20-947 Medical Policies - 3rd Quarter 2020

Polymerase Chain Reaction Respiratory Viral Panel Testing

• Split medical necessity statements to address panels of five pathogens or less and panels of six or more separately
• Added criteria for panels of five or less pathogens in the outpatient setting. Specified that the test will influence the plan of care, and added the following as indications: testing for other pathogens when COVID-19 suspected and COVID-19 testing is not available soon enough to influence the plan of care; when immunocompromised; or when ordered by an infectious disease specialist or when an infectious disease specialist is not available
• Moved codes 87632 and 87633 to a table of medically necessary codes when billed with Place of Service (POS) Codes in Table 3
• Added codes 0098U, 0099U, 0100U, and 0115U as medically necessary when billed with Place of Service (POS) codes in Table 3

Thymus Transplantation

Policy provides medical necessity criteria for this procedure

Acupuncture

Section I.C., Added contraindications of severe neutropenia or malignancy or infection at the site of insertion

Air Ambulance

• Renamed policy from Fixed Wing Air Transportation to Air Ambulance
• Removed criteria for fixed wing stating that transport distance exceeds that of rotary wing
• Applied other fixed wing criteria to both rotary and fixed wing
• Added example conditions
• Added indications for which air ambulance transport is not considered medically necessary

Applied Behavioral Analysis (ABA)

• Replaced “Lovaas therapy” with Early Intensive Behavior Intervention (EIBI)
• Updated Section I.A. to include “ABA recommended by a qualified licensed professional” and added definition of “qualified licensed professional”
• Replaced “plan of care” with “treatment plan” in Section I.D. and added “the number of service hours necessary to effectively address the skill deficits and behavioral excesses is listed in the treatment plan and considers the member’s age, school attendance requirements and other daily activities when determining the number of hours of medically necessary direct service, group and supervision hours” to Section I.E
• Added “Assessments, evaluations, treatment plans, and documentation is expected to be current within each profession, licensure and state standards.” to Section II.J

Bone-Anchored Hearing Aid (BAHA)

• Removed HCPCS code L8613. Added L8692
• Added ICD-10 diagnosis codes H61.111–H61.119

Cell Free Fetal DNA Testing

• Replaced I.B. “A cell-free fetal DNA test has not been performed in this pregnancy” with “No documentation that a chromosomal abnormality screening test has been performed in this pregnancy,” with examples noted
• Removed requirement and criteria for high risk for aneuploidy
• Added requirement of no documentation of a prior abnormal nuchal translucency screening in this pregnancy
• Removed restriction that fetus is < 23 weeks gestation at the time of the blood draw
• Added twin gestation as an option in addition to singleton
• Added CPT code 0168U as medically necessary

Diagnostic Testing Guidelines for 2019 Novel Coronavirus

• Modified criteria to reflect Centers for Disease Control and Prevention (CDC) testing guidelines as of July 20, 2020
• Added criteria for neonatal testing
• Added criteria for discontinuation of transmission-based precautions, home isolation and for return to work for healthcare providers
• Changed antibody/serology testing medical necessity statement to medically necessary for those presenting late in illness, in conjunction with viral testing, and when post-acute infection syndrome is suspected
• Added antibody testing code 86328 to the table supporting medical necessity, as well as codes 0202U, 0223U, 0224U

Facet Joint Interventions

• Section I, Added that interventions should be performed under fluoroscopy or computed tomographic (CT) guidance
• Added criteria I.A.6 requiring that radiofrequency joint denervation/ablation procedure is being considered
• Added the following CPT codes as investigational: 0213T, 0214T, 0215T, 0216T, 0217T, and 0218T (diagnostic or therapeutic facet injections by U.S. ultrasound guidance) and noted in background that there is insufficient evidence to support U.S. guided interventions

