Local Coverage Determinations and Article Updates March/April 2020
The medical policies and related articles can be found in our Medical Policy Center.
New LCDs/Articles effective April 1, 2020
Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea (L38387) and Billing and Coding: Hypoglossal Nerve Stimulation for Treatment of Obstructive Sleep Apnea (A57092)
OSA is a disease characterized by recurrent episodes of upper airway obstruction during sleep. The disruption in airflow caused by OSA has been associated with multiple comorbidities, including hypertension, cardiovascular disease, cardiac arrhythmia, cerebrovascular disease, excessive daytime sleepiness, and mood disorders. CPAP has long been the primary treatment modality of choice for OSA, showing improvements in many comorbidities. Unfortunately, despite attempts to improve compliance, many people are unable to tolerate treatment with CPAP. Because of the large percentage of patients not tolerating CPAP, alternative treatment strategies are necessary.
Salvage High-intensity Focused Ultrasound (HIFU) Treatment in Prostate Cancer (PCa) (L38262) and Billing and Coding: Salvage High-intensity Focused Ultrasound (HIFU) Treatment in Prostate Cancer (PCa) (A56702)
Originally developed in the 1940s, HIFU is an energy-based, minimally invasive, ablative treatment. For PCa, a transrectal ultrasound probe both images the prostate and delivers timed bursts of heat to create coagulation necrosis in a targeted area. A cooling balloon surrounding the probe protects the rectal mucosa from the high temperature. HIFU is typically performed in an outpatient setting under spinal or general anesthesia. Salvage HIFU is intended to completely ablate all prostate tissue that remains after primary EBRT.
Revised LCDs/Articles effective April 1, 2020
Billing and Coding: Rituximab, biosimilars and Rituximab and hyaluronidase human (Rituxan Hycela™) (A52452)
The article has been updated to add rituximab-pvvr effective for dates of service on or after 7/23/2019. HCPCS codes C9399 and J3590 have been added to the “CPT/HCPCS Codes Group 1 Paragraph” section to report rituximab-pvvr. HCPCS codes C9399 and J3590 have been added to the “CPT/HCPCS Codes” section. References to rituximab-pvvr have been added throughout the article.
Select Minimally Invasive GERD Procedures (L35080)
Based on a reconsideration request for the LINX® Reflux Management System, the “Summary of Evidence” and “Analysis of Evidence” sections have been revised and sources have been added to the “Bibliography” section of the LCD. No changes were made in coverage.
Stereotactic Radiation Therapy: Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT) (L35076)
Based on a reconsideration request, choroidal and other ocular melanomas has been added as an indication, the "Summary of Evidence" and the "Analysis of Evidence" sections have been revised and sources have been added to the "Bibliography" and under the "Sources of Information" section.
Stereotactic Radiation Therapy: Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT) (A56874)
Based on a reconsideration request, the following diagnosis codes have been added to Group 1 in the "ICD-10 Codes that support medical necessity" section: C69.31 and C69.32.
Added CPT codes: 61796, 61797, 61798, 61799, 61800, 63620 and 63621 to Group 1 in the "CPT/HCPCs Codes" section.
Revised Articles
Routine Foot Care and Debridement of Nails (A57759)
Article revised to clarify coverage for debridement of mycotic nails and to remove the following documentation requirements:
For debridement of mycotic nails, each service encounter, the medical record should contain a description of each nail which requires debridement. This should include, but is not limited to, the size (including thickness) and color of each affected nail. In addition, the local symptomatology caused by each affected nail resulting in the need for debridement must be documented.For CPT code 11720 documentation of at least one nail will be accepted. For CPT code 11721 complete documentation must be provided for at least 6 nails.
Self-Administered Drug Exclusion List: Medical Policy Article (A53021 (JK) and A53022 (J6))
The article has been updated to add: Guselkumab (Tremfya®) (J1628) and Ustekinumab (Stelara®) (J3357) effective for dates of service on or after 5/3/2020. Medicare data supports greater than 50% is self-administered. Pasireotide (Signifor®) (C9399, J3490) has been added and is effective for dates of service on or after 5/3/2020.
Transthoracic Echocardiography (TTE) (A56781)
Article revised to add ICD-10 codes I12.0, I12.9, I13.10 and I13.11 to Group 1. As a result of these additions, Group 3 became redundant and has been deleted. Groups 4 and 5 have been renumbered to Group 3 and 4.
Posted 3/26/2020