Medical Policy and Coding Updates

Effective January 1, 2020

Biofeedback for Incontinence, 2.01.540
Biofeedback for the treatment of incontinence in children and adults may be considered medically necessary when criteria are met.

Cardiac Defibrillator, Subcutaneous Implantable, 2.02.512
Subcutaneous implantable cardiac defibrillators may be considered medically necessary for cardiac conditions when criteria are met.

Continuous Home Pulse Oximetry, 1.01.533
Continuous home pulse oximetry may be considered medically necessary in specific situations when criteria are met.

Digital Breast Tomosynthesis, 6.01.526
Digital breast tomosynthesis may be considered medically necessary in screening for breast cancer when criteria are met.

Endometrial Ablation, 7.01.578
Endometrial ablation may be considered medically necessary for abnormal uterine bleeding when criteria are met.

Endovascular Repair/Stent for Abdominal Aortic Aneurysm, 2.02.513
Endovascular repair/stent for abdominal aortic aneurysm may be considered medically necessary to repair the aorta and/or its major branches when criteria are met.

Experimental and Investigational Services, 9.01.504
Policy outlines the conditions under which experimental and investigational services and devices may be considered medically necessary.

External Counterpulsation Therapy, 2.02.514
External counterpulsation therapy may be considered medically necessary for the treatment of chronic disabling stable angina when criteria are met.

Eye-Anterior Segment Optical Coherence Tomography, 9.03.509
Eye-anterior segment optical coherence tomography may be considered medically necessary for several eye conditions when criteria are met.

Glaucoma, Invasive Procedures, 9.03.510
Ex-PRESS™ Mini Glaucoma Shunt, iSTENT^® Trabecular Micro-Bypass Stent, and canalopasty may be considered medically necessary for the treatment of glaucoma when criteria are met.

Hepatitis A Vaccine, 9.01.505
The Hepatitis A vaccine may be considered medically necessary for children and adults when criteria are met.

High-Resolution Anoscopy, 2.01.539
High-resolution anoscopy may be considered medically necessary for the identification, management, and treatment of anal dysplasia when criteria are met.

Home Apnea Monitoring, 1.01.534
Home apnea monitoring may be considered medically necessary for infants 12 months or younger when criteria are met.

Home Oxygen Therapy, 1.01.535
Home oxygen therapy may be considered medically necessary for low blood oxygen levels in severe lung disease when criteria are met.

Home Prothrombin Time/International Normalized Ratio (PT/INR) Monitoring, 1.01.536
Home prothrombin time/international normalized ratio (PT/INR) monitoring may be considered medically necessary for patients taking warfarin with specific heart conditions when criteria are met.

Human Papillomavirus (HPV) Vaccine, 9.01.506
Laryngeal injections may be considered medically necessary for the treatment of glottal incompetence in specific conditions when criteria are met.

Laryngeal Injection for Vocal Cord Augmentation, 2.01.541
Laryngeal injections may be considered medically necessary for the treatment of glottal incompetence in specific conditions when criteria are met.

Meningococcal Vaccine, 9.01.507
Meningococcal vaccines may be considered medically necessary when criteria are met.

Negative Pressure Wound Therapy, 1.01.532
Negative pressure wound therapy in a home or an inpatient setting may be considered medically necessary for ulcers and wounds when criteria are met.

Nerve Block, Paravertebral, Facet Joint, and SI Injections, 7.01.575
Paravertebral, facet joint, and sacroiliac joint injections may be considered medically necessary for the treatment of chronic pain and other conditions when criteria are met.

Posterior Tibial Nerve Stimulators, 7.01.579
Posterior tibial nerve stimulators (PTNS) may be considered medically necessary for the treatment of urinary incontinence when criteria are met.

Presbyopia Correcting Intraocular Lenses (PIOLs) and Astigmatism Correcting Intraocular Lenses (ACIOLs), 9.03.511
Presbyopia correcting intraocular lenses (PIOLs) and astigmatism correcting intraocular lenses (ACIOLs) may be considered medically necessary as part of cataract surgery when criteria are met.

