Medical Policy and Coding Updates April 2018

  • 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

    Special notice: new medical policies effective in June

    Effective June 1, 2018

    Drugs for Rare Diseases, 5.01.576

    These drugs may be considered medically necessary when the criteria in the policy are met. Each drug below is also reviewed for site of service administration:

    • Cerezyme® (imiglucerase)
    • Elaprase® (idursulfase)
    • Fabrazyme® (agalsidase beta)
    • Lumizyme® (alglucosidase alfa)
    • Vimizim® (elosulfase alfa)
    • Vpriv® (velaglucerase alfa)

    Nonpharmacologic Treatment of Rosacea, 2.01.71
    Nonpharmacologic treatment of rosacea, including but not limited to laser and light therapy, dermabrasion, chemical peels, surgical debulking, and electrosurgery, is considered investigational. Replaces policy 2.01.519.

    Site of Service, Select Surgical Procedures, 11.01.524
    Preferred medically necessary sites of service for elective surgical procedures are off campus-outpatient hospital/medical center, on campus-outpatient hospital/medical center, and ambulatory surgical center. When select elective procedures are requested at an inpatient hospital/medical center the plan will review the site of service to ensure this site is medically necessary. Consult the policy for the full list of elective surgical procedures and inpatient hospital/medical center inclusion criteria.

    Exondys 51® (eteplirsen), 5.01.570
    Exondys 51® (eteplirsen) is subject to review for site of service administration.

    New medical policies

    Effective March 1, 2018

    Gene Therapy for Inherited Retinal Dystrophy with Luxturna™ (Voretigene Neparvovec), 8.01.536
    Voretigene neparvovec-rzyl adeno-associated virus vector-based gene therapy subretinal injection is considered medically necessary for patients with vision loss due to biallelic RPE65 variant-associated retinal dystrophy meeting criteria. This service is only available at specified sites across the country.
    Note: The services originally described in this policy are now found in policy 2.04.144 Gene Therapy for Inherited Retinal Dystrophy.

    Revised medical policies

    Effective April 1, 2018

    Hematopoietic Cell Transplantation for Chronic Lymphocytic Leukemia and Small Lymphocytic Lymphoma, 8.01.15
    The American Society for Blood and Marrow Transplantation no longer recommends autologous hematopoietic cell transplant for the treatment of high risk CLL or small lymphocytic leukemia. The investigational policy statement was revised to support this new position.

    Hyperbaric Oxygen Therapy, 2.01.505
    The policy was revised to update the conditions that are considered medically necessary and add a list of conditions that are considered investigational. See policy for details.

    New pharmacy policies

    Effective April 15, 2018

    Criteria for Safe Management of Opioid Therapy, 5.01.583
    For patients who are opioid-naïve, a quantity of short-acting opioids sufficient for a 7-day supply will be covered without prior authorization; additional quantities for greater than a 7-day supply will require review. (See policy for exceptions.) Long-acting opioids may be considered medically necessary in patients who are not opioid-naïve, or who have pain severe enough to require daily, around-the-clock opioid treatment when criteria are met. See policy for additional detail. Note: The services originally described in this policy are now found in policy 5.01.529 Management of Opioid Therapy

    Revised pharmacy policies

    Effective April 1, 2018

    Granulocyte Colony-Stimulating Factor (G-CSF) Use in Adult Patients, 5.01.551
    Neulasta Onpro® was added to the policy for clarity. The medical necessity criteria for Neulasta Onpro are identical to the coverage criteria for Neulasta® (pegfilgrastim).

    Herceptin® (trastuzumab) and Other HER2 Inhibitors, 5.01.514
    The criteria for Perjeta® (pertuzumab) were updated to include medical necessity criteria for neoadjuvant treatment of patients with HER2-positive early stage breast cancer and adjuvant treatment for HER2-positive early stage cancer at high risk of recurrence.

    Pharmacotherapy of Type I and Type II Diabetes Mellitus, 5.01.569
    The policy was revised to state that Soliqua® (insulin glargine and lixisenatide) is now considered a nonpreferred combination product. Qtern® (dapagliflozin and saxagliptin) and Stegluja™ (ertugliflozin and sitagliptin) were added as preferred oral products when criteria are met.

