Medical Guidelines |
Reason for Update |
Artificial Intervertebral Disc |
References added. Change in terminology from 'artificial intervertebral disc arthroplasty of the cervical spine' to 'cervical disc arthroplasty' throughout policy. |
Balloon Ostial Dilation (Balloon Sinuplasty) |
Medical Director review. Added mucocele to when not covered section. Updated Wegener's granulomatosis to more current name of Granulomatosis with polyangiitis (GPA). |
Bariatric Surgery |
Medical Director review. Updated Policy Guideline #4 for consistency with established 2019 Clinical Practice Guidelines for the Perioperative Nutrition, Metabolic, and Nonsurgical Support of Patients Undergoing Bariatric Procedures. |
Bioimpedance Devices for Detection of Lymphedema |
Reference added. Description section updated. Related policy added. Policy Guidelines updated. |
Decompression of the Intervertebral Disc Using Laser Energy (Laser Discectomy) or Radiofrequency Coblation (Nucleoplasty) |
Reference added. |
Dynamic Posturography |
Reference added. |
Gender Confirmation Surgery and Hormone Therapy |
Medical Director review. Provider Documentation Criteria updated to include "licensed" behavioral health professional, and "with established competence and clinical expertise in the assessment and treatment of gender dysphoria". |
Handheld Radiofrequency Spectroscopy for Intraoperative Assessment of Surgical Margins during Breast-Conserving Surgery |
Reference added. |
Microprocessor-Controlled Prostheses for the Lower Limb |
Reference added. |
Pharmacogenetics Testing AHS – M2021 |
Specialty Matched Consultant Advisory Panel review 7/2020. Medical Director review 7/2020. |
Sacral Nerve Neuromodulation/Stimulation for Pelvic Floor Dysfunction |
Reference added. Expired code 95973 removed from Billing/Coding section. |
Semi-Implantable and Fully Implantable Middle Ear Hearing Aid |
Reference added. |
Spinal Cord and Dorsal Root Ganglion Stimulation |
Reference added. |
Subtalar Arthroereisis |
Reference added. |
Topical Negative Pressure Therapy for Wounds |
Medical Director review. Added "One week of negative pressure wound therapy (NPWT) is considered medically necessary as part of the post-operative care for patients who receive split thickness skin grafting (STSG)" to the When Covered section. |
Total Facet Arthroplasty |
Reference added. |