Medical Policy Update for June 13, 2023
| Medical Guidelines | Reason for Update |
|---|---|
| BioZorb® (PDF) | Specialty Matched Consultant Advisory Panel review 5/17/2023. No change to policy statement. |
| Brachytherapy, Intracavitary Balloon Catheter for Brain Cancer (PDF) | Specialty Matched Consultant Advisory Panel review 5/17/2023. No change to policy statement. Updated description section. Reference added. |
| Specialty Matched Consultant Advisory Panel review 5/17/2023. Reference added. No change to policy statement. | |
| Added HCPCS code C1767 to Billing/Coding section. | |
Intensity Modulated Radiation Therapy for Tumors of the Central Nervous System (PDF) | 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 (PDF) | Specialty Matched Consultant Advisory Panel review 5/17/2023. No change to policy statement. |
Intensity Modulated Radiation Therapy (IMRT) of Abdomen and Pelvis (PDF) | Specialty Matched Consultant Advisory Panel review 5/17/2023. No change to policy statement. |
| Intensity Modulated Radiation Therapy (IMRT) of Head and Neck (PDF) | Specialty Matched Consultant Advisory Panel review 5/17/2023. No change to policy statement. |
Intensity Modulated Radiation Therapy (IMRT) of the Chest (PDF) | Specialty Matched Consultant Advisory Panel review 5/17/2023. No change to policy statement. |
Intensity-Modulated Radiation Therapy (IMRT) of the Prostate (PDF) | Specialty Matched Consultant Advisory Panel review 5/17/2023. No change to policy statement. |
| Neurostimulation, Electrical (PDF) | Added HCPCS code C1767 to Peripheral Subcutaneous Field Stimulation Billing/Coding section. |
| Specialty Matched Consultant Advisory Panel review 5/17/2023. Code C1767 added to Billing/Coding section. | |
| 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 (PDF) | 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 (PDF) | 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 (PDF) | Specialty Matched Consultant Advisory Panel review 5/17/2023. No change to policy statement. |
| Radiosurgery, Stereotactic Approach (PDF) | 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 (PDF) | Added HCPCS code C1767 to the Billing/Coding section. |
| Added HCPCS code C1767 to the Billing/Coding section. | |
Surgery for Obstructive Sleep Apnea and Upper Airway Resistance Syndrome (PDF) | Added HCPCS codes C1767 to Billing/Coding section. |
Transurethral Water Vapor Thermal Therapy for Benign Prostatic Hyperplasia (PDF) | Policy review. References updated. Specialty Matched Consultant Advisory Panel review 11/16/2022. |
Vesicoureteral Reflux, Treatment with Periureteral Bulking Agents (PDF) | Policy review. Specialty Matched Consultant Advisory Panel review 11/16/2022. |
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