Medical Policy and Coding Updates October 2018

Effective January 4, 2019

Surgical Treatments for Lymphedema, 7.01.162
Lymphatic physiologic microsurgery to treat lymphedema in individuals who have been treated for breast cancer is considered investigational. Lymphatic physiologic microsurgery performed during nodal dissection or breast reconstruction to prevent lymphedema in individuals who are being treated for breast cancer is considered investigational.
Note: The services originally described in this policy are now found in policy 7.01.567 Surgical Treatments for Lymphedema.

Update to AIM Radiation Oncology clinical appropriateness guidelines

Effective January 28, 2019

Breast cancer

• Removed age and tumor size criteria for accelerated whole breast irradiation (AWBI)

Rectal cancer

• The modified criteria no longer limits treatment with IMRT for rectal adenocarcinoma

Pancreatic cancer

• Added criteria for SBRT in treating locally advanced or recurrent disease without evidence of distant metastasis

Head and neck cancer

• Added criteria to allow IMRT for head and neck lymphomas
• Clarified no IMRT for stage I/II glottic cancer

Lung cancer

• Added DVH parameter for cardiac V50

Sarcoma

• Removed preoperative and joint sparing requirements for IMRT

Prostate cancer

• Added discussion on hypofractionation
• Added discussion on brachytherapy

Update to AIM Cardiology clinical appropriateness guidelines

Effective January 28, 2019

Carotid duplex ultrasound

• Criteria removed for evaluation of syncope in patients with suspected extracranial arterial disease
• New criteria address evaluation of TAVR (TAVI) in patients with suspected or established extracranial arterial disease

Myocardial perfusion imaging (MPI), stress echocardiography, cardiac PET, and coronary CT angiography (CCTA)

• Clarifications address exercise-induced syncope and exercise-induced dizziness, lightheadedness, or near syncope in symptomatic patients with suspected coronary artery disease

MPI, stress echocardiography, cardiac PET

• Criteria added to allow annual surveillance of coronary artery disease in patients with established CAD post-cardiac transplant
• Clarified definition of established coronary artery disease when diagnosed by CCTA
  • more restrictive for patients diagnosed with coronary artery disease by prior coronary angiography, as FFR must be ≤0.8
  • more permissive for patients diagnosed with coronary artery disease by CCTA with FFR ≤0.8 (patients previously excluded)

Resting transthoracic echocardiography (TTE)

• New criteria for evaluation of ventricular function in patients who have undergone cardiac transplantation

Cardiac MRI

• New criteria allows for annual study to quantify cardiac iron load in chronically ill patients with cardiomyopathy who require frequent blood transfusions (eg, thalassemia)
• Removed allowance for annual LV function evaluation when echocardiography is suboptimal

Effective December 6, 2018

Ablative Treatments for Occipital Neuralgia, Chronic Headaches, and Atypical Facial Pain, 7.01.563
Ablative procedures for the treatment of chronic headaches, occipital neuralgia, and persistent idiopathic facial pain/atypical facial pain are considered investigational.

Pulsed Radiofrequency, 7.01.564
Pulsed radiofrequency for the treatment of various chronic pain syndromes is considered investigational.

Effective November 2, 2018

Ablation Procedures for Peripheral Neuromas, 7.01.147
Minimally invasive ablation procedures such as radiofrequency ablation or cryoablation are considered investigational for the treatment of peripheral neuromas.

Alcohol Injections for Treatment of Peripheral Neuromas, 2.01.97
Alcohol injections are considered investigational for the treatment of peripheral neuromas (eg, Morton’s neuroma).

Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting, 2.02.24
This policy was previously archived and is being reinstated. Cardiac hemodynamic monitoring for the management of heart failure in the ambulatory care and outpatient setting using arterial pressure during the Valsalva maneuver, implantable direct pressure monitoring of the pulmonary artery, inert gas rebreathing, or thoracic bioimpedance is considered investigational.

