062025 Form

Medical policy announcements Posted March 2025

This document announces new medical policy changes that take effect June 1, 2025. Changes affect these specialties:

Orthopedics Plastic Surgery – Panniculectomy

Genetic Testing Guidelines Chromosomal Microarray Analysis Whole Exome and Whole Genome Sequencing Pharmacogenomic Testing Predictive and Prognostic Polygenic Testing

Note that revised, clarified, or retired policies may have separate effective dates. See details in the table below.

Orthopedics Policy Title Policy No. Policy Change Summary Effective Date Products Affected Provider Actions
required Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions

111 Policy retired.
Codes 27415, 27416, 29866 29867 from retired MP 111 added to MP 221 Musculoskeletal Services Management CPT and HCPCS Codes.

Code 28446 will no longer require prior authorization effective 3.1.25. This is a covered service.

March 1, 2025 Commercial
Medicare No action required.

Musculoskeletal Services Management CPT and HCPCS Codes

221 Policy clarified. Codes 27415, 27416, 29866 29867 from retired MP 111 added to MP 221.
March 1, 2025 Commercial
Medicare PA is required for codes 27415, 27416, 29866 29867 through InterQual.

Musculoskeletal Services Management

220 Policy clarified. MP 111 Autografts and Allografts in the Treatment of Focal Articular Cartilage March 1, 2025 Commercial
Medicare PA is required for codes 27415, 27416, 29866 29867 through InterQual.

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Lesions noted as retired.

Codes 27415, 27416, 29866 29867 from retired MP 111 added to MP 221 Musculoskeletal Services Management CPT and HCPCS Codes.

Meniscal Allografts and Other Meniscal Implants 110 Policy retired.
Code 29868 from retired MP 110 added to MP 221 Musculoskeletal Services Management CPT and HCPCS Codes.

Ongoing investigational code G0428 transferred to MP 400 Non-covered Services List.

March 1, 2025 Commercial
Medicare No action required.

Musculoskeletal Services Management CPT and HCPCS Codes

221 Policy clarified. Code 29868 from retired MP 110 added to MP 221.
March 1, 2025 Commercial
Medicare PA is required for code 29868 through InterQual.

Musculoskeletal Services Management

220 Policy clarified. MP 110 Meniscal Allografts and Other Meniscal Implants noted as retired.

Codes 29868 from retired MP 110 added to MP 221 Musculoskeletal Services Management CPT and HCPCS Codes.

March 1, 2025 Commercial
Medicare PA is required for code 29868 through InterQual.

Plastic Surgery
Policy Title Policy No. Policy Change Summary Effective Date Products Affected Provider Actions
required

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Plastic Surgery

068 Policy revised.
Clinical criteria on panniculectomy updated.
June 1, 2025 Commercial Prior authorization is required.

Genetic Testing Guidelines Legend Text color Indicates… Guideline Change Summary
Blue Change to guideline wording

Black Preservation of existing guideline wording

Changes expected to be… Explanation of Change Green More expansive on appropriateness Red More restrictive on appropriateness Black Have minimal if any impact on appropriateness review and exists primarily to clarify intent

The following updates will apply to the Carelon Clinical Appropriateness Guidelines for Genetic Testing. You may access and download a copy of the current guidelines here. For questions related to the guidelines, please contact Carelon via email at MedicalBenefitsManagement.guidelines@carelon.com

Clinical Appropriateness Framework Added this statement that will appear in all Carelon guidelines: Genetic tests not specifically mentioned in the guidelines are considered not medically necessary.

Carelon Guideline
Policy Change Summary Effective Date Chromosomal Microarray Analysis
Postnatal/ Pediatric evaluation Postnatal/Pediatric evaluation
Chromosomal microarray analysis is considered medically necessary as a first-line test in the initial postnatal evaluation of individuals with ANY of the following:
• Multiple congenital anomalies without an established diagnosis
• Congenital or early onset epilepsy (before age 3 years) without suspected environmental causes
• Autism spectrum disorder with no identifiable cause (idiopathic)
• Developmental delay or intellectual disability with no identifiable cause (idiopathic)
• Early neonatal death up to 7 days after birth o Note: If chromosomal microarray has been performed prenatally, it is not medically necessary to repeat it postnatally.

Explanation of change
Expansive edit to include neonatal death to the list of indications considered medically necessary for chromosomal microarray analysis.

June 15, 2025 Optical Genome Mapping

Optical Genome Mapping Optical Genome Mapping is considered not medically necessary in prenatal and postnatal evaluation.

June 15, 2025

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Explanation of change
New section for Optical Genome Mapping clarifies current position as not medically necessary. OGM may be an alternative methodology for structural variant analysis, but more studies are required before considering this technique as medically necessary.

Carelon Guideline
Policy Change Summary Effective Date Whole Exome and Whole Genome Sequencing
Whole Exome Sequencing Whole Exome Sequencing
Whole exome sequencing (WES) is considered medically necessary in the following scenarios.

