MP/CG Update/Notice - April 2020 Form

Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. April 1, 2020

[Provider Name] [Address] [City], [State] [Zip]

Dear Provider:

Anthem Blue Cross is pleased to provide you with our new and updated Medical Policies and Clinical UM Guidelines.
Please refer to the specific policy for coding, language, and rationale updates and changes that are not summarized below.

Updates to AIM Specialty Health® (AIM) programs, a separate company, apply to local fully-insured Anthem members and select members who are covered under self-insured (ASO) benefit plans with services medically managed by AIM.
They do not apply to HMO, BlueCard®, Medicare Advantage, Medicaid, Medicare Supplement, Federal Employee Program® (FEP®). For more information, please contact the phone number of the back of the member ID card.

New Medical Policies and Clinical Guidelines

 CG-MED-87 Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications:
This document addresses the use of single photon emission computed tomography (SPECT) for non- cardiovascular indications. o Content moved from RAD.00023 o Prior authorization required effective July 1, 2020

 CG-SURG-104 Intraoperative Neurophysiological Monitoring: This document addresses the various types of evoked response studies and their use in intraoperative neurophysiological monitoring. o Prior authorization required effective July 1, 2020

 CG-SURG-105 Corneal Collagen Cross-Linking: This document addresses corneal collagen cross-linking (CXL, also known as 3-CR or C3R), a minimally invasive photochemical treatment of progressive keratoconus and other corneal thinning processes, such as ectasia after laser in-situ keratomileusis (LASIK).
o Content moved from MED.00109 o Prior authorization required effective July 1, 2020

 CG-SURG-106 Venous Angioplasty with or without Stent Placement or Venous Stenting Alone: This document addresses venous angioplasty with or without stent placement, or venous stenting alone, as a treatment modality for a variety of conditions.
o Prior authorization required effective July 1, 2020

 CG-SURG-107 Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH):
This document addresses various surgical and minimally invasive procedures used in the treatment of benign prostatic hyperplasia, and the use of these procedures. o Content moved from SURG.00028 effective April 15, 2020 o Investigational & Not Medically Necessary changed to Not Medically Necessary as a result of transition o Added examples of technologies for prostatic urethral lift, transurethral convective water vapor thermal ablation and waterjet tissue ablation o Added Not Medically Necessary statement for prostatic urethral lift when the intent is to treat symptoms of conditions other than benign prostatic hyperplasia

 CG-SURG-108 Stereotactic Radiofrequency Pallidotomy: This document addresses the use of stereotactic radiofrequency pallidotomy for the treatment of Parkinson’s disease and other conditions.
o Content moved from SURG.00016 effective April 15, 2020 o Investigational & Not Medically Necessary changed to Not Medically Necessary as a result of transition o Prior authorization required effective July 1, 2020

Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

 DME.00041 Low Intensity Therapeutic Ultrasound for the Treatment of Pain: This document addresses the use of a low intensity therapeutic ultrasound device for the treatment of pain. o The use of a low intensity therapeutic ultrasound device is considered Investigational & Not Medically Necessary for all indications

 GENE.00053 Metagenomic Sequencing for Infectious Disease in the Outpatient Setting: This document addresses metagenomic sequencing of infectious pathogens in the outpatient setting. o Metagenomic sequencing for infectious diseases in the outpatient setting is considered Investigational & Not Medically Necessary for all indications

 GENE.00054 Paired DNA and Messenger RNA (mRNA) Genetic Testing to Detect, Diagnose and Manage Cancer: This document addresses testing for DNA in combination with mRNA to detect, diagnose and manage cancer.
o Messenger RNA (mRNA) sequence analysis alone or in conjunction with DNA sequence analysis to aid in the classification of variations of uncertain significance or to otherwise detect, diagnose or manage cancer is considered Investigational & Not Medically Necessary

