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Medical Policy Update for June 30, 2023
| Medical Guidelines | Reason for Update |
|---|---|
| Adaptive Behavioral Treatment for Autism Spectrum Disorders | Specialty Matched Consultant Advisory Panel Review 6/2023. References added. No change to policy statement. Medical Director review 6/2023. |
| Artificial Pancreas Device Systems | Description updated regarding FDA approved devices and indications. References added. Specialty Matched Consultant Advisory Panel review 6/2023. Medical Director review 6/2023. No change to policy statement. |
| Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions | Reference added. Description section updated to include definition of microfracture. Minor edits to Policy Guidelines. Specialty Matched Consultant Advisory Panel review 6/2023. Medical Director review 6/2023. |
| Autologous Chondrocyte Implantation | Reference added. Description section updated with minor edits. Minor edits to Policy Guidelines. Specialty Matched Consultant Advisory Panel review 6/2023. Medical Director review 6/2023. |
| Automated Percutaneous and Endoscopic Discectomy | Specialty Matched Consultant Advisory Panel review 5/17/2023. |
| Bariatric Surgery | Policy updated with terminology change from “morbid” obesity to “Class III” obesity. Description section updated. Regulatory Status updated. Other Therapies updated. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 4/19/2023. Added codes C9784 and C9785 to Billing/Coding section. Medical Director review. |
| Cardiac (Heart) Transplantation | Description, Policy Guidelines and References updated. When Covered section edited for clarity, no change to policy intent. Specialty Matched Consultant Advisory Panel review 6/2023. Medical Director review 6/2023. |
| Carotid Artery Angioplasty/Stenting (CAS) | Description, Policy Guidelines and References sections updated. When Covered and Not Covered sections edited for clarity, no changes to policy statement. Specialty Matched Consultant Advisory Panel review 6/2023. Medical Director review 6/2023. |
| Charged Particle Radiotherapy | Specialty Matched Consultant Advisory Panel review 5/17/2023. No change to policy statement. |
| Computer Assisted Surgical Navigational Orthopedic Procedures | Description section updated. References added. Specialty Matched Consultant Advisory Panel review 6/2023. Medical Director review 6/2023. |
| Congenital Heart Defect Repair Devices | Description section updated. References added. Specialty Matched Consultant Advisory Panel review 6/2023. Medical Director review 6/2023. |
| Continuous Monitoring of Glucose in the Interstitial Fluid | Policy Guidelines updated. References updated. Updated FDA approved device list to include Dexcom® G7 Mobile CGM. Specialty Matched Consultant Advisory Panel review 6/2023. Medical Director review 6/2023. No change to policy statement. |
| Cranial Electrotherapy Stimulation (CES) and Auricular Electrostimulation | References added. Specialty Matched Consultant Advisory Panel review 5/17/2023 |
| Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate, or Dermatologic Tumors | Specialty Matched Consultant Advisory Panel review 4/19/2023. |
| Cryosurgical Ablation of Primary or Metastatic Liver Tumors | Specialty Matched Consultant Advisory Panel review 4/19/2023. |
| Endovascular Procedures for Intracranial Arterial Disease | References added. Specialty Matched Consultant Advisory Panel review 5/17/2023. Additional FDA approved devices for treatment of acute stroke added to Regulatory Status. |
| Endovascular Therapies for Extracranial Vertebral Artery Disease | Reference added. Specialty Matched Consultant Advisory Panel review 5/17/2023. |
| Esophageal Pathology Testing AHS – M2171 | Code 0398U added to Billing/Coding section, effective 7/1/23. |
| Folate Testing AHS – G2154 | Added CPT code 0399U to Billing/Coding section, effective 7/1/2023. |
| Gender Affirmation Surgery and Hormone Therapy | Specialty Matched Consultant Advisory Panel review 4/19/2023. |
| Genetic Markers for Assessing Risk of Cardiovascular Disease AHS – M2180 | Code 0401U added to Billing/Coding section, effective 7/1/23. |
| Human Immunodeficiency Virus – M2116 | Added “For Policy Titled Human Immunodeficiency Virus” to Policy Implementation Section for clarity. |
| Image-Guided Minimally Invasive Decompression (IG-MLD) for Spinal Stenosis | Policy Guidelines updated. References added. Specialty Matched Consultant Advisory Panel review 5/17/2023. |
| Implantable Cardioverter Defibrillator | Description, Policy Guidelines and References updated. When Covered and Not Covered sections edited for clarity, no change to policy intent. Specialty Matched Consultant Advisory Panel review 6/2023. Medical Director review 6/2023. |
| Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence | Policy review. Expired code 0377T removed from Billing/Coding section. Specialty Matched Consultant Advisory Panel review 11/16/2022. |
| Insulin Therapy, Chronic Intermittent Intravenous (CIIIT) | References added. Specialty Matched Consultant Advisory Panel review 6/2023. Medical Director review 6/2023. No changes to policy statement or intent. |
| Interspinous Fixation (Fusion) Devices | Policy review. Specialty Matched Consultant Advisory Panel review 5/17/2023 |
| Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers) | References added. Specialty Matched Consultant Advisory Panel review 5/17/2023. |
