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Medical Policy Update for May 03, 2022 May 03, 2022
Medical GuidelinesReason for Update
Diagnosis and Treatment of Sacroiliac Joint PainReferences added. Related policies updated. No change to policy statement. Specialty Matched Consultant Advisory Panel review 4/2022
Epidural Steroid Injections for Back PainPolicy guidelines updated. References added. Specialty Matched Consultant Advisory Panel review 4/2022. Medical Director review 4/2022. No change to policy statement.
Facet Joint DenervationReferences added. Specialty Matched Consultant Advisory Panel review 4/2022. Medical Director Review 4/2022. No change to policy statement
Hemodialysis Treatment for ESRDSpecialty Matched Consultant Advisory Panel review 4/2022. Medical Director review 4/2022.
Infertility Diagnosis and Treatment – B0006Codes 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 NutritionSpecialty Matched Consultant Advisory Panel review 4/2022. Medical Director review 4/2022.
Intravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric DisordersReferences added. Specialty Matched Consultant Advisory Panel review 4/2022. Medical Director review 4/2022. No Change to policy statement.
Neural TherapyReferences added. Specialty Matched Consultant Advisory Panel review 4/2022. Medical Director review 4/2022. No change to policy statement.
Neurostimulation, ElectricalReferences 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.
ProlotherapyRelated 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 HypertensionReferences updated. Specialty Matched Advisory Panel review 4/2022. Medical Director review 4/2021.
Renal (Kidney) TransplantationReferences updated. Specialty Matched Specialty Advisory Panel review 4/2022. Medical Director review 4/2022.
Skin and Soft Tissue SubstitutesUpdated 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.