Medical Policy Update for March 12, 2025

Medical Guidelines	Reason for Update
Ablation and Neural Therapy Procedures for Headache and Pain Management	References added. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 2/2025. Medical Director review 2/2025.
Ambulance and Medical Transport Services	Specialty Matched Consultant Advisory Panel review 2/2025. Medical Director Review 2/2025. No change to policy statement.
Balloon Dilation of the Eustachian Tube	Description, Regulatory Status, and References updated. Added a Related Policy. When Covered section simplified by removing a, b, and c sub bullets under criterion 5. Criterion 5 now reads, “The individual's ETD has been shown to be temporarily reversible.” Removed Samter’s Triad from list of contraindications to BDET. Medical Director review 2/2025. Specialty Matched Consultant Advisory Panel review 2/2025.
Bone Morphogenetic Protein	Reference added. Specialty Matched Consultant Advisory Panel review 2/2025. Medical Director review 2/2025.
Cervical Spine Procedures	Reference added. Specialty Matched Consultant Advisory Panel review 2/2025. Medical Director review 2/2025.
Chelation Therapy	References updated. Specialty Matched Consultant Advisory Panel review 2/2025. Medical Director Review 2/2025. No change to policy statement.
Clinical Trial Services	References updated. Specialty Matched Consultant Advisory Panel review 2/2025. Medical Director review 2/2025. No change to policy.
Complementary and Alternative Medicine	Related policies updated. Added the following to When Not Covered: “Outpatient intravenous insulin therapy (OIVIT) is considered investigational.” Specialty Matched Consultant Advisory Panel review 02/2025. Medical Director review 2/2025.
Dynamic Posturography	Description section updated. Regulatory Status and References updated. Specialty Matched Consultant Advisory Panel review 2/2025. Medical Director review 2/2025.
Electrical Stimulation for the Treatment of Arthritis	References updated. No change to policy statement. Specialty Matched Consultant Advisory Panel review 2/2025. Medical Director Review 2/2025.
Implantable Bone Conduction Hearing Aids	Regulatory Status and References updated. When Covered section updated as follows: removed 12-year age requirement from the Osia system to be consistent with the updated FDA approval. Specialty Matched Consultant Review 2/2025. Medical Director review 2/2025.
Infusion Therapy in the Home	References updated. Specialty Matched Consultant Advisory Panel review 2/2025. Medical Director review 2/2025. No change to policy statement.
Inpatient Interfacility Transfers	References updated. No change to policy statement. Specialty Matched Consultant Advisory Panel review 2/2025. Medical Director review 2/2025.
Intravenous Antibiotic Therapy for Lyme Disease	Minimal edits made to Description section. References updated. Added sub-heading text “Lyme Disease” to When Covered section to provide clarity. Medical Director review 2/2025. Specialty Matched Consultant Advisory Panel review 2/2025.
Microprocessor-Controlled Prostheses for the Lower Limb	References added. Specialty Matched Consultant Advisory Panel review 2/2025. Medical director review 2/2025.
Observation Room Services	Related policy added. Specialty Matched Consultant Advisory Panel review 2/2025. Medical Director review 2/2025. No change to policy statement.
Orthopedic Applications of Stem Cell Therapy	References added. Policy guidelines updated. Specialty Matched Consultant Advisory Panel review 2/2025. Medical Director review 2/2025.
Orthotics	References added. Specialty Matched Consultant Advisory review 2/2025. Medical Director review 2/2025.
Powered Exoskeleton for Ambulation in Patients with Lower Limb Disabilities	Regulatory Status updated. Policy Guidelines updated. References added. Specialty Matched Consultant Advisory Panel review 2/2025. Medical Director review 2/2025.
Private Duty Nursing Services	References updated. Specialty Matched Consultant Advisory Panel review 2/2025. Medical Director review 2/2025. No change to policy statement.
Psychiatric Partial Hospitalization Programs	Minor edits throughout policy. Updated description to add “A partial hospitalization is a day or evening (non-residential) treatment alternative to a hospital admission. The service may be rendered in either a hospital or free-standing facility setting. A partial hospitalization service is designed to provide clinical diagnostic and treatment services at an inpatient program intensity level.” Add the following statement to When Not Covered section: “Partial hospitalization programs are not covered for telehealth or virtual services.” Medical Director review 2/2025.
Remote Therapeutic and Physiologic Monitoring	References updated. Medical Director Review 2/2025. Specialty Matched Consultant Panel review 2/2025. No change to policy statement.
Semi-Implantable and Fully Implantable Middle Ear Hearing Aid	Updated Regulatory Status and References. Specialty Matched Consultant Review 2/2025. Medical Director review 2/2025.
Skilled Nursing Facility Care	References updated. Specialty Matched Consultant Advisory Panel review 2/2025. Medical Director review 2/2025. No change to policy statement.
Skilled Nursing Services	References updated. Specialty Matched Consultant Advisory Panel review 2/2025. Medical Director Review 2/2025. No change to policy statement.
Substance Use Disorder Partial Hospitalization Programs	Minor edits throughout policy. Updated description to add “A partial hospitalization is a day or evening (non-residential) treatment alternative to a hospital admission. The service may be rendered in either a hospital or free-standing facility setting. A partial hospitalization service is designed to provide clinical diagnostic and treatment services at an inpatient program intensity level.” Add the following statement to When Not Covered section: “Partial hospitalization programs are not covered for telehealth or virtual services.” Medical Director review 2/2025.
Subtalar Arthroereisis	Minor wording edits to Description section. Reference added. Specialty Matched Consultant Advisory Panel review 2/2025. Medical Director review 2/2025.
Surgical Treatment of Sinus Disease	References updated. Medical Director review 2/2025. Specialty Matched Consultant Advisory Panel review 2/2025.
Synthetic Cartilage Implants for Joint Pain	Reference added. Specialty Matched Consultant Advisory Panel review 2/2025. Medical Director review 2/2025.
Three Dimensional Printed Orthopedic Implants	Reference added. Specialty Matched Consultant Advisory Panel review 2/2025. Medical Director review 2/2025.
Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders	Updated when covered to replace “adults” with “individuals” for clarity. Updated coverage criteria for Repeat rTMS to decrease age requirement from 18 years and older to 15 years and older for consistency with initial coverage criteria.
Ultrasound Accelerated Fracture Healing Device	Minor wording edits to Description section. Reference added. Specialty Matched Consultant Advisory Panel review 2/2025. Medical Director review 2/2025.
Vestibular Function Testing	References updated. Specialty Matched Consultant Advisory Panel review 2/2025. Medical Director review 2/2025.

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