New medical policies

Effective October 1, 2018

Therapeutic Radiopharmaceuticals in Oncology, 6.01.60
The use of lutetium 177 dotatate is considered medically necessary for patients with gastroenteropancreatic, bronchopulmonary, and thymus neuroendocrine tumors.
Note: Effective April 1, 2019, the services originally described in this policy are now found in policy Therapeutic Radiopharmaceuticals in Oncology 6.01.525 Therapeutic Radiopharmaceuticals in Oncology.

Revised medical policies

Effective October 1, 2018

Genetic Testing for Li‐Fraumeni Syndrome, 12.04.512
Policy statement for early‐onset breast cancer is updated to align with NCCN age cutoff of less than 31 years.
Note: Effective January 4, 2019, the services originally described in this policy are reviewed by AIM Specialty Health^®.

Knee Orthoses, Ankle‐Foot, and Knee‐Ankle‐Foot Orthoses, 1.03.501
The policy is revised to state that custom ankle-foot orthoses and custom knee-ankle-foot orthoses are considered medically necessary when criteria are met and not medically necessary when criteria are not met. Policy title changed to Knee Orthoses, Ankle‐Foot, and Knee‐Ankle‐Foot Orthoses. (Policy replaced with InterQual® criteria, effective July 2, 2020.)

Magnetic Resonance‐Guided Focused Ultrasound, 7.01.109
This policy is revised to state that MRgFUS ablation may be considered medically necessary for the treatment of medicine‐refractory essential tremors.

Revised pharmacy policies

Effective September 12, 2018

Excessively High Cost Drug Products with Lower Cost Alternatives, 5.01.560
Medical necessity criteria are added for Vexasyn. Removed medical necessity criteria for Differin^® and Adapalene^® from this policy as they are moved to policy 5.01.605.

Medical Necessity Criteria for Pharmacy Edits, 5.01.605
This policy is revised as follows:

• Specific criteria are added for Differin^® (adapalene)
• These products are added to the criteria for brand acne products: Finacea (azelaic acid), Clindamycin‐Benzoyl Peroxide, Clindamycin Phosphate, Tazorac (tazarotene), and Avage^® (tazarotene).
• This product is added to the criteria for brand topical corticosteroid: Pediaderm^® HC (hydrocortisone)

Effective September 21, 2018

Pharmacotherapy of Arthropathies, 5.01.550
This policy is revised to add criteria for Cimzia^® (certolizumab) as second-line treatment of plaque psoriasis.

Effective October 1, 2018

Granulocyte Colony‐Stimulating Factor (G‐CSF) Use in Adult Patients, 5.01.551
Medical necessity criteria are added for Nivestym™ (filgrastim-aafi) and Fulphila™ (pegfilgrastim biosimilar).

Management of Opioid Therapy, 5.01.529
This policy is significantly revised. Contents of policies 5.01.579 and 5.01.583 are added to this policy. Title changed to Management of Opioid Therapy.

Pharmacotherapy of Thrombocytopenia, 5.01.566
The policy is revised to add medical necessity criteria for Doptelet^® (avatrombopag) and Mulpleta^®(lusutrombopag), both of which have been recently approved by the Food and Drug Administration for chronic liver disease patients undergoing invasive procedures.

A deleted policy is one whose number is no longer used but the content is either moved into another policy or replaced with a new policy and number.

Deleted October 1, 2018

Criteria for Safe Management of Opioid Therapy, 5.01.583. Contents move to policy 5.01.529. Quantity Limits for Opioid Drugs, 5.01.579. Contents move to policy 5.01.529.

