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Commercial Medical Policy Update for June 12, 2024
| Medical Guidelines | Reason for Update |
|---|---|
| BioZorb® (PDF) | Specialty Matched Consultant Advisory Panel review 5/15/2024. Reference added. No change to policy statement. |
| Brachytherapy, Intracavitary Balloon Catheter for Brain Cancer (PDF) | Specialty Matched Consultant Advisory Panel review 5/15/2024. Reference added. No change to policy statement. |
| Carrier Screening for Genetic Disease | Specialty Matched Consultant Advisory Panel review 4/2024. Medical Director review 4/2024. Policy archived with annual review. |
| Electronic Brachytherapy for Nonmelanoma Skin Cancer (PDF) | Specialty Matched Consultant Advisory Panel review 5/15/24. Reference added. No change to policy statement. |
| Gender Affirmation Surgery (PDF) | Updated References. Removed codes 15876, 15877, and 15830 from Applicable noncovered codes. Added code 15830 to Applicable covered code. Updated description section to add information regarding detransition. Benefits application section updated with statement “Gender affirming surgery is considered an irreversible intervention. Although infrequent, reversal of prior gender affirming surgery may be covered when the medical necessity criteria below for the requested treatment is met and the individual has the available benefits.” Updated When Covered section to change for those candidates without a medical contraindication, the candidate has undergone a minimum of 12 months of continuous hormonal therapy to 6 months of continuous hormonal therapy. Added LCMHC to list of licensed behavioral health professionals. When not covered section updated to remove statement “Reversal of gender affirmation surgery, except for revision surgery as outlined in the when covered section, is considered investigational”. Specialty Matched Consultant Advisory Panel review 4/2024. Medical Director review 4/2024. |
| General Approach to Evaluating the Utility of Genetic Panels | Specialty Matched Consultant Advisory Panel review 4/2024. Medical Director review 4/2024. Policy archived with annual review. |
| Intensity Modulated Radiation Therapy for Tumors of the Central Nervous System (PDF) | Specialty Matched Consultant Advisory Panel review 5/15/2024. Per Medical Director/CAP review: removed items 1-3 under “When Covered” section. IMRT is considered medically necessary for the treatment of tumors of the central nervous system. |
| Intensity Modulated Radiation Therapy (IMRT) for Sarcoma of the Extremities (PDF) | Specialty Matched Consultant Advisory Panel review 5/15/2024. Reference added. No change to policy statement. |
| Intensity Modulated Radiation Therapy (IMRT) of Abdomen and Pelvis (PDF) | Specialty Matched Consultant Advisory Panel review 5/15/2024. Reference added. No change to policy statement. |
| Intensity Modulated Radiation Therapy (IMRT) of Head and Neck (PDF) | Specialty Matched Consultant Advisory Panel review 5/15/24. Under “When Covered” section, removed statement “when 3D CRT planning is not able to meet dose volume constraints for normal tissue tolerance” per Medical Director/CAP review. Reference added. No change to policy statement. |
| Intensity Modulated Radiation Therapy (IMRT) of the Chest (PDF) | Specialty Matched Consultant Advisory Panel review 5/15/2024. Per Medical Director/CAP review: Under “When Covered” section, pg.3 last 2 paragraphs, added statement “5 daily fractions or up to 10 fractions twice a day; also removed statement concerning use of 3D conformal radiation. Pg.4 under “When Covered”, removed bullets A. and B. Reference added. |
| Intensity-Modulated Radiation Therapy (IMRT) of the Prostate (PDF) | Specialty Matched Consultant Advisory Panel review 5/15/2024. Under “When Covered” section, Post-Prostatectomy A & B: removed statement “to the prostate bed and/or pelvis” per Medical Director/CAP review. Reference added. No change to policy statement. |
| Intraoperative Neurophysiologic Monitoring (PDF) | Added one Related Policy. Added Regulatory Status section. Removed terminated CPT code 92585 and added CPT codes 92652 and 92653 to the Billing/Coding section. Medical Director review 5/2024. Specialty Matched Consultant Advisory Panel review 5/2024. |
| Perirectal Spacer Use During Radiotherapy for Prostate Cancer (PDF) | Specialty Matched Consultant Panel review 5/15/2024. No change to policy statement. |
| Radioembolization for Primary and Metastatic Tumors of the Liver (PDF) | Specialty Matched Consultant Advisory Panel review 5/15/2024. Reference added. No change to policy statement. |
| Sacroiliac Joint Fusion/Stabilization (PDF) | Regulatory Status section updated. Added Related Policies section. Clinical Trials information updated. Medical Director review 5/2024. Specialty Matched Consultant Advisory Panel review 5/2024. |
| Surgical Deactivation of Headache Trigger Sites (PDF) | Description section updated. Added one Related Policy. References updated. Medical Director review 5/2024. Specialty Matched Consultant Advisory Panel review 5/2024. |
| Vagus Nerve Stimulation (PDF) | Policy Guidelines updated. No change to intent of policy. Removed listing of ICD 10 codes and terminated CPT codes 95974 and 95975 from the Billing/Coding section. References updated. Medical Director review 5/2024. Specialty Matched Consultant Advisory Panel review 5/2024. |
Vertebroplasty, Kyphoplasty, and Sacroplasty, Percutaneous (PDF) | Description section updated. Regulatory Status updated with additional devices and reformatted for clarity. Added related policy. Updated Policy Guidelines. No change to policy intent. Specialty Matched Consultant Advisory Panel review 5/2024. Medical Director review 5/2024. |
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