Prophylactic Bilateral Salpingo-Oophorectomy, 7.01.580
Prophylactic bilateral salpingo-oophorectomy may be considered medically necessary for individuals at high risk of ovarian or breast cancer when criteria are met.

Prophylactic Mastectomy, 7.01.581
Prophylactic mastectomy may be considered medically necessary for individuals at high risk of breast cancer when criteria are met.

Rabies Vaccine, Home, 9.01.508
The rabies vaccine given in a home setting may be considered medically necessary for possible rabies exposure when criteria are met.

Rotavirus Vaccine, 9.01.509
The rotavirus vaccine may be considered medically necessary for infants as part of preventive immunization guidelines.

Services Reviewed Using InterQual® Criteria, 10.01.530
Services listed in this policy may be considered medically necessary based on InterQual criteria. See policy for details.

Shingles Vaccine, 9.01.510
The shingles vaccine may be considered medically necessary in adults ages 50 and older when criteria are met.

Spinal Orthosis, 1.03.502
Thoracic-Lumbar-Sacral Orthoses (TLSO), Lumbar-Sacral Orthoses (LSO), Lumbar Orthoses, and custom spinal orthoses may be considered medically necessary to reduce pain or provide structural support when criteria are met.

Supervised Exercise Therapy for Peripheral Artery Disease, 8.01.537
Supervised exercise therapy for symptomatic peripheral artery disease (PAD) may be considered medically necessary when criteria are met.

Surgical Dressings and Wound Care Supplies, 9.01.511
Specific surgical dressings and wound care supplies may be considered medically necessary for removing tissue from a wound or treatment of a wound caused by surgery when criteria are met.

Total Ankle Replacement, 7.01.577
Total ankle replacement surgery may be considered medically necessary for the treatment of advanced end-stage arthritis or for revision of prior total ankle replacement when criteria are met.

Transient Elastography, 2.01.536
Transient elastography may be considered medically necessary for fibrosis with a diagnosis of hepatitis C when criteria are met.

Trigger Point and Transforaminal Epidural Injections, 2.01.537
Trigger point injections may be considered medically necessary for myofascial pain syndrome when criteria are met.

Ultraviolet B Light Therapy in the Home to Treat Skin Conditions, 2.01.542
Ultraviolet B (UVB) light therapy in the home may be considered medically necessary for specific skin conditions when criteria are met.

Visual Evoked Response Test, 9.03.512
Visually evoked response testing may be considered medically necessary to detect problems that affect sight when criteria are met.

Wireless Capsule Endoscopy, 2.01.538
Wireless capsule endoscopy may be considered medically necessary for the evaluation of obscure gastrointestinal bleeding, symptomatic small bowel neoplasm, Crohn’s disease, and Celiac disease when criteria are met.

Now requires review for Medical Necessity.

Added codes

Effective January 1, 2020

Eye-Anterior Segment Optical Coherence Tomography, 9.03.509
92132

Biofeedback for Incontinence, 2.01.540
90911, 90901

Continuous Home Pulse Oximetry, 1.01.533
E0445, A4606

Digital Breast Tomosynthesis, 6.01.526
77061, 77062, 77063, 77046, 77047, 77048, 77049, 77065, 77066, 77067, G0279

Endometrial Ablation, 7.01.578
58353, 58356, 58563

Endovascular Repair/Stent for Abdominal Aortic Aneurysm, 2.02.513
0254T, 34701, 34702, 34703, 34704, 34705, 34706, 34707, 34708, 34709, 34710, 34711, 34712, 34713, 34714, 34715, 34716, 34808, 34812, 34813, 34820, 34833, 34834, 34841, 34842, 34843, 34844, 34845, 34846, 34847, 34848

External Counterpulsation Therapy, 2.02.514
G0166

Glaucoma, Invasive Procedures, 9.03.510
0191T, 0253T, 66174, 66175, 66183

Hepatitis A Vaccine, 9.01.505
90460, 90461, 90471, 90472, 90632, 90633, 90634, 90636

