Medical Policy and Coding Updates September 2019

Effective January 1, 2020

Biofeedback for Incontinence, 2.01.540
Biofeedback for the treatment of incontinence in children and adults may be considered medically necessary when criteria are met.

Cardiac Defibrillator, Subcutaneous Implantable, 2.02.512
Subcutaneous implantable cardiac defibrillators may be considered medically necessary for cardiac conditions when criteria are met.

Continuous Home Pulse Oximetry, 1.01.533
Continuous home pulse oximetry may be considered medically necessary in specific situations when criteria are met.

Digital Breast Tomosynthesis, 6.01.526
Digital breast tomosynthesis may be considered medically necessary in screening for breast cancer when criteria are met.

Endometrial Ablation, 7.01.578
Endometrial ablation may be considered medically necessary for abnormal uterine bleeding when criteria are met.

Endovascular Repair/Stent for Abdominal Aortic Aneurysm, 2.02.513
Endovascular repair/stent for abdominal aortic aneurysm may be considered medically necessary to repair the aorta and/or its major branches when criteria are met.

Experimental and Investigational Services, 9.01.504
Policy outlines the conditions under which experimental and investigational services and devices may be considered medically necessary.

External Counterpulsation Therapy, 2.02.514
External counterpulsation therapy may be considered medically necessary for the treatment of chronic disabling stable angina when criteria are met.

Eye-Anterior Segment Optical Coherence Tomography, 9.03.509
Eye-anterior segment optical coherence tomography may be considered medically necessary for several eye conditions when criteria are met.

Glaucoma, Invasive Procedures, 9.03.510
Ex-PRESS™ Mini Glaucoma Shunt, iSTENT^® Trabecular Micro-Bypass Stent, and canalopasty may be considered medically necessary for the treatment of glaucoma when criteria are met.

Hepatitis A Vaccine, 9.01.505
The Hepatitis A vaccine may be considered medically necessary for children and adults when criteria are met.

High-Resolution Anoscopy, 2.01.539
High-resolution anoscopy may be considered medically necessary for the identification, management, and treatment of anal dysplasia when criteria are met.

Home Apnea Monitoring, 1.01.534
Home apnea monitoring may be considered medically necessary for infants 12 months or younger when criteria are met.

Home Oxygen Therapy, 1.01.535
Home oxygen therapy may be considered medically necessary for low blood oxygen levels in severe lung disease when criteria are met.

Home Prothrombin Time/International Normalized Ratio (PT/INR) Monitoring, 1.01.536
Home prothrombin time/international normalized ratio (PT/INR) monitoring may be considered medically necessary for patients taking warfarin with specific heart conditions when criteria are met.

Human Papillomavirus (HPV) Vaccine, 9.01.506
Laryngeal injections may be considered medically necessary for the treatment of glottal incompetence in specific conditions when criteria are met.

Laryngeal Injection for Vocal Cord Augmentation, 2.01.541
Laryngeal injections may be considered medically necessary for the treatment of glottal incompetence in specific conditions when criteria are met.

Meningococcal Vaccine, 9.01.507
Meningococcal vaccines may be considered medically necessary when criteria are met.

Negative Pressure Wound Therapy, 1.01.532
Negative pressure wound therapy in a home or an inpatient setting may be considered medically necessary for ulcers and wounds when criteria are met.

Nerve Block, Paravertebral, Facet Joint, and SI Injections, 7.01.575
Paravertebral, facet joint, and sacroiliac joint injections may be considered medically necessary for the treatment of chronic pain and other conditions when criteria are met.

Posterior Tibial Nerve Stimulators, 7.01.579
Posterior tibial nerve stimulators (PTNS) may be considered medically necessary for the treatment of urinary incontinence when criteria are met.

Presbyopia Correcting Intraocular Lenses (PIOLs) and Astigmatism Correcting Intraocular Lenses (ACIOLs), 9.03.511
Presbyopia correcting intraocular lenses (PIOLs) and astigmatism correcting intraocular lenses (ACIOLs) may be considered medically necessary as part of cataract surgery when criteria are met.

