Commercial Medical Policy Update for September 18, 2024

Medical Guidelines	Reason for Update
Abdominoplasty and Panniculectomy	References updated. Specialty Matched Consultant Review 8/2024. Medical Director review 8/2024. No change to policy statement.
Absorbable Nasal Implant for Treatment of Nasal Valve Collapse	References updated. Specialty Matched Consultant Advisory Panel review 8/2024. Medical Director review 8/2024.
Breast Surgeries	Updated References. Updated Section II description, Section III Policy Guidelines, and Section IV Policy Guidelines. Specialty Matched Consultant Advisory Panel review 8/2024. Medical Director review 8/2024. No change to policy statement.
Cochlear Implant	Description and Regulatory Status sections updated. When Covered section updated for clarity by rearranging bullets contained in the second coverage indication, added subsection headers, and clarified hearing aids under Bilateral Sensorineural Deafness to read, “appropriately fit, conventional hearing aids”. Policy Guidelines updated. No change to policy intent. References updated. Specialty Matched Consultant Advisory Panel review 8/2024. Medical Director review 8/2024.
Composite Allotransplantation of the Hand and Face	References updated. Specialty Matched Consultant Advisory Panel 8/2024. Medical Director review 8/2024. No change to policy statement.
Cosmetic and Reconstructive Surgery	Related Policies updated. References updated. Specialty Matched Consultant Advisory Panel 8/2024. Medical Director review 8/2024. No change to policy statement.
Cryoablation, Radiofrequency Ablation, and Laser Ablation for Treatment of Chronic Rhinitis	Description and Policy Guidelines sections updated. No change to policy intent. Regulatory Status and References updated. Medical Director Review 8/2024. Specialty Matched Consultant Advisory Panel review 8/2024.
Extracorporeal Photopheresis	Specialty Matched Consultant Advisory Panel review 8/21/2024. Updated description section. References added. No change to policy statement.
Hematopoietic Cell Transplantation	Specialty Matched Consultant Advisory Panel review 8/21/2024. References added. No change to policy statement.
Infertility Diagnosis and Treatment – B0006	Description updated to further define infertility for clarification. Minor changes made to when not covered section for clarity. No changes to policy statement. Medical Director review 8/2024.
Laser Treatment of Port Wine Stains	References updates. Specialty Matched Consultant Advisory Panel review 8/2024. Medical Director review 8/2024. No change to policy statement.
Reconstructive Eyelid Surgery and Brow Lift	Specialty Matched Consultant Advisory Panel review 8/2024. Medical Director review 8/2024. References updated. No change to policy statement.
Septoplasty	Added Related Policy. When Septoplasty is Covered section updated as follows: removed the following “The ethmoid bone is the bone in the nose through which the olfactory nerves pass. Olfactory nerves are connected with the sense of smell” as this statement is more definitional in nature. Added additional coverage bullet: “A deviated septum that precludes access for functional endoscopic surgery”. Updated references. Specialty Matched Consultant Advisory Panel review 8/2024. Medical Director review 8/2024.
Skin and Soft Tissue Substitutes	References updated. Specialty Matched Consultant Advisory Panel review 8/2024. Updated coverage criteria to remove tables and utilized list format. Replaced “patient” with “individual” throughout policy. Added TheraSkin® to approved products for treatment of diabetic ulcers when criteria are met. Removed CPT code C1762 from Billing/Coding section. Medical Director review 8/2024
Surgical Treatment for Lipedema	References updated. Medical Director review 8/2024. Specialty Matched Consultant Advisory Panel Review 8/2024. No change to policy statement.
Surgical Treatment of Chest Wall Deformities (Congenital or Acquired)	Specialty Matched Consultant Advisory Panel 8/2024. Medical Director review 8/2024. References updated. No change to policy statement.
Surgical Treatment of Sinus Disease	Description and Regulatory Status updated. Added two related policies. Policy Guidelines updated. No change to policy intent. Medical Director review 8/2024. Specialty Matched Consultant Advisory Panel review 8/2024.
Tinnitus Treatment	Description section updated. Regulatory Status section header added. Updated listing of FDA-approved devices. Policy Guidelines updated without change to policy intent. Removed terminated CPT code 96152 from Billing/Coding section. Specialty Matched Consultant Advisory Panel review 8/2024. Medical Director review 8/2024.
Tumor-Treatment Fields Therapy	Specialty Matched Consultant Advisory Panel review 8/21/2024. Updated description section and references added. No change to policy statement.

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