Billing chart: Blues highlight medical, benefit policy changes

81406

Not covered:
81408 (used to report ATM variant),
81479 (used to report CHEK2 variant)

Basic benefit and medical policy

Moderate penetrance variants associated with breast cancer in individuals at high risk

The safety and effectiveness of testing for PALB2 variants for breast cancer risk assessment in adults have been established. It may be considered a useful diagnostic option when indicated, effective Jan. 1, 2020.

Inclusions:
Testing for PALB2 variants for breast cancer risk assessment in adults who meet all the following criteria:

• The individual meets criteria for genetic risk evaluation (BRCA testing).
• The individual has undergone testing for sequence variants in BRCA1 and BRCA2 with negative results.

Criteria for genetic risk evaluation:
The National Comprehensive Cancer Network, known as NCCN, provides criteria for genetic risk evaluation for individuals with no history of breast cancer and for those with breast cancer. Updated versions of the criteria are available on the NCCN website.**

Exclusions:

• Testing for PALB2 sequence variants in individuals who don’t meet the criteria outlined above is considered experimental.
• Testing for CHEK2 and ATM variants in the assessment of breast cancer risk is considered experimental.

J9023

Basic benefit and medical policy

Bavencio (avelumab)

Q4132, Q4133, Q4151, Q4154, Q4186, 65778, 65779

Not covered codes:
Q4100, Q4137-Q4140, Q4145, Q4148, Q4150, Q4153, Q4155- Q4157, Q4159, Q4160, Q4162, Q4163, Q4168-Q4171, Q4173, Q4174, Q4181, Q4183-Q4185, Q4187-Q4192, Q4194, Q4198, Q4201, Q4204-Q4206, Q4208-Q4219, Q4221

Basic benefit and medical policy

Amniotic membrane and amniotic fluid

The safety and effectiveness of select human amniotic membrane products have been established. They may be useful therapeutic options when indicated.

Injection of amniotic fluid is experimental for all indications. The safety, effectiveness and improvement in health outcomes hasn’t been scientifically demonstrated.

Policy updates are effective Jan. 1, 2020.

Inclusions:
Treatment of nonhealing** diabetic lower-extremity/venous stasis ulcers using the following human amniotic membrane products:

• AmnioBand^® Membrane
• Biovance^®
• Epifix^®
• Grafix^™

**Nonhealing is defined as less than a 20% decrease in wound area with standard wound care for at least two weeks.

Human amniotic membrane grafts with or without suture (Prokera, AmbioDisk^™) for the treatment of any of the following ophthalmic indications:

• Neurotrophic keratitis with ocular surface damage and inflammation that does not respond to conservative therapy^a
• Corneal ulcers and melts that don’t respond to initial conservative therapy^a
• Corneal perforation when there is active inflammation after corneal transplant, requiring adjunctive treatment
• Bullous keratopathy as a palliative measure in patients who aren’t candidates for curative treatment (e.g., endothelial or penetrating keratoplasty)
• Partial limbal stem cell deficiency with extensive diseased tissue where selective removal alone isn’t sufficient
• Moderate or severe Stevens-Johnson syndrome
• Persistent epithelial defects that don’t respond within two days to conservative therapy^a
• Severe dry eye (DEWS 3 or 4)^b with ocular surface damage and inflammation that remains symptomatic after conservative therapy^a
• Moderate or severe acute ocular chemical burn

Human amniotic membrane grafts with suture or glue for the treatment of any of the following ophthalmic indications:

• Corneal perforation when corneal tissue isn’t immediately available
• Pterygium repair when there is insufficient healthy tissue to create a conjunctival autograft

^aConservative treatment is defined as use of topical lubricants or topical antibiotics or therapeutic contact lens or patching.

^bSee policy guidelines for definition.

Exclusions:
All other human amniotic membrane products and indications not outlined under inclusions, including, but not limited to:

• Grafts with or without suture for ophthalmic indications
• Injection of micronized or particulated human amniotic membrane for all indications including, but not limited to, treatment of:
  • Osteoarthritis and plantar fasciitis
• Injection of human amniotic fluid for all indications
• Treatment of lower-extremity ulcers due to venous insufficiency

Policy guidelines:

Dry eye severity level DEWS 3 to 4

• Discomfort, severity and frequency — Severe frequent or constant
• Visual symptoms — chronic or constant, limiting to disabling
• Conjunctival injection — +/- or +/+
• Conjunctive staining — moderate to marked
• Corneal staining — marked central or severe punctate erosions
• Corneal/tear signs — filamentary keratitis, mucus clumping, increase in tear debris
• Lid/meibomian glands — frequent
• Tear film breakup time — < 5
• Schirmer score (mm/5 min) — < 5

0440T, 0441T, 0442T

Basic benefit and medical policy

Cryoablation for the treatment of peripheral neuropathy is experimental

Cryoablation (i.e., cryoneurolysis, cryoanalgesia) for the treatment of peripheral neuropathy is experimental. It hasn’t been scientifically demonstrated to improve patient clinical outcomes.

