Insurance Updates: August 10

By Policy and Advocacy Brief posted 08-10-2022 15:16


Insurance Updates:  August 10

Each week, the AUA publishes weekly updates on the latest insurance issues pertaining to urology. This week’s update includes the release of policies regarding benign prostatic hyperplasia and infertility.


Aetna reviewed its Benign Prostatic Hyperplasia Policy adding CPT code 0714T to the non-covered list.

Read the update.


Anthem reviewed its Infertility and HCG Agents policy adding gender dysphoria as an approved indication for agents for fertility preservation, along with associated criteria.

Read the update.

BCBS Federal Employee Plan

BCBS Federal Employee Plan reviewed its ART Drugs Policy updating hypogonadism requirements to clarify that hypogonadism must be hypogonadotropic to meet criteria.

Read the update.

BCBS Federal Employee Plan published its new Pluvicto Pharmaceutical Policy stating Pluvicto may be considered medically necessary when criteria are met.

Read the update.


Noridian issued a new version of its Positron Emission Tomography Scans Local Coverage Article (LCA) with the following changes:

  • Added HCPCS A9596 to code group 19 effective July 1.
  • Added the statement “Effective May 10, PSMA-PET/CT or PSMA-PET/MRI with Gallium 68-ga Gozetotide/PSMA-11 may be used to screen patients for Pluvicto eligibility per NCCN Guidelines and SNMMI AUC” to group 19.
  • Added the PI modifier and following statement “NOTE: The PI modifier must be billed with C79.81 along with one of the C50.XXX diagnosis codes listed below AND the KX modifier to attest the initial anti-tumor treatment strategy is for male and female breast cancer only when used in staging distant metastasis per NCD effective 1/1/2021” to code group 14.

Read the update. (JE, A54666)

Read the update. (JF, A54668)

United Healthcare

United Healthcare reviewed its Genetic Testing (Medicare) Policy updating the table of molecular diagnostic genetic tests included in the Palmetto MolDX Program.

Read the update.

WPS Government Health Administrators

WPS Government Health Administrators retired its Progensa PCA3 Assay (MolDX) (A55202) Local Coverage Article (LCA), effective July 2. Progensa has been incorporated into the new article A58759 Billing and Coding: MolDX: Molecular Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate Cancer.

Read the update.

WPS Government Health Administrators reviewed its ProMark Risk Score (J05, J08) (A57587) Local Coverage Article (LCA) adding the CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §80.1.2 A/B MAC (B) Contacts with Independent Clinical Laboratories to CMS National Coverage Policy section.

Read the update.