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Medical Policy Bulletin

Not Medically Necessary Services and Obsolete or Unreliable Diagnostic Tests
00.01.24k

This policy is applicable to the Company's commercial products only. Policies that are applicable to the Company's Medicare Advantage products are accessible via a separate Medicare Advantage policy database.


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member's medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member's medical needs and condition. This decision is based on the member's current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the Policy Types and Descriptions section of this Medical Policy Web site.


Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract.

Not medically necessary services and obsolete or unreliable diagnostic tests are considered not medically necessary and, therefore, not covered because the available published peer-reviewed literature does not support their use in the diagnosis or treatment of illness or injury.

DIAGNOSTIC LAB TESTS

The following diagnostic tests are considered obsolete or unreliable and have been replaced by more advanced testing procedures:
  • Amylase, blood isoenzymes, electrophoretic
  • Animal inoculation, small animal; with observation
  • Animal inoculation, small animal; with observation and dissection
  • Bendien's test for cancer and tuberculosis
  • Bolen test for cancer (Bolen clot retraction test)
  • Calcium, feces, 24-hour quantitative
  • Calcium saturation clotting time
  • Capillary fragility test (Rumpel-Leede)
  • Cephalin flocculation
  • Chromium, blood
  • Chymotrypsin, duodenal contents
  • Circulation time, one test
  • Colloidal gold
  • Congo red, blood
  • Gastric analysis, pepsin
  • Gastric analysis, tubeless
  • Guanase, blood
  • Hair analysis
  • Hormones, adrenocorticotropin quantitative animal tests
  • Hormones, adrenocorticotropin quantitative bioassay
  • Rehfuss test for gastric acidity
  • Serum seromucoid assay for cancer and other diseases
  • Skin test, actinomycosis
  • Skin test, brucellosis
  • Skin test, cat scratch fever (cat scratch disease; Bartonella infection)
  • Skin test, lymphopathia venereum
  • Skin test, psittacosis
  • Skin test, trichinosis
  • Starch, feces, screening
  • Thymol turbidity, blood
  • Zinc sulphate turbidity, blood
MEDICAL SERVICES

The following medical services are considered obsolete or unreliable due to having limited clinical usefulness​, and as such are not appropriate with regard to generally accepted standards of medical practice within the medical community:
  • Adrenal tissue transplant to the brain
  • Arthroscopic electrothermal joint repair or thermal capsulorrhaphy or electrothermal capsulorrhaphy or thermal or electrothermal shrinkage
  • Cardiointegram (CIG)
  • Continuous noninvasive glucose monitoring using the Glucowatch
  • Electron beam computed tomography (EBCT)
  • Fabric wrapping of abdominal aortic aneurysms
  • Home uterine activity monitoring (HUAM) devices
  • Intracardiac phonocardiogram
  • Intragastric hypothermia (gastric freezing)
  • Phonocardiogram with or without electrocardiogram (ECG) lead, with or without indirect carotid artery and/or jugular vein tracing, and/or apex cardiogram
  • Transtympanic micropressure device 
  • Vectorcardiogram (VCG), with or without electrocardiogram (ECG); with or without tracing
PHARMACEUTICAL PRODUCTS 

Pharmaceutical products are considered not medically necessary when the approved authorization has been rescinded​ by the US Food and Drug Administration (FDA) for a specific approved condition or diagnosis​ or the product has been withdrawn from the market based on having limited clinical usefulness​and as such are not appropriate with regard to generally accepted standards of medical practice within the medical community:

  • Single-agent ​belantamab mafodotin-blmf (Blenrep)
  • Hydroxyprogesterone caproate (Makena and compounded or generic products) to reduce the risk of preterm birth 
  • Melphalan flufenamide (Pepaxto)
  • Olaratumab (Lartruvo)​
  • Copanlisib (Aliqopa)

Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, not medically necessary services and obsolete or unreliable diagnostic tests are not eligible for payment under the medical benefits of the Company's products because these tests and services are considered not medically necessary and, therefore, not covered.

Description

Obsolete or unreliable diagnostic tests are tests that are no longer routinely used and, in some instances, are outdated and found to be of little clinical value. Some of these tests have been replaced with improved technology. The not medically necessary medical services included in this policy are services or treatments that are rarely performed and lack scientific or statistical evidence in peer-reviewed literature to document their effectiveness. These services are not appropriate with regard to generally accepted standards of medical practice within the medical community due to having limited clinical usefulness. 

