April 2024 Form

WPS Medical Policy Updates The Medical Affairs Medical Policy Committee recently approved medical policies that will become effective on the specified dates. Disclaimer: Medical Policies are for informational purposes only and do not constitute medical advice, plan authorization, an explanation of benefits, or a guarantee of payment. Benefit plans vary in coverage and some plans may not provide coverage for all services listed in a policy. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and federal law. Some benefit plans administered by the organization may not utilize Medical Affairs medical policy in all their coverage determinations. Contact Customer Service as listed on the customer ID card for specific plan, benefit, and network status information. Medical policies are based on constantly changing medical science and are reviewed annually and subject to change. The organization uses tools developed by third parties, such as the evidence-based clinical guidelines developed by MCG to assist in administering health benefits. Medical Policies and MCG guidelines are intended to be used in conjunction with the independent professional medical judgment of a qualified health care provider.

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To obtain a referenced MCG guideline specific to your patient’s review, contact Medical Affairs toll-free at 800-333-5003. •
For general medical policy or MCG requests, email medical.policies@wpsic.com. •
If you have specific questions or comments regarding development of policy content, contact the Medical Policy Editor at medical.policies@wpsic.com or 800-333-5003, ext. 06984. •
For questions regarding medical coding related to Medical Policy Committee policies, contact the Code Governance Committee at codegovernance@wpsic.com.

Medical Policy Highlights Reviewed Jan. 2024 Multiplex Pathogen Testing for Infectious Disease
Effective Feb. 1, 2024 Indications of Coverage: ADDED-sexually transmitted infection, and vaginal pathogens. Non-Covered Services (NCS) and Procedures DME section only Effective July 1, 2024 DME: ADDED-Volara (Hillrom) for Respiratory Therapy. E/I/U. Reviewed Feb. 2024 Ankle Arthroplasty, Total Effective March 1, 2024 Limitations of Coverage: ADDED-Subtalar arthroereisis (subtalar joint implantation).

Artificial Disc Replacement Effective March 1, 2024 Limitations of coverage: ADDED to Contraindications-Severe facet degeneration at the operative level REMOVED-Presence of lumbosacral scoliosis. ADDED-Spinal navigation systems for any disc replacement are considered integral to the primary procedure and are not separately reimbursable.
Bone Growth Stimulators Effective March 1, 2024 Limitations of Coverage: ADDED-Except in cases of arthrodesis nonunion. Meniscal Allograft Transplant Effective March 1, 2024 Indications of Coverage: ADDED-EITHER irreparable meniscal tear or prior meniscectomy with absence of at least 50% of the meniscus. Reviewed March 2024 NCS-Genetics section Effective July. 1, 2024 ADDED-Alzheimer disease test-Quest AD-Detect test.
ADDED-Avise Lupus Test (Exagen Inc.). ADDED-Bladder EpiCheck (Nucleix). ADDED-Coagulation Disorder Panel (Versiti). ADDED-Comprehensive genomic profiling for Tumor evaluation tests, including but not limited to OncoExTra (Exact Sciences Corp.). ADDED-Congenital Neutropenia Panel (Versiti Diagnostic Laboratories). ADDED-Invitae Comprehensive Lipidemia Panel (Invitae Corp.). ADDED-Lung Transplant Rejection testing to include AlloSure Lung (CareDX). ADDED-Multiprotein biomarker panels/tests, to include HART CADhs for Coronary Artery Disease. ADDED-GeneStrat (Biodesix Inc.) targeted genomic test. ADDED-Pharmacogenetic Genotyping for Altering Drug Treatment: MTHFR. NCS-Genetics section Effective July. 1, 2024 ADDED-Barostim Neo System (CVRx Inc.).

ADDED-Bariatric Surgery with any of the following: Intragastric Balloons, Single Anastomosis Duodenal Switch, OverStitch Endoscopic Suturing system, AspireAssist, Endoluminal Functional Lumen Imaging Probe (EndoFLIP), Mini Gastric Bypass-One Anastomosis Gastric Bypass. Indications: For weight loss, morbid obesity. ADDED-Cunningham Panel (Moleculara Labs). ADDED-EpiSwitch Checkpoint Inhibitor Response Test (CiRT) (Oxford BioDynamics PLC). ADDED-Intrinsic Hepcidin IDx (IntrinsicDx) . ADDED-KidneyIntelX (.dkd) (Renalytix). ADDED-miraDry Microwave Therapy (miraDry Inc.). REMOVED-Platelet Injections (Platelet Rich Plasma) AND Autologous Blood Injections, refer to MCG PRP A-0630. ADDED-RestorU Method (uMethod). ADDED-Syn-One Test (CND Life Sciences). ADDED-Synovasure (Zimmer Biomet). ADDED-TissueCypher Barrett’s Esophagus Assay (Castle Biosciences, Inc.). Sleep Disorder Testing
Effective April. 1, 2024 Indications of coverage: ADDED-(or STOP-BANG score of 5 or higher) after Epworth sleep score of 10 or higher. Pediatric (Child, Infant, or Neonate) In-Laboratory Polysomnogram ADDED- Please refer to MCG for criteria. Sleep Disorder Treatment
Effective July. 1, 2024 Indications of Coverage: H. Hypoglossal nerve stimulation (Inspire) for OSA: 3. A polysomnography (PSG) is performed ADDED-no more than 24 months prior to the first consultation for Inspire implant. Limitations of Coverage: ADDED-Drug Induced Sleep Endoscopy when used for any indication other than to evaluate if the patient is an appropriate candidate for hypoglossal nerve stimulation to treat obstructive sleep apnea. ADDED-Radiofrequency Ablation of palate for snoring or obstructive sleep apnea is considered experimental, investigational, unproven AND not medically necessary as there are alternative services considered standard of care. ADDED-PAP cleaning devices and supplies (e.g., SoCleane2® CPAP Cleaner and Sanitizer Machine) are considered convenience items (most member plans have a general exclusion for convenience items). In the absence of plan language, these are considered not medically necessary. ADDED-Devices considered duplicate, to include Back up units, travel units (ResMed Air Mini CPAP), or secondary units are considered a health plan exclusion.

Whole Exome and Whole Genome Sequencing
Effective April. 1, 2024 Indications of coverage: ADDED-Autism spectrum disorder. ADDED-CMA (chromosomal microarray analysis) has already been completed and is either negative or inconclusive. ADDED-Whole genome sequencing (WGS) should be referred to the medical director for individual consideration of necessity. Limitations of Coverage: Testing of a fetus using Whole Exome Sequencing (WES) ADDED-or Whole Genome Sequencing (WGS). REMOVED-Whole Genome Sequencing (WGS) is considered experimental, investigational, and unproven for evaluating any genetic disorder. Reminder All genetic, genomic, pharmacogenetic, pharmacogenomic, molecular genetic, mRNA, DNA, chromosome, telomere, single nucleotide polymorphism (SNP), gene sequencing, gene expression profiles, and gene- related panels, tests, and analyses require prior authorization BEFORE the testing is completed. Determination of genetic panel coverage is based on assessment of the test’s analytical and clinical validity, the clinical utility of the test, and evidence demonstrating a positive impact of the test panel on the care of individuals with, or at risk for, the conditions being tested. The Medical Policy Committee (MPC) considers multi-gene test panels experimental, investigational, and unproven to affect health outcomes unless otherwise determined during prior authorization review. The complete library of our medical policies and the quarterly Medical Policy Update reports can be found online at wpshealth.com. No password required! ©2024 Wisconsin Physicians Service Insurance Corporation and WPS Health Plan, Inc. All rights reserved. JO25661
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