Laminectomy, 7.01.551
    Currently requires prior authorization and medical necessity review. Now medical necessity criteria includes site of service.

    63005 - Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; lumbar, except for spondylolisthesis

    63012 - Laminectomy with removal of abnormal facets and/or pars inter-articularis with decompression of cauda equina and nerve roots for spondylolisthesis, lumbar (Gill type procedure)

    63017 - Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 vertebral segments; lumbar

    63030 - Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar

    63035 - Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; each additional interspace, cervical or lumbar (List separately in addition to code for primary procedure)

    63042 - Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; lumbar

    63044 - Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; each additional lumbar interspace (List separately in addition to code for primary procedure)

    63047 - Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; lumbar

    63048 - Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; each additional segment, cervical, thoracic, or lumbar (List separately in addition to code for primary procedure)

    63056 - Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; lumbar (including transfacet, or lateral extraforaminal approach) (eg, far lateral herniated intervertebral disc)

    63057 - Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; each additional segment, thoracic or lumbar (List separately in addition to code for primary procedure)

    63185 - Laminectomy with rhizotomy; 1 or 2 segments

    63190 - Laminectomy with rhizotomy; more than 2 segments

    63191 - Laminectomy with section of spinal accessory nerve

    63267 - Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; lumbar

    63272 - Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; lumbar

    Reduction Mammaplasty for Breast-Related Symptoms, 7.01.503
    Currently requires prior authorization and medical necessity review. Now medical necessity criteria includes site of service.

    19318 - Reduction Mammaplasty

    Rhinoplasty, 7.01.558
    Currently requires prior authorization and medical necessity review. Now medical necessity criteria includes site of service.

    30400 - Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip

    30410 - Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip

    30420 - Rhinoplasty, primary; including major septal repair

    30430 - Rhinoplasty, secondary; minor revision (small amount of nasal tip work)

    30435 - Rhinoplasty, secondary; intermediate revision (bony work with osteotomies)

    30450 - Rhinoplasty, secondary; major revision (nasal tip work and osteotomies)

    Sinus Surgery, 7.01.559
    Currently requires prior authorization and medical necessity review. Now medical necessity criteria includes site of service.

    31254 - Nasal/sinus endoscopy, surgical with ethmoidectomy; partial (anterior)

    31255 - Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior)

    31256 - Nasal/sinus endoscopy, surgical, with maxillary antrostomy;

    31267 - Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus

    31276 - Nasal/sinus endoscopy, surgical, with frontal sinus exploration, including removal of tissue from frontal sinus, when performed

    32187 - Nasal/sinus endoscopy, surgical, with sphenoidotomy

    31288 - Nasal/sinus endoscopy, surgical, with sphenoidotomy; with removal of tissue from the sphenoid sinus

    31295 - Nasal/sinus endoscopy, surgical; with dilation of maxillary sinus ostium (eg, balloon dilation), transnasal or via canine fossa

    31296 - Nasal/sinus endoscopy, surgical; with dilation of frontal sinus ostium (eg, balloon dilation)

    31297 - Nasal/sinus endoscopy, surgical; with dilation of sphenoid sinus ostium (eg, balloon dilation)

    Spinal Cord and Dorsal Root Ganglion Stimulation, 7.01.546
    Currently requires prior authorization and medical necessity review. Now medical necessity criteria includes site of service.

    63650 - Percutaneous implantation of neurostimulator electrode array, epidural

    63655 - Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural

    63661 - Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed

    63662 - Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed

    63663 - Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed

    63664 - Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed

    63685 - Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling

    63688 - Revision or removal of implanted spinal neurostimulator pulse generator or receiver

    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

    Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome, 7.01.554
    Currently requires prior authorization and medical necessity review. Now medical necessity criteria includes site of service.

    42145 - Palatopharyngoplasty (eg, uvulopalatopharyngoplasty, uvulopharyngoplasty)

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