PHARMACEUTICAL PRODUCTS 

BELANTAMAB MAFODOTIN-BLMF (BLENREP)

On August 5, 2020, belantamab mafodotin-blmf (Blenrep) was approved by the U.S. Food and Drug Administration (FDA) for the treatment of adults with relapsed or refractory multiple myeloma who have received at least four prior therapies, including an anti-CD38 monoclonal antibody, a proteasome inhibitor, and an immunomodulatory agent.


On November 22, 2022, GlaxoSmithKline initiated the process for withdrawal of the biologics license application (BLA) for this biologic, at the request of the FDA. Belantamab mafodotin-blmf (Blenrep) was granted accelerated approval based on the primary endpoint of overall response rate (ORR) from the DREAMM-2 study, with full approval contingent on confirmed clinical benefit from the DREAMM-3 randomized Phase 3 trial. However, this confirmatory trial did not meet its primary endpoint of superior progression-free survival (PFS). 


HYDROXYPROGESTERONE CAPROATE (MAKENA)


On February 3, 2011, hydroxyprogesterone caproate (Makena) received an Orphan Drug designation from the FDA after showing the drug's efficacy in decreasing the risk of preterm birth in women with a singleton pregnancy who have a history of singleton spontaneous preterm birth. Hydroxyprogesterone caproate (Makena) is administered weekly by a healthcare provider through an intramuscular injection in the upper quadrant of the gluteus maximus (available in vials), or a subcutaneous injection in the back of either upper arm (available as an auto-injector). In February 2018, the FDA approved hydroxyprogesterone caproate (Makena)​ subcutaneous auto-injector.   

On April 6, 2023, the FDA announced the final decision to withdraw approval of hydroxyprogesterone caproate (Makena)​ and its generic compound for decreasing the risk of preterm birth. Hydroxyprogesterone caproate (Makena)​ was FDA approved under accelerated approval pathway in 2011, based on a determination that the sponsor had demonstrated a drug effect on an intermediate clinical endpoint that was reasonably likely to predict clinical benefit. However, the Phase 3 confirmatory trial (PROLONG 2020) failed to verify the clinical benefit of hydroxyprogesterone caproate (Makena)​ for neonatal outcomes or preventing preterm birth. On March 7, 2023, Covis Pharma initiated the process for withdrawal of the New Drug Application (NDA) for this drug, in response to the FDA's Obstetrics, Reproductive and Urologic Drugs Advisory Committee (ORUDAC) vote (14-1) in October 2022 recommending that the drug be pulled from the market due to the results from the confirmatory trial.  

MEPHALAN FLUFENAMIDE (PEPAXTO)

On December 7, 2022, the FDA requested that the marketing authorization for melphalan flufenamide (Pepaxto) be withdrawn from the United States market following confirmatory findings from the Phase 3 OCEAN trial (NCT03151811), according to a press release from Oncopeptides AB.

Data from the OCEAN 3 trial indicated the hazard ratio for overall survival by independent review committee in the intent-to-treat population was 1.104 (95% confidence interval [CI], 0.846–1.441), with notable differences in survival findings for both melphalan flufenamide (Pepaxto) in the experimental arm and pomalidomide (Pomalyst) in the comparator arm across a number of patient subgroups. Other findings from the OCEAN trial indicated that melphalan flufenamide (Pepaxto) yielded a progression-free survival that was 42% higher than pomalidomide by investigator and independent review committee (IRC) assessment (HR,0.817; 95% CI, 0.659–1.012; P=0.064; HR, 0.790; 95% CI, 0.639–0.976). Additionally, the overall response rate was 32.1% versus 26.5% in the melphalan flufenamide (Pepaxto) and pomalidomide (Pomalyst) arms, respectively.

OLARATUMAB (LARTRUVO) 

On October 19, 2016, the FDA approved the BLA for olaratumab (Lartruvo) injection (Eli Lilly and Co.), indicated, in combination with doxorubicin, for the treatment of adult patients with soft tissue sarcoma with a histologic subtype for which an anthracycline-containing regimen is appropriate and that is not amenable to curative treatment with radiotherapy or surgery, under the Agency's accelerated approval regulations. 

Results from the confirmatory ANNOUNCE trial did not meet the primary endpoints of overall survival for olaratumab (Lartruvo) in combination with doxorubicin compared with doxorubicin alone in the full study population or within the leiomyosarcoma subpopulation.​ On February 25, 2020, the FDA issued a letter to Eli Lilly revoking the approval to manufacture and market olaratumab (Lartruvo)  injection (BLA 761038).