Cryoablation treatment for peripheral neuropathy includes, but isn’t limited to, the following conditions:

• Peripheral neuropathy brought on by diabetes, genetic predisposition (hereditary causes), exposure to toxic chemicals, alcoholism, malnutrition, inflammation (infectious or autoimmune), injury and nerve compression or by taking certain medications such as those used to treat cancer and HIV/AIDS
• Peripheral neuromas
• Post-thoracotomy/intercostal pain
• Total knee arthroplasty and osteoarthritis pain
• Chronic headaches (e.g., migraine, tension, cluster, cervicogenic, occipital neuralgia)

The policy exclusions have been updated, effective Jan. 1, 2020.

Revenue code
0891

Basic benefit and medical policy

New revenue code

32850, 32853, 32854, 32855, 32856, 47133, 47135, 47140, 47141, 47142, 47143, 47144, 47145, 47146, 47147

Basic benefit and medical policy

Combined lung, double lung and liver transplants

Combined double lung and liver transplants have been established as clinically safe and effective for carefully selected patients with end-stage lung and liver disease when transplantation of a single organ is precluded by severe disease in the other organ system, such that the patient’s prognosis after combined transplantation is felt to be better than with sequential transplantation.

This policy is effective Jan. 1, 2020.

Inclusions:
Indications for combined lung-double lung and liver transplant include, but are not limited to, progressive chronic lung/liver disease unresponsive to other medical and surgical therapy. In general, patients are selected for combined lung-liver transplant if one or more of the following apply:

• A lung transplant is typically required for irreversible, chronic lung diseases for which there is no further medical or surgical therapy available and survival is limited.
• Bilateral lung transplantation is typically required when chronic lung infection disease is present, i.e., associated with cystic fibrosis and bronchiectasis. Some, but not all, cases of pulmonary hypertension will require bilateral lung transplantation.
• A liver transplant is typically required for irreversibly damaged livers for which there is no further medical or surgical therapy available, prognosis is poor and end stage liver disease (e.g., alcoholic liver disease, viral hepatitis, autoimmune hepatitis, protoporphyria, biliary cirrhosis, vascular disease, trauma or toxic reactions)
• End-stage lung disease and end-stage liver disease.

Exclusions:

• Patients with coronary artery disease not amenable to percutaneous intervention or bypass grafting, or associated with significant impairment of left ventricular function
• Patients with colonized,highly resistant or highly virulent bacteria, fungi or mycobacteria
• Patients with intrahepatic cholangiocarcinoma
• Patients with hepatocellular carcinoma that has extended beyond the liver
• Patients with ongoing alcohol or drug abuse as defined by the transplant program.

Established
33361, 33362, 33363, 33364, 33365, 33366, 33367, 33368, 33369

Investigational
33999

Basic benefit and medical policy

Transcatheter Aortic Valve Implantation for Aortic Stenosis policy

The criteria have been updated for the Transcatheter Aortic Valve Implantation for Aortic Stenosis policy. This policy is effective Jan. 1, 2020.

Medical policy statement

Transcatheter aortic valve replacement performed with an FDA-approved transcatheter heart valve system, performed via an approach consistent with the device’s FDA-approved labeling, may be indicated for patients with aortic stenosis.

Inclusions:
Transcatheter aortic valve replacement with a device approved by the FDA and performed via an approach consistent with the device’s FDA-approved labeling is established for patients with aortic stenosis when all the following conditions are present:

• One of the following:
  • Severe aortic stenosis with a calcified aortic annulus
  • Failure (stenosed, insufficient or combined) of a surgical bioprosthetic aortic valve
• New York Heart Association heart failure class II, III or IV symptoms
• Left ventricular ejection fraction greater than 20%
• One of the following:
  • Patient isn’t an operable candidate for open surgery, as judged by at least two cardiovascular specialists including a cardiac surgeon.
  • Patient is an operable candidate but is at high risk for open surgery (i.e., Society of Thoracic Surgeons operative risk score ≥ 8% or at a ≥ 15% risk of mortality at 30 days).
  • Patient is at intermediate or greater surgical risk for open aortic valve replacement (only when used in concordance with FDA regulations for Sapien XT Transcatheter Heart Valve; see below).
  • Patient is at low surgical risk for open aortic valve replacement (only when used in concordance with FDA regulations for Sapien 3, Sapien 3 Ultra, CoreValve Evolut R or CoreValve Evolut PRO).

Edwards SAPIEN XT Transcatheter Heart Valve:

1. Severe aortic stenosis with a calcified aortic annulus and one or more of the following:
   • An aortic valve area of ≤ 1.0 cm² or aortic valve area index ≤ 0.6 cm2/m2
   • A mean aortic valve gradient ≥ 40 mmHg
   • A peak aortic-jet velocity ≥ 4.0 m/sec
   • Native anatomy appropriate for the 23, 26, or 29 mm valve system (between 18 and 28 mm)
2. New York Heart Association heart failure Class II, III or IV symptoms.
3. Patient isn’t a candidate for open surgery, as judged by a heart team, including a cardiac surgeon, or is at high or greater risk for open surgical therapy (i.e., Society of Thoracic Surgeons operative risk score ≥ 8% or at a ≥ 15% risk of mortality at 30 days).
4. Patient is at intermediate surgical risk for open aortic valve replacement (i.e., predicted risk of surgical mortality ≥ 3% at 30 days based on the Society of Thoracic Surgeons [STS] risk score and other clinical comorbidities unmeasured by the STS Risk Calculator).

Edwards SAPIEN and Edwards SAPIEN 3 Ultra Patient with severe aortic valve stenosis who is at low risk for death or major complications associated with open-heart surgery.

LOTUS Edge^™ Valve System

1. Aortic stenosis in patients with symptomatic heart disease due to severe native calcific aortic stenosis.
   • An aortic valve area of ≤ 1.0 cm2 OR aortic valve area index ≤ 0.6 cm2/m2)
2. Patient isn’t a candidate for open surgery, as judged by a heart team, including a cardiac surgeon or is at high or greater risk for open surgical therapy (i.e., predicted risk of surgical mortality ≥ 8% at 30 days, based on the Society of Thoracic Surgeons risk score and other clinical comorbidities unmeasured by the STS risk calculator).

Medtronic CoreValve^™ (Evolut) system:

1. Severe aortic stenosis with a calcified aortic annulus and one or more of the following:
   • An aortic valve area of ≤ 1.0 cm² or aortic valve area index ≤ 0.6 cm2/m2
   • A mean aortic valve gradient ≥ 40 mmHg.
   • A peak aortic-jet velocity ≥ 4.0 m/sec
   • Native aortic annulus diameters between 23 and 31 mm
2. New York Heart Association heart failure Class II, III or IV symptoms
3. Patient with severe aortic valve stenosis who is at low risk or higher for death or major complications associated with open-heart surgery

Exclusions:
Transcatheter aortic valve replacement is considered experimental for all other indications, including, but not limited to:

• The individual is an appropriate candidate for the standard, open surgical approach but has refused.
• Hypersensitivity or contraindication to an anticoagulation/antiplatelet regimen
• Presence of active bacterial endocarditis or other active infections
• Non-FDA approved systems or approaches including:
  • Portico and JenaValve systems
  • Transcaval approach

58674
Experimental:
58578, 58999, 0404T

Basic benefit and medical policy

Laparoscopic ultrasound-guided radiofrequency ablation

Laparoscopic ultrasound-guided radiofrequency ablation (e.g., Acessa^™) for the treatment of uterine fibroids is established. It may be considered a useful therapeutic option when indicated.

Laparoscopic and percutaneous techniques of myolysis as a treatment of uterine fibroids other than laparoscopic ultrasound-guided radiofrequency ablation (e.g., Acessa^™) are considered experimental; this includes Nd: YAG lasers, bipolar electrodes and cryomyolysis. There is insufficient published evidence to assess the safety and effect on health outcomes in the treatment of uterine fibroids.

Transcervical ultrasound-guided radiofrequency ablation (e.g., Sonata^® System) in the treatment of uterine fibroids is experimental. There is insufficient published evidence to assess the effect on health outcomes.

The medical policy exclusions have been updated, effective Jan. 1, 2020.

Inclusions:
Laparoscopic ultrasound-guided radiofrequency ablation (e.g., Acessa^™) for the treatment of uterine fibroids may be indicated as an alternative to hysterectomy or myomectomy when the member has one or more of the following:

• Severe menorrhagia causing anemia
• Bulk-related symptoms (e.g., pelvic pain, pressure or discomfort, urinary symptoms related to compression of the ureter or bladder, or dyspareunia)
• Contraindications to general anesthesia
• Pre-menopausal state with symptomatic fibroids in members who want to avoid a hysterectomy

Exclusions:

• Laparoscopic ultrasound-guided radiofrequency ablation (e.g., Acessa^™) for all situations other than those specified above
• Transcervical ultrasound-guided radiofrequency ablation (e.g., Sonata^® System) in the treatment of uterine fibroids

81210, 81275, 81276, 81311, 81403, 81404, 88363, 0111U

Experimental procedures:
86152, 86153

Basic benefit and medical policy

KRAS, NRAS and BRAF analyses in metastatic colorectal cancer

The safety and effectiveness of KRAS, NRAS and BRAF mutation analyses have been established and may be considered a useful diagnostic option to predict nonresponse to anti-EGFR monoclonal antibodies cetuximab and panitumumab in the treatment of all patients with metastatic colorectal cancer. It’s a useful therapeutic option when indicated.

KRAS, NRAF and BRAF variant analysis using circulating tumor DNA or circulating tumor cell testing (liquid biopsy) to guide treatment for patients with metastatic colorectal cancer is considered experimental.

Inclusions:

Established
86294, 86386, 88120, 88121

Experimental
0012M, 0013M, 81599

Basic benefit and medical policy

Urinary Biomarkers for Cancer Screening, Diagnosis and Surveillance policy

The medical policy statement has been updated for the Urinary Biomarkers for Cancer Screening, Diagnosis and Surveillance policy. The policy is effective Jan. 1, 2020.

Medical policy statement

The safety and effectiveness of Food and Drug Administration-approved urinary tumor markers for bladder cancer have been established. It may be considered a useful diagnostic option when used as an adjunct to cytology and cystoscopy.

The use of urinary tumor markers in screening for precancerous colonic polyps is experimental. There is insufficient evidence in the peer-reviewed medical literature to determine the effects of this technology on health outcomes.

Inclusions:
The assessment of FDA-approved urinary tumor markers for bladder cancer, as an adjunct to cytology and cystoscopy, is considered indicated in:

• The diagnosis of urinary bladder malignancy in members at very high risk
• The follow-up of members with a history of urinary bladder malignancy when the measurements of these markers is deemed essential in making management decisions

Exclusions:

• All other indications for bladder cancer not specified under the inclusions

Established
L8699, S0812, 65710, 65767, 65785

Experimental
65760, 65765, 65770, 65771, 65775, S0800, S0810, 66999

Basic benefit and medical policy

Refractive Keratoplasties, Phototherapeutic Keratectomy and Implantation of Intrastromal corneal Ring Segments policy

The criteria have been updated for the Refractive Keratoplasties, Phototherapeutic Keratectomy and Implantation of Intrastromal Corneal Ring Segments policy. The policy is effective Jan. 1, 2020.

Medical policy statement

Epikeratophakia (donor cornea is transplanted onto the anterior surface of the recipient’s cornea) for the treatment of aphakia (absence of the eye lens) is an established procedure. It may be a useful therapeutic option when indicated.

Refractive procedures mentioned in this policy may be considered cosmetic and not medically necessary when used to correct myopia (nearsightedness), hyperopia (farsightedness), astigmatism (imperfection in the curvature of the cornea) or presbyopia (gradual loss of ability to focus on nearby objects, acquired with age). Individual contract language will apply.

Implantation of intrastromal corneal ring segments (Intacs^®) is established for the treatment of keratoconus (cornea thins and begins to bulge into a cone-like shape). It may be a useful therapeutic option when indicated.

Implantation of intrastromal corneal ring segments (Intacs^®) for the treatment of myopia (nearsightedness) isn’t medically necessary.

Keratophakia (placement of a donor cornea under the recipient’s cornea) is experimental. It hasn’t been scientifically demonstrated to be as safe and effective as conventional treatment.

Phototherapeutic keratectomy for treatment of recurrent corneal erosions is an established procedure. It may be a therapeutic useful option when indicated.

Inclusions:

• Epikeratophakia (donor cornea is transplanted onto the anterior surface of the recipient’s cornea) for the treatment of aphakia (absence of the eye lens).
• Implantation of intrastromal corneal ring segments (Intacs^®) for the treatment of keratoconus (cornea thins and bulges like a cone) is appropriate when all the following criteria are met:
  • The patient has experienced a deterioration in their vision.
  • Corneal transplantation is the only alternative to improve their functional vision.
  • The patient has a clear central cornea with a corneal thickness of 450 microns or greater at the proposed incision site.
• Phototherapeutic keratectomy is an established surgical modality for treatment of recurrent corneal erosions when non-operative methods have failed.

Exclusions:

• Refractive keratoplasty procedures for indications not listed above, including those that are cosmetic in nature.
• Implantation of intrastromal corneal ring segments (Intacs^®) for the treatment of myopia (nearsightedness) and all other conditions not listed above
• Keratophakia (placement of a donor cornea under the recipient’s cornea)

Quicken Loans

Effective Jan. 1, 2020, the following group numbers have been added under Quicken Loans:

• 000071807 — Rock Ventures LLC
• 000071808 — Xenith LLC
• 000071809 — Stock X LLC

Alpha prefix: PPO (IQU)
Platform: NASCO

Plans offered:
PPO
Prescription drug
CDH — HSA