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

    Archived on March 31, 2018

    Bioimpedance Devices for Detection and Management of Lymphedema, 2.01.82 Electrostimulation and Electromagnetic Therapy for Treating Wounds, 2.01.57

    Added codes

    Effective April 1, 2018

    Chimeric Antigen Receptor (CAR) T-Cell Therapies, 5.01.580
    Now requires medical necessity review, now requires prior authorization

    Q2041 - Axicabtagene ciloleucel, up to 200 million autologous anti-CD19 CAR T cells, including leukapheresis and dose preparation procedures, per infusion

    Expended Molecular Panel Testing of Cancers to Identify Targeted Therapies, 12.04.115
    Now reviewed for investigative

    0037U - Targeted genomic sequence analysis, solid organ neoplasm, DNA analysis of 324 genes, interrogation for sequence variants, gene copy number amplifications, gene rearrangements, microsatellite instability and tumor mutational burden

    Intraoperative Neurophysiologic Monitoring, 7.01.562
    Now requires medical necessity review

    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

    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)

    Intraoperative Neurophysiologic Monitoring, 7.01.562
    Now reviewed for investigative

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

    Pharmacotherapy of Arthropathies, 5.01.550,
    Pharmacotherapy of Inflammatory Bowel Disorders, 5.01.563,
    Pharmacotherapy of Miscellaneous Autoimmune Diseases, 5.01.564,
    Site of Service Infusion Drugs and Biologic Agents, 11.01.523
    Now requires medical necessity review, now requires prior authorization

    Q5103 - Injection, infliximab-dyyb, biosimilar, ( enflexis), 10 mg

    Q5104 - Injection, infliximab-abda, biosimilar, ( enflexis), 10 mg

    Total Artificial Hearts and Implantable Ventricular Assist Devices, 7.03.11
    Now requires medical necessity review, now requires prior authorization

    33927 - Implantation of a total replacement heart system (artificial heart) with recipient cardiectomy

    33928 - Removal and replacement of total replacement heart system (artificial heart)

    33929 - Removal of a total replacement heart system (artificial heart) for heart transplantation

    Urinary Tumor Markers for Bladder Cancer, 2.04.07
    Now reviewed for investigative

    0012M - Oncology (urothelial), mRNA, gene expression profiling by real-time quantitative PCR of five genes (MDK, HOXA13, CDC2 [CDK1], IGFBP5, and XCR2), utilizing urine, algorithm reported as a risk score for having urothelial carcinoma

    0013M - Oncology (urothelial), mRNA, gene expression profiling by real-time quantitative PCR of five genes (MDK, HOXA13, CDC2 [CDK1], IGFBP5, and CXCR2), utilizing urine, algorithm reported as a risk score for having recurrent urothelial carcinoma

    Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders, 12.04.102
    Now requires medical necessity review, now requires prior authorization

    0036U - Exome (ie, somatic mutations), paired formalin-fixed paraffin-embedded tumor tissue and normal specimen, sequence analyses

    Revised codes

    Effective April 1, 2018

    Dopamine Transporter Imaging with Single-Photon Emission Computed Tomography, 6.01.54
    No longer requires investigational review, now requires review for medical necessity

    78607 - Brain imaging, tomographic (SPECT)

    Genetic Testing for the Diagnosis of Inherited Peripheral Neuropathies, 12.04.89
    No longer requires investigational review, now requires review for medical necessity; currently requires review for prior authorization

    81324 - PMP22 (peripheral myelin protein 22) (eg, Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; duplication/deletion analysis

    81325 - PMP22 (peripheral myelin protein 22) (eg, Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; full sequence analysis

    81326 - PMP22 (peripheral myelin protein 22) (eg, Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; known familial variant

    Recombinant and Autologous Platelet-Derived Growth Factors for Wound Healing and Other Non-Orthopedic Conditions, 2.01.16
    Now reviewed for investigative, no longer requires review for medical necessity or prior authorization

    S9055- Procuren or other growth factor preparation to promote wound healing

    Single Photon Emission Computed Tomography (SPECT) for Non-Cardiac Indications, 6.01.502
    No longer requires investigational review, now requires review for medical necessity

    78607 - Brain imaging, tomographic (SPECT)

    Removed codes

    Effective April 1, 2018

    Bioimpedance Devices for Detection and Management of Lymphedema, 2.01.82
    No longer reviewed for investigational

    93702 - Bioimpedance spectroscopy (BIS), extracellular fluid analysis for lymphedema assessment(s)

    Electrostimulation and Electromagnetic Therapy for treating wounds, 2.01.57
    No longer reviewed for investigational

    E0761 - Nonthermal pulsed high frequency radiowaves, high peak power electromagnetic energy treatment device

    E0769 - Electrical stimulation or electromagnetic wound treatment device, not otherwise classified

    G0281 - Electrical stimulation, (unattended), to one or more areas, for chronic Stage III and Stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care, as part of a therapy plan of care

    G0282 - Electrical stimulation, (unattended), to one or more areas, for wound care other than described in G0281

    G0295 - Electromagnetic therapy, to one or more areas, for wound care other than described in G0329 or for other uses

    G0329 - Electromagnetic therapy, to one or more areas for chronic Stage III and Stage IV pressure ulcers, arterial ulcers, diabetic ulcers and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care

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