​COPANLISIB (ALIQOPA)

On September 14 2017, the FDA approved copanlisib (Aliqopa), a kinase inhibitor, indicated for the treatment of adult individuals with relapsed follicular lymphoma who have received at least two prior systemic therapies. Accelerated approval was granted for this indication based on overall response rate. Continued approval for this indication may be contingent upon verification and description of clinical benefit in a confirmatory trial.

Aditional data from the phase 3 confirmatory trial indicated that copanlisib (Aliqopa) plus immunochemotherapy did not fulfill the trial’s primary end point of PFS compared with immunochemotherapy alone. On November 8, 2023, Bayer confirmed that they will voluntarily withdraw copanlisib (Aliqopa) from the US market after the drug failed to demonstrate expected efficacy outcomes in the confirmatory trial. As of March 18, 2024, the FDA has withdrawn the new drug application for copanlisib​ (Aliqopa)

References

American Academy of Orthopaedic Surgeons (AAOS). Thermal capsulorrhaphy. [AAOS Web site]. October 2007 (last reviewed September 2010). Available at: http://orthoinfo.aaos.org/topic.cfm?topic=a00034. Accessed April 18, 2024.

American Academy of Otolaryngology–​Head and Neck Surgery. AAO-HNS position on micropressure therapy. 2012. Available at: https://www.entnet.org/resource/position-statement-micropressure-therapy/. Accessed April 18, 2024.

American Academy of OtolaryngologyHead and Neck Surgery. Available at: http://www.enthealth.org/conditions/menieres-disease
Accessed April 18, 2024.

American College of Obstetricians and Gynecologists; Committee on Practice Bulletins—Obstetrics. ACOG practice bulletin no. 171: Management of preterm labor. Obstet Gynecol. 2016;128:e155-164 (Interim Update).

American College of Obstetricians and Gynecologists (ACOG). Practice Bulletin No. 130: Prediction and Prevention of Preterm Birth. Obstet Gynecol. 2012;120:964-973. Reaffirmed 2016. 

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). Fabric Wrapping of Abdominal Aneurysms (20.23). [CMS web site]. Available at:
http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=51&ncdver=1&DocID=20.23&bc=gAAAABAAAAAA&. Accessed April 18, 2024.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD).20.27 Cardiointegram (CIG) as an Alternative to Stress Test or Thallium Stress Test [CMS Web site]. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=259&ncdver=1&DocID=20.27&bc=gAAAABAAAAAA&. Accessed April 18, 2024.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). 100.6: Gastric freezing [CMS Web site]. Available at:
http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=87&ncdver=1&DocID=100.6&bc=gAAAABAAAAAA&. Accessed April 18, 2024.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). 190.6 Hair Analysis [CMS Web site]. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=189&ncdver=1&DocID=190.6&bc=gAAAABAAAAAA&. Accessed April 18, 2024.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). 300.1: Obsolete or unreliable diagnostic tests. [CMS Web site]. 06/19/06. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=204&ncdver=2&DocID=300.1&bc=gAAAABAAAAAA&. Accessed April 18, 2024.

Chen S, Haen PS, Walton J, et al. The effects of thermal capsular shrinkage on the outcomes of arthroscopic stabilization for primary anterior shoulder instability. Am J Sports Med. 2005;33(5):705-711.

D’Alessandro DF, Bradley JP, Fleischli JE, Connor PM. Prospective evaluation of thermal capsulorrhaphy for shoulder instability: indications and results, two- to five-year follow-up. Am J Sports Med. 2004;32(1):21-33.

Jansen N, Van Riet RP, Meermans G, et al. Thermal capsulorrhaphy in internal shoulder impingement: a 7-year follow-up study. Acta Orthop Belg. 2012;78(3):304-308.

Gates GA, Green JD. Intermittent pressure therapy of intractable Mé​niè​re's disease using the Meniett device: a preliminary report. Laryngoscope. 2002;112(8 pt 1):1489-1493.


Gates GA, Green JD, Tucci DL, et al. The effects of transtympanic micropressure treatment in people with unilateral Mé​niè​re's disease. Arch Otolaryngol Head Neck Surg. 2004;130(6):718-725.

Gates GA, Verrall A, Green JD, Jr., et al. Meniett clinical trial: long-term follow-up. Arch Otolaryngol Head Neck Surg. 2006;132(12):1311-1316.