| Intraoperative Neurophysiologic Monitoring | Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 5/17/2023. |
| Islet Cell Transplantation | References added. Description and Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 6/2023. Medical Director review 6/2023. No changes to policy statement or intent. |
| Laboratory Procedures Medical Policy AHS - R2162 | Codes 0389U, 0390U, 0393U, 0394U added to Billing/Coding section, effective 7/1/23. |
| Leadless Cardiac Pacemakers | Added codes 0795T, 0796T, 0797T, 0798T, 0799T, 0800T, 0801T, 0802T, 0803T, 0804T to Billing/Coding section, effective 7/1/23. |
| Liver Transplant and Combined Liver-Kidney Transplant | Specialty Matched Consultant Advisory Panel review 5/17/2023. |
| Paraspinal Surface Electromyography (SEMG) | Specialty Matched Consultant Advisory Panel review 5/17/2023. |
| Patient-Specific Instrumentation (e.g., Cutting Guides) for Joint Arthroplasty | Reference added. Specialty Matched Consultant Advisory Panel review 6/2023. Medical Director review 6/2023. |
| Percutaneous Intradiscal and Intraosseous Radiofrequency Procedures of the Spine | Policy Guidelines updated. Regulatory Status updated. Reference added. Specialty Matched Consultant Advisory Panel review 5/17/2023. |
| Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention | Description, Policy Guidelines and References updated. Minor edits to the When Covered and Not Covered sections for clarity, no change to policy intent. Specialty Matched Consultant Advisory Panel review 6/2023. Medical Director review 6/2023. |
| Pharmacogenetics Testing AHS – M2021 | Code 0392U added to Billing/Coding section, effective 7/1/23. |
| Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers | Policy statement regarding the use of lymphedema pumps to treat the trunk or chest in patients with lymphedema was clarified to apply regardless of the involvement of the upper and lower limbs; intent unchanged. Specialty Matched Consultant Advisory Panel review 4/19/2023. |
| Polysomnography for Non‒Respiratory Sleep Disorders | Reference added. Specialty Matched Consultant Advisory Panel review 5/17/2023. |
| Preimplantation Genetic Testing AHS – M2039 | Added CPT code 0396U to Billing/Coding section, effective 7/1/2023. |
| Prenatal Screening (Genetic) AHS – M2179 | Added CPT code 0400U to Billing/Coding section, effective 7/1/2023. |
| Quantitative Electroencephalography as a Diagnostic Aid for Attention Deficit/Hyperactivity Disorder | Updated Regulatory Status. References added. Specialty Matched Consultant Advisory Panel review 6/2023. Medical Director review 6/2023. No change to policy statement. |
| Sacroiliac Joint Fusion/Stabilization | Clinical Trials information updated. Specialty Matched Consultant Advisory Panel review 5/17/2023. Added new code 0809T to Billing/Coding section. |
| Sensory Integration Therapy and Auditory Integration Therapy | Minor edits made to Description and Policy Guidelines. References added. Specialty Matched Consultant Advisory Panel review 6/2022. Medical Director review 6/2023. No change to policy statement. |
| Skin and Soft Tissue Substitutes | Added HCPCS codes Q4272, Q4273, Q4274, Q4275, Q4276, Q4277, Q4278, Q4280, Q4281, Q4282, Q4283, Q4284 to Billing/Coding section, effective 7/1/2023. |
| Surgery for Groin Pain in Athletes | References added. Specialty Matched Consultant Advisory Panel review 6/2023. Medical Director review 6/2023. |
| Surgical Deactivation of Headache Trigger Sites | Specialty Matched Consultant Advisory Panel review 5/17/2023. |
| Surgical Management of Transcatheter Heart Valves | Regulatory Status, Policy Guidelines and References sections updated. When Covered section edited for clarity, no change to policy statement. Codes 0805T and 0806T added to Billing/Coding section, effective 7/1/23. Specialty Matched Consultant Advisory Panel review 6/2023. Medical Director review 6/2023. |
| Surgical Ventricular Restoration | Minor update to Description section, References updated. Specialty Matched Consultant Advisory Panel review 6/2023. Medical Director review 6/2023. |
| Topical Negative Pressure Therapy for Wounds | Policy Guidelines updated. Rationale updated. Specialty Matched Consultant Advisory Panel review 4/19/2023. |
| Transcatheter Closure of Ventricular Septal Defects | References updated. Specialty Matched Consultant Advisory Panel review 6/2023. Medical Director review 6/2023. |
| Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders | Description updated with FDA approved devices. Policy Guidelines updated. References added. Specialty Matched Consultant Advisory Panel review 6/2023. Medical Director review 6/2023. No change to policy statement. |
| Treatment For Opioid Use Disorder in Opioid Treatment Programs (OTPs) | References added. Specialty Matched Consultant Advisory Panel review 6/2023. Medical Director review 6/2023. No change to policy statement. |
| Vagus Nerve Stimulation | Policy Guidelines updated. Description updated. Reference added. Specialty Matched Consultant Advisory Panel review 5/17/2023. Code C1767 added to Billing/Coding section. |
| Vertebroplasty, Kyphoplasty, and Sacroplasty Percutaneous | Description section updated. Policy Guidelines updated. References added. Specialty Matched Consultant Advisory Panel review 5/17/2023. |
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