Intensity-Modulated Radiotherapy (REVISED POLICY TITLE)

Effective 1 de agosto de 2023, the following 5 policies will be consolidated into this one policy:

• Intensity Modulated Radiotherapy of the Abdomen, Pelvis and Chest
• Intensity Modulated Radiotherapy of the Breast and Lung
• Intensity Modulated Radiotherapy of the Central Nervous System Tumors
• Intensity Modulated Radiotherapy of the Head and Neck or Thyroid
• Intensity Modulated Radiotherapy of the Prostate

Additionally, medical necessity criteria have been added for esophageal cancer, bladder cancer, and sarcoma. Please refer to the policy for additional details here.

Digestive Enzyme Cartridges

Effective 1 de agosto de 2023, coverage for digestive enzyme cartridges (e.g., Relizorb) for commercial products only will change from not medically necessary to prior authorization and will be approved when the medical necessity criteria is met. There will be no changes for Medicare Advantage plans. Please refer to the policy for additional details here.

Cochlear Implants

Effective 1 de agosto de 2023, there will be several changes to the medical necessity criteria for Cochlear Implants for Medicare Advantage plans, based on recent updates to the Centers for Medicare and Medicaid Services (CMS) National and Local Coverage Determinations. There are no changes for commercial products. Please refer to the policy for additional details here.

Genomic Sequence Analysis Panels in the Treatment of Hematolymphoid Diseases

This new policy, Genomic Sequence Analysis Panels in the Treatment of Hematolymphoid Diseases, will be effective 1 de agosto de 2023 and will address CPT codes 81450 and 81451. The policy will include medical necessity criteria for Medicare Advantage plans and commercial products. Please refer to the policy for additional details here.

Genomic Sequence Analysis Panels in the Treatment of Solid Organ Neoplasms        

This new policy, Genomic Sequence Analysis Panels in the Treatment of Solid Organ Neoplasms, will be effective 1 de agosto de 2023 and will address CPT codes 81445, 81449, 81455, 81456, and 0048U. The policy will include medical necessity criteria for Medicare Advantage plans and commercial products. CPT code 0048U was previously addressed in the Comprehensive Genomic Profiling for Selecting Targeted Cancer Therapies policy, but has been moved to this policy, with some additional criteria. Please refer to the policy for additional details here.

Genetic Testing Services

Effective 1 de agosto de 2023, CPT codes 81445, 81449, 81450, 81451, 81455, and 81456 will change to being reviewed against criteria found in associated policies “Genomic Sequence Analysis Panels in the Treatment of Hematolymphoid Diseases" and “Genomic Sequence Analysis Panels in the Treatment of Solid Organ Neoplasms," for both Medicare Advantage plans and commercial products. Please refer to the policy for additional details here.

Comprehensive Genomic Profiling for Selecting Targeted Cancer Therapies

Effective 1 de agosto de 2023, CPT code 0048U has been removed from this policy and will be found in the new policy, Genomic Sequence Analysis Panels in the Treatment of Solid Organ Neoplasms, with some additional criteria for Medicare Advantage plans and commercial products. Please refer to the policy for additional details here.

Non-Reimbursable Health Service Codes effective 4.1.2023

Effective 1 de abril de 2023, the following codes were added to this policy: A2019, A2020, A2021, A4341, A4342, E0677, E0711, J2403, K1024, K1025, K1031, K1032, K1033, and L8678. In addition, the indicator for certain DME codes was updated to reflect which codes are reimbursable for DME providers. Please refer to the policy for additional details here.

Preventive Services for Medicare Advantage Plans

Effective 1 de enero de 2023, the following codes were added to this policy: 0353U (Sexually Transmitted Infection Screening) and 0359U (Prostate Cancer Screening). Please refer to the policy for additional details here.

Preventive Services for Commercial Members                      

The preventive service grid was updated to refer to recommendation from the USPSTF for screening for anxiety for children and adolescents for code 96127. This code is also covered under other preventive service categories. Please refer to the policy for additional details here.

Total Joint Arthroplasty - Hip & Knee   

Effective 1 de agosto de 2023, the current criteria “Nicotine/smoking: 4 weeks off of ANY nicotine product prior to scheduled surgery" will be changed to “Tobacco use: 4 weeks off of tobacco use prior to scheduled surgery". Please refer to the policy for additional details here.

Coding and Payment Guidelines Modifiers

Effective 1 de julio de 2023, payments for subsequent services under multiple radiology services/diagnostic imaging section will be paid at 60%. Prior to this change, these services were paid at 60.4%. Please refer to the policy for additional details here.