Grundy SM, Stone NJ, Bailey AL, et al. AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2019;73(24):3168-3209.

GSK press release. GSK provides an update on Blenrep (belantamab mafodotin-blmf) US marketing authorisation. November 22, 2022.  Available at: https://www.gsk.com/en-gb/media/press-releases/gsk-provides-update-on-blenrep-us-marketing-authorisation/. Accessed on April 18, 2024.

Gurkov R, Filipe Mingas LB, Rader T, et al. Effect of transtympanic low-pressure therapy in patients with unilateral Mé​niè​re's disease unresponsive to betahistine: a randomised, placebo-controlled, double-blinded, clinical trial. J Laryngol Otol. 2012;126(4):356-362.

Kazandjian D. Multiple myeloma epidemiology and survival: A unique malignancy. Semin Oncol. 2016;43(6):676-681.

Kramer CM, Villines TC. Coronary artery calcium scoring (CAC): Overview and clinical utilization. Up to Date. [UpToDate Web site]. 08/23/2022. Available at: http://www.uptodate.com/home/index.html [via subscription only]. 

Kulkarni S, Rumberger JA, Jha S. Electron Beam CT: A Historical Review. AJR Am J Roentgenol. 2021;216(5):1222-1228. 

Lonial S, Lee HC, Badros A, et al. Belantamab mafodotin for relapsed or refractory multiple myeloma (DREAMM-2): a two-arm, randomised, open-label, phase 2 study. Lancet Oncol. 2020;21(2):207-221.

Matasar MJ, Dreyling M, Leppä S, et al. Feasibility of combining the phosphatidylinositol 3-kinase inhibitor copanlisib With rituximab-based immunochemotherapy in patients with relapsed indolent B-cell Lymphoma. Clin Lymphoma Myeloma Leuk. 2021 Nov;21(11):e886-e894. 

Mattox DE, Reichert M. Meniett device for Ménière's disease: use and compliance at 3 to 5 years. Otol Neurotol. 2008;29(1):29-32.

Mohtadi NG, Hollinshead RM, Ceponis PJ, et al. A multi-centre randomized controlled trial comparing electrothermal arthroscopic capsulorrhaphy versus open inferior capsular shift for patients with shoulder instability: protocol implementation and interim performance: lessons learned from conducting a multi-centre RCT [ISRCTN68224911; NCT00251160]. Trials. 2006;7:4.

National Cancer Institute. The surveillance, epidemiology, and end results (SEER) Cancer Facts & Figures 2019. Available at: https://seer.cancer.gov/statfacts/html/mulmy.html. Accessed April 18, 2024.

National Institute for Clinical Excellence (NICE). Micropressure therapy for refractory Ménière's disease. NICE interventional procedure guidance 426. 2012: Available at: https://www.nice.org.uk/guidance/ipg426/chapter/1-Guidance. Accessed April 18, 2024.

National Institute of Child Health and Human Development. Home uterine monitors not useful for predicting premature birth. January 23, 2002. Available at: https://www.nichd.nih.gov/newsroom/releases/uterine. Accessed April 18, 2024.

Nooka AK, Kastritis E, Dimopoulos MA. Treatment options for relapsed and refractory multiple myeloma. Blood. 2015;125(20):3085-3099.

Oakes DA, McAllister DR. Failure of heat shrinkage for treatment of a posterior cruciate ligament tear. Arthroscopy. 2003;19(6):E1-E4.

Oncopeptides provides update on Pepaxto US marketing authorization. News release. Oncopeptides AB. December 7, 2022. Available at: https://bit.ly/3YcSMuG. Accessed on April 18, 2024. 

Oncopeptides withdraws Pepaxto® in US, scale down organization and focus on R&D. News release. Oncopeptides AB. October 22, 2021. Available at: https://bit.ly/3B5OCICAccessed April 18, 2024.

Oncopeptides​. Important information regarding PEPAXTO® in the United States. News release. Oncopeptides. March 1, 2022.  Available at: https://bit.ly/3hq2VUEAccessed April 18, 2024.

Reinsch N, Mahabadi AA, Lehmann N, et al. Comparison of dual-source and electron-beam CT for the assessment of coronary artery calcium scoring. Br J Radiol. 2012;85(1015):e300-e306. 

