| Medical Guidelines | Reason for Update |
|---|---|
| Ablative Techniques for the Myolysis of Uterine Fibroids | Added coverage for Acessa and Sonata. Policy Guidelines updates. References updated. Medical Director review 6/2022 |
| Adaptive Behavioral Treatment for Autism Spectrum Disorders | Update made to When Covered section to remove following criteria: “There is an established and current (within 5 years) DSM-5 diagnosis of Autism Spectrum Disorder using one or more validated assessment tool (e.g., Autism Diagnostic Observation Schedule (ADOS), Autism Diagnostic Interview (ADI-R), Childhood Autism Rating Scale (CARS), Social Communication Questionnaire (SCQ), Social Reciprocity Scale (SRS), Gilliam Autism Rating Scale (GARS);” Specialty Matched Consultant Advisory Panel Review 6/2022. Medical Director Review 6/2022. References added. |
| Artificial Pancreas Device Systems | Related policies added. References added. Specialty Matched Consultant Advisory Panel review 6/2022. Medical Director review 6/2022. No change to policy statement. |
| Cardiac (Heart) Transplantation | Minor update to description section. Specialty Matched Consultant Advisory Panel review 6/2022. Medical Director review 6/2022. |
| Carotid Artery Angioplasty/Stenting (CAS) | Specialty Matched Consultant Advisory Panel review 6/2022. Medical Director review 6/2022. |
| Congenital Heart Defect, Repair Devices | Specialty Matched Consultant Advisory Panel review 6/2022. Medical Director review 6/2022. |
| Continuous Monitoring of Glucose in the Interstitial Fluid | References updated. Specialty Matched Consultant Advisory Panel review 6/2022. Medical Director review 6/2022. Added codes G0308 and G0309 to Billing/Coding section, effective 7/1/2022. Updated FDA approved device list to include Freestyle Libre 3. No change to policy statement. |
| Diagnosis of Vaginitis including Multi-target PCR Testing AHS – M2057 | Added the following statement to When Not Covered section “Reimbursement is not allowed for all other tests for vaginitis not addressed above.” to align with Avalon |
| Heart-Lung Transplantation | Minor updates only. Specialty Matched Consultant Advisory Panel review 6/2022. Medical Director review 6/2022. |
| Implantable Cardioverter Defibrillator | Specialty Matched Consultant Advisory Panel review 6/2022. Medical Director review 6/2022. |
| Insulin Therapy, Chronic Intermittent Intravenous (CIIIT) | References added. Specialty Matched Consultant Advisory Panel review 6/2022. Medical Director review 6/2022. No changes to policy statement or intent. |
| Islet Cell Transplantation | References added. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 6/2022. Medical Director review 6/2022. No changes to policy statement or intent. |
| Neurostimulation, Electrical | Updated CPT code under “Other Electrical Stimulation Devices” section for Percutaneous electrical nerve stimulation (PENS) (Code 64999; HCPCS Code E1399) and added the following statement “Providers may submit claims for these services using the unlisted code 64999. Providers should not be using 64553-64565, or 64590 to bill this service as these codes are not appropriate.” No change to policy statement. Medical Director Review 6/2022. |
| Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention | Description including regulatory status updated. Added “or Amplatzer Amulet” to both the Covered and Non-Covered sections. Added “, including the Lariat and Amplatzer Cardiac Plug devices,” to the second non-covered statement for clarity. No change to policy intent. Policy guidelines updated. Specialty Matched Consultant Advisory Panel review 6/2022. Medical Director review 6/2022. |
| Quantitative Electroencephalography as a Diagnostic Aid for Attention Deficit/Hyperactivity Disorder | Updated Description section. References added. Specialty Matched Consultant Advisory Panel review 6/2022. Medical Director review 6/2022. No change to policy statement. |
| Sensory Integration Therapy and Auditory Integration Therapy | Description updated. References added. Specialty Matched Consultant Advisory Panel review 6/202. Medical Director review 6/2022. No change to policy statement. |
| Surgical Management of Transcatheter Heart Valves | Minor updates to regulatory status and policy guidelines. Specialty Matched Consultant Advisory Panel review 6/2022. Medical Director review 6/2022. |
| Surgical Ventricular Restoration | Specialty Matched Consultant Advisory Panel review 6/2022. Medical Director review 6/2022. |
| TENS (Transcutaneous Electrical Nerve Stimulator) | Removed code 64550. Added codes 97014 and 97032. No changes to policy statement or intent |
| Transcatheter Closure of Ventricular Septal Defects | Specialty Matched Consultant Advisory Panel review 6/2022. Medical Director review 6/2022. |
| Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders | Related policies added. References added. Specialty Matched Consultant Advisory Panel review 6/2022. Medical Director review 6/2022. No change to policy statement. |
| Treatment For Opioid Use Disorder in Opioid Treatment Programs (OTPs) | References added. Specialty Matched Consultant Advisory Panel review 6/2022. Medical Director review 6/2022. No change to policy statement. |
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