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| Medical Guidelines | Reason for Update |
|---|---|
| Diagnosis and Treatment of Sacroiliac Joint Pain | References added. Related policies updated. No change to policy statement. Specialty Matched Consultant Advisory Panel review 4/2022 |
| Epidural Steroid Injections for Back Pain | Policy guidelines updated. References added. Specialty Matched Consultant Advisory Panel review 4/2022. Medical Director review 4/2022. No change to policy statement. |
| Facet Joint Denervation | References added. Specialty Matched Consultant Advisory Panel review 4/2022. Medical Director Review 4/2022. No change to policy statement |
| Hemodialysis Treatment for ESRD | Specialty Matched Consultant Advisory Panel review 4/2022. Medical Director review 4/2022. |
| Infertility Diagnosis and Treatment – B0006 | Codes 0664T-0670T from Billing/Coding section and investigational statement F. under “When not Covered” section: “Uterine transplant is considered investigational as a treatment of infertility” inadvertently removed during 10/19/21 update. Codes and statement re-added. |
| Intradialytic Parenteral Nutrition | Specialty Matched Consultant Advisory Panel review 4/2022. Medical Director review 4/2022. |
| Intravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric Disorders | References added. Specialty Matched Consultant Advisory Panel review 4/2022. Medical Director review 4/2022. No Change to policy statement. |
| Neural Therapy | References added. Specialty Matched Consultant Advisory Panel review 4/2022. Medical Director review 4/2022. No change to policy statement. |
| Neurostimulation, Electrical | References added. Specialty Matched Consultant Advisory Panel review 4/2022. Medical Director review 4/2022. No change to policy statement. |
| Percutaneous Electrical Nerve Stimulation (PENS) or Neuromodulation Therapy and Percutaneous Electrical Nerve Field Stimulation (PENFS) | References updated. Specialty Matched Consultant Advisory Panel review 4/2022. Medical Director review 4/2022. No change to policy statement. |
| Prolotherapy | Related policy added. References added. Specialty Matched Consultant Advisory Panel review 4/2022. Medical Director review 4/2022. No change to policy statement. |
| Radiofrequency Ablation of the Renal Nerves as a Treatment of Hypertension | References updated. Specialty Matched Advisory Panel review 4/2022. Medical Director review 4/2021. |
| Renal (Kidney) Transplantation | References updated. Specialty Matched Specialty Advisory Panel review 4/2022. Medical Director review 4/2022. |
| Skin and Soft Tissue Substitutes | Updated information to When Skin and Soft Tissue Substitutes are covered. Criteria to include clarification of 2nd degree burn products: “Kerecis* (formerly known as MariGen™*). |
| TENS (Transcutaneous Electrical Nerve Stimulator) | Regulatory status updated. References added. Specialty Matched Consultant Advisory Panel review 4/2022. Medical Director review 4/2022. No change to policy statement. |
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