Prophylactic Bilateral Salpingo-Oophorectomy, 7.01.580
Prophylactic bilateral salpingo-oophorectomy may be considered medically necessary for individuals at high risk of ovarian or breast cancer when criteria are met.

Prophylactic Mastectomy, 7.01.581
Prophylactic mastectomy may be considered medically necessary for individuals at high risk of breast cancer when criteria are met.

Rabies Vaccine, Home, 9.01.508
The rabies vaccine given in a home setting may be considered medically necessary for possible rabies exposure when criteria are met.

Rotavirus Vaccine, 9.01.509
The rotavirus vaccine may be considered medically necessary for infants as part of preventive immunization guidelines.

Services Reviewed Using InterQual® Criteria, 10.01.530
Services listed in this policy may be considered medically necessary based on InterQual criteria. See policy for details.

Shingles Vaccine, 9.01.510
The shingles vaccine may be considered medically necessary in adults ages 50 and older when criteria are met.

Spinal Orthosis, 1.03.502
Thoracic-Lumbar-Sacral Orthoses (TLSO), Lumbar-Sacral Orthoses (LSO), Lumbar Orthoses, and custom spinal orthoses may be considered medically necessary to reduce pain or provide structural support when criteria are met.

Supervised Exercise Therapy for Peripheral Artery Disease, 8.01.537
Supervised exercise therapy for symptomatic peripheral artery disease (PAD) may be considered medically necessary when criteria are met.

Surgical Dressings and Wound Care Supplies, 9.01.511
Specific surgical dressings and wound care supplies may be considered medically necessary for removing tissue from a wound or treatment of a wound caused by surgery when criteria are met.

Total Ankle Replacement, 7.01.577
Total ankle replacement surgery may be considered medically necessary for the treatment of advanced end-stage arthritis or for revision of prior total ankle replacement when criteria are met.

Transient Elastography, 2.01.536
Transient elastography may be considered medically necessary for fibrosis with a diagnosis of hepatitis C when criteria are met.

Trigger Point and Transforaminal Epidural Injections, 2.01.537
Trigger point injections may be considered medically necessary for myofascial pain syndrome when criteria are met.

Ultraviolet B Light Therapy in the Home to Treat Skin Conditions, 2.01.542
Ultraviolet B (UVB) light therapy in the home may be considered medically necessary for specific skin conditions when criteria are met.

Visual Evoked Response Test, 9.03.512
Visually evoked response testing may be considered medically necessary to detect problems that affect sight when criteria are met.

Wireless Capsule Endoscopy, 2.01.538
Wireless capsule endoscopy may be considered medically necessary for the evaluation of obscure gastrointestinal bleeding, symptomatic small bowel neoplasm, Crohn’s disease, and Celiac disease when criteria are met.

Now requires review for medical necessity.

Added codes

Effective January 1, 2020

Eye-Anterior Segment Optical Coherence Tomography, 9.03.509
92132

Biofeedback for Incontinence, 2.01.540
90911, 90901

Continuous Home Pulse Oximetry, 1.01.533
E0445, A4606

Digital Breast Tomosynthesis, 6.01.526
77061, 77062, 77063, 77046, 77047, 77048, 77049, 77065, 77066, 77067, G0279

Endometrial Ablation, 7.01.578
58353, 58356, 58563

Endovascular Repair/Stent for Abdominal Aortic Aneurysm, 2.02.513
0254T, 34701, 34702, 34703, 34704, 34705, 34706, 34707, 34708, 34709, 34710, 34711, 34712, 34713, 34714, 34715, 34716, 34808, 34812, 34813, 34820, 34833, 34834, 34841, 34842, 34843, 34844, 34845, 34846, 34847, 34848

External Counterpulsation Therapy, 2.02.514
G0166

Glaucoma, Invasive Procedures, 9.03.510
0191T, 0253T, 66174, 66175, 66183

Hepatitis A Vaccine, 9.01.505
90460, 90461, 90471, 90472, 90632, 90633, 90634, 90636

High Resolution Anoscopy, 2.01.539
46601, 46607

Home Apnea Monitoring, 1.01.534
94774, 94775, 94776, 94777

Home Oxygen Therapy, 1.01.535
E0424, E0431, E0433, E0434, E0439, E0441, E0442, E0443, E0444, E1390, E1391, E1392, E1405, E1406, K0738