Russo FY, Nguyen Y, De Seta D, et al. Meniett device in Ménière disease: randomized, double-blind, placebo-controlled multicenter trial. Laryngoscope. 2017;127(2):470-475. 

Siegel RL, Miller KD, Jemal A. Cancer statistics, 2020. CA Cancer J Clin. 2020;70(1):7-30. 

​Syed MI, Rutka JA, Hendry J, et al. Positive pressure therapy for Ménière's syndrome/disease with a Meniett device: a systematic review of randomised controlled trials. Clin Otolaryngol. 2015;40(3):197-207.

Thomsen J, Sass K, Odkvist L, et al. Local overpressure treatment reduces vestibular symptoms in patients with Ménière's disease: a clinical, randomized, multicenter, double-blind, placebo-controlled study. Otol Neurotol. 2005;26(1):68-73.

Urquhart C, Currell R, Harlow F, et al. Home uterine monitoring for detecting preterm labour. Cochrane Database Syst Rev. 2017;2:CD006172.

US Preventive Services Task Force. Screening Home Uterine Activity Monitoring. January 1996. Available at: http://www.uspreventiveservicestaskforce.org. Last accessed on September 7, 2017.​ 


US Food and Drug Administration. Makena (hydroxyprogesterone caproate injection) information. 04/06/2023. Available at: https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/makena-hydroxyprogesterone-caproate-injection-information. Accessed April 18, 2024. 

US Food  and Drug Administration. Federal Register. Final decision on withdrawal of MAKENA (hydroxyprogesterone caproate) and eight abbreviated new drug applications following public hearing; availability of final decision. 05/15/2023. Available at: https://www.federalregister.gov/documents/2023/05/15/2023-10264/final-decision-on-withdrawal-of-makena-hydroxyprogesterone-caproate-and-eight-abbreviated-new-drug. Accessed April 18, 2024.
US Food and Drug Administration. Federal Register. Eli Lilly and Co.; Announcement of the revocation of the biologics license for LARTRUVO.  07/17/2020. Available at: https://www.federalregister.gov/documents/2020/07/17/2020-15516/eli-lilly-and-co-announcement-of-the-revocation-of-the-biologics-license-for-lartruvo. Accessed April 18, 2024.

US Food and Drug Adminstration. Federal Register. Bayer HealthCare Pharmaceuticals Inc.; Withdrawal of approval of new drug application for ALIQOPA (Copanlisib).  03/18/2024. Available at: https://www.govinfo.gov/content/pkg/FR-2024-03-18/pdf/2024-05619.pdf​. Accessed April 10, 2024. 

Virgil H. FDA requests Melphalan Flufenamide be withdrawn from US market. Dec 18, 2022. Available at: https://www.cancernetwork.com/view/fda-requests-melphalan-flufenamide-be-withdrawn-from-us-market. ​Accessed April 18, 2024.

Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates. 

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

87003


The following code is used to represent Arthroscopic electrothermal joint repair, Thermal capsulrorrhaphy, Electrothermal capsulorrhaphy, and Thermal or electrothermal shrinkage procedures:
29999 

 
The following code is used to represent Amylase, blood isoenzymes, electrophoretic, Bolen's test for cancer (Bolen's clot retraction test [CRT]), Colloidal gold, Chromium, blood, Chymotrypsin; duodenal contents, Gastric analysis, pepsin, Gastric analysis, tubeless, Guanase, blood, Hormones, adrenocorticotropin quantitative animal tests, Hormones, adrenocorticotropin quantitative bioassay, and Starch, Feces, Screening procedures:
84999 

 
The following code is used to represent Calcium saturation clotting time, Capillary fragility test (Rumpel-Leede), and Circulation time, one test procedures:
85999 

The following code is used to represent Skin test, Actinomycosis, Skin test, Brucellosis, Skin test, Cat scratch fever (cat scratch disease; Bartonella Infection), Skin test, Lymphopathia venereum, Skin test, Psittacosis, and Skin test, Trichinosis:
86486 

The following code is used to represent Bendien's test for cancer and tuberculosis, Calcium, feces, 24-hour quantitative, and Zinc sulphate turbidity, blood tests:
89240 

The following code is used to represent Rehfuss test for gastric acidity procedure:
91299 
 
The following code is used to represent​ Intracardiac phonocardiogram, Phonocardiogram with or without electrocardiogram (ECG) lead, with or without indirect carotid artery and/or jugular vein tracing, and/or apex cardiogram, and Vectorcardiogram (VCG), with or without electrocardiogram (ECG); with or without tracing SER services:

93799


ICD - 10 Procedure Code Number(s)
N/A

ICD - 10 Diagnosis Code Number(s)
N/A

HCPCS Level II Code Number(s)

A4638 Replacement battery for patient-owned ear pulse generator, each
E2120 Pulse generator system for tympanic treatment of inner ear endolymphatic fluid

J1726 Injection, hydroxyprogesterone caproate, (Makena), 10 mg
J9037 Injection, belantamab mafodontin-blmf, 0.5 mg

J9057 Injection, copanlisib, 1 mg​​​
J9247 Injection, melphalan flufenamide, 1 mg
J9285   Injection, olaratumab, 10 mg​​

M0100 Intragastric hypothermia using gastric freezing

M0301 Fabric wrapping of abdominal aneurysm

P2028 Cephalin flocculation, blood

P2029 Congo red, blood

P2031 Hair analysis (excluding arsenic)

P2033 Thymol turbidity, blood

P2038 Mucoprotein, blood (seromucoid)

S1030 Continuous noninvasive glucose monitoring device, purchase (for physician interpretation of data, use CPT code)

S1031 Continuous noninvasive glucose monitoring device, rental, including sensor, sensor replacement, and download to monitor (for physician interpretation of data, use CPT code)

S2103 Adrenal tissue transplant to brain

S2300 Arthroscopy, shoulder, surgical; with thermally-induced capsulorrhaphy

S8092 Electron beam computed tomography (also known as ultrafast CT, cine CT)​

S9001 Home uterine monitor with or without associated nursing services

S9025 Omnicardiogram/cardiointegram


THE FOLLOWING CODE IS USED TO REPRESENT hydroxyprogesterone caproate, (Makena) TO REDUCE THE RISK OF PRETERM BIRTH: 
J1729 Injection, hydroxyprogesterone caproate, not otherwise specified, 10 mg​

Revenue Code Number(s)
N/A

Policy History

Revisions From 01.01.24k:
06/03/2024
This version of the policy will become effective 06/03/2024. ​​

​The following pharmaceutical products were added to the policy: 
  • ​Copanlisib (Aliqopa) 
The following HCPCS codes have been added to the policy:

​J9057 Injection, copanlisib, 1 mg​​

Revisions From 01.01.24j:
07/01/2023
This version of the policy will become effective 07/01/2023. The policy title was updated to: Not Medically Necessary Services and Obsolete or Unreliable Diagnostic Tests.

The following medical service was added to the policy: electron beam computed tomography (EBCT).​

Policy coverage statement was added to include pharmaceutical products. The following pharmaceutical products were added to the policy: 
  • Single-agent ​belantamab mafodotin-blmf (Blenrep) ​
  • Hydroxyprogesterone caproate (Makena and generic products) 
  • Melphalan flufenamide (Pepaxto)
  • Olaratumab (Lartruvo
The following codes have been added to the policy: 
J1726 Injection, hydroxyprogesterone caproate, (Makena), 10 mg
J1729 Injection, hydroxyprogesterone caproate, not otherwise specified, 10 mg
J9037 Injection, belantamab mafodontin-blmf, 0.5 mg
J9247 Injection, melphalan flufenamide, 1 mg
J9285 Injection, olaratumab, 10 mg
S8092 Electron beam computed tomography (also known as ultrafast CT, cine CT)​​

Revisions From 01.01.24i:
11/21/2022
This version of the policy will become effective 11/21/2022. The following medical service was added to the policy: transtympanic micropressure device. The following codes have been added to the policy:  A4638,E2120.​

Revisions From 00.01.24h:
06/30/2021This policy has been reissued in accordance with the Company's annual review process.​
​10/07/2020

This policy has been reissued in accordance with the Company's annual review process.​
​05/06/2019
This version of the policy will become effective 05/06/2019. The following medical device was added to the policy: home uterine activity monitoring devices. The following HCPCS code has been added to the policy:

S9001 Home uterine monitor with or without associated nursing services (Not Medically Necessary)
Revisions From 00.01.24g:
01/14/2019This version of the policy will become effective 01/14/2019. The following medical service was added to the policy: arthroscopic electrothermal joint repair. The following codes have been added to the policy: 29999, S2300.

Effective 10/05/2017 this policy has been updated to the new policy template format.
06/03/2024
06/03/2024
N/A
00.01.24
Medical Policy Bulletin
Commercial
No