Medical Policy and Coding Updates

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    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!

  • Updates for both non-individual and individual plans

  • Effective October 2, 2020

    Miscellaneous Oncology Drugs, 5.01.540

    New drugs added to policy

    • Kyprolis® (carfilzomib)
    • Velcade® (bortezomib)

    Pharmacotherapy of Arthropathies, 5.01.550

    Site of service review added

    • Avsola™ (infliximab-axxq)

    Pharmacotherapy of Inflammatory Bowel Disorder, 5.01.563

    Site of service review added

    • Avsola™ (infliximab-axxq)

    Pharmacologic Treatment of Infertility, 5.01.610

    New policy

    The following drugs have been added and may be considered medically necessary when criteria are met:

    • Brand Chorionic Gonadotropin
    • Bravelle® (urofollitropin)
    • Follistim® AQ (follitropin beta)
    • Pregnyl® (chorionic gonadotropin)

    Prostate Cancer Targeted Therapies, 5.01.544

    New drugs added to policy

    • Jevtana® (cabazitaxel)
    • Xofigo® (radium Ra 223 dichloride)

    Rituximab Non-Oncologic and Miscellaneous Uses, 5.01.556

    Site of service review added

    • Ruxience™ (rituximab-pvvr)

    Effective September 4, 2020

    Folate Antimetabolites, 5.01.617

    New policy

    The following drugs have been added and may be considered medically necessary when criteria are met:

    Alimta® (pemetrexed)

    • In combination with Keytruda® (pembrolizumab) and platinum chemotherapy for the initial treatment of metastatic non-squamous non-small cell lung cancer (NSCLC)
    • In combination with cisplatin for the initial treatment of locally advanced or metastatic, non-squamous NSCLC
    • As a single agent for the maintenance treatment of locally advanced or metastatic, non-squamous NSCLC in patients whose disease has not progressed after four cycles of platinum-based first-line chemotherapy
    • As a single agent for the treatment of recurrent, metastatic non-squamous, NSCLC after prior chemotherapy
    • Initial treatment, in combination with cisplatin, of malignant pleural mesothelioma in patients whose disease can't be surgically treated or who are not candidates for curative surgery

    Folotyn® (pralatrexate)

    • Treatment of relapsed or refractory peripheral T-cell lymphoma (PTCL)

    Pharmacologic Treatment of Gout, 5.01.616

    New policy

    The following drug has been added and may be considered medically necessary when criteria are met:

    Krystexxa® (pegloticase)

    • Treatment of chronic gout in patients age 18 and older

    Effective August 16, 2020

    Updates to AIM Specialty Health® Clinical Appropriateness Guidelines

    Effective for dates of service on and after August 16, 2020, the following updates by will apply to the AIM Specialty Health® Clinical Appropriateness Guidelines for Radiology: Chest Imaging

    Updates by section:

    Tumor or Neoplasm

    • Allowed follow up of nodules less than 6 mm in size seen on incomplete thoracic CT, in alignment with follow up recommendations for nodules of the same size seen on complete thoracic CT
    • Added new criteria for which follow up is indicated for mediastinal and hilar lymphadenopathy
    • Separated mediastinal/hilar mass from lymphadenopathy, which now has its own entry

    Parenchymal Lung Disease – not otherwise specified

    • Removed as it is covered elsewhere in the document (parenchymal disease in “Occupational lung diseases” and pleural disease in “Other thoracic mass lesions”)

    Interstitial lung disease (ILD), non-occupational, including idiopathic pulmonary fibrosis (IPF)

    • Defined criteria warranting advanced imaging for both diagnosis and management

    Occupational lung disease (Adult only)

    • Moved parenchymal component of asbestosis into this indication
    • Added Berylliosis

    Chest Wall and Diaphragmatic Conditions

    • Removed screening indication for implant rupture due to lack of evidence indicating that outcomes are improved
    • Limited evaluation of clinically suspected rupture to patients with silicone implants

    Effective for dates of service on and after August 16, 2020, the following updates by will apply to the AIM Specialty Health® Clinical Appropriateness Guidelines for Radiology: Oncology Imaging

    Updates by section:

    MRI breast

    • New indication for BIA-ALCL
    • New indication for pathologic nipple discharge
    • Further define the population of patients most likely to benefit from preoperative MRI

    Breast cancer screening

    • Added new high risk genetic mutations appropriate for annual breast MRI screening

    Lung cancer screening

    • Added asbestos-related lung disease as a risk factor

    Effective for dates of service on and after August 16, 2020, the following updates by will apply to the AIM Specialty Health® Clinical Appropriateness Guidelines for Sleep Disorder Management

    Updates by section:

    Bi-Level Positive Airway Pressure Devices

    • Change in BPAP FiO2 from 45 to 52 mmHg based on strong evidence and aligns with Medicare requirements for use of BPAP

    Multiple Sleep Latency Testing and/or Maintenance of Wakefulness Testing

    • Style change for clarity

    Effective August 7, 2020

    IL-5 Inhibitors, 5.01.559

    The following drug has been added and may be considered medically necessary when criteria are met:

    Cinqair® (reslizumab)

    • As an add-on maintenance treatment of severe asthma for patients ages 18 and older

    Re-authorization criteria have been added

    • A decrease in requirement for oral steroids, exacerbation frequency, ER and urgent care visits, and hospitalizations; or a decrease in the frequency and severity of asthma symptoms; or an increase in quality of life measures and ability to perform activities of daily living

    Effective July 2, 2020

    Electrostimulation and Electromagnetic Therapy for Treating Wounds, 2.01.57

    New policy

    • This policy was archived in 2018 and is being reinstated
    • Electrical stimulation and electromagnetic therapy for the treatment of wounds is considered investigational

    Erythroid Maturation Agents, 5.01.614

    The following drug has been added and may be considered medically necessary when criteria are met:

    Reblozyl® (luspatercept-aamt)

    • Treatment of anemia in adults ages 18 and older with beta thalassemia

    Miscellaneous Oncology Drugs, 5.01.540

    The following drug has been added and may be considered medically necessary when criteria are met:

    Padcev™ (enfortumab vedotin-ejfv)

    • Treatment of locally advanced or metastatic urothelial cancer (mUC) in patients ages 18 and older

    Site of Service – Select Surgical Procedures, 11.01.524

    • See policy for specific procedures that will be moving to InterQual® medical necessity criteria
    • This policy will be used for the site of service review only for those services

    New medical policies

    Effective July 1, 2020

    Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions, 7.01.48

    New policy

    • This policy replaces Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions, 7.01.569
    • Includes criteria for site of service review
    • All other statements remain unchanged

    Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures, 7.01.85 

    New policy

    • This policy replaces Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures, 7.01.571
    • All other statements remain unchanged

    Revised medical policies

    Effective July 1, 2020

    SARS-CoV-2 Serology (Antibody) Testing, 2.04.518

    Medical necessity criteria updated

    • To align with Centers for Disease Control (CDC) interim guidelines issued May 23, 2020

    Revised medical policies

    Effective June 10, 2020

    Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions, 7.01.569

    Policy reinstated (was to be deleted 7/1/20)

    • Medical necessity criteria remain unchanged
    • Includes criteria for site of service review

    Meniscal Allografts and Other Meniscal Implants, 7.01.15

    Policy reinstated (was to be deleted 7/1/20)

    • Medical necessity criteria remain unchanged
    • Includes criteria for site of service review

    Reconstructive Breast Surgery/Management of Breast Implants, 7.01.533

    Policy reinstated (was to be deleted 7/1/20)

    Medical necessity criteria updated

    • Removal of breast implants with breast implant-associated anaplastic large cell lymphoma (BIA-ALCL)

    New pharmacy policies

    Effective July 1, 2020

    Chimeric Antigen Receptor Therapy for Hematologic Malignancies, 8.01.63

    This is a new policy. The following drugs have been moved from Adoptive Immunotherapy, 8.01.01, added to this policy, and may be considered medically necessary when criteria are met:

    • Kymriah™ (tisagenlecleucel)
    • Yescarta™ (axicabtagene ciloleucel)

    Revised pharmacy policies

    Effective July 1, 2020

    Adoptive Immunotherapy, 8.01.01

    Drugs for Rare Diseases, 5.01.576

    New drug added to policy

    • Endari® (L-glutamine)

    Medical necessity criteria updated

    • Crysvita® (burosumab)

    Excessively High Cost Drug Products with Lower Cost Alternatives, 5.01.560

    New drug added to policy

    • Sitavig® (acyclovir buccal tablets)

    Herceptin® (trastuzumab) and Other HER2 Inhibitors, 5.01.514

    Drug with new indication

    • Nerlynx ® (neratinib)

    New drug added to policy

    • Tukysa™ (tucatinib)

    Immune Checkpoint Inhibitors, 5.01.591

    Drugs with new indications

    • Imfinzi® (durvalumab)
    • Keytruda® (pembrolizumab)
    • Opdivo® (nivolumab)
    • Tecentriq® (atezolizumab)
    • Yervoy® (ipilimumab)

    Medical Necessity Criteria for Pharmacy Edits, 5.01.605

    New drugs added to policy

    • Caplyta™ (lumateperone)
    • Ongentys® (opicapone)

    Medical necessity criteria updated

    • Palforzia™ [peanut (Arachis hypogaea) allergen powder-dnfp]
    • Sirturo® (bedaquiline)

    Miscellaneous Oncology Drugs, 5.01.540

    Dose limits added

    • Erivedge® (vismodegib)
    • Odomzo® (sonidegib)

    Drugs with new indications

    • Lynparza® (olaparib)
    • Rubraca® (rucaparib)
    • Zejula® (niraparib)

    New drugs added to policy

    • Gleostine® (lomustine)
    • Pemazyre™ (pemigatinib)
    • Sarclisa® (isatuximab-irfc)
    • Trodelvy™ (sacituzumab govitecan-hziy)

    Removed from policy

    • Lartruvo® (olaratumab)

    Multiple Receptor Tyrosine Kinase Inhibitors, 5.01.534

    New drug added to policy

    • Qinlock™ (ripretinib)

    Pharmacologic Treatment of Interstitial Lung Disease, 5.01.555

    Policy renamed

    • From "Pharmacologic Treatment of Idiopathic Pulmonary Fibrosis" to "Pharmacologic Treatment of Interstitial Lung Disease"

    Drug with new indication:

    • Ofev® (nintedanib)

    Medical necessity criteria updated

    • Esbriet® (pirfenidone)
    • Ofev® (nintedanib)

    Pharmacotherapy of Arthropathies, 5.01.550

    Medical necessity criteria updated

    • Cimzia® (certolizumab pegol)
    • Orencia® (abatacept)
    • Otezla® (apremilast)
    • Simponi® (golimumab)
    • Simponi Aria® (golimumab)
    • Taltz® (ixekizumab)

    Pharmacotherapy of Inflammatory Bowel Disorder, 5.01.563

    Medical necessity criteria updated

    • Stelara® (ustekinumab)

    Pharmacotherapy of Multiple Sclerosis, 5.01.565

    Medical necessity criteria updated

    • Lemtrada® (alemtuzumab)

    New drug added to policy

    • Bafiertam™ (monomethyl fumarate)

    Rituximab Non-Oncologic and Miscellaneous Uses, 5.01.556

    Medical necessity criteria updated

    • Rituxan® (rituximab)
    • Ruxience™ (rituximab-pvvr)
    • Truxima® (rituximab-abbs)

    Use of Vascular Endothelial Growth Factor Receptor (VEGF) Inhibitors and Other Angiogenesis Inhibitors in Oncology Treatment, 5.01.517

    Drugs with new indications

    • Avastin® (bevacizumab)
    • Mvasi™ (bevacizumab-awwb)
    • Pomalyst® (pomalidomide)
    • Zirabev™ (bevacizumab-bvzr)

    Deleted policies

    Effective July 1, 2020

    Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions, 7.01.569
    This policy is replaced with Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions, 7.01.48.

    Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures, 7.01.571
    This policy is replaced with Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures, 7.01.85.

    Added codes

    Effective July 2, 2020

    Electrostimulation and Electromagnetic Therapy for Treating Wounds, 2.01.57
    Now requires review for investigative.

    E0769, G0281, G0282, G0295, G0329

    Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease, 2.01.38
    Now requires review for medical necessity.

    43266


    Effective July 1, 2020

    AIM Specialty Health® Genetic Testing
    Now requires review for medical necessity and prior authorization.

    0172U, 0173U, 0175U, 0177U, 0179U

    Drugs for Rare Diseases, 5.01.576
    Now requires review for medical necessity and prior authorization.

    J0791, J0223

    Electrical Stimulation Devices, 1.01.507
    Now requires review for medical necessity and prior authorization.

    E0761

    Erythyroid Maturation Agents, 5.01.614
    Now requires review for medical necessity and prior authorization.

    J0896

    Granulocyte Colony-Stimulating Factor (G-CSF) Use in Adult Patients), 5.01.551
    Now requires review for medical necessity and prior authorization.

    Q5120

    Herceptin (trastuzumab) and Other HERS Inhibitors, 5.01.514
    Now requires review for medical necessity and prior authorization.

    J9358

    Immune Globulin Therapy, 8.01.503
    Now requires review for medical necessity and prior authorization.

    J1558

    Irreversible Electroporation (NanoKnife® System), 7.01.572
    Now requires review for investigative.

    0600T, 0601T

    Miscellaneous Oncology Drugs, 5.01.540
    Now requires review for medical necessity and prior authorization.

    J9177

    Pharmacologic Treatment of Duchenne Muscular Dystrophy, 5.01.570

    Now requires review for medical necessity and prior authorization.

    J1429

    Pharmacotherapy of Arthropathies, 5.01.550

    Now requires review for medical necessity and prior authorization.

    Q5121

    Pharmacotherapy of Spinal Muscular Atrophy (SMA), 5.01.574
    Now requires review for medical necessity and prior authorization.

    J3399

    Rituximab: Non-oncologic and Miscellaneous Uses, 5.01.556
    Now requires review for medical necessity and prior authorization.

    Q5119

    Removed codes

    Effective July 2, 2020

    Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions, 7.01.569
    No longer requires review for medical necessity and prior authorization.

    S2112

    Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting, 2.02.24
    No longer requires review for investigative.

    93701

    Chimeric Antigen Receptor Therapy for Hematologic Malignancies, 8.01.63
    No longer requires review for medical necessity and prior authorization.

    0537T, 0538T, 0539T, 0540T

    Coronary Angiography for Known Suspected Coronary Artery Disease, 2.02.507
    No longer requires review for medical necessity and prior authorization. This policy is now covered under InterQual® criteria.

    93460, 93461

    Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate or Dermatologic Tumors, 7.01.92
    No longer requires review for investigative.

    19105

    Deep Brain Stimulation, 7.01.63
    No longer requires review for medical necessity and prior authorization. This policy is now covered under InterQual® criteria.

    61868

    Diagnosis and Treatment of Sacroiliac Joint Pain, 6.01.23
    No longer requires review for medical necessity and prior authorization.

    27280

    Diagnosis and Treatment of Sacroiliac Joint Pain, 6.01.23
    No longer requires review for investigative.

    64625

    Hospital Beds and Accessories, 1.01.520
    No longer requires review for medical necessity and prior authorization. This policy is now covered under InterQual® criteria.

    E0265, E0266, E0296, E0297, E0300, E0912

    In Vitro Chemoresistance and Chemosensitivity Assays, 2.03.01
    No longer requires review for investigative and prior authorization.

    0564T

    Lipid Apheresis, 8.02.04
    No longer requires review for investigative and prior authorization.

    0342T

    Lipid Apheresis, 8.02.04
    No longer requires review for medical necessity and prior authorization.

    S2120

    Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Conditions, 1.01.15
    No longer requires review for medical necessity and prior authorization. This policy is now covered under InterQual® criteria.

    E0481

    Patient Lifts, Seat Lifts and Standing Devices, 1.01.519
    No longer requires review for medical necessity and prior authorization. This policy is now covered under InterQual® criteria.

    E0642

    Percutaneous and Vertebroplasty and Sacroplasty, 6.01.25
    No longer requires review for investigational and prior authorization.

    0200T, 0201T

    Postsurgical Outpatient Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis, 1.01.28
    No longer requires review for medical necessity and prior authorization.

    E0675

    Power Operated Vehicle (Scooters) (excluding motorized wheelchairs), 1.01.527
    No longer requires review for medical necessity and prior authorization. This policy is now covered under InterQual® criteria.

    E1230, K0899

    Quantitative Assay for Measurement of HER2 Total Protein Expression and HER2 Dimers, 2.04.76
    No longer requires review for investigative and prior authorization.

    0009U

    Recombinant and Autologous Platelet Derived Growth Factors for Wound Healing and Other Non-Orthopedic Conditions, 2.01.16
    No longer requires review for investigative.

    G0460, S9055

    Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome, 7.01.101
    No longer requires review for investigative.

    41512, 41530

    Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome, 7.01.101
    No longer requires review for investigative and prior authorization.

    S2080

    Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome, 7.01.101
    No longer requires review for medical necessity and prior authorization.

    21685, 42950

    Total Artificial Hearts and Implantable Ventricular Assist, 7.03.11
    No longer requires review for medical necessity and prior authorization.

    33981, 33982, 33983

    Total Artificial Hearts and Implantable Ventricular Assist, 7.03.11
    No longer requires review for investigative.

    33990, 33991, 33992, 33993

    Wheelchairs (Manual or Motorized), 1.01.501
    No longer requires review for medical necessity and prior authorization. This policy is now covered under InterQual® criteria.

