Medical Policy Update for November 7, 2023

Medical Guidelines	Reason for Update
Ambulatory Event Monitors	Description section, Policy Guidelines and References updated. When Covered and Not Covered sections edited for clarity, no change to policy statement. Specialty Matched Consultant Advisory Panel review 10/2023. Medical Director review 10/2023
Anesthesia Services	References updated. Specialty Matched Consultant Advisory Panel review 10/2023. Medical Director Review 10/2023. No change to policy statement.
Artificial Intervertebral Disc	References updated. Related policies added. FDA approved devices updated. Minor edits to Policy Guidelines. No change to policy intent. Specialty Matched Consultant Review 10/2023. Medical Director review 10/2023.
Autonomic Nervous System Testing	References updated. Added related policy. Updated listing of U.S. FDA approved ANS testing devices. Specialty Matched Consultant Review 10/2023. Medical Director review 10/2023.
Bariatric Surgery	Policy Guidelines section updated to remove “an assessment of thyroid levels is required” from A thorough preoperative evaluation. No change to coverage criteria. Medical Director Review.
Baroreflex Stimulation Devices	Description, Policy Guidelines and References updated. No change to policy statement. Specialty Matched Consultant Advisory Panel review 10/2023. Medical Director review 10/2023.
Cardiac Monitoring Devices in the Outpatient Setting	Description, Regulatory Status, Policy Guidelines and References updated. No change to policy statement. Specialty Matched Consultant Advisory Panel review 10/2023. Medical Director review 10/2023.
Carotid Intimal-Medial Thickness	Description section, Policy Guidelines, and References updated. Specialty Matched Consultant Advisory Panel review 10/2023. Medical Director review 10/2023.
Computed Tomography to Detect Coronary Artery Calcification	Description, Policy Guidelines and References updated. Specialty Matched Consultant Advisory Panel review 10/2023. Medical Director review 10/2023.
Decompression of the Intervertebral Disc Using Laser Energy (Laser Discectomy) or Radiofrequency Coblation (Nucleoplasty)	Added Related Policies. References updated. Specialty Matched Consultant Advisory Panel review 10/2023. Medical Director review 10/2023.
Dental Criteria for use of Hospital Inpatient or Outpatient Facility Services or Ambulatory Surgery Center Facility Services	Specialty Matched Consultant Advisory Panel review 10/2023. Medical Director Review 10/2023. No change to policy statement.
Dental Reconstructive Services	References updated. Specialty Matched Consultant Advisory Panel review 10/2023. Medical Director Review 10/2023. Added the following statement to the Billing/Coding section: “Charges related to an accidental injury must be submitted within 2 years of the accident when stated in the member benefit booklet.” No change to policy statement.
Electrodiagnostic Studies	Updated Description section, References, and title of Related Policy. Added Regulatory Status section. Updated Policy Guidelines. No change to policy intent. Specialty Matched Consultant Advisory Panel review 10/2023. Medical Director review 10/2023
Enhanced External Counterpulsation (EECP)	Policy Guidelines and References updated. When Covered section edited for clarity, no change to policy statement. Specialty Matched Consultant Advisory Panel review 10/2023. Medical Director review 10/2023.
Hyperbaric Oxygen Therapy	Regulatory status updated. Updated “patients” to “individuals” in coverage criteria. References updated. Specialty Matched Consultant Advisory Panel review 10/2023. Medical Director review 10/2023. No change to policy statement
Injection Therapy for Headache (Migraine and Other) and Non-Spine Management	Minor edits to Description section. References updated. Updated ICD 10 code from R51 to R51.0 and R51.9 in the Billing/Coding section. Specialty Matched Consultant Advisory Panel review 10/2023. Medical Director review 10/2023.
Interferential Stimulation	Updated title of one Related Policy. References updated. Specialty Matched Consultant Advisory Panel review 10/2023. Medical Director review 10/2023.
Leadless Cardiac Pacemakers	Description, Policy Guidelines and References updated, When Covered Section edited for clarity, no change to policy statement. Specialty Matched Consultant Advisory Panel review 10/2023. Medical Director review 10/2023.
MRI-guided Laser Interstitial Thermal Therapy for Neurological Indications	Updated Description, Regulatory Status and references. Removed CPT code 64999. Specialty Matched Consultant Advisory Panel review 10/2023. Medical Director review 10/2023.
Navigated Transcranial Magnetic Stimulation (nTMS)	Regulatory Status updated. Reference added. Specialty Matched Consultant Advisory Panel review 10/2023. Medical Director review 10/2023.
Orthodontics for Pediatric Patients	References updated. Removed D8690 from Billing/Coding section. Specialty Matched Consultant Advisory Panel review 10/2023. Medical Director Review 10/2023. No change to policy statement.
Orthognathic Surgery	References updated. Specialty Matched Consultant Advisory Panel review 10/2023. Medical Director Review 10/2023. No change to policy statement.
Progenitor Cell Therapy for the Treatment of Damaged Myocardium Due to Ischemia	Policy Guidelines and References updated. Specialty Advisory Consultant Advisory Panel review 10/2023. Medical Director review 10/2023.
Quantitative Sensory Testing	Updated FDA approved devices. Updated references. Medical Director review 10/2023. Specialty Matched Consultant Advisory Panel review 10/2023.
Signal-Averaged ECG	Description section and References updated. Not Covered section edited for clarity, no change to policy statement. Specialty Matched Consultant Advisory Panel review 10/2023. Medical Director review 10/2023.
Spinal Cord and Dorsal Root Ganglion Stimulation	Updated Description. Reformatted Regulatory Status and added an FDA approved device to the list. Removed terminated CPT code 95973 from Billing/Coding section. Specialty Matched Consultant Panel review 10/2023. Medical Director review 10/2023.
Spinal Manipulation Under Anesthesia	References updated. Specialty Matched Consultant Advisory Panel Review 10/2023. Medical Director Review 10/2023. No change to policy statement.
Stem-Cell Therapy for Peripheral Arterial Disease	Description section, Regulatory Status, Policy Guidelines and References updated. Specialty Matched Consultant Advisory Panel review 10/2023. Medical Director review 10/2023.
Temporomandibular Joint Dysfunction (TMJD)	Benefits application section updated for clarity. When not covered updated for clarity. Policy guidelines updated. References updated. Specialty Matched Consultant Advisory Panel review 10/2023. Medical Director Review 10/2023. No change to policy statement.
Total Facet Arthroplasty	Added and updated title of one Related Policy. Updated Regulatory Status. Policy Guidelines updated. No change to policy intent. References updated. Specialty Matched Consultant Advisory Panel review 10/2023. Medical Director review 10/2023.
Wearable Cardioverter Defibrillators	Description section, Policy Guidelines and References updated. When Covered section edited for clarity, no change to policy statement. Specialty Matched Consultant Advisory Panel review 10/2023. Medical Director review 10/2023.

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