Home Prothrombin Time/International Normalized (PT/INR) Monitoring, 1.01.536
G0248, G0249, G0250

Human Papillomavirus (HPV) Vaccine, 9.01.506
90649, 90650, 90651

Laryngeal Injections for Vocal Cord Augmentation, 2.01.541
31513, 31570, 31571, 31573, 31574

Meningococcal Vaccines, 9.01.507
90621, 90644, 90733, 90734

Posterior Tibial Nerve Stimulators, 7.01.579
64566

Presbyopia Correcting Intraocular Lenses (PIOLs) and Astigmatism Correcting Intraocular Lenses (ACIOLs), 9.03.511
66982, 66983, 66984, V2630, V2631, V2632

Prophylactic Bilateral Salpingo-Oophorectomy, 7.01.580
58720, 58940

Rabies Vaccine, Home, 9.01.508
90675, 90676, 90375, 90376

Rotavirus Vaccine, 9.01.509
90460, 90461, 90471, 90472, 90680, 90681

Shingles Vaccine, 9.01.510
90736, 90750

Supervised Exercise Therapy for Peripheral Artery Disease, 8.01.537
93668

Surgical Dressings and Wound Care Supplies, 9.01.511
A4450, A4452, A4461, A4463, A4649, A6010, A6011, A6021, A6022, A6023, A6024, A6154, A6196, A6197, A6198, A6199, A6203, A6204, A6205, A6206, A6207, A6208, A6209, A6210, A6211, A6212, A6213, A6214, A6215, A6216, A6217, A6218, A6219, A6220, A6221, A6222, A6223, A6224, A6231, A6232, A6233, A6234, A6235, A6236, A6237, A6238, A6239, A6240, A6241, A6242, A6243, A6244, A6245, A6246, A6247, A6248, A6251, A6252, A6253, A6254, A6255, A6256, A6257, A6258, A6259, A6261, A6262, A6266, A6402, A6403, A6404, A6407, A6410, A6411, A6413, A6441, A6442, A6443, A6444, A6445, A6446, A6447, A6448, A6449, A6450, A6451, A6452, A6453, A6454, A6455, A6456, A6457, A6501, A6502, A6503, A6504, A6505, A6506, A6507, A6508, A6509, A6510, A6511, A6512, A6513, A6545

Ultraviolet B Light Therapy in the Home to Treat Skin Conditions, 2.01.542
E0691, E0692, E0693, E0694, A4633

Visually Evoked Response Test, 9.03.512
95930

Now requires review for medical necessity and prior authorization.

Added codes

Effective January 1, 2020

Cardiac Defibrillator, Subcutaneous Implantable, 2.02.512
33270

Negative Pressure Wound Therapy, 1.01.532
A6550, A7000, E2402

Nerve Block, Paravertebral, Facet Joint, and SI Injections, 7.01.575
20526, 27096, 64450, 64455, 64461, 64462, 64463, 64490, 64491, 64492, 64493, 64494, 64495, 77003, G0260

Spinal Orthosis, 1.03.502
L0450, L0452, L0454, L0455, L0456, L0457, L0458, L0460, L0462, L0464, L0466, L0467, L0468, L0469, L0470, L0472, L0480, L0482, L0484, L0486, L0488, L0490, L0491, L0492, L0621, L0622, L0623, L0624, L0625, L0626, L0627, L0628, L0629, L0630, L0631, L0632, L0633, L0635, L0636, L0637, L0638, L0639, L0640, L0641, L0642, L0643, L0648, L0649, L0650, L0651, L0980, L0982, L0984, L4002

Total Ankle Replacement, 7.01.577
27702, 27703

Transient Elastography, 2.01.536
91200

Trigger Point and Transforaminal Epidural Injections, 2.01.537
20552, 20553, 64479, 64480, 64483, 64884

Wireless Capsule Endoscopy, 2.01.538
91110, 91111

Effective January 1, 2020

Hip Arthroplasty, 7.01.573
Hip arthroplasty may be considered medically necessary for the treatment of osteoarthritis, replacement/revision of previous arthroplasty, or other specific conditions.

