Islet Transplantation for Chronic Pancreatitis and Donislecel-jujn for Type 1 Diabetes (REVISED POLICY TITLE)
Policy formerly known as Islet Transplantation. Allogeneic islet transplantation using an FDA-approved cellular therapy product (donislecel-jujn [i.e., Lantidra]) is considered not medically necessary for the treatment of type 1 diabetes as the evidence is insufficient to determine the effects of the technology on health outcomes.Allogeneic Pancreatic islet cell transplantation will remain for Medicare Advantage plans only as part of an approved clinical trial. This will go into effect 1 de abril, 2024. For additional information related to this policy, please click here.
Speech Therapy
Provided clarification that, to ensure proper claim filing for both Medicare Advantage plans and commercial products, when any of the speech therapy CPT codes in the policy are filed, modifier GN (services delivered under an outpatient ST plan of care) must be appended to the CPT code(s) to distinguish the discipline under which the service is delivered. There are no changes in coverage or medical criteria. For additional information related to this policy, please click here.
Gene Therapies for Duchenne Muscular Dystrophy
Effective 1 de janeiro, 2024, HCPCS code J1413 (New Code Effective 1 de janeiro, 2024) was considered not covered for Medicare Advantage plans and not medically necessary for commercial products. This coverage determination was also included in the provider update article, “Additional HCPCS Level II Code Changes and Modifier Changes for 20 de janeiro24." For additional information related to this policy, please click here.
Allergy Testing
Effective 1 de abril, 2024, ELISA/Act (Enzyme-linked Immunosorbent Assay/Advanced Cell Test) qualitative antibody testing and LMRA (Lymphocyte Mitogen Response Assays) by ELISA/Act will be considered not covered for Medicare Advantage plans and not medically necessary for commercial products. CPT codes 86003 and 86008 will remain covered when filed with a covered diagnosis for Medicare Advantage plans and commercial products, and when filed appropriately for the applicable laboratory test. For both Medicare Advantage plans and commercial products unlisted CPT code 86849 will also be added to the policy for any test identified in the policy that does not have a specific CPT code. IgG and IgG subclass antibody tests for food allergy will be removed from the policy. The annual maximum allowed units will be revised for both Medicare Advantage plans and commercial products for CPT codes 95004 (will change from 70 to 80 units), 95027 (will change from 80 to 90 units) and 95052 (will change from 20 to 36 units). Additional language will clarify that positive or negative control testing may not be included in the number of units reported for In Vivo Allergy Testing. For additional information related to this policy, please click here.
Novel Biomarkers in Risk Assessment and Management of Cardiovascular Disease
Effective 1 de abril, 2024, CPT codes 83700, 83701, and 83704 will be covered when filed with a covered diagnosis for Medicare Advantage plans and CPT codes 82610, 83695, 83722, 85384, and 85385 will be considered not covered for Medicare Advantage plans. No changes for commercial products. For additional information related to this policy, please click here.
Percutaneous Electrical Nerve Stimulation, Percutaneous Neuromodulation Therapy, and Restorative Neurostimulation Therapy (REVISED POLICY TITLE)
There has been a change to a previous article in the December Provider Update related to this policy.
Restorative neurostimulation therapy (Reactiv8). This will be covered for Medicare Advantage Plans and not medically necessary for Commercial Products. This will go into effect 1 de fevereiro, 2024. For additional information related to this policy, please click here.