Fecal Incontinence Treatments

• Additional criteria added for sacral nerve stimulators from local coverage article (A53017)
• Clarified definition of chronic fecal incontinence as greater than two incontinent episodes on average per week and duration of incontinence greater than six months or for more than twelve months after vaginal childbirth
• Added additional criteria requiring a successful percutaneous test stimulation. Added sacral nerve stimulation for the treatment of chronic constipation or chronic pelvic pain to the not medically necessary Section II

Laser Therapy for Skin Conditions

Section I.A., Revised indication from “Mild, moderate, or severe psoriasis with < 10% body surface area (BSA) involvement” to “Localized plaque psoriasis < 10% body surface area (BSA) involvement, individual lesions, or with more extensive disease”

Mechanical Stretching Devices for Joint Stiffness and Contracture

Added a table of HCPCS codes not supporting medical necessity, including the following codes: E1399, E1801, E1806, E1811, E1815, E1816, E1818, E1830, E1831, E1840, E1841 (stretching devices)

Neonatal Sepsis Management Guidelines

• Under Section III. Discharge criteria, added E. Follow-up planned with provider within 48 hours of discharge
• In background section I.G., changed ≥ 10⁵ colony forming units (CFU) to ≤ 10⁵ CFU

Nerve Blocks for Pain Management

Section I.A.3.b., For occipital nerve block, added “trigger point at the emergence of the greater occipital nerve or in the distribution of C2” as an alternative to tenderness at the affected nerve branch

Reduction Mammoplasty and Gynecomastia Surgery

• Added note to reference CP.MP.95 Gender Affirming Procedures for breast surgeries that pertain to gender affirming procedures
• Section I.A.2., Added criteria for breast reduction for females that cup size has not changed in 6 months
• Section II.A.4., Added criteria for adolescent males requiring that adult testicular size has been attained

Sacroiliac Joint Fusion

Added clarification to Section II., “that sacroiliac joint fusion procedures, either open or minimally invasive (e.g., iFuse), are investigational for all other indications, including but not limited to, treatment of……”

Sacroiliac Joint Interventions

Added Patrick’s test/flexion, abduction and external rotation (FABER) test as an acceptable pain provocation test in I.A.3

Sclerotherapy for Varicose Veins

In I.A.2., added tributary and accessory vein treatment as indications when meeting the established criteria

Selective Nerve Root Blocks

Clarified criteria in II.B, C, and D.1 that a request for transforaminal epidural steroid injection (TFESI) is for one level bilaterally or up to two levels unilaterally 

Skin Substitutes for Chronic Wounds

• Section I.A., Added criteria of age ≥ 18 years, or type 1 diabetic
• Section I.E., Added to the requirement for documentation of effort to cease nicotine use that this does not include nicotine replacement therapy
• Added to Section II that all indications not noted in section I are not medically necessary
• Added CPT codes: 15271–15278; updated list of HCPCS codes of current products available, although not inclusive or guarantee of coverage

Tandem Transplant

• Section I.B.2., Changed contraindication of significant systemic or multisystem disease to “significant, uncorrectable, life-limiting medical condition
• Removed substance abuse or dependence contraindication

Testing Select GU Conditions

Added ICD10 codes: O09.521–O09.529

Transcranial Magnetic Stimulation (TMS)

• Clarified that Section I. refers to initial approval of TMS sessions
• Updated item I.B. to reflect “Oversight of treatment is provided by a licensed psychiatrist”
• Updated I.C. to include “Other standardized scale indicating moderately severe to severe depression”
• Added Section I.I., “The initial request can be reviewed for up to 20 TMS sessions”
• Added Section II., to include criteria for authorization of additional TMS sessions

Trigger Point Injections

Section I.B.4, Changed maximum of six injections per year to four 

Vagus Nerve Stimulation

• Added additional investigational indications for vagus nerve stimulation (VNS) to Section II
• Removed ICD-10 codes: G40.001, G40.009, G40.201, G40.209, G40.309, G40.A09, G40.409, G40.509, G40.802, G40.909, G40.911 and G40.919
• Added ICD-10: G40.813, G40.814