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Medical Policy Update June 14, 2022 June 14, 2022
Medical GuidelinesReason for Update
Automated Percutaneous and Endoscopic DiscectomyReferences added. Specialty Matched Consultant Advisory Panel review 5/18/2022.
Bariatric SurgeryReference added. Specialty Matched Consultant Advisory Panel review 4/20/2022.
Complementary and Alternative MedicineAdded CPT code 0736T to Billing/Coding section. Effective 7/1/2022
Cranial Electrotherapy Stimulation (CES) and Auricular ElectrostimulationReference added. Regulatory Status updated. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 5/18/2022.
Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate, or Dermatologic TumorsSpecialty Matched Consultant Advisory Panel review 4/20/2022.
Cryosurgical Ablation of Primary or Metastatic Liver TumorsReference added. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 4/20/2022.
Endovascular Procedures for Intracranial Arterial DiseaseSpecialty Matched Consultant Advisory Panel review 5/18/2022.
Endovascular Therapies for Extracranial Vertebral Artery DiseaseSpecialty Matched Consultant Advisory Panel review 5/18/2022.
Gender Affirmation Surgery and Hormone TherapySpecialty Matched Consultant Advisory Panel review 4/20/2022.
Image-Guided Minimally Invasive Decompression (IG-MLD) for Spinal StenosisSpecialty Matched Consultant Advisory Panel review 5/18/2022.
Interspinous Fixation (Fusion) DevicesSpecialty Matched Consultant Advisory Panel review 5/18/2022.
Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers)Specialty Matched Consultant Advisory Panel review 5/18/2022.
Intraoperative Neurophysiologic MonitoringSpecialty Matched Consultant Advisory Panel review 5/18/2022.
Liver Transplant and Combined Liver-Kidney TransplantReference added. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel 4/20/2022.
Lumbar Spine Fusion SurgerySpecialty Matched Consultant Advisory Panel review 5/18/2022
Neurostimulation, ElectricalAdded CPT code 0720T to Billing/Coding section. Effective 7/1/2022.
Occipital Nerve StimulationSpecialty Matched Consultant Advisory Panel review 5/18/2022.
Paraspinal Surface Electromyography (SEMG)Specialty Matched Consultant Advisory Panel review 5/18/2022.
Percutaneous Electrical Nerve Stimulation (PENS) or Neuromodulation Therapy and Percutaneous Electrical Nerve Field Stimulation (PENFS)Added CPT code 0720T to Billing/Coding section. Effective 7/1/2022
Percutaneous Intradiscal and Intraosseous Radiofrequency Procedures of the SpinePolicy Guidelines updated. Removed deleted codes C9752 and C9753 from Billing/Coding section. Specialty Matched Consultant Advisory Panel review 5/18/2022.
Pneumatic Compression Pumps for Treatment of Lymphedema and Venous UlcersSpecialty Matched Consultant Advisory Panel review 4/20/2022
Polysomnography for Non‒Respiratory Sleep DisordersSpecialty Matched Consultant Advisory Panel review 5/18/2022
Radioembolization for Primary and Metastatic Tumors of the LiverRemoved ICD-9 diagnoses codes (153.0, 153.1, 155.0, 155.1, 155.2, 197.7, 573.8, 573.9) from Billing/Coding section. No change to policy statement.
Sacroiliac Joint Fusion/StabilizationReference added. Description section updated. "Transiliac placement" and "e.g., iFuse" added to the medically necessary statement on sacroiliac joint fusion. Policy Guidelines updated. Clinical Trials information updated. Specialty Matched Consultant Advisory Panel review 5/18/2022
Skin and Soft Tissue SubstitutesThe following codes were added to the Billing/Coding section: Q4259, Q4260, Q4261 effective 7/1/2022.
Surgical Deactivation of Headache Trigger SitesSpecialty Matched Consultant Advisory Panel review 5/18/2022.
Three Dimensional Printed Orthopedic ImplantsSpecialty Matched Consultant Advisory Panel review 2/16/2022.
Topical Negative Pressure Therapy for WoundsReference added. Rationale section updated. Specialty Matched Consultant Advisory Panel review 4/20/2022.
Vagus Nerve StimulationPolicy Guidelines updated. Specialty Matched Consultant Advisory Panel review 5/18/2022.
Vertebroplasty, Kyphoplasty, and Sacroplasty PercutaneousReferences added. Specialty Matched Consultant Advisory Panel review 5/18/2022.