Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions, 7.01.78 These services may be considered medically necessary for the knee or ankle when criteria are met. They're considered investigational when criteria aren't
met. The policy also lists investigational indications. Read the full policy.
Intraoperative Neurophysiologic Monitoring, 7.01.562 Intraoperative monitoring may be medically necessary for spinal, brain and vascular surgeries. Intraoperative monitoring of the recurrent laryngeal nerve is considered medically necessary
for high-risk thyroid and anterior cervical spine surgeries. Intraoperative neurophysiologic monitoring for peripheral nerve surgery is considered not medically necessary. Visual-evoked potentials and motor evoked potentials using transcranial magnetic
stimulation are considered investigational. Read the full policy.
General Approach to Evaluating the Utility of Genetic Panels, 12.04.520 Genetic panels that use next-generation sequencing or chromosomal microarray may be considered medically necessary when criteria are met. (Criteria on cancer and reproductive
panels are addressed in separate policies.)Note: Effective January 4, 2019 the services originally described in this policy are reviewed by AIM Specialty Health®.
Psychiatric Evaluation in Inpatient and Residential Behavioral Health Treatment, 3.01.521 This utilization management guideline supports InterQual medical necessity requirements for psychiatric evaluations and provides clarification on the
provider types that must conduct the evaluations. Read the full policy.
Bioengineered Skin and Soft Tissue Substitutes, 7.01.113 The policy was revised to update the medical necessity criteria for products used for breast reconstructive surgery. CellerateRX® (CRXa™) was removed from the investigational policy
statement. Integra® Omnigraft™ Dermal Regeneration Matrix was removed from the investigational policy statement and may be considered medically necessary if criteria are met. DermaPure™ is considered investigational. Read the full policy.
Immune Globulin Therapy, 8.01.503 The policy was revised to update the criteria for the use of immune globulin therapy to treat ITP in adults and children. Read the full policy.
Rhinoplasty, 7.01.558 The medical necessity policy statement was revised to add trauma and other congenital craniofacial deformity. The conservative care requirements for obstructive symptoms were clarified. Read the full policy.
Total Artificial Hearts and Implantable Ventricular Assist Devices, 7.03.11 The medical necessity policy statements were revised to add criteria regarding total artificial hearts and implantable ventricular assist devices. Percutaneous ventricular
assist devices remain investigational. Read the full policy.
Medical Necessity Criteria for Pharmacy Edits, 5.01.605 The policy was revised to update the medical necessity criteria for oral acne antibiotics and brand testosterone products. Read the full policy.
Pharmacotherapy of Spinal Muscular Atrophy (SMA), 5.01.574 The policy was clarified to include medical necessity criteria for Spinraza® (nusinersen) for spinal muscular atrophy 1, 2, and 3 when confirmed by genetic testing. Using Spinraza
for type 4 SMA (adult onset) is investigational. Read the full policy.
Pharmacotherapy of Type I and Type II Diabetes Mellitus, 5.01.569 The policy was revised to update the medical necessity criteria in those instances when metformin is contraindicated. Read the full policy.
An archived policy is no longer active and is not used for reviews.
Prophylactic Mastectomy, 7.01.561
Effective November 1, 2017
Preimplantation Genetic Testing in Embryos, 12.04.305 Now requires review for medical necessity, now requires prior authorization.
89290 - Biopsy, oocyte polar body or embryo blastomere, microtechnique (for preimplantation genetic diagnosis); less than or equal to 5 embryos.
89291 - Biopsy, oocyte polar body or embryo blastomere, microtechnique (for preimplantation genetic diagnosis); greater than 5 embryos.
Erythropoiesis-Stimulating (ESAs) Agents, 5.01.535 No longer requires medical necessity review; no longer requires prior authorization
J0890 - Injection, peginesatide, 0.1 mg (for ESRD on dialysis)
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