Medical Guidelines |
Reason for Update |
Absorbable Nasal Implant for Treatment of Nasal Valve Collapse |
References added. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 8/19/2020. |
Allergen Testing AHS – G2031 |
Specialty Matched Consultant Advisory Panel review 11/2020. Medical Director review 11/2020. |
Allergy Immunotherapy (Desensitization) |
References updated. Specialty Matched Consultant Advisory Panel review 11/2020. Medical Director review 11/2020. |
Allergy Skin and Challenge Testing |
References updated. Specialty Matched Consultant Advisory Panel review 11/2020. Medical Director review 11/2020. |
Bioimpedance Devices for Detection of Lymphedema |
Regulatory status updated. Specialty Matched Consultant Advisory Panel review 11/18/2020. |
Celiac Disease Testing AHS – G2043 |
Specialty Matched Consultant Advisory Panel review 11/2020. Medical Director review 11/2020. |
Chromoendoscopy as an Adjunct to Colonoscopy |
References updated. Specialty Matched Consultant Advisory Panel 11/2020. Medical Director review 11/2020. |
Confocal Laser Endomicroscopy |
References updated. Specialty Matched Consultant Advisory Panel 11/2020. Medical Director review 11/2020. |
Diagnosis of Idiopathic Environmental Intolerance AHS – G2056 |
Specialty Matched Consultant Advisory Panel review 11/2020. Medical Director review11/2020. |
Electrostimulation and Electromagnetic Therapy for Wounds |
Specialty Matched Consultant Advisory Panel review 11/18/2020. |
Esophageal Pathology Testing AHS – M2171 |
Specialty Matched Consultant Advisory Panel review 11/2020. Medical Director review 11/2020. |
Fecal Calprotectin Testing AHS – G2061 |
Specialty Matched Consultant Advisory Panel review 11/2020. Medical Director review 11/2020. |
Gastroesophageal Reflux Disease, Transendoscopic Therapies |
Specialty Matched Consultant Advisory Panel 11/2020. Medical Director review 12/2020. |
Genetic Testing for Acute Myeloid Leukemia AHS-M2062 |
Specialty Matched Consultant Advisory Panel review 11/18/2020. No change to policy statement. |
Handheld Radiofrequency Spectroscopy for Intraoperative Assessment of Surgical Margins during Breast-Conserving Surgery |
Specialty Matched Consultant Advisory Panel review 11/18/2020. |
Hematopoietic Cell Transplantation |
Specialty Matched Consultant Advisory panel review 11/18/2020. No change to policy statement. |
Ingestible pH and Pressure Capsule |
Policy archived. Specialty Matched Consultant Advisory Panel 11/2020. Medical Director review 11/2020. |
Investigational (Experimental) Services - B0005 |
Specialty Matched Consultant Advisory Panel review 11/18/2020. No change to policy statement. |
Laboratory Testing for the Diagnosis of Inflammatory Bowel Disease AHS–G2121 |
Specialty Matched Consultant Advisory Panel review 11/2020. Medical Director review 11/2020. |
Laser Treatment of Onychomycosis |
Medical Director review 11/17/2020, policy archived. |
Lysis of Epidural Adhesions |
Medical Director review 11/17/2020, policy archived. |
Magnetic Esophageal Sphincter Augmentation to Treat Gastroesophageal Reflux Disease (GERD) |
Specialty Matched Consultant Advisory Panel review 11/18/2020. |
Medical Necessity |
Updated Medical Necessity Definition section to include setting. Medical Director Review. Specialty Matched Consultant Advisory Panel review 11/18/2020 |
Mohs' Micrographic Surgery |
Medical Director review 11/17/2020, policy archived. |
Mutation Analysis in Myeloproliferative Neoplasms AHS - M2101 |
Specialty Matched Consultant Advisory Panel review 11/18/2020. No change to policy statement. |
Non-Contact Ultrasound Treatment for Wounds |
Specialty Matched Consultant Advisory Panel review 11/18/2020. |
Nusinersen (Spinraza™) |
Specialty Matched Consultant Advisory Panel review 10/21/2020. No change to policy statements. |
Onasemnogene abeparvovec (Zolgensma®) |
Specialty Matched Consultant Advisory Panel review 10/21/2020. |
PD-1 Inhibitors |
Removed the following statement from "When Covered" section for Keytruda for unresectable or metastatic tumor mutational burden-high (TMB-H) solid tumors: "as determined by an FDA-approved test". Medical Director review 11/2020. |
Plugs for Fistula Repair |
Specialty Matched Consultant Advisory Panel review 11/18/2020. |
Postsurgical Home Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis |
Specialty Matched Consultant Advisory Panel review 11/18/2020. |
Surgery for Obstructive Sleep Apnea and Upper Airway Resistance Syndrome |
Reference added. Specialty Matched Consultant Advisory Panel review 8/19/2020. |
Surgical Treatment of Sinus Disease |
Specialty Matched Consultant Advisory Panel review 8/19/2020. Description section updated. Removed "Chronic headache or facial pain caused by a demonstrable anatomic or pathologic sinus disorder" from coverage criteria. Policy Guidelines updated. |
Surgical Treatments for Lymphedema |
Reference added. Specialty Matched Consultant Advisory Panel review 11/18/2020. |
Transanal Endoscopic Microsurgery (TEMS) |
References updated. Specialty Matched Consultant Advisory Panel 11/2020. Medical Director review 11/2020. |
Transanal Radiofrequency Treatment of Fecal Incontinence |
Policy archived. Specialty Matched Consultant Advisory Panel 11/2020. Medical Director review 11/2020. |
Tumor-Treatment Fields Therapy |
Updated Policy Guidelines and Regulatory section. Reference added. Specialty Matched Consultant Advisory Panel review 11/18/2020. No change to policy statement. |
Ultraviolet Light Therapy in the Home Setting(UVB) |
Medical Director review 11/17/2020, policy archived. |
Varicose Veins of the Lower Extremities, Treatment for |
Reference added. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 11/18/2020. |