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| Medical Guidelines | Reason for Update |
|---|---|
| Bariatric Surgery | Description section updated with current information to include Clinical Practice Guidelines of conditions weight-related complications. Regulatory status and Other Therapies updated with FDA Medical Devices for Weight Loss and Weight Management: What to Know dated 10/27/22. Clinical Guidelines updated. No changes to coverage criteria or policy intent. References added. Specialty Matched Consultant Advisory Panel review 4/2025. Medical Director review 4/2025. |
| Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate, or Dermatologic Tumors | Reference added. Specialty Matched Consultant Advisory Panel review 4/2025. Medical Director review 4/2025. |
| Cryosurgical Ablation of Primary or Metastatic Liver Tumors | Reference added. Specialty Matched Consultant Advisory Panel review 4/2025. Medical Director review 4/2025. |
| Diagnosis and Treatment of Sacroiliac Joint Pain | Regulatory status, policy guidelines, and references updated. No change to policy statement. Specialty Matched Consultant Advisory Panel review 4/2025. Medical Director review 4/2025. |
| Epidural Steroid Injections for Back Pain | Description and policy guidelines updated. References added. Specialty Matched Consultant Advisory Panel review 4/2025. Medical Director review 4/2025. No change to policy statement. |
| Facet Joint Denervation | Description, policy guidelines, and references updated. Specialty Matched Consultant Advisory Panel review 4/2025. Medical Director Review 4/2025. No change to policy statement. |
| Gender Affirmation Surgery | Related policies updated to include Cosmetic and Reconstructive Surgery. Updated References. Specialty Matched Consultant Advisory Panel review 4/2025. Medical Director review 4/2025. |
| Hemodialysis Treatment for ESRD | Specialty Matched Consultant Advisory Panel review 4/2025. References updated. Medical Director review 4/2025. |
| Intradialytic Parenteral Nutrition | References updated. Specialty Matched Consultant Advisory Panel review 4/2025. Medical Director review 4/2025. |
| Intravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric Disorders | Description and Policy guidelines updated. References added. Updated when not covered section to include treatment-resistant depression and post-traumatic stress disorder. Removed deleted code J2001 from Billing/Coding section. Specialty Matched Consultant Advisory Panel review 4/2025. Medical Director review 4/2025. |
| Liver Transplant and Combined Liver-Kidney Transplant | Reference added. Specialty Matched Consultant Advisory Panel review 4/2025. Medical Director review 4/2025. |
| Neurostimulation, Electrical | References added. Specialty Matched Consultant Advisory Panel review 4/2025. Medical Director review 4/2025. No change to policy statement. Added A4544 and E0743 to Section I Billing/Coding section. |
| Percutaneous Electrical Nerve Stimulation (PENS) or Neuromodulation Therapy and Percutaneous Electrical Nerve Field Stimulation (PENFS) | References updated. Specialty Matched Consultant Advisory Panel review 4/2025. Medical Director review 4/2025. No change to policy statement. |
| Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers | References updated. Updated related policies to include Surgical Treatment for Lymphedema. Policy guidelines updated. Specialty Matched Consultant Advisory Panel review 4/2025. Medical Director review 4/2025. |
| Prolotherapy | Specialty Matched Consultant Advisory Panel review 4/2025. Medical Director review 4/2025. Archive policy. |
| Renal (Kidney) Transplantation | Description and References sections updated. Specialty Matched Specialty Advisory Panel review 4/2025. Medical Director review 4/2025. |
| TENS (Transcutaneous Electrical Nerve Stimulator) | Regulatory status and references updated. Removed A4544 and A4540 from Billing/Coding section. Specialty Matched Consultant Advisory Panel review 4/2025. Medical Director review 4/2025. |
| Trigger Point and Tender Point Injections | References added. Specialty Matched Consultant Advisory Panel review 4/2025. Medical Director review 4/2025. No change to policy statement. |
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