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 December 5, 2019

C5 Complement Inhibitors, 5.01.571
Ultomiris™ (ravulizumab-cwvz) is added to the site of service review. Soliris^® (eculizumab) medical necessity criteria are updated for atypical hemolytic uremic syndrome (aHUS), generalized myasthenia gravis (gMG), and is now indicated for neuromyelitis optica spectrum disorder (NMOSD) in adult patients.

Radicava® (edaravone), 5.01.578
Medical necessity criteria are updated and require the diagnosis of definite and probable Amyotrophic Lateral Sclerosis (ALS).

Steroid-Eluting Sinus Stents, 7.01.134
Steroid-eluting sinus stents used after sinus surgery and the use of drug-eluting sinus stents in all situations is considered investigational.

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. Positron 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 November 1, 2019

Implantable Peripheral Nerve Stimulation for the Treatment of Chronic Pain of Peripheral Nerve Origin, 7.01.574
Trial or permanent placement of an implantable peripheral nerve stimulator for the management of chronic pain is considered investigational.

New medical policies

Effective September 1, 2019

Transurethral Water Vapor Thermal Therapy for Benign Prostatic Hyperplasia, 2.01.49
Transurethral water vapor thermal therapy for the treatment of benign prostatic hyperplasia (BPH) and prostate cancer using the Rezum System™ is considered investigational.

Revised medical policies

Effective September 1, 2019

Home Nutritional Support, 8.01.502
The policy has been renamed and now covers only home oral nutritional support and includes medical necessity criteria for inborn errors of metabolism and eosinophilic gastrointestinal disorders.

Injectable Clostridial Collagenase for Fibroproliferative Disorders, 5.01.595
Injectable clostridial collagenase may be considered medically necessary for the treatment of Peyronie’s disease if a sexual dysfunction treatment benefit is available.

Revised pharmacy policies

Effective September 1, 2019

Dupixent® (dupilumab), 5.01.575
Dupixent^® (dupilumab) is now indicated for chronic rhinosinusitis with nasal polyposis.

Granulocyte Colony-Stimulating Factor (G-CSF) Use in Adult Patients, 5.01.551
New indications are added for use in patients undergoing autologous peripheral blood progenitor cell collection and patients acutely exposed to myelosuppressive doses of radiation. Medical necessity criteria are updated for patients treated with myelosuppressive anti-cancer regimens who are at risk of severe febrile neutropenia. Granix^® (tbo-filgrastim) and Nivestym™ (filgrastim-aafi) do not need preapproval for coverage.

Pharmacotherapy of Perinatal/Infantile and Juvenile-Onset Hypophosphatasia (HPP), 5.01.573
Medical necessity criteria for Strensiq^® (asfotase alfa) are updated and criteria added to support the diagnosis of hypophosphatasia (HPP).

Use of Vascular Endothelial Growth Factor Receptor (VEGF) Inhibitors and Other Angiogenesis Inhibitors in Oncology Patients, 5.01.517
Zirabev™ (bevacizumab-bvzr), a biosimilar to Avastin^® (bevacizumab), is added to the policy. Medical necessity criteria are updated for Revlimid® (lenalidomide).

Added codes

Effective September 1, 2019

Pharmacologic Treatment of Osteoporosis, 5.01.596
Now requires review for medical necessity and prior authorization

J0897 - Injection, denosumab, 1 mg

Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome, 7.01.554
Now requires review for medical necessity and prior authorization

21685 - Hyoid myotomy and suspension

Revised codes

Effective September 1, 2019

Automated Percutaneous and Percutaneous Endoscopic Discectomy, 7.01.18
Now requires review for Investigative (previously reviewed for Medical Necessity); No longer requires Prior Authorization

62380 - Endoscopic decompression of spinal cord, nerve root(s), including laminotomy, partial facetectomy, foraminotomy, discectomy and/or excision of herniated intervertebral disc, 1 interspace, lumbar

Automated Percutaneous and Percutaneous Endoscopic Discectomy, 7.01.18
Currently requires review for Investigative; no longer requires Prior Authorization

62287 - Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, any method, single or multiple levels, lumbar