Medical Policy Update Summary May 2019


Ocular Photoscreening


Gene Expression Profiling

  • Added genomic sequence analysis panels (e.g., OncoVantage® [Quest]) for Medicare members.

Genetic Testing for Colorectal Cancer/Lynch Syndrome

  • Updated commensurate with National Cancer Care Network (NCCN).

Insulin Delivery Devices and Continuous Glucose Monitoring Systems

  • Added alternate controller enabled t:Slim X2 pump.

Obstructive Sleep Apnea Diagnosis and Treatment

  • Revised attended polysomnography section regarding factors that could degrade accuracy of testing; severe heart failure (EF ≤ 15) changed to moderate–severe heart failure (EF < 45 [if treatment of heart disease has been optimized])

Otoacoustic Emissions Testing (OAE) Effective 7/15/19

  • Added diagnostic indications.
  • Qualified that routine evoked OAE screening at a well-child visit is not considered medically necessary for children 3 years of age and younger who have passed the newborn hearing screen unless specified clinical indicators are present.
  • Added that comprehensive auditory evoked response testing and comprehensive otoacoustic emissions are considered experimental and investigational.

Stereotactic Radiosurgery and Proton Beam Therapy (PBT)

  • Added Commercial and Medicaid coverage of proton beam therapy (PBT) for malignancies requiring craniospinal irradiation (CSI).
  • Added Commercial and Medicaid PBT coverage consideration language for unresectable hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma.
  • Added PBT case-by-case review language for Commercial and Medicaid members specific to: Locally advanced breast cancer when treating the internal mammary nodes, primary CNS cancer, esophageal cancer, head and neck cancer (excluding T1-T2N0M0 laryngeal cancer), remaining cases of unresectable HCC and intrahepatic cholangiocarcinoma, Hodgkin’s lymphoma, non-Hodgkin's lymphoma, stage IIIB non-small cell lung cancer, pancreatic cancer, prostate cancer (unoperated), retroperitoneal sarcoma, thymomas and thymic carcinoma.