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Commercial Medical Policy Update for July 17, 2024
| Medical Guidelines | Reason for Update |
|---|---|
| Adaptive Behavioral Treatment for Autism Spectrum Disorders (PDF) | Specialty Matched Consultant Advisory Panel Review 6/2024. References added. No change to policy statement. Medical Director review 6/2024. |
| Amniotic Membrane and Amniotic Fluid Injections for Ophthalmic Indications (PDF) | Specialty Matched Consultant Advisory Panel review 6/19/2024. Medical Director review 6/2024. References added. No change to policy statement. |
| Aqueous Shunts and Devices for Glaucoma (PDF) | Specialty Matched Consultant Advisory Panel review 6/19/2024. Updated description section and added references. Medical Director review 6/2024. No change to policy statement. |
| Artificial Pancreas Device Systems (PDF) | Description and Policy Guidelines updated. References added. Specialty Matched Consultant Advisory Panel review 6/2024. Updated When covered to remove requirement for “at least 2 documented nocturnal hypoglycemic events in a 2-week period”, updated requirement for insulin pump therapy from 6 months to 3 months, added medical necessity criteria for closed loop delivery systems, and removed HgbA1c limit of 10% from when covered. Medical Director review 6/2024. |
| Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions (PDF) | Updated Policy Guidelines. Reference added. Specialty Matched Consultant Advisory Panel review 6/2024. Medical Director review 6/2024. |
| Autologous Chondrocyte Implantation (PDF) | Policy guidelines updated to include the steps for autologous chondrocyte implantation procedure. Specialty Matched Consultant Advisory Panel review 6/2024. Medical Director review 6/2024. |
| Biochemical Markers of Alzheimer Disease and Dementia AHS – G2048 (PDF) | Added code 0459U to Billing/Coding section, effective 7/1/2024 |
| Biomarker Testing for Autoimmune Rheumatic Disease AHS – G2022 (PDF) | Updated Billing/Coding section to add PLA code 0456U |
| Cardiac (Heart) Transplantation (PDF) | Description, Policy Guidelines and References updated. Specialty Matched Consultant Advisory Panel review 6/2024. Medical Director review 6/2024. |
| Carotid Artery Angioplasty/Stenting (CAS) (PDF) | Description and References sections updated. When Covered section edited for clarity, no changes to policy statement. Specialty Matched Consultant Advisory Panel review 6/2024. Medical Director review 6/2024. |
| Chromosomal Microarray AHS – M2033 (PDF) | Updated Billing/Coding section to add PLA code 0469U |
| Computer Assisted Surgical Navigational Orthopedic Procedures (PDF) | Reference updated. Description updates to manufacture names. Specialty Matched Consultant Advisory Panel review 6/2024. Medical Director review 6/2024. |
| Computerized Corneal Topography (PDF) | Specialty Matched Consultant Advisory Panel review 6/19/2024. Medical Director review 6/2024. Reference added. No change to policy statement. |
| Congenital Heart Defect, Repair Devices (PDF) | Description, Policy Guidelines and References updated. Specialty Matched Consultant Advisory Panel review 6/2024. Medical Director review 6/2024. |
| Continuous Monitoring of Glucose in the Interstitial Fluid (PDF) | Description, Policy Guidelines, FDA approved device list, and References updated. Updated Billing/Coding section to remove deleted codes K0553 and K0554. Specialty Matched Consultant Advisory Panel review 6/2024. Updated When Covered “B” as follows: Continuous monitoring of glucose levels in interstitial fluid, with non-implanted or implantable device, including real-time monitoring, as a technique in diabetic monitoring may be considered medically necessary. Updated When Not Covered as follows: Continuous glucose monitoring using an implantable glucose sensor (i.e., Eversense™ CGM system) is considered investigational for individuals not 18 years of age or older. Medical Director review 6/2024. |
| Continuous Passive Motion in the Home Setting (PDF) | Specialty Matched Consultant Advisory Panel review 6/2024. Medical Director review 6/2024. |
| Corneal Collagen Cross-Linking (PDF) | Specialty Matched Consultant Advisory Panel review 6/19/2024. Medical Director review 6/2024. References added. No change to policy statement. |
| Diagnostic Testing of Sexually Transmitted Infections AHS – G2157 (PDF) | Deleted terminated CPT code 0353U from Billing/Coding section. Added CPT code 0455U and 0463U to Billing/Coding section, effective 7/1/24. |
| Durable Medical Equipment (DME) (PDF) | Code S9002 added to Billing/Coding section. |
| Electrical Bone Growth Stimulation (PDF) | Updated Related Policies. Reference added. Specialty Matched Consultant Advisory Panel review 6/2024. Medical Director review 6/2024. |