 SURG.00154 Microsurgical Procedures for the Treatment of Lymphedema: This document addresses select surgical procedures for the treatment of lymphedema in the upper and lower extremities. o Microsurgery for the treatment of lymphedema (including lymphedema as a result of a mastectomy) is considered Investigational & Not Medically Necessary, including but not limited to the following:  Lymphaticolymphatic bypass;  Lymphovenous bypass;  Lymphaticovenular anastomosis;  Vascularized lymph node transfer;  Tissue/Flap transfer (for example, omental flap transfer) o Prior authorization required effective July 1, 2020

 SURG.00155 Cryoneurolysis for Treatment of Peripheral Nerve Pain: This document addresses cryoneurolysis for treatment of peripheral nerve pain, including the relief of pain and symptoms associated with osteoarthritis of the knee. o Cryoneurolysis for treatment of peripheral nerve pain is considered Investigational & Not Medically Necessary for all indications, including osteoarthritis of the knee

UPDATED Medical Policies and Clinical Guidelines effective July 1, 2020

 DME.00011 Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices: This document specifically addresses auricular electrostimulation, H-Wave stimulation, interferential stimulation therapy, microcurrent electrical nerve stimulation, pulsed electrical stimulation (including pulsed electromagnetic field stimulation), percutaneous neuromodulation therapy, supraorbital transcutaneous neurostimulation, and sympathetic therapies. o Revised title (previous title: Electrical Stimulation as a Treatment for Pain and Related Conditions: Surface and Percutaneous Devices) o Revised scope of document to include other conditions and devices o Added cranial electrical stimulation (CES) as Investigational & Not Medically Necessary for all indications o Added remote electrical neuromodulation (REN) as Investigational & Not Medically Necessary for all indications

 GENE.00052 Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling: This document addresses whole genome sequencing, whole exome sequencing, and gene panel testing. For the purposes of this document, a gene panel is defined by five or more genes or gene mutation variants tested on the same day on the same member by the same rendering provider.
o Added CPT PLA code 0171U for MyMRD® NGS Panel, considered Investigational & Not Medically Necessary

Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

 LAB.00011 Analysis of Proteomic Patterns: This document addresses the use of proteomics, which is the qualitative and quantitative analysis of the collection of protein constituents in a biological sample. o Revised Investigational & Not Medically Necessary statement to include management of disease

 MED.00120 Gene Therapy for Ocular Conditions: This document addresses the use of voretigene neparvovec-rzyl (Luxturna), a gene replacement therapy intended to treat retinal dystrophies caused by biallelic RPE65 gene mutations. o Revised title (previous title: Voretigene neparvovec-rzyl [Luxturna®]) o Expanded scope of document to include all gene therapies for ocular conditions o Removed redundant language "gene therapy" o Added the use of all other gene replacement therapies to treat any ocular condition as Investigational & Not Medically Necessary

 SURG.00032 Patent Foramen Ovale and Left Atrial Appendage Closure Devices for Stroke Prevention:
This document addresses the transcatheter closure of patent foramen ovale and transcatheter or open left atrial appendage (LAA) closure when performed to prevent stroke using cardiac occlusion devices. o Revised title (previous title: Transcatheter Closure of Patent Foramen Ovale and Left Atrial Appendage for Stroke Prevention) o Added left atrial appendage closure via surgical (non-percutaneous) implantation of a device as Investigational & Not Medically Necessary for all indications

UPDATED Medical Policies and Clinical Guidelines for AIM eligible members only effective July 1, 2020

 CG-MED-88 Preimplantation Genetic Diagnostic Testing: This document addresses the use of preimplantation genetic diagnosis (PGD) and preimplantation genetic screening (PGS) which is performed as part of an assisted reproductive procedure.
o Content moved from CG-GENE-06 o Added Medically Necessary and Investigational & Not Medically Necessary statements addressing preimplantation embryo biopsy o Minor wording change in clinical indication section

Medical Policy converted to Clinical Criteria effective February 5, 2020

MP Number Title CC Number MED.00123 Axicabtagene ciloleuce (Yescarta®) ING-CC-0151 MED.00124 Tisagenlecleucel-T (Kymriah®) ING-CC-0150