Added codes

Effective October 1, 2018

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

0028U - CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, copy number variants, common variants with reflex to targeted sequence analysis

0029U - Drug metabolism (adverse drug reactions and drug response), targeted sequence analysis (ie, CYP1A2, CYP2C19, CYP2C9, CYP2D6, CYP3A4, CYP3A5, CYP4F2, SLCO1B1, VKORC1 and rs12777823)

0031U - CYP1A2 (cytochrome P450 family 1, subfamily A, member 2) (eg, drug metabolism) gene analysis, common variants (ie, *1F, *1K, *6, *7)

0070U - CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, common and select rare variants (ie, *2, *3, *4, *4N, *5, *6, *7, *8, *9, *10, *11, *12, *13, *14A, *14B, *15, *17, *29, *35, *36, *41, *57, *61, *63, *68, *83, *xN)

0071U - CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, full gene sequence (List separately in addition to code for primary procedure)

0072U - CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, targeted sequence analysis (ie, CYP2D6-2D7 hybrid gene) (List separately in addition to code for primary procedure)

0073U - CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, targeted sequence analysis (ie, CYP2D7-2D6 hybrid gene) (List separately in addition to code for primary procedure)

0074U - CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, targeted sequence analysis (ie, non-duplicated gene when duplication/multiplication is trans) (List separately in addition to code for primary procedure)

0075U - CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, targeted sequence analysis (ie, 5’ gene duplication/multiplication) (List separately in addition to code for primary procedure)

0076U - CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, targeted sequence analysis (ie, 3’ gene duplication/ multiplication) (List separately in addition to code for primary procedure)

Granulocyte Colony-Stimulating Factor (G-CSF) Use in Adult Patients, 5.01.551
Now requires medical necessity review, now requires prior authorization

Q5108 - Injection, pegfilgrastim-jmdb, biosimilar, (Fulphila), 0.5 mg

Q5110 - Injection, filgrastim-aafi, biosimiliar, (Nivestym), 1 microgram

Home Enteral Nutrition, 8.01.502
Now reviewed for investigative

Q9994 - In-line cartridge containing digestive enzyme(s) for enteral feeding, each

Knee Orthoses, Ankle-Foot, and Knee-Ankle-Foot Orthoses, 1.03.501
Now requires medical necessity review, now requires prior authorization

L1945 - Ankle-foot orthotic (AFO), plastic, rigid anterior tibial section (floor reaction), custom fabricated

L2755 - Addition to lower extremity orthotic, high strength, lightweight material, all hybrid lamination/prepreg composite, per segment, for custom fabricated orthotic only

Magnetic Resonance-Guided Focused Ultrasound, 7.01.109
Now requires medical necessity review, now requires prior authorization

0398T - Magnetic resonance image guided high intensity focused ultrasound (MRgFUS), stereotactic ablation lesion, intracranial for movement disorder including stereotactic navigation and frame placement when performed

Noncovered Services and Procedures, 10.01.517
Now a noncovered service

T5999 - Supply, not otherwise specified

Pharmacogenetic Testing for Pain Management, 12.04.131
Now reviewed for investigative

0078U - Pain management (opioid-use disorder) genotyping panel, 16 common variants (ie, ABCB1, COMT, DAT1, DBH, DOR, DRD1, DRD2, DRD4, GABA, GAL, HTR2A, HTTLPR, MTHFR, MUOR, OPRK1, OPRM1), buccal swab or other germline tissue sample, algorithm reported as positive or negative risk of opioid-use disorder

Sphenopalatine Ganglion Block for Headache, 7.01.159
Now reviewed for investigative

64505 - Injection, anesthetic agent; sphenopalatine ganglion

Removed codes

Effective October 1, 2018

Drug Testing in Pain Management and Substance Use Disorder Treatment Settings, 2.04.513
No longer requires medical necessity review

0020U - Drug test(s), presumptive, with definitive confirmation of positive results, any number of drug classes, urine, with specimen verification including DNA authentication in comparison to buccal DNA, per date of service

Knee Orthoses, Ankle‐Foot, and Knee‐Ankle‐Foot Orthoses, 1.03.501
No longer requires medical necessity review, no longer requires prior authorization

L1847 - Knee orthosis, double upright with adjustable joint, with inflatable air support chamber(s), prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise