Commercial Medical Policy Update for May 1, 2024
| Medical Guidelines | Reason for Update |
|---|---|
| Bariatric Surgery (PDF) | Reference added. Specialty Matched Consultant Advisory Panel review 4/2024. Medical Director review 4/2024. |
| Breast Surgeries (PDF) | Added HCPCS code C1789 to Section V Billing/Coding section. |
| Capsule Endoscopy, Wireless (PDF) | Code 91111 added to Billing/Coding section. |
| Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate, or Dermatologic Tumors (PDF) | Reference added. Specialty Matched Consultant Advisory Panel review 4/2024. Medical Director review 4/2024. |
Cryosurgical Ablation of Primary or Metastatic Liver Tumors (PDF) | Reference added. Specialty Matched Consultant Advisory Panel review 4/2024. Medical Director review 4/2024. |
| Diagnosis and Treatment of Sacroiliac Joint Pain (PDF) | References added. Policy guidelines updated. No change to policy statement. Specialty Matched Consultant Advisory Panel review 4/2024. Medical Director review 4/2024. |
| Epidural Steroid Injections for Back Pain (PDF) | References added. Specialty Matched Consultant Advisory Panel review 4/2024. Medical Director review 4/2024. No change to policy statement. |
| Facet Joint Denervation (PDF) | References added. Specialty Matched Consultant Advisory Panel review 4/2024. Medical Director Review 4/2024. No change to policy statement. |
| Hemodialysis Treatment for ESRD (PDF) | Added reimbursement policy Bundling Guidelines to Related Policies section. Specialty Matched Consultant Advisory Panel review 4/2024. References updated. Medical Director review 4/2024. |
| Intradialytic Parenteral Nutrition (PDF) | Minor edits made to Description and Policy Guidelines sections, no change to policy statement. References updated. Specialty Matched Consultant Advisory Panel review 4/2024. Medical Director review 4/2024. |
| Intravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric Disorders (PDF) | References added. Specialty Matched Consultant Advisory Panel review 4/2024. Medical Director review 4/2024. No Change to policy statement. |
| Liver Transplant and Combined Liver-Kidney Transplant (PDF) | Reference added. Specialty Matched Consultant Advisory Panel review 4/2024. Medical Director review 4/2024. |
| Neural Therapy (PDF) | References added. Specialty Matched Consultant Advisory Panel review 4/2024. Medical Director review 4/2024. No Change to policy statement. |
| Neurostimulation, Electrical (PDF) | Updated Section II title to read “Peripheral Subcutaneous Field Stimulation and Peripheral Nerve Stimulation”. Updated Section II throughout to reflect section title change. Section Added CPT code 64555 to Section II Billing/Coding section. References added. Specialty Matched Consultant Advisory Panel review 4/2024. Medical Director review 4/2024. No change to policy statement. |
| Ovarian and Internal Iliac Vein Embolization, Ablation and Sclerotherapy (PDF) | Updated Billing/Coding section to include CPT codes 37243, 37244, and 75894. |
| Percutaneous Electrical Nerve Stimulation (PENS) or Neuromodulation Therapy and Percutaneous Electrical Nerve Field Stimulation (PENFS) | Policy Guidelines updated for clarity. References updated. Specialty Matched Consultant Advisory Panel review 4/2024. Medical Director review 4/2024. No change to policy statement. |
| Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers (PDF) | Removed coverage criteria from Policy Guidelines and added to When Pneumatic Compression Pumps are covered. Lymphedema pumps/sequential pneumatic compression devices are eligible for initial coverage when ALL of the following criteria are met: Confirmed diagnosis of primary or secondary lymphedema; and Lymphedema is associated with functional impairment e.g., impairment of activities of daily living; and When there is failure of a four-week trial of conservative medical therapies, (examples include elevation of the affected limb, exercise, massage, use of an appropriate compression bandage system or compression garment); and The patient has demonstrated compliance with past recommended medical treatment(s). No changes in coverage criteria. References added. Specialty Matched Consultant Advisory Panel review 4/2024. Medical Director review 4/2024. |
| Prolotherapy (PDF) | References added. Specialty Matched Consultant Advisory Panel review 4/2024. Medical Director review 4/2024. No change to policy statement. |
| Radiofrequency Ablation of the Renal Nerves as a Treatment of Hypertension (PDF) | Description, Policy Guidelines and References updated. Not Covered section edited for clarity, replaced “resistant” hypertension with “uncontrolled” hypertension. No change to policy statement. Specialty Matched Advisory Panel review 4/2024. Medical Director review 4/2024. |
| Renal (Kidney) Transplantation (PDF) | Description and References sections updated. Specialty Matched Specialty Advisory Panel review 4/2024. Medical Director review 4/2024. |
| TENS (Transcutaneous Electrical Nerve Stimulator) (PDF) | Policy guidelines updated. References added. Updated When Not Covered section to include “TENS is considered investigational for prevention and treatment of migraines” for clarity. Specialty Matched Consultant Advisory Panel review 4/2024. Medical Director review 4/2024. |
| Topical Negative Pressure Therapy for Wounds (PDF) | Updated link in description section to FDA safety article. Reference added. Policy Guidelines updated to remove “and the wound edges were reduced to 2 cm in width or diameter.” from sentence. Complete healing of a wound would normally be anticipated if all bone, cartilage, tendons, and foreign material were completely covered, healthy granulation were present to within 5 mm of the surface, and the wound edges were reduced to 2 cm in width or diameter. Specialty Matched Consultant Advisory Panel review 4/2024. Medical Director review 4/2024. |
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