Medical Policies to be archived

 BEH.00002 Transcranial Magnetic Stimulation – effective July 1, 2020  MED.00007 Prolotherapy for Joint and Ligamentous Conditions - effective April 15, 2020  MED.00074 Computer Analysis and Probability Assessment of Electrocardiographic-Derived Data - effective April 15, 2020  RAD.00012 Ultrasound for the Evaluation of Paranasal Sinuses - effective April 15, 2020  SURG.00067 Percutaneous Vertebroplasty, Kyphoplasty and Sacroplasty - effective May 17, 2020  THER-RAD.00009 Intraocular Epiretinal Brachytherapy - effective April 15, 2020

Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

Specialty Pharmacy Updates

Prior Authorization updates

Effective for dates of service on and after July 1, 2020, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process. Clinical criteria document information is available at www11.anthem.com/ca/pharmacyinformation/clinicalcriteria.html.

Please note, inclusion of NDC code on your claim will shorten the claim processing time of drugs billed with a Not Otherwise Classified (NOC) code.

Pre-service clinical review of non-oncology specialty pharmacy drugs will be managed by the Anthem Blue Cross medical specialty drug review team. *Review of specialty pharmacy drugs for oncology indications will be managed by AIM Specialty Health® (AIM), a separate company and are in italics.

Clinical Criteria HCPCS or CPT Code(s) Drug *ING-CC-0003 C9399, J3490, J3590 Xembify ING-CC-0062 J3590 Eticovo ING-CC-0062 J3490 Hadlima ING-CC-0072 J0179 Bevou ING-CC-0152 J3490 Vyondys 53 ING-CC-0153 C9399, J3490, J3590 Adakveo ING-CC-0154 C9399, J3490, J3590 Givlaari Step therapy updates
Effective for dates of service on and after July 1, 2020, the following specialty pharmacy codes from new or current clinical criteria will be included in our existing specialty pharmacy medical step therapy review process.
Orencia will be the non-preferred agent for rheumatoid arthritis, polyarticular juvenile idiopathic arthritis and psoriatic arthritis. The table below will assist you in identifying the applicable preferred agents and clinical criteria. Rheumatoid Arthritis (RA) Clinical Criteria HCPCS or CPT Code Preferred Agent Clinical Criteria HCPCS Code
Non-Preferred Agent ING-CC-0062 J1438 Enbrel ING-CC-0078 J0129 Orencia ING-CC-0062 J0135 Humira ING-CC-0062 J3590 Simponi ING-CC-0062 J1602 Simponi Aria ING-CC-0062 J1745 Remicade

Polyarticular Juvenile Idiopathic Arthritis (PJIA) Clinical Criteria HCPCS or CPT Code Preferred Agent Clinical Criteria HCPCS Code
Non-Preferred Agent ING-CC-0062 J1438 Enbrel ING-CC-0078 J0129 Orencia ING-CC-0062 J0135 Humira

Psoriatic Arthritis (PsA) Clinical Criteria HCPCS or CPT Code Preferred Agent Clinical Criteria HCPCS Code
Non-Preferred Agent ING-CC-0042 C9399, J3490, J3590 Cosentyx ING-CC-0078 J0129 Orencia ING-CC-0062 J1438 Enbrel ING-CC-0062 J0135 Humira ING-CC-0062 J3590 Simponi

Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

ING-CC-0062 J1602 Simponi Aria ING-CC-0062 J1745 Remicade ING-CC-0063 J3357 Stelara

Updates to AIM Clinical Appropriateness Guidelines

Effective for dates of service on and after August 16, 2020, the following updates will apply to the AIM Clinical Appropriateness Guidelines.

