Medical Policy and Billing and Coding Updates

LCDs in Notice Period (7/24/2025-9/6/2025)

L38367 - Fluid Jet System Treatment for LUTS/BPH

Based on a Reconsideration Request, the Indications of Coverage have been revised by removing the voided volume requirement and by eliminating the requirement to determine prostate volume by transrectal ultrasound (TRUS). The LCD is in alignment with the Multi-jurisdictional, collaborative Workgroup.

A56797 - Billing and Coding: Fluid Jet System Treatment for LUTs/BPH

No changes have been made to the Billing and Coding Article.

L39314 - Off-Label Use of Intravenous Immune Globulin (IVIG)

Effective 9/7/2025, based on a reconsideration request received in December 2024, off-label use of IVIG for Susac syndrome has been rigorously evaluated, and off-label coverage has been expanded.

The Indications of Coverage, Summary of Evidence, Analysis of Evidence, and Bibliography sections have been updated.

A59105 - Billing and Coding: Off-Label Use of Intravenous Immune Globulin (IVIG)

This article is related to the Off-Label Use of IVIG LCD and recognizes the expanded use of IVIG as an appropriate treatment for Susac Syndrome. The LCD was presented at the June 25, 2025 Open Meeting.

L39297 - Off-label Use of Rituximab and Rituximab Biosimilars

Effective 9/7/2025, based on Reconsideration Requests, received in February 2025, the following off-label uses of Rituximab for ANCA, IgG4-related pancreatitis, and Susac Syndrome have been rigorously evaluated, and off label coverage has been expanded.

The Indications of Coverage, Summary of Evidence, Analysis of Evidence and Bibliography sections have been updated.

A59101 - Billing and Coding: Off-label Use of Rituximab and Rituximab Biosimilars

Effective 9/7/2025, based on a Reconsideration Request, coverage was provided for the Off-label Use of Rituximab and Rituximab Biosimilars as an appropriate treatment for Susac Syndrome, ANCA-Associated Vasculitis (AAV), and IgG4-Related Disease.

The Indications of Coverage, Summary of Evidence, Analysis of Evidence, and Bibliography have been updated.

LCD Updates

L33398 – Transcranial Magnetic Stimulation

The LCD has been updated to clarify the use of the acronym NPPs under the indications. (Effective 7/24/25)

Billing and Coding Article Updates

A56793 - Billing and Coding: Genomic Sequence Analysis Panels in the Treatment of Hematolymphoid Diseases

Effective 7/13/2025, added the following diagnosis codes to the "ICD-10-CM Codes that Support Medical Necessity"- Group1: C92.01, C92.41, C92.51. C92.61, C92.A1, C92.Z1, C92.91, C93.01, C94.01, C94.21.

Effective 7/13/2025, added the following diagnosis codes to the "ICD-10-CM Codes that Support Medical Necessity"- Group 2: C92.12, C92.21, C92.31, C92.Z1.

Effective 7/13/2025, added the following diagnosis codes to the "ICD-10-CM Codes that Support Medical Necessity"- Group 3: C92.10, C92.11. C92.12, C92.21, C92.Z1.

A56199 - Billing and Coding: Molecular Pathology Procedures

Effective 7/13/2025, the following CPT codes from A56199-Group1: 81225, 81226, 81227, 81335, 81374, 81377, 81381, 81383, 0070U; Group 2-81306 and Group 3- 81230, 81231, 81247, 81283, 81328, 81346, 81350, 81355 have been transitioned to Billing and Coding Article A59915 Pharmacogenomic Testing.

A59915 - Billing and Coding: Pharmacogenomic Testing

Effective 7/13/2025, the "CPT/HCPCS Code" sections- Groups 17, 18, and 21 have been updated. PLA codes 0347U, 0348U, 0349U, 0350U, and 0434U have been added to Groups 17, 18, and 21 to align with the "ICD-10-CM Diagnosis Codes That Support Medical Necessity" section-Groups 17, 18, and 21 Paragraphs.

A53019 - Polysomnography and Sleep Studies – Medical Policy Article

Added Coding Information, " WatchPAT must be billed as CPT code 95800 or 95801" to article text, effective 7/24/2025.

A52848 - Botulinum Toxins

Under the Article Text, the following has been updated:

Due to the short life span of the drug once it is reconstituted, Medicare will reimburse the unused portions of Botulinum toxins. Therefore, scheduling of more than one patient, where possible, is allowed to prevent wastage of botulinum toxin.

In all cases, the documentation must show the exact dosage of the drug given to the patient, the reason for unavoidable wastage, and the amount of the discarded portion of the drug.

If a single dose vial is split between multiple patients, Medicare will allow payment only for the portion used for the beneficiary plus a pro rata amount for wastage. Note that if non-Medicare patients are treated with a portion of the same vial, it would be expected that those non-Medicare patients be billed for their pro rata share of wastage.

Bill Medicare patients for wastage using the -JW modifier on a separate line and the appropriate number of units, rounded to the nearest unit such that the total billed does not exceed the contents of the vial. The medical record must clearly show the amount administered and the amount discarded.

For split vials, for example, if patient 1 received 30 units and patient 2 received 60 units from a 100 unit vial, wastage billed with -JW would be:

• patient 1: 3 units [(30 units used for the patient/90 total units used) * 10 units of wastage = 3.33 rounded to 3]
• patient 2: 7 units [(60 units used for the patient/90 total units used) * 10 units of wastage = 6.66 rounded to 7]

If additional vials are needed to address the needs of a set of patients, pro rata wastage should be calculated over the total vial volume for that session. Furthermore, it is expected that a provider will use the most economical combination of vials that will meet the needs of a set of patients should multiple sizes be available.

Effective 7/1/2023 (CR 13056) JZ Modifier is required on all claims that bill for drugs separately payable under Medicare Part B when there are no discarded amounts from single-dose containers or single-use packages.

A56747 - Billing and Coding: Magnetic Resonance Angiography (MRA)

Effective 7/17/2025, the following ICD-10-CM codes have been added to Group 1 in the ICD-10-CM Codes that Support Medical Necessity section; G81.01, G81.02, G81.03, G81.04, G81.11, G81.12, G81.13, G81.14, G81.90, G81.91, G81.92, G81.93, G81.94, G83.10, G83.11, G83.12, G83.13, G83.14, G83.20, G83.21, G83.22, G83.23, G83.24, H81.90, I67.6, I67.81, I67.82, I82.890, I82.90, I82.C11, I82.C12, I82.C13, I82.C19, R26.0, R27.0, R29.810, R41.0, R41.82, R47.01, R47.02, R47.1, R47.81, R48.1, R48.2, and R53.1.

Posted 7/18/2025