Medical Policy and Coding Updates September 2018

Special notice: New medical policies effective in December

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.

Special notice: New medical policies effective in November

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.

Special notice: Update to AIM Advanced Imaging clinical appropriateness guidelines

Effective October 29, 2018

CT Chest

• Expanded list of diagnostic testing abnormalities that may be followed up with CT to include endoscopy, fluoroscopy, and ultrasound in addition to specific chest radiography findings
• Lengthening of timeframe required prior to imaging for chronic cough from 3 to 8 weeks, and more specifics of preliminary workup required prior to imaging
• Lower threshold for defining unexplained weight loss, and more explicit definition of preliminary workup required prior to imaging
• Allowance for use of imaging in the staging of malignancy prior to biopsy confirmation
• Allowance for imaging of suspected pulmonary embolism in pregnancy
• New criteria for appropriate imaging of chest wall mass

CT Angiography (CTA) Chest

• Allowance for imaging of suspected pulmonary embolism in pregnancy

CT Abdomen/CT Pelvis/CT Abdomen & Pelvis

• Lower threshold for defining unexplained weight loss, and more explicit definition of preliminary workup required prior to imaging

MRI Chest

• New guideline for imaging of suspected pectoralis muscle tear
• New criteria for appropriate imaging of chest wall mass

MRI Abdomen

• Addition of hemochromatosis as an indication for imaging in pediatric patients

Special notice: New medical policies effective in October

Effective October 5, 2018

Orthognathic Surgery, 9.02.501
This policy is revised as follows:

• Removed the policy statement for orthognathic surgery for correction of articulation disorders and other impairments in the production of speech
• Added medical necessity criteria for the treatment of severe malocclusion contributing to TMJ syndrome symptoms
• Specified that the criteria for treatment of mandibular and maxillary deformities contributing to airway dysfunction and associated obstructive sleep apnea include report of AHI of ≥ 30, 90-day trial of PAP, and participation in PAP compliance program

Orthoptic and Vision Therapy, Visual Perceptual Training, Vision Restoration Therapy, and Neurovisual Rehabilitation, 9.03.508
This policy replaces policy 9.03.03. These services are considered investigational:

• Orthoptic training or vision therapy for learning and reading disabilities, including dyslexia
• Orthoptic training or vision therapy for visual disorders other than convergence insufficiency
• Visual perceptual training
• Vision restoration therapy
• Neurovisual (optometric) rehabilitation

Treatment of Hyperhidrosis, 8.01.519
Iontophoresis and radiofrequency ablation are considered investigational for all categories. Botulinum toxin is considered investigational for plantar, craniofacial, and secondary gustatory hyperhidrosis.

Revised medical policies

Effective September 1, 2018

Molecular Markers in Fine Needle Aspirates of the Thyroid, 12.04.510
TERT single-gene testing is considered investigational. Thyroid cancer targeted mutational analysis is considered medically necessary:

• PAX8/PPARgamma
• PIK3CA
• RAS (HRAS, KRAS, NRAS),
• RET/PTC

Testing these genes was previously considered not medically necessary.
Note: Effective January 4, 2019, the services originally described in this policy are reviewed by AIM Specialty Health^®

Upper Gastrointestinal (UGI) Endoscopy for Adults, 2.01.533
The policy was revised to add surveillance criteria for Barrett’s esophagus with no dysplasia (metaplasia).

Urinary Biomarkers for Cancer Screening, Diagnosis, and Surveillance, 2.04.07
Screening for precancerous colonic polyps is considered investigational. The policy title is changed.
Note: Effective January 4, 2019, the services originally described in this policy are reviewed by AIM Specialty Health^®.

Revised pharmacy policies

Effective September 1, 2018

Medical Necessity Criteria for Pharmacy Edits, 5.01.605
Medical necessity criteria are added for brand topical corticosteroids, brand topical acne products, brand gabapentin products, Nuedexta^® (dextromethorphan hydrobromide and quinidine sulfate). Methylphenidate ER 72mg^® (methylphenidate hydrochloride) and Relexxii^® (methylphenidate Hcl), are added to the criteria for brand ADHD drugs.

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

Archived on September 1, 2018

Navigated Transcranial Magnetic Stimulation, 2.01.90

Added codes

Effective September 1, 2018

Medical Necessity Criteria for Pharmacy Edits, 5.01.605
Now requires review for medical necessity, now requires prior authorization

S0189 - Testosterone pellet, 75 mg

Molecular Markers in Fine Needle Aspirates of the Thyroid, 12.04.510
Now requires review for medical necessity, now requires prior authorization

0026U - Oncology (thyroid), DNA and mRNA of 112 genes, next-generation sequencing, fine needle aspirate of thyroid nodule, algorithmic analysis reported as a categorical result ("Positive, high probability of malignancy" or "Negative, low probability of malignancy")

Urinary Biomarkers for Cancer Screening, Diagnosis, and Surveillance, 2.04.07
Now requires review for investigative, now requires prior authorization

0002U - Oncology (colorectal), quantitative assessment of three urine metabolites (ascorbic acid, succinic acid and carnitine) by liquid chromatography with tandem mass spectrometry (LC-MS/MS) using multiple reaction monitoring acquisition, algorithm reported as likelihood of adenomatous polyps

Revised codes

Effective September 1, 2018

Bronchial Thermoplasty, 7.01.127
Currently reviewed for investigative, no longer requires prior authorization

31660 - Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial thermoplasty, 1 lobe

31661 - Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial thermoplasty, 2 or more lobes

Expanded Molecular Panel Testing of Cancers to Identify Targeted Therapies, 12.04.115
Currently reviewed for investigative, no longer requires prior authorization

81455 - Targeted genomic sequence analysis panel, solid organ or hematolymphoid neoplasm, DNA analysis, and RNA analysis when performed, 51 or greater genes (e.g., ALK, BRAF, CDKN2A, CEBPA, DNMT3A, EGFR, ERBB2, EZH2, FLT3, IDH1, IDH2, JAK2, KIT, KRAS, MLL, NPM1, NRAS, MET, NOTCH1, PDGFRA, PDGFRB, PGR, PIK3CA, PTEN, RET), interrogation for sequence variants and copy number variants or rearrangements, if performed

Gene Expression Profiling and Protein Biomarkers for Prostate Cancer Management, 12.04.111
Currently reviewed for investigative, no longer requires prior authorization

81551 - Oncology (prostate), promoter methylation profiling by real-time PCR of 3 genes (GSTP1, APC, RASSF1), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a likelihood of prostate cancer detection on repeat biopsy

Molecular Markers in Fine Needle Aspirates of the Thyroid, 12.04.510
Currently reviewed for medical necessity, now requires prior authorization

81545 - Oncology (thyroid), gene expression analysis of 142 genes, utilizing fine needle aspirate, algorithm reported as a categorical result (eg, benign or suspicious)

Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Conditions, 1.01.15
Currently reviewed for medical necessity, now requires prior authorization

E0481 - Intrapulmonary percussive ventilation system and related accessories

E0483 - High frequency chest wall oscillation air-pulse generator system, (includes hoses and vest), each

Removed codes

Effective September 1, 2018

Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Conditions, 1.01.15
No longer requires medical necessity review, no longer requires prior authorization

A7025 - High frequency chest wall oscillation system vest, replacement for use with patient-owned equipment, each

A7026 - High frequency chest wall oscillation system hose, replacement for use with patient-owned equipment, each