GENERAL CRITERIA
ALL of the following general criteria must be met:
• The results of testing would confirm or establish a clinical diagnosis • Counseling, which encompasses ALL of the following components, has been performed:
o Interpretation of family and medical histories to provide a risk assessment for disease occurrence or recurrence o Education about inheritance patterns, genetic testing, disease management, prevention, and resources
o Counseling to promote informed choices and adaptation to the risk or presence of a genetic condition
o Counseling for the psychological aspects of genetic testing
o Counseling should include the following details:
▪ Limitations of the testing used
▪ A negative result does not indicate heritable risk is zero or low
▪ Identification of incidental secondary findings and inconclusive results called variants of uncertain significance is possible
▪ Modifications to genetic variants’ pathogenicity interpretations can occur, and patients may be recontacted with reclassified results in the future
• Post-test counseling should be performed for genetic test results

SPECIFIC CRITERIA REQUIRED BASED ON CLINICAL PRESENTATION:
A. Prenatal (required):
• Abnormal fetal anatomic findings which are characteristic of a genetic abnormality and no diagnostic findings found on karyotype and/or chromosomal microarray testing
OR

June 15, 2025

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B. Postnatal:
Whole exome sequencing (WES) is indicated if ONE of the following criteria is met:
• Multiple anomalies (i.e., structural and/or functional) apparent before one year of age not suggestive of a specific genetic condition for which a targeted gene panel is available or chromosomal microarray is the appropriate diagnostic methodology
• Developmental delay, autism spectrum disorders, or intellectual disability with onset prior to 18 years of age with no identifiable cause (idiopathic)
• Congenital or early onset epilepsy (before age 3 years) without suspected environmental etiology

Whole exome sequencing (WES) is considered not medically necessary in the following scenario:
• Genomic autopsy for early neonatal death (up to 7 days after birth)

Note: WES may include comparator WES testing of the biologic parent(s) or sibling (duo or trio testing) of the affected individual.

Explanation of change
Clarify and restructure the criteria for improved readability. Restrictive edit specifies that WES for early neonatal death is an exclusion.

Carelon Guideline
Policy Change Summary Effective Date Pharmacogenomic Testing
Pharmaco- genomic Testing For each of the therapies and associated biomarkers in Table 1, genotyping for the appropriate biomarker is considered medically necessary when ALL the following conditions are met:
• The medication for which genotyping is being done is the most appropriate treatment for the individual’s underlying condition
• The pharmacogenomic test has demonstrated analytical and clinical validity and clinical utility for the individual, including consideration of the frequency of relevant alleles in the individual’s subgroup (when applicable)
• The biomarker testing is focused on the specific genetic polymorphisms relevant to guiding treatment for the individual’s condition and expected treatment
Explanation of change
Clarifications

June 15, 2025

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Table 1. Therapies and associated biomarkers considered medically necessary for genotyping Biomarker Drug Therapeutic Area ApoE4
Lecanemab, donanemab-azbt Neurology CFTR ivacaftor Pediatrics CYP2C19 clopidogrel Cardiology CYP2C9 siponimod Neurology CYP2C9 deuruxolitnib Dermatology CYP2D6 eliglustat Hematology CYP2D6 tetrabenazine Neurology G6PD rasburicase Hematology G6PD tafenoquine, primaquine Infectious Diseases HLA-B1502 carbamazepine, oxcarbazepine Neurology HLA-B5701 abacavir Infectious Diseases HLA-B*58:01 allopurinol Rheumatology NAGS carglumic acid Gastroenterology POLG divalproex sodium, valproic acid Neurology TPMT NUDT15 mercaptopurine, thioguanine Hematology

Explanation of change
Clarified title of Table
Expansive changes:
• donanemab-azbt added for association with genotyping for ApoE ε4 in the realm of Neurology for treatment of Alzheimer’s disease
• deuruxolitinib added for association with genotyping for CYP2C9 in the realm of Dermatology for treatment of alopecia areata
• NUDT15 risk allele added to explain the majority of thiopurine-related myelosuppression risk in Asians and Hispanics. It is reasonable to expand the table and include it in this testing

Clarification: eliglustat’s therapeutic area clarified as being related to hematology rather than pediatrics

Predictive and Prognostic Polygenic Testing Guideline reaffirmed. Edited Description/Scope and Rationale.

New 2025 Category III CPT Codes All category III CPT Codes, including new 2025 codes are non-covered unless they are explicitly described as “medically necessary” in a BCBSMA medical policy. To search for a particular code, click the following link:

https://www.bluecrossma.org/medical-policies/ and type the code in the search box on the page. Consult the coverage statement of any associated medical policy. If there is no associated policy, the code is non-covered.

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A full draft version of each policy is available only by request, to ordering participating clinician providers, one month prior to the effective date of the policy. To request draft policies, contact Medical Policy Administration at ebr@bcbsma.com.

Definitions Medically Necessary: Procedure, services or supplies needed to diagnose or treat an illness, injury, condition, disease, or its symptoms, and that meet accepted standards of medicine.

Edits: Blue Cross Blue Shield of Massachusetts uses edits to enforce medical policies. These system edits use CPT/HCPCS and ICD-10 diagnosis codes to ensure claims are processing according to the medical policy.

Post Payment Review: After a claim has been paid, Blue Cross Blue Shield of Massachusetts will review the paid claim and determine if the claim has been paid appropriately.

Prior Authorization: Certain inpatient and outpatient services are reviewed to determine if they are medically necessary and appropriate for the member. If the determination is made that the services are medically necessary, an approval—or authorization— is sent in writing to the member, primary care provider (PCP), the treating physician, and the facility (if applicable) to let them know that the services have been approved.

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