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Medical Policy Update for August 29, 2023
Medical GuidelinesReason for Update
Abdominoplasty and Panniculectomy

References updated. Specialty Matched Consultant Review 8/2023. Medical Director review 8/2023. No change to policy statement.

Absorbable Nasal Implant for Treatment of Nasal Valve Collapse

References updated. Specialty Matched Consultant Advisory Panel review 8/2023. Medical Director review 8/2023.

Breast SurgeriesUpdated Related Policies section. References updated. Updated “When Reduction Mammaplasty is covered” section D to change “risk factor” to “contributing factor”. Updated “Reconstructive Breast Surgery After Mastectomy” description. Specialty Matched Consultant Advisory Panel review 8/2023. Medical Director review 8/2023. No change to policy statement.
Colorectal Cancer Screening AHS-B0001

Reviewed by Avalon Q1 2023 CAB. No changes to policy statement.

Composite Allotransplantation of the Hand and Face

References updated. Specialty Matched Consultant Advisory Panel 8/2023. Medical Director review 8/2023. No change to policy statement.

Extracorporeal Photopheresis

Specialty Matched Consultant Advisory Panel review 8/16/2023. Updated description section. References added. No change to policy statement.

Laser Treatment of Port Wine Stains

References updates. Specialty Matched Consultant Advisory Panel review 8/2023. Medical Director review 8/2023. No change to policy statement.

Microarray-Based Gene Expression Profile Testing for Multiple Myeloma Risk Stratification AHS-B0002

General review per Avalon CAB Q2 2023. Medical Director review 8/2023. No change to policy statement.

Reconstructive Eyelid Surgery and Brow Lift

Specialty Matched Consultant Advisory Panