Medical Policy Updates

Medical Policy Update for November 12, 2019

Medical Guidelines Reason for Update
Absorbable Nasal Implant for Treatment of Nasal Valve Collapse Specialty Matched Consultant Advisory Panel review 8/21/2019.
Ambulatory Event Monitors The following code was added to the Billing/Coding section: C1764.
Patisiran (OnpattroTM) Under "When Covered" section, removed family history requirement for diagnosis of hATTR. Medical Director review 11/2019. 
Rhinoplasty Specialty Matched Consultant Advisory Panel review 8/21/2019. 
Septoplasty Specialty Matched Consultant Advisory Panel review 8/21/2019. 
Sleep Apnea: Diagnosis and Medical Management  References added. Policy statements clarified that sleep studies may report the Respiratory Disturbance Index or Respiratory Event Index. Criteria for changes in weight or changes in symptoms were removed from the policy statement on in-laboratory polysomnography and added to the statement on auto-adjusting positive airway pressure. Terminology changed from home sleep study to home sleep apnea test. Devices that include a minimum of the following 3 sensors: nasal pressure, chest and abdominal respiratory inductance plethysmography, and oximetry; or alternatively peripheral arterial tone with oximetry and actigraphy may be considered adequate for home sleep apnea testing for obstructive sleep apnea. Policy statements revised to include new terminology of home sleep apnea test and clarify that devices include a minimum of 3 sensors. Specialty Matched Consultant Advisory Panel review 8/21/2019.
Surgery for Obstructive Sleep Apnea and Upper Airway Resistance Syndrome Reference added. The indication for hypoglossal nerve stimulation changed to apnea/hypopnea index of ≥15 for alignment with the Food and Drug Administration-approved indication. Criteria for hypoglossal nerve stimulation for adolescents or young adults with Down syndrome and OSA added to When Covered section. Codes 0424T - 0436T removed from Billing/Coding section. These codes are now addressed in medical policy "Phrenic Nerve Stimulation for Central Sleep Apnea". Specialty Matched Consultant Advisory Panel review 8/21/2019.
Tinnitus Treatment Specialty Matched Consultant Advisory Panel 8/21/2019. 

Transurethral Water Vapor Thermal Therapy for Benign Prostatic Hyperplasia

New policy developed. Transurethral water vapor thermal therapy (Rezūm) for BPH may be considered medically necessary with criteria.