Medical Policy Updates

New Medical Policy Effective 03-29-2018

(The following policy is new and determined to not have significant changes.)

• MED.00120 - Voretigene neparvovec-rzyl (Luxturna™)

 

Revised Medical Policies Effective 03-29-2018

(The following policies were revised to expand medical necessity indications or criteria.)

• DRUG.00078 - Proprotein Convertase Subtilisin Kexin 9 (PCSK9) Inhibitors
• GENE.00028 - Genetic Testing for Colorectal Cancer Susceptibility
• SURG.00098 - Mechanical Embolectomy for Treatment of Acute Stroke

Revised Medical Policies Effective 04-25-2018

(The following policies were revised to expand medical necessity indications or criteria.)

• RAD.00029 - CT Colonography (Virtual Colonoscopy) for Colorectal Cancer
• SURG.00033 - Cardioverter Defibrillators
• SURG.00121 - Transcatheter Heart Valve Procedures

 

Revised Medical Policies Effective 04-25-2018

(The following policies were reviewed and had no significant changes to the policy position or criteria.)

• ANC.00008 - Cosmetic and Reconstructive Services of the Head and Neck
• DME.00032 - Automated External Defibrillators for Home Use
• DRUG.00086 - Mecasermin (Increlex®)
• DRUG.00108 - Edaravone (Radicava®)
• GENE.00003 - Genetic Testing and Biochemical Markers for the Diagnosis of Alzheimer's Disease
• GENE.00012 - Preconception or Prenatal Genetic Testing of a Parent or Prospective Parent
• MED.00004 - Technologies for the Evaluation of Skin Lesions (including Dermatoscopy, Epiluminescence Microscopy, Videomicroscopy and Ultrasonography)
• MED.00007 - Prolotherapy for Joint and Ligamentous Conditions
• MED.00011 - Sensory Stimulation for Brain-Injured Individuals in Coma or Vegetative State
• MED.00059 - Idiopathic Environmental Illness (IEI)
• MED.00101 - Physiologic Recording of Tremor using Accelerometer(s) and Gyroscope(s)
• RAD.00012 - Ultrasound for the Evaluation of the Paranasal Sinuses
• RAD.00038 - Use of 3-D, 4-D or 5-D Ultrasound in Maternity Care
• RAD.00044 - Magnetic Resonance Neurography
• RAD.00052 - Positional MRI
• REHAB.00003 - Hippotherapy
• SURG.00043 - Electrothermal Shrinkage of Joint Capsules, Ligaments and Tendons
• SURG.00045 - Extracorporeal Shock Wave Therapy for Orthopedic Conditions
• SURG.00048 - Panniculectomy and Abdominoplasty
• SURG.00053 - Unicondylar Interpositional Spacer
• SURG.00056 - Transanal Radiofrequency Treatment of Fecal Incontinence
• SURG.00061 - Presbyopia and Astigmatism-Correcting Intraocular Lenses
• SURG.00062 - Ovarian and Internal Iliac Vein Embolization as a Treatment of Pelvic Congestion Syndrome
• SURG.00066 - Percutaneous Neurolysis for Chronic Neck and Back Pain
• SURG.00070 - Photocoagulation of Macular Drusen
• SURG.00073 - Epiduroscopy
• SURG.00079 - Nasal Valve Suspension
• SURG.00096 - Surgical and Ablative Treatments for Chronic Headaches
• SURG.00100 - Cryoablation for Plantar Fasciitis and Plantar Fibroma
• SURG.00111 - Axial Lumbar Interbody Fusion
• SURG.00145 - Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts)
• SURG.00150 - Leadless Pacemaker
• TRANS.00008 - Liver Transplantation
• TRANS.00009 - Lung and Lobar Transplantation
• TRANS.00011 - Pancreas Transplantation and Pancreas Kidney Transplantation
• TRANS.00013 - Small Bowel, Small Bowel/Liver, and Multivisceral Transplantation
• TRANS.00026 - Heart/Lung Transplantation
• TRANS.00033 - Heart Transplantation

Revised Medical Policy Effective 05-12-2018

(The following policy was revised to expand medical necessity indications or criteria.)

• DME.00009 - Vacuum Assisted Wound Therapy in the Outpatient Setting

 

Archived Medical Policies Effective 06-28-2018

(The following policies have been archived and their content has been transferred to new Clinical UM Guidelines.)

• BEH.00004 - Activity Therapy for Autism Spectrum Disorders and Rett Syndrome [Note: Content transferred to new CG-BEH-15.]
• DRUG.00028 - Intravitreal Treatment for Retinal Vascular Conditions [Note: Content transferred to new CG-DRUG-90.]
• DRUG.00032 - Intravitreal Corticosteroid Implants [Note: Content transferred to new CG-DRUG-91.]
• DRUG.00072 - Alpha-1 Proteinase Inhibitor Therapy [Note: Content transferred to new CG-DRUG-92.]
• DRUG.00101 - Sarilumab (Kevzara®) [Note: Content transferred to new CG-DRUG-93.]
• LAB.00020 - Skin Nerve Fiber Density Testing [Note: Content transferred to new CG-LAB-13.]
• MED.00076 - Inhaled Nitric Oxide [Note: Content transferred to new CG-MED-69.]
• RAD.00030 - Wireless Capsule Endoscopy for Gastrointestinal Imaging and the Patency Capsule [Note: Content transferred to new CG-MED-70.]
• SURG.00081 - Total Ankle Replacement [Note: Content transferred to new CG-SURG-74.]
• SURG.00110 - Transanal Endoscopic Microsurgical (TEM) Excision of Rectal Lesions [Note: Content transferred to new CG-SURG-75.]
• THER-RAD.00003 - Intravascular Brachytherapy (Coronary and Non-Coronary) [Note: Content transferred to new CG-THER-RAD-07.]

 

Revised Medical Policy Effective 06-28-2018

(The following policy was revised and had no significant changes to the policy position or criteria.)

• SURG.00089 - Self-Expanding Absorptive Sinus Ostial Dilation [Note: Content for balloon sinuplasty has been moved to new CG-SURG-73.]

 

Archived Medical Policy Effective 09-01-2018

(The following policy has been archived and its content has been transferred to a new Clinical UM Guideline.)

• DRUG.00092 - Buprenorphine Implant (Probuphine®) [Note: Content transferred to new CG-DRUG-89.]

 

New Medical Policy Effective 09-15-2018

(The policy below was created and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational.)

• SURG.00151 - Balloon Dilation of Eustachian Tubes

 

Revised Medical Policies Effective 09-15-2018

(The policies below were revised and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational.)

• DRUG.00003 - Chelation Therapy
• OR-PR.00003 - Microprocessor Controlled Lower Limb Prostheses
• SURG.00037 - Treatment of Varicose Veins (Lower Extremity)
• SURG.00132 - Drug-Eluting Devices for Maintaining Sinus Ostial Patency

 

Archived Medical Policy Effective 10-31-2018

(The following policy has been archived and has been replaced by MCG guidelines.)

• BEH.00001 - Opioid Antagonists Under Heavy Sedation or General Anesthesia as a Technique of Opioid Detoxification