    E0950, E0955, E1012, E1014, E1031, E1037, E1038, E1039, E1050, E1060, E1070, E1083, E1084, E1085, E1086, E1087, E1088, E1089, E1090, E1092, E1093, E1100, E1110, E1130, E1140, E1150, E1160, E1170, E1171, E1172, E1180, E1190, E1195, E1200, E1220, E1221, E1222, E1223, E1224, E1225, E1226, E1229, E1240, E1250, E1260, E1270, E1285, E1290, E1295, E2227, E2228, E2230, E2291, E2292, E2293, E2294, E2295, E2300, E2310, E2311, E2331, E2341, E2342, E2343, E2351, E2398, E2603, E2604, E2605, E2606, E2607, E2608, E2610, E2613, E2614, E2615, E2616, E2620, E2621, E2622, E2623, E2624, E2625, K0003, K0004, K0009, K0010, K0011, K0012, K0014, K0830, K0831, K0898, K0900


  • Updates for only non-individual plans

  • Effective July 2, 2020

    InterQual® Criteria: Services Reviewed for Medical Necessity, 10.01.531

    This policy outlines the specific services for which the Plan will use InterQual® criteria to review for medical necessity starting for dates of service July 2, 2020 and after. (* InterQual® criteria may vary from the medical policies listed below). Sign in to our website to view InterQual® criteria.

    • Adjustable Cranial Orthoses for Positional Plagiocephaly and Craniosynostoses, 1.01.11
    • Artificial Pancreas Device Systems, 1.01.30
    • Cochlear Implant, 7.01.05
    • Continuous Passive Motion in the Home Setting, 1.01.10
    • Coronary Angiography for Known or 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
    • Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers, 1.01.18
    • Power Operated Vehicles (Scooters) (Excluding Motorized Wheelchairs), 1.01.527
    • Reduction Mammaplasty for Breast-Related Symptoms, 7.01.503*
    • Responsive Neurostimulation for the Treatment of Refractory Focal Epilepsy, 7.01.143
    • Rhinoplasty, 7.01.558
    • Sacral Nerve Neuromodulation/Stimulation, 7.01.69
    • 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
    • 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

    Added codes

    Effective July 2, 2020

    InterQual® Criteria: Services Reviewed for Medical Necessity, 10.01.531
    Now requires review for medical necessity and prior authorization.

    27438, 27442, 36475, 36476, 36478, 36479, 36465, 36466, 36470, 36471, 43235, 43236, 43238, 43239, 43242, 95961, L1907, L1940, L1950, L1960, L1990, L2000, L2010, L2020, L2030, L2034, L2036, L2037, L2038, L2106, L2108, L2126, L2128, L4631

  • Updates for only individual plans

  • Effective July 2, 2020

    Services Reviewed Using InterQual® Criteria, 10.01.530
    This policy outlines the specific services for which the Plan will use InterQual® criteria with those added for dates of service beginning July 2, 2020 and after. (*InterQual® criteria may vary from the medical policies listed below). Sign in to our website to view InterQual® criteria.

    • Adjustable Cranial Orthoses for Positional Plagiocephaly and Craniosynostoses, 1.01.11
    • Artificial Pancreas Device Systems, 1.01.30
    • Cochlear Implant, 7.01.05
    • Continuous Passive Motion in the Home Setting, 1.01.10
    • Coronary Angiography for Known or 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
    • Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers, 1.01.18
    • Power Operated Vehicles (Scooters) (Excluding Motorized Wheelchairs), 1.01.527
    • Reduction Mammaplasty for Breast-Related Symptoms, 7.01.503*
    • Responsive Neurostimulation for the Treatment of Refractory Focal Epilepsy, 7.01.143
    • Rhinoplasty, 7.01.558
    • Sacral Nerve Neuromodulation/Stimulation, 7.01.69
    • 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/Venous Insufficiency, 7.01.519
    • Upper Gastrointestinal (UGI) Endoscopy for Adults, 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

    Added codes

    Effective July 2, 2020

    InterQual® Criteria: Services Reviewed for Medical Necessity, 10.01.530
    Now requires review for medical necessity and prior authorization.

    27438, 27442, 36475, 36476, 36478, 36479, 36465, 36466, 36470, 36471, 43235, 43236, 43238, 43239, 43242, 95961, L1907, L1940, L1950, L1960, L1990, L2000, L2010, L2020, L2030, L2034, L2036, L2037, L2038, L2106, L2108, L2126, L2128, L4631

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