20-437 Medial Policies - 1st Quarter 2020

•  Under III.C.8., revised “sublingual provocative therapy” to state “non-FDA approved sublingual immunotherapy” and added note under II.E. to refer to pharmacy policy for coverage criteria
• Added R06.2 to ICD-10-CM code table 1

Removed I.A.4. Requirement of a standard, myeloablative conditioning regimen

• Gait trainers: Removed code E1399 as it is not necessary
• Under Ambulatory Assist Products, added criteria for standing frames 
• Changed coverage for Cold pad pump to “not medically necessary” 
• Added criteria for cervical traction equipment for E0849 that targets temporomandibular joint (TMJ) 
• Changed male vacuum erection devices (VED) to medically necessary 
• Added hip labral tears as an indication for a hip orthotic 
• Positioning seat requires physician or therapist review
• For wheelchair repairs, added criteria for E1399, K0108 and K0739 
• Added criteria for E2300 Power Seat Elevator 
• Under Functional neuromuscular stimulator, added E0770 when the diagnosis is spinal cord injury

Removed Quantitative Electroencephalography (EEG) from criteria I 

•  I.A., Somatosensory Evoked Potentials (SSEP) Testing, added time frame for evaluation of prognosis during acute anoxic encephalopathy; removed evaluation of brain death; removed assessment of CNS deficiency and localization of the cause of neurologic deficits as inclusive to assessment of central nervous system (CNS) deficiency noted in I.A.5 
• Added peripheral nerve degeneration to I.A.6. 
• Brain Auditory Evoked Potential (BAEP) Testing, I.B, removed indication “testing in acquired metabolic function”; I.B.1., added “during tumor infiltration to the brainstem” to assessment of brainstem function  
• I.B.4., added evaluation of prognosis during coma within the initial 72 hours of coma onset as an indication 
• I.C.2., added assessment of pre-optic chiasmic radiations to criteria 

Under III, clarified that facet joint injections of the thoracic region are not medically necessary 

Under Policy/Criteria, added that testing fractional exhaled nitric oxide (FeNO) is investigational for all other conditions, in addition to asthma, with supporting sources

Under Background, initial therapy section, noted that an extended release pyridoxine/doxylamine combination product is preferred

Section IV, added liposuction as the sole method of removing axillary sweat glands as investigational 

In continuation criteria, clarified that member must have previously met initial approval criteria

Added “neurolysis” as a not medically necessary procedure to Section V. on genicular nerve block 

• Moved multiple myeloma and neuroblastoma to the list of experimental/investigational (E/I) indications under Section II
• Section II, removed sickle cell anemia from list of E/I indications
• Removed CPT 38206 as code is for autologous transplant; 
• Added ICD-10-CM codes D59.5, D75.81

• Pre-eclampsia program: I.H.2.c. changed dipstick reading from 1+ to 2+
• Updated background with American College of Obstetricians and Gynecologists’ (ACOG) statement on administration of hydroxyprogesterone caproate

• In I.D.2.b for simultaneous pancreas kidney transplant (SPK), changed glomerular filtration rate (GFR) “< 20” to GFR “≤ 20” 
• Added 2020 CPT codes that do not support coverage criteria and added ICD-10-CM Z94.83

In I.D.15., replaced “Class II or III obesity (body mass index (BMI) ≥35.0 kg/m2) with BMI ≥120% of the 95th percentile and added a link to the CDC clinical growth charts

I.C.13., added contraindication of substance use or dependence

• IV, added implantable tibial nerve stimulation is investigational 
• Added the following CPT codes as investigational: 0587T, 0588T,0589T and 0590T

I.L., I.M., I.N, added indications for non-Hodgkin’s lymphoma, esophageal and esophagogastric junction cancers and non-small cell lung cancers 

• Added new 2020 CPT code 64625 as not medically necessary 
• Added criteria stating sacroiliac joint (SIJ) nerve blocks as not medically necessary, along with code 64451

• Removed restriction of transforaminal epidural steroid injections (TFESI) to lumbar region 
• Added CPT codes 64479 and 64480 
• Added ICD-10-CM codes G56.00–G56.93, M50.00–M50.93, M54.12, M54.13 
• II.A.2., II.B.2., II.C.2. and II.D.2., added the statement to all TFESI indications that for cervical TFESI, non-particulate steroid must be used and the procedure must be conducted with real-time imaging, such as fluoroscopy 
• II.F., revised the not medically necessary statement regarding TFESI for all other indications and locations to only note all other indications

• Added to Sections I.G. and I.H., indications for stereotactic body radiation therapy (SBRT): Pancreatic cancer and high risk prostate cancer, when specific criteria are met 
• Added to section II.I., indication for stereotactic radiosurgery (SRS) refractory epileptic seizures in children, when criterion is met  

Note that the changes are based on updates from the United States Preventive Services Task Force (USPSTF) in 2019 that address:

Breast cancer (BRCA) testing, screening for HIV infection in adults and prophylactic medications, risk reducing medications for women at increased risk for breast cancer

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