Musculoskeletal Program: Interventional Pain Guideline updates by section:
General Requirements – Conservative Management  Addition of physical therapy or home therapy requirement and one complementary modality based on preponderance of benefit over harm to conservative care  Align with approach to conservative management defined in spine and joint surgery guidelines Epidural Injection Procedures and Diagnostic Selective Nerve Root Blocks
 Addition of statement about adherence to ESI procedural best practices established by FDA Safe Use Initiative. Recommendations are intended for provider education and will not be used for adjudication.  Clarification of intent around requirement for advanced imaging for repeat injections Paravertebral Facet Injection/Nerve Block/Neurolysis  Remove indication for 4 unilateral medial branch blocks per session based on panel consensus
Paravertebral Facet Injection/Nerve Block/Neurolysis continued  Procedural clarification restricting use of corticosteroids for diagnostic MBB based on panel consensus  Limit use of intra-articular steroid injection to mechanical disruption of a facet synovial cyst  Remove indication for intra-articular steroid injections based on new evidence for lack of efficacy  Increase duration of initial RFN efficacy needed to avoid a MBB to 6 months based on panel consensus  Clarification that MBB or RFN is not medically necessary after spinal fusion 

Spinal Cord and Nerve Root Stimulators  Clarify inclusion of different stimulation methods for spinal cord stimulation  Add new indication for dorsal root ganglion stimulation  Clarify exclusions for spinal cord and dorsal root ganglion stimulation

Chest Imaging updates by section: Congenital and Developmental Conditions  Added criteria to allow chest CT testing for people under investigation for Coronavirus Disease 2019 (COVID-19) pneumonia when reverse transcription polymerase chain reaction (RT-PCR) is negative or cannot be performed (as defined by the Centers for Disease Control [CDC]) Tumor or Neoplasm  Allowed follow up of nodules less than 6 mm in size seen on incomplete thoracic CT, in alignment with follow up recommendations for nodules of the same size seen on complete thoracic CT  Added new criteria for which follow up is indicated for mediastinal and hilar lymphadenopathy  Separated mediastinal/hilar mass from lymphadenopathy, which now has its own entry Parenchymal Lung Disease – not otherwise specified  Removed as it is covered elsewhere in the document (parenchymal disease in Occupational lung diseases and pleural disease in Other thoracic mass lesions) Interstitial lung disease (ILD), non occupational including idiopathic pulmonary fibrosis (IPF)  Defined criteria warranting advanced imaging for both diagnosis and management Occupational lung disease (Adult only)  Moved parenchymal component of asbestosis into this indication  Added Berylliosis Chest Wall and Diaphragmatic Conditions  Removed screening indication for implant rupture due to lack of evidence indicating that outcomes are improved  Limited evaluation of clinically suspected rupture to patients with silicone implants

Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

Oncologic Imaging updates by section: MRI breast  New indication for BIA-ALCL
 New indication for pathologic nipple discharge
 Further define the population of patients most likely to benefit from preoperative MRI
Breast cancer screening  Added new high risk genetic mutations appropriate for annual breast MRI screening Lung cancer screening  Added asbestos-related lung disease as a risk factor

Sleep Disorder Management updates by section: Bi-Level Positive Airway Pressure Devices
 Change in BPAP FiO2 from 45 to 52 mmHg based on strong evidence and aligns with Medicare requirements for use of BPAP. Multiple Sleep Latency Testing and/or Maintenance of Wakefulness Testing  Style change for clarity

As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:
 Access AIM’s ProviderPortalSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.  Access AIM via the Availity Web Portal at availity.com  Call the AIM Contact Center toll-free number: 877-291-0360, Monday–Friday, 7:00 a.m.–5:00 p.m. PT.

For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines at http://www.aimspecialtyhealth.com/ClinicalGuidelines.html.

MCG Care Guidelines 24th Edition

Effective July 1, 2020, we will upgrade to the 24th edition of MCG care guidelines for the following modules: Inpatient & Surgical Care (ISC), General Recovery Care (GRC), Chronic Care (CC), Recovery Facility Care (RFC), and Behavioral Health Care (BHC). The below tables highlight new guidelines and changes that may be considered more restrictive.

