20-436 Medical Policies - 1st Quarter 2020

CP.MP.183

Diagnostic Testing Guidelines for 2019 Novel Coronavirus 

CP.MP. 252

Allergy Testing and Therapy 

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

CP.MP.108

Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia

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

CP.MP.107

DME and O&P Criteria

• 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

CP.MP.105

Digital EEG Spike Analysis

Removed Quantitative Electroencephalography (EEG) from criteria I 

CP.MP.134

Evoked Potential Testing

• 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 

CP.MP.171

Facet Joint Interventions

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

CP.MP.103

Fractional Exhaled Nitric Oxide

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

CP.MP.34

Hyperemesis Gravidarum Treatment

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

CP.MP.62

Hyperhidrosis Treatments

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

CP.MP.87

Inhaled Nitric Oxide

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

CP.MP.170

Nerve Blocks for Pain Management

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

CP.MP.141

Non-Myeloablative Allogeneic Stem Cell Transplants

• 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
• Added ICD-10-CM codes D59.5, D75.81

CP.MP.91

Obstetrical Home Health Programs

• 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

CP.MP.102

Pancreas Transplantation

• 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

CP.MP.138

Pediatric Heart Transplant

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 Centers for Disease Control and Prevention (CDC) clinical growth charts

CP.MP.120

Pediatric Liver Transplant

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

CP.MP.133

Posterior Tibial Nerve Stimulation for Voiding Dysfunction

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

CP.MP.70

Proton and Neutron Beam Therapy

• I.L., I.M., I.N, added indications for non-Hodgkin’s lymphoma, esophageal and esophagogastric junction cancers and non-small cell lung cancers 
• Updated ICD-10-CM codes

CP.MP.166

Sacroiliac Joint Interventions for Pain Management

• 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

CP.MP.165

Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections

• 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

CP.MP.22

Stereotactic Body Radiation Therapy

• 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  
• Updated ICD-10-CM codes