High Resolution Anoscopy, 2.01.539
46601, 46607

Home Apnea Monitoring, 1.01.534
94774, 94775, 94776, 94777

Home Oxygen Therapy, 1.01.535
E0424, E0431, E0433, E0434, E0439, E0441, E0442, E0443, E0444, E1390, E1391, E1392, E1405, E1406, K0738

Home Prothrombin Time/International Normalized (PT/INR) Monitoring, 1.01.536
G0248, G0249, G0250

Human Papillomavirus (HPV) Vaccine, 9.01.506
90649, 90650, 90651

Laryngeal Injections for Vocal Cord Augmentation, 2.01.541
31513, 31570, 31571, 31573, 31574

Meningococcal Vaccines, 9.01.507
90621, 90644, 90733, 90734

Posterior Tibial Nerve Stimulators, 7.01.579
64566

Presbyopia Correcting Intraocular Lenses (PIOLs) and Astigmatism Correcting Intraocular Lenses (ACIOLs), 9.03.511
66982, 66983, 66984, V2630, V2631, V2632

Prophylactic Bilateral Salpingo-Oophorectomy, 7.01.580
58720, 58940

Rabies Vaccine, Home, 9.01.508
90675, 90676, 90375, 90376

Rotavirus Vaccine, 9.01.509
90460, 90461, 90471, 90472, 90680, 90681

Shingles Vaccine, 9.01.510
90736, 90750

Supervised Exercise Therapy for Peripheral Artery Disease, 8.01.537
93668

Surgical Dressings and Wound Care Supplies, 9.01.511
A4450, A4452, A4461, A4463, A4649, A6010, A6011, A6021, A6022, A6023, A6024, A6154, A6196, A6197, A6198, A6199, A6203, A6204, A6205, A6206, A6207, A6208, A6209, A6210, A6211, A6212, A6213, A6214, A6215, A6216, A6217, A6218, A6219, A6220, A6221, A6222, A6223, A6224, A6231, A6232, A6233, A6234, A6235, A6236, A6237, A6238, A6239, A6240, A6241, A6242, A6243, A6244, A6245, A6246, A6247, A6248, A6251, A6252, A6253, A6254, A6255, A6256, A6257, A6258, A6259, A6261, A6262, A6266, A6402, A6403, A6404, A6407, A6410, A6411, A6413, A6441, A6442, A6443, A6444, A6445, A6446, A6447, A6448, A6449, A6450, A6451, A6452, A6453, A6454, A6455, A6456, A6457, A6501, A6502, A6503, A6504, A6505, A6506, A6507, A6508, A6509, A6510, A6511, A6512, A6513, A6545

Ultraviolet B Light Therapy in the Home to Treat Skin Conditions, 2.01.542
E0691, E0692, E0693, E0694, A4633

Visually Evoked Response Test, 9.03.512
95930

The following new policies apply to Individual plans only:

Now requires review for Medical Necessity and Prior Authorization.

Added codes

Effective January 1, 2020

Cardiac Defibrillator, Subcutaneous Implantable, 2.02.512
33270

Negative Pressure Wound Therapy, 1.01.532
A6550, A7000, E2402

Nerve Block, Paravertebral, Facet Joint, and SI Injections, 7.01.575
20526, 27096, 64450, 64455, 64461, 64462, 64463, 64490, 64491, 64492, 64493, 64494, 64495, 77003, G0260

Spinal Orthosis, 1.03.502
L0450, L0452, L0454, L0455, L0456, L0457, L0458, L0460, L0462, L0464, L0466, L0467, L0468, L0469, L0470, L0472, L0480, L0482, L0484, L0486, L0488, L0490, L0491, L0492, L0621, L0622, L0623, L0624, L0625, L0626, L0627, L0628, L0629, L0630, L0631, L0632, L0633, L0635, L0636, L0637, L0638, L0639, L0640, L0641, L0642, L0643, L0648, L0649, L0650, L0651, L0980, L0982, L0984, L4002

Total Ankle Replacement, 7.01.577
27702, 27703

Transient Elastography, 2.01.536
91200

Trigger Point and Transforaminal Epidural Injections, 2.01.537
20552, 20553, 64479, 64480, 64483, 64884

Wireless Capsule Endoscopy, 2.01.538
91110, 91111