Goal Length of Stay (GLOS) Changes for Inpatient & Surgical Care (ISC) and Behavioral Health Care (BHC)

Guideline MCG Code 24th Edition GLOS
23rd Edition GLOS
Aortic Valve Replacement, Transcatheter S-1320
2 days postoperative
3 days postoperative Appendectomy, with Abscess or Peritonitis, by Laparoscopy S-185 Ambulatory or 2 days postoperative
2 days postoperative
Appendectomy, without Abscess or Peritonitis, by Laparoscopy S-175 Ambulatory postoperative
Ambulatory or 1 day postoperative
Repair of Pelvic Organ Prolapse S-1020 Ambulatory postoperative
Ambulatory or 1 day postoperative
Urethral Suspension Procedures S-850 Ambulatory postoperative
Ambulatory or 1 day postoperative
Appendectomy, with Abscess or Peritonitis, by Laparoscopy, Pediatric P-30 Ambulatory or 2 days postoperative
2 or 3 days postoperative
Appendectomy, without Abscess or Peritonitis, by Laparoscopy, Pediatric P-20 Ambulatory postoperative
Ambulatory or 1 day postoperative

Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

Guideline MCG Code 24th Edition GLOS
23rd Edition GLOS
Tibial Osteotomy, Child or Adolescent S-1131 Ambulatory or 1 day postoperative
1 day postoperative
Schizophrenia Spectrum Disorders, Adult: Inpatient Care B-014-IP 5 days 6 days Schizophrenia Spectrum Disorders, Child or Adolescent: Inpatient Care B-027-IP 5 days 6 days Transcranial Magnetic Stimulation
B-801-T Utilize B-801-T for Clinical Indications for procedure Refer to BEH.00002 for Clinical Indications for procedure

New Optimal Recovery Guidelines (ORGs) for Inpatient & Surgical Care (ISC) and New Behavioral Health Care (BHC) New Guidelines Body System Guideline Title MCG - Code Pediatrics Appendectomy, with Abscess or Peritonitis, Pediatric P-35 Pediatrics Appendectomy, without Abscess or Peritonitis, Pediatric P-25 Home Care Behavioral Health Attention-Deficit and Disruptive Behavior Disorders B-003-HC Home Care Behavioral Health Autism Spectrum Disorders B-012-HC

Anthem Customizations to MCG care guideline 24th Edition
Effective July 1, 2020, the following MCG care guideline 24th edition customizations will be implemented.
 Carotid Artery Stenting (W0165) – Clinical Indications were customized to reference CG-SURG-76 Carotid, Vertebral and Intracranial Artery Stent Placement with or without Angioplasty  Deep Brain Stimulation (W0164) – Clinical Indications were customized to refer to SURG.00026 Deep Brain, Cortical, and Cerebellar Stimulation.
 Vagus Nerve Stimulation, Implantable (W0166) – Clinical Indications were customized to refer to SURG.00007 Vagus Nerve Stimulation.

To view a detailed summary of customizations, go to https://www.anthem.com/ca/provider/policies/clinical-guidelines/, scroll down to Other Criteria section and select Customizations to MCG Care Guidelines 24th Edition. For questions, please contact the provider service number on the back of the member's ID card.

The complete list of our Medical Policies and Clinical UM Guidelines may be accessed on the Anthem Blue Cross Web site at http://www.anthem.com/ca and then selecting “Providers”, then selecting “Policies, Guidelines & Manuals” under the Provider Resources column, scrolling down to select “View Medical Policies & Clinical UM Guidelines”, then selecting ”Full List page” or by entering a keyword or code in the search box..

We thank you for your continued efforts on behalf of our members and your partnership toward improved access to quality health care for Californians.

