| Medical Policy | Revision |
|---|---|
| Colorectal Cancer Screening AHS - G2181 | Reviewed by Avalon 3rd Quarter 2026 CAB. Policy Guidelines and References updated. When Covered section criterion #2 revised to allow reimbursement for multi-target stool RNA-based test, ColoSense™, in average-risk individuals 45 to 75 years of age once every three years. When Not Covered section revised to clarify that reimbursement is not allowed for use of any multi-target stool-based test at an interval of less than three years. Added new When Not Covered criterion #3 that reimbursement is not allowed for use of a different approved multi-target stool-based test when a multi-target stool-based test has already been performed within the previous three years in individuals 45 to 75 years of age at average risk of colorectal cancer. Edited wording in both the When Covered (criterion #2) and When Not Covered (criterion #2) sections by updating “DNA analysis of stool samples” to “multi-target stool-based test.” Added PLA code 0421U to Billing and Coding section. Medical Director review 7/2026. Notification given 8/19/2026 for effective date 11/4/2026. |
| Genetic Testing for Epilepsy AHS – M2075 | Reviewed by Avalon 3rd Quarter 2026 CAB. Added one Related Policy. Policy Guidelines and References updated. Exome and genome sequencing allowances for epilepsy moved from this policy into the Genome and Exome Sequencing AHS-M2032 policy. This results in the following changes to the When Covered section: Removed WES and WGS from criterion #1, removed WES from criterion #2, and removed criterion #3 which read, “WGS is considered medically necessary when WES is unable to identify a causative variant, and the clinical suspicious of a genomic etiology remains in situations where any of the above criteria are met in their entirety.” When Not Covered section updated to add new criterion #2 “Single-gene or multi-gene panel testing of an individual is considered investigational when exome or genome sequencing has already been performed on that individual. “Medical Director review 7/2026. Notification given 8/19/2026 for effective date 11/4/2026. |
| Genome and Exome Sequencing AHS – M2032 | Reviewed by Avalon 3rd Quarter 2026 CAB. Description, Policy Guidelines and References updated. Added new CC1 and 2 to the When Covered section that read: “1. Genetic counseling provided by an ABMGG board-certified medical geneticist or an ABGC board-certified genetic counselor IS REQUIRED for individuals prior to exome sequencing (ES) or genome sequencing (GS). 2. For individuals with an epilepsy syndrome (in which epilepsy is the core clinical symptom), ES or GS is considered medically necessary only when a positive test result would lead to changes in at least one of the following: a. Medication management. b. Diagnostic testing (alternative potentially invasive tests are avoided). c. Reproductive decision making." Adding genome sequencing as an allowed first-tier testing strategy for conditions in which ES was allowed followed by GS if ES was negative. Results in addition of “or GS and comparator analysis GS” to former CC1 and 2 now CC3 and 4 and addition of “or GS” to former CC1.e.i. and CC1.e.ii., now CC3.e.i. and CC3.e.ii.; former CC3.a., CC3.c., and CC3.d., now CC5.a., CC5.c., and CC5.d.; Former CC3, now CC5, added allowance for reanalysis of ES and GS for epilepsy with new CC5.e.: “e. For individuals with epilepsy who initially had negative ES or GS results, if a new causative gene for epilepsy has been identified since the initial testing was performed.” Added new CC1 and 2 to Not Covered section: "1. When GS has already been performed on the individual or their comparator, ES of the individual with complete GS is considered investigational. 2. ES or GS is considered investigational in the following situations: a. When the individual has already had ES performed, repeat ES is not allowed. b. When the individual has already had GS (excluding low-pass genome sequencing) performed, repeat GS is not allowed." Coverage criteria under the Not Covered section now numbered for clarity. Added GS testing to former first criteria which now reads "3. If ES or GS has been previously performed, further genetic tests involving only exome analyses is considered investigational." Combined two former coverage criteria into a single criteria that now reads "5. For all other situations not described above, ES and GS is considered investigational." Medical Director reviewed 7/2026. Notification given 8/19/26 for effective date 11/4/26. |
| Laboratory Procedures Medical Policy AHS - R2162 | Reviewed by Avalon 3rd Quarter 2026 CAB. Under Policy Guidelines section added new section titled "Reimbursement Based Edits" that states: “The AMA publishes unlisted codes for tests lacking a specific CPT code and “not otherwise specified” (NOS) codes for defined test methodologies applied to unspecified targets (e.g., CPT 87798 for nucleic acid detection of infectious agents without a designated code). While diagnosis- or unit-based restrictions may apply to target-specific codes, NOS codes cannot be managed the same way, even when guidelines suggest appropriate limitations for a given target billed under a NOS code. However, unit limits may still be applied. This rule currently applies to the following codes: •CPT 87798: A maximum of 5 units will be reimbursed per date of service (DOS). If more than 5 units of 87798 are billed on the same day, ALL units of 87798 will be denied. •CPT 87801: A maximum of 3 units will be reimbursed per DOS. If more than 3 units of 87801 are billed on the same day, ALL units of 87801 will be denied." Medical Director reviewed 7/2026. Notification given 8/19/26 for effective date 11/4/26. |
| Pathogen Panel Testing AHS – G2149 | Reviewed by Avalon 3rd Quarter 2026 CAB. Added new CC7 under Not Covered section: "7. Reimbursement is not allowed for molecular-based panel testing to screen for or diagnose joint infections (e.g., BIOFIRE® Joint Infection (JI) Panel, Synovasure® Comprehensive PJI Test Panel with SynTuition™).", remaining CC renumbered. Updates to Billing/Coding section: added codes 87627 and 0601U and removed codes 0441U and 0442U. Policy Guidelines and References updated. Medical Director reviewed 7/2026. Notification given 8/19/26 for effective date 11/4/26. |
| Prenatal Screening (Genetic) AHS - M2179 | Reviewed with Avalon Q3 CAB 2026. Updated policy guidelines and references. Added the following to When Covered section: “Genetic counseling IS REQUIRED for individuals prior to and after undergoing genetic testing for prenatal or pre-conception care.” Updated Billing/Coding section to add “Note: Do not report 0488U in conjunction with 0632U.” Medical Director review 7/2026. Notification given 8/19/2026 for effective date 11/4/2026. |
| Transplant Rejection Testing AHS - M2091 | Reviewed by Avalon 3rd Quarter 2026 CAB. Description, Policy Guidelines and References updated. The following updates were made to the Not Covered section: CC5 edited for clarity and consistency. CC renumbered to add new CC6 and 7 which read “6. Tests designed to assess for allograft rejection using microRNA gene expression profiling (e.g., Hepato-Track™) are considered investigational. 7. Tests designed to identify graft-specific immune responses by assessing antibodies to non-human leukocyte antigens (e.g., Autoantibody to Non-Human Leukocyte Antigen (non-HLA)) are considered investigational.” Updates to the Billing/Coding section: added codes 0575U and 0581U, removed codes 0221U, 0508U, 0509U and 0544U. Medical Director review 7/2026. Notification given 8/19/26 for effective date 11/4/26. |
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