Medical Policies and Clinical Utilization Management Guidelines update

The Medical Policies, Clinical Utilization Management (UM) Guidelines, and Third­-Party Criteria below were developed and/or revised during Quarter Two, 2024. Note, several policies and guidelines were revised to provide clarification only and are not included. Some may have expanded rationales, medical necessity indications, or criteria, and some may involve changes to policy position statements that might result in services that previously were covered being found to be not medically necessary.

Please share this notice with other providers in your practice and office staff.

To view a guideline, visit the Criteria Search Page.

Notes/updates

Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive:

• MED.00148 ­ Gene Therapy for Metachromatic Leukodystrophy:
• Outlines the Medically Necessary and Not Medically Necessary criteria for gene therapy for metachromatic leukodystrophy

Medical Policies

On May 9, 2024, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies. These medical policies take effect January 5, 2025.