Sincerely,

John Yao, MD, MPH, MBA, MPP, FACP Chief Medical Officer

Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

Attachment A – Updates as of April 1, 2020 Revised Medical Policies and Clinical Guidelines Policy/Guideline Number Title Medical Policy / Clinical Guideline Changes CG-GENE-04 Molecular Marker Evaluation of Thyroid Nodules • Revised Medically Necessary statement to reflect updated second generation Affirma test, Genomic Sequencing Classifier (GSC) CG-GENE-09 Genetic Testing for CHARGE Syndrome • Made minor wording change in clinical indication section CG-GENE-12 PIK3CA Mutation Testing for Malignant Conditions • Revised descriptor for 0155U CG-GENE-13 Genetic Testing for Inherited Diseases • Updated formatting in Clinical Indications section CG-GENE-16 BRCA Testing for Breast and/or Ovarian Cancer Syndrome • Updated Discussion/General Information section

CG-SURG-76 Carotid, Vertebral and Intracranial Artery Stent Placement with or without Angioplasty • Reformatted Not Medically Necessary statements CG-SURG-78 Locoregional and Surgical Techniques for Treating Primary and Metastatic Liver Malignancies • Re-ordered clinical indications statements with no change to intent • Revised term SIRT (selective internal radiation therapy) to SIRT/TARE (transarterial radioembolization) within all clinical indications statements CG-SURG-95 Sacral Nerve Stimulation and Percutaneous Tibial Nerve Stimulation for Urinary and Fecal Incontinence; Urinary Retention • New CPT codes 0587T, 0588T, 0589T, 0590T added GENE.00010 Panel Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status • Updated Rationale section GENE.00011 Gene Expression Profiling for Managing Breast Cancer Treatment • Added MammaPrint as a technique of managing the treatment of breast cancer as Medically Necessary when criteria are met • Added MammaPrint as Investigational & Not Medically Necessary for repeat testing • Revised other Not Medically Necessary and Investigational & Not Medically Necessary statements regarding MammaPrint • Removed Breast Cancer Gene Expression Ratio (also known as Theros H/I), BreastNext and THEROS Breast Cancer Index tests from Investigational & Not Medically Necessary statement; BreastNext test is addressed in GENE.00052 Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling and the other two tests are obsolete GENE.00026 Cell-Free Fetal DNA-Based Prenatal Testing • Added new CPT PLA code 0168U effective 04/01/20 for Vanadis® NIPT MED.00059 Idiopathic Environmental Illness (IEI) • Removed specific drug names from position statement

Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

RAD.00059 Catheter-based Embolization Procedures for Malignant Lesions Outside the Liver • Previous title: Transcatheter Arterial Chemoembolization (TACE) and Transcatheter Arterial Embolization (TAE) for Malignant Lesions Outside the Liver except Central Nervous System (CNS) and Spinal Cord SURG.00023 Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures • Corrected ICD-10-CM diagnosis code T81.40XA-T81.40XS replacing T81.4XXA-T81.4XXS (deleted) SURG.00096 Surgical and Ablative Treatments for Chronic Headaches • Added existing CPT codes 14040, 14041, 14060, 14061, 64716, 64771, 64772, 64787 and diagnosis codes G50.1, M54.81, R51 as Investigational & Not Medically Necessary for headache diagnoses SURG.00103 Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir) • Clarified Medically Necessary statement for Ex-PRESS Glaucoma Filtration Device • Added the XEN Glaucoma Treatment System as Medically Necessary when criteria are met • Updated the Investigational & Not Medically Necessary statement SURG.00124 Carotid Sinus Baroreceptor Stimulation Devices • Expanded scope of document to include heart failure • No change to position statement SURG.00127 Sacroiliac Joint Fusion • Clarified Medically Necessary statement for minimally invasive/percutaneous sacroiliac joint fusion by adding separate line for criteria that states: “individual has a history of pelvic girdle trauma which has caused chronic sacroiliac joint pain or functional impairment” SURG.00137 Focused Microwave Thermotherapy for Breast Cancer • Removed ICD-10-PCS codes 0H5TXZZ, 0H5UXZZ, 0H5VXZZ deleted 09/30/2019 SURG.00139 Intraoperative Assessment of Surgical Margins During Breast- Conserving Surgery with Radiofrequency Spectroscopy or Optical Coherence Tomography • Removed 19499 (no longer applicable; replaced by 0546T effective 7/01/2019) SURG.00150 Leadless Pacemaker • Added ICD-10-PCS procedure code 02HK3NZ