We regularly review policies to make sure they’re consistent with the latest medical evidence. We'd like your feedback on policies scheduled for review. In the document, you can open any title to read the current policy. Email us your policy comments or suggestions today!
The following policies are being reinstated and used to review medical necessity for dates of service starting February 5, 2021 and after:
Adjustable Cranial Orthoses for Positional Plagiocephaly and Craniosynostoses, 1.01.11
Artificial Pancreas Device Systems, 1.01.30
Medical necessity criteria updated
Cochlear Implant, 7.01.05
Continuous Passive Motion in the Home Setting, 1.01.10
Coronary Angiography for Known Suspected Coronary Artery Disease, 2.02.507
Deep Brain Stimulation, 7.01.63
Hip Arthroplasty in Adults, 7.01.573
Hospital Beds and Accessories, 1.01.520
Knee Arthroplasty in Adults, 7.01.550
Knee Arthroscopy in Adults, 7.01.549
Knee Orthoses (Braces), Ankle foot Orthoses and Knee-Ankle-Foot-Orthoses, 1.03.501
Mastectomy for Gynecomastia, 7.01.521
Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Conditions, 1.01.15
Panniculectomy and Excision of Redundant Skin, 7.01.523
Patient Lifts, Seat Lifts, and Standing Devices, 1.01.519
Percutaneous Left Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation, 2.02.26
Power Operated Vehicle (Scooters) (excluding motorized wheelchairs), 1.01.527
Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers, 1.01.18
Reduction Mammoplasty for Breast Related Symptoms, 7.01.503
Responsive Neurostimulation for the Treatment of Refractory Focal Epilepsy, 7.01.143
Semi-Implantable and Fully Implantable Middle Ear Hearing Aids, 7.01.84
Spinal Cord and Dorsal Root Ganglion Stimulation, 7.01.546
Transcatheter Aortic Valve Implantation for Aortic Stenosis, 7.01.132
Treatment of Varicose Veins, 7.01.519
Upper GI Endoscopy, 2.01.533
Vagus Nerve Stimulation, 7.01.20
Wearable Cardioverter Defibrillators as a Bridge to Implantable Cardioverter-Defibrillator Placement , 2.02.506
Wheelchairs (Manual or Motorized), 1.01.501
Pharmacotherapy of Arthropathies, 5.01.550
Pharmacotherapy of Inflammatory Bowel Disorder, 5.01.563
Site of service review added
Pharmacotherapy of Miscellaneous Autoimmune Diseases, 5.01.564
New drug added to policy
Pharmacotherapy of Multiple Sclerosis, 5.01.565
Site of Service: Infusion Drugs and Biologic Agents, 11.01.523
Use of Granulocyte Colony-Stimulating Factors (G-CSF), 5.01.551
Hematopoietic Cell Transplantation for Hodgkin Lymphoma, 8.01.29
Miscellaneous Oncology Drugs, 5.01.540
New drugs added to policy
Use of Vascular Endothelial Growth Factor Receptor (VEGF) Inhibitors and Other Angiogenesis Inhibitors in Oncology Treatment, 5.01.517
Radioimmunotherapy in the Treatment of Non-Hodgkin Lymphoma, 8.01.533
Investigational criteria updated
Selective Estrogen Receptor Modulators and Down Regulators, 5.01.618
The following brand drugs have been added and may be considered medically necessary when criteria are met:
Drugs for Rare Diseases, 5.01.576
Erythroid Maturation Agents, 5.01.614
Medical Necessity Criteria for Pharmacy Edits, 5.01.605
All drugs listed below may be considered medically necessary when criteria are met.
New policy section
Pharmacologic Treatment of Duchenne Muscular Dystrophy, 5.01.570
Pharmacologic Treatment of Sleep Disorders, 5.01.599
Pharmacotherapy of Spinal Muscular Atrophy (SMA), 5.01.574
Absorbable Nasal Implant for Treatment of Nasal Valve Collapse, 7.01.163Now requires review for investigative.
Automated Percutaneous and Percutaneous Endoscopic Discectomy, 7.01.18Now requires review for investigative.
Balloon Dilation of the Eustachian Tube, 7.01.158Now requires review for investigative.
Bioengineered Skin and Soft Tissues Substitutes, 7.01.582Now requires review for investigative.
C1849, C9354, C9356, C9358, C9360, C9363, C9364
Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers), 7.01.107Now requires review for investigative.
Islet Transplantation, 7.03.12Now requires review for medical necessity and prior authorization.
0584T, 0585T, 0586T
Keraprosthesis, 9.03.01Now requires review for medical necessity.
Microwave Tumor Ablation, 7.01.133Now requires review for medical necessity.
Non-covered Services and Procedures, 10.01.517Now considered non-covered.
Phrenic Nerve Stimulation for Central Sleep Apnea, 2.02.33Now requires review for investigative.
Total Artificial Hearts and Implantable Ventricular Assist Devices, 7.03.11Now requires review for medical necessity and prior authorization.
33981, 33982, 33983
Total Artificial Hearts and Implantable Ventricular Assist Devices, 7.03.11Now requires review for investigative.
33990, 33991, 33992, 33993
Sinus Surgery, 7.01.559Now requires review for medical necessity and prior authorization.
Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome, 7.01.101Now requires review for medical necessity.
InterQual® Criteria: Services Reviewed for Medical Necessity, 10.01.531
This policy is updated to remove reference to services replaced with individual policies that address medical procedures and durable medical equipment. See the Special notices (above) under the Updates for non-individual and individual plans for the specific policies.
No updates this month
Services Reviewed Using InterQual® Criteria, 10.01.530
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