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Medical Policy Update for June 13, 2023 June 13, 2023
Medical GuidelinesReason for Update
BioZorb®Specialty Matched Consultant Advisory Panel review 5/17/2023. No change to policy statement.
Brachytherapy, Intracavitary Balloon Catheter for Brain CancerSpecialty Matched Consultant Advisory Panel review 5/17/2023. No change to policy statement. Updated description section. Reference added.

Electronic Brachytherapy for Nonmelanoma Skin Cancer

Specialty Matched Consultant Advisory Panel review 5/17/2023. Reference added. No change to policy statement.

Gastric Electrical Stimulation

Added HCPCS code C1767 to Billing/Coding section.

Intensity Modulated Radiation Therapy for Tumors of the Central Nervous System

Specialty Matched Consultant Advisory Panel review 5/17/2023. Updated policy guidelines and reference added. No change to policy statement.

Intensity Modulated Radiation Therapy (IMRT) for Sarcoma of the Extremities

Specialty Matched Consultant Advisory Panel review 5/17/2023. No change to policy statement.

Intensity Modulated Radiation Therapy (IMRT) of Abdomen and Pelvis

Specialty Matched Consultant Advisory Panel review 5/17/2023. No change to policy statement.
Intensity Modulated Radiation Therapy (IMRT) of Head and Neck

Specialty Matched Consultant Advisory Panel review 5/17/2023. No change to policy statement.

Intensity Modulated Radiation Therapy (IMRT) of the Chest

Specialty Matched Consultant Advisory Panel review 5/17/2023. No change to policy statement.

Intensity-Modulated Radiation Therapy (IMRT) of the Prostate

Specialty Matched Consultant Advisory Panel review 5/17/2023. No change to policy statement.
Neurostimulation, ElectricalAdded HCPCS code C1767 to Peripheral Subcutaneous Field Stimulation Billing/Coding section.

Occipital Nerve Stimulation

Specialty Matched Consultant Advisory Panel review 5/17/2023. Code C1767 added to Billing/Coding section.

Percutaneous Electrical Nerve Stimulation (PENS) or Neuromodulation Therapy and Percutaneous Electrical Nerve Field Stimulation (PENFS)

Related policies updated. References updated. Specialty Matched Consultant Advisory Panel review 4/2023. Medical Director review 4/2023. No change to policy statement.

Percutaneous Tibial Nerve Stimulation for Voiding Dysfunction

Routine review.  Related Policies added.  Policy Guidelines updated.  Specialty Matched Consultant Advisory Panel review 11/16/2022.

Perirectal Spacer Use During Radiotherapy for Prostate Cancer

Specialty Matched Consultant Panel review 5/17/2023. No change to policy statement. Policy guidelines updated. Reference added.

Radioembolization for Primary and Metastatic Tumors of the Liver

Specialty Matched Consultant Advisory Panel review 5/17/2023. No change to policy statement.
Radiosurgery, Stereotactic Approach

Specialty Matched Consultant Advisory Panel review 5/17/2023. Under “When covered” section: removed bullet (d) under Section B #2 which stated patient is not currently anticoagulated. No change to policy statement.

Sacral Nerve Neuromodulation/Stimulation for Pelvic Floor Dysfunction

Added HCPCS code C1767 to the Billing/Coding section.

Spinal Cord and Dorsal Root Ganglion Stimulation

Added HCPCS code C1767 to the Billing/Coding section.

Surgery for Obstructive Sleep Apnea and Upper Airway Resistance Syndrome

Added HCPCS codes C1767 to Billing/Coding section.

Transurethral Water Vapor Thermal Therapy for Benign Prostatic Hyperplasia

Policy review.  References updated.  Specialty Matched Consultant Advisory Panel review 11/16/2022.

Vesicoureteral Reflux, Treatment with Periureteral Bulking Agents

Policy review.  Specialty Matched Consultant Advisory Panel review 11/16/2022.