| Epiretinal Radiation Therapy for Age-Related Macular Degeneration (PDF) | Specialty Matched Consultant Advisory Panel review 6/19/2024. Medical Director review 6/2024. References added. No change to policy statement |
| Extracorporeal Shock Wave Treatment for Musculoskeletal Conditions and Wound Healing (PDF) | Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 6/2024. Medical Director Review 6/2024. |
| Eyelid Thermal Pulsation for the Treatment of Dry Eye Syndrome (PDF) | Specialty Matched Consultant Advisory Panel review 6/19/2024. Medical Director review 6/2024. Updated regulatory status and policy guidelines. References added. |
| Fundus Photography (PDF) | Specialty Matched Consultant Advisory Panel review 6/19/2024. Medical Director review 6/2024. No change to policy statement. |
| Gastric Electrical Stimulation (PDF) | Added HCPCS code C1820 to Billing/Coding section. |
| Genetic Markers for Assessing Risk of Cardiovascular Disease AHS – M2180 (PDF) | Code 0466U added to Billing/Coding section, effective 7/1/24. |
| Glaucoma, Evaluation by Ophthalmologic Techniques (PDF) | Specialty Matched Consultant Advisory Panel review 6/19/2024. Updated description section and added references. Medical Director review 6/2024. No change to policy statement. |
| Implantable Cardioverter Defibrillator (PDF) | Policy Guidelines and References updated. When Covered section edited for clarity. Added the following statement to Not Covered section: “The use of an extravascular ICD is considered investigational.” Specialty Matched Consultant Advisory Panel review 6/2024. Medical Director review 6/2024. |
| Insulin Therapy, Chronic Intermittent Intravenous (CIIIT) (PDF) | References added. Specialty Matched Consultant Advisory Panel review 6/2023. Medical Director review 6/2023. No changes to policy statement or intent. |
| Intensity Modulated Radiation Therapy (IMRT) of Abdomen and Pelvis (PDF) | Off cycle review with extensive editing for clarity. Under “When Covered” section: added curative to medical necessity statement, moved anal cancer coverage statement to item g., added hepatobiliary cancer coverage to item c., added pancreatic cancer coverage to item e. “When not covered” statement edited for clarity. References added. Medical Director review 6/2024. |
| Islet Cell Transplantation (PDF) | Policy Guidelines updated. References added. Specialty Matched Consultant Advisory Panel review 6/2024. Medical Director review 6/2024. No changes to policy statement or intent. |
| Keratoprosthesis (PDF) | Specialty Matched Consultant Advisory Panel review 6/19/2024. Deleted related policies section. Medical Director review 6/2024. No change to policy statement. |
| Laboratory Procedures Medical Policy AHS - R2162 (PDF) | Codes 0450U, 0451U, 0457U, 0458U and 0472U added to Billing/Coding section, effective 7/1/24 |
| Meniscal Allografts and Other Meniscal Implants (PDF) | References added. Specialty Matched Consultant Advisory Panel review 6/2024. Medical Director review 6/2024. |
| Myoelectric Prosthetic Components for the Upper Limb (PDF) | Reference added. In when covered section replaced the word Patient with Individual, no change to coverage criteria. Specialty Matched Consultant Advisory Panel review 6/2024. Medical Director review 6/2024. |
| Occipital Nerve Stimulation (PDF) | Added HCPCS code C1820 to the Billing/Coding section. |
| Optical Coherence Tomography (OCT) Anterior Segment of the Eye (PDF) | Specialty Matched Consultant Advisory Panel review 6/19/2024. Updated regulatory section as well as related policies. Medical Director review 6/2024. References added. No change to policy statement. |
| Patient-Specific Instrumentation (e.g., Cutting Guides) for Joint Arthroplasty (PDF) | Reference added. Specialty Matched Consultant Advisory Panel review 6/2024. Medical Director review 6/2024. |
| Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF) | Description, Policy Guidelines and References updated. Specialty Matched Consultant Advisory Panel review 6/2024. Medical Director review 6/2024. |
| Pharmacogenetics Testing AHS – M2021 (PDF) | Codes 0460U and 0461U added to Billing/Coding section, effective 7/1/24. |
| Psychiatric Intensive Outpatient Programs (PDF) | Specialty Matched Consultant Advisory Panel Review 6/2024. References added. Updated coverage criteria to include “treatment days” for clarity. Medical Director review 6/2024. |
| Psychiatric Partial Hospitalization Programs (PDF) | Specialty Matched Consultant Advisory Panel Review 6/2024. References added. Updated when covered #3 as follows: “A physician or physician extender evaluates the client within 7 treatment days of admission, or sooner as needed based on the members clinical presentation and within 3 treatment days of admission in the following circumstances: Withdrawal Management; Medication Assisted Treatment (MAT); Co-Occurring Mental Health Disorders; Medical Co-morbidities.” Medical Director review 6/2024. |
| Quantitative Electroencephalography as a Diagnostic Aid for Attention Deficit/Hyperactivity Disorder (PDF) | References added. Specialty Matched Consultant Advisory Panel review 6/2024. Medical Director review 6/2024. No change to policy statement. |
| Refractive Surgery (PDF) | Specialty Matched Consultant Advisory Panel review 6/19/2024. Reference added. Medical Director review 6/2024. No change to policy statement. |
| Residential Treatment (PDF) | Specialty Matched Consultant Advisory Panel Review 6/2024. References added. No change to policy statement. Medical Director review 6/2024. |
| Retinal Prosthesis (PDF) | Specialty Matched Consultant Advisory Panel review 6/19/2024. Updated description section and added reference. Medical Director review 6/2024. No change to policy statement. |
| Sacral Nerve Neuromodulation/Stimulation for Pelvic Floor Dysfunction (PDF) | Added HCPCS code C1820 to the Billing/Coding section. |
| Salivary Hormone Testing AHS – G2120 (PDF) | Updated Billing/Coding section to add PLA code 0462U. |
| Sensory Integration Therapy and Auditory Integration Therapy (PDF) | References added. Specialty Matched Consultant Advisory Panel review 6/2024. Medical Director review 6/2024. No change to policy statement. |
| Serum Testing for Hepatic Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease AHS – G2110 (PDF) | Code 0468U added to Billing/Coding section, effective 7/1/24. |
| Substance Use Disorder Intensive Outpatient Programs (PDF) | Specialty Matched Consultant Advisory Panel Review 6/2024. Added the following statement to When Covered: “A licensed BH/SUD professional conducts an initial assessment to determine the requested level of care prior to submitting the authorization request.” Updated coverage criteria to include “treatment days” for clarity. Medical Director review 6/2024. |
| Substance Use Disorder Partial Hospitalization Programs (PDF) | Specialty Matched Consultant Advisory Panel Review 6/2024. References added. Updated when covered #3 (current #4) as follows: “A physician or physician extender evaluates the client within 7 treatment days of admission, or sooner as needed based on the members clinical presentation and within 3 treatment days of admission in the following circumstances: Withdrawal Management; Medication Assisted Treatment (MAT); Co-Occurring Mental Health Disorders; Medical Co-morbidities.” Added new #3 criteria to when covered: “A licensed BH/SUD professional conducts an initial assessment to determine the requested level of care prior to submitting the authorization request.” Medical Director review 6/2024. |
| Surgery for Femoroacetabular Impingement (PDF) | Policy Guidelines updated. Reference added. Specialty Matched Consultant Advisory Panel review 6/2024. Medical Director review 6/2024. |
| Surgery for Groin Pain in Athletes (PDF) | Reference added. Specialty Matched Consultant Advisory Panel review 6/2024. Medical Director review 6/2024. |
| Surgical Management of Transcatheter Heart Valves (PDF) | Description, Policy Guidelines and References updated. When Covered section edited for clarity, no change to policy statement. Specialty Matched Consultant Advisory Panel review 6/2024. Medical Director review 6/2024. |
| Surgical Ventricular Restoration (PDF) | References updated. Specialty Matched Consultant Advisory Panel review 6/2024. Medical Director review 6/2024. |
| Transcatheter Closure of Ventricular Septal Defects (PDF) | References updated. Specialty Matched Consultant Advisory Panel review 6/2024. Medical Director review 6/2024. |
| Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders (PDF) | Description, FDA approved devices, and Policy Guidelines updated. References added. Specialty Matched Consultant Advisory Panel review 6/2021. Medical Director review. No change to policy statement. Updated Billing/Coding section to add 0889T, 0890T, 0891T, 0892T, effective 7/1/2024. |
| Treatment For Opioid Use Disorder in Opioid Treatment Programs (OTPs) (PDF) | References added. Specialty Matched Consultant Advisory Panel review 6/2024. Medical Director review 6/2024. No change to policy statement. |
| Vagus Nerve Stimulation (PDF) | Added HCPCS code C1820 to the Billing/Coding section. |
| Vertebral Axial Decompression (VAD-X) (PDF) | Reference added. Specialty Matched Consultant Advisory Panel review 6/2024. Medical Director review 6/2024 |
| Viscocanalostomy and Canaloplasty (PDF) | Specialty Matched Consultant Advisory Panel review 6/19/2024. Updated policy guidelines and added references. Medical Director review 6/2024. No change to policy statement. |
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