MHK Updates

• Effective 1 de noviembre de 2024, IQ criteria updates to the CP:Procedures Transcatheter Aortic Valve Replacement (TAVR) Subset
• Effective 1 de noviembre de 2024, HCPC Code L5841 criteria will move to IQ subset Medicare: Post Acute & Durable Medical Equipment Lower Limb Prostheses following LCD Lower Limb Prostheses (L33787)

Powered Exoskeleton for Ambulation in Patients with Lower-Limb Disabilities

Effective 1 de noviembre de 2024, for both Medicare Advantage plans and commercial products, CPT E0739 will be removed from the 2024 New Technology and Miscellaneous Services policy. CPT E0739 will be added to Powered Exoskeleton for Ambulation in Patients with Lower-Limb Disabilities Medical Policy. CPT E0739 will change from requiring prior authorization for Medicare Advantage plans to being not covered for Medicare Advantage plans. E0739 will continue to be not medically necessary for commercial products using the Powered Exoskeleton for Ambulation in Patients with Lower-Limb Disabilities medical policy. For additional details related to this policy, please click here. 

Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer 

Effective 1 de noviembre de 2024, CPT codes 81518, 81519, 81520, 81521, 81522 and 81523 will change from requiring prior authorization to covered when filed with a covered ICD-10 code for Medicare Advantage plans and commercial products. CPT codes 81518, 81519, 81520, 81521, 81522, and 81523 will be denied as not covered for Medicare Advantage plans and not medically necessary for commercial products when not filed with a covered ICD-10 code listed in the policy. For additional details related to this policy, please click here.

Ovarian and Internal Iliac Vein Embolization as a Treatment of Pelvic Congestion Syndrome

Effective 1 de noviembre de 2024, CPT code 37241, when filed with ICD-10 code N94.89, will change from not covered for Medicare Advantage plans and not medically necessary for commercial products to requiring prior authorization when filed with ICD-10 code N94.89 for both Medicare Advantage plans and commercial products. For additional details related to this policy, please click here.

Prostate Cancer Detection with IsoPSA

Effective 1 de noviembre de 2024, for CPT code 0359U, prior authorization will now be required for Medicare Advantage plans and will continue to be recommended for commercial products using the medical criteria in this policy. For additional details related to this policy, please click here.

Genetic Testing Services 

Effective 1 de noviembre de 2024, for Medicare Advantage plans and commercial products, CPT Codes 81225 and 81226 will no longer require prior authorization when filed with ICD-10 diagnosis codes F01 – F99. Additionally, the following CPT codes will be included in the policy due to consideration as biomarkers, but can also be found in the related policy, Novel Biomarkers in Risk Assessment and Management of Cardiovascular Disease: 82610, 83695, 83722, 83880, 85384, and 85385. Finally, CPT codes 81518 – 81523 will no longer require authorization. They will be covered when filed with a covered ICD-10 diagnosis code, as noted above in the article for the related policy, Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer. For additional details related to this policy, please click here.

Proprietary Laboratory Analyses (PLA) and Multianalyte Assays with Algorithmic Analyses (MAAA)

Effective 1 de noviembre de 2024, for Medicare Advantage plans and commercial products, CPT codes 0400U and 0449U will change from being reviewed against the criteria in this policy to being reviewed against InterQual criteria found in the online authorization tool for determination of medical necessity. Additionally, CPT code 0438U will no longer require prior authorization when filed with ICD-10 diagnosis codes F01 – F99. Finally, CPT code 0359, which will also be found in the new policy, Prostate Cancer Detection with IsoPSA mentioned above, will change to requiring authorization for Medicare Advantage plans following the criteria in the related policy, and determination of medical necessity for commercial products will change from utilizing criteria in this policy to utilizing criteria in the new policy. For additional details related to this policy, please click here.

Prior Authorization via Web-Based Tool for Durable Medical Equipment (DME)                                                                   Effective 1 de octubre de 2024, HCPCS code E2298 will change from not covered to requiring prior authorization for Medicare Advantage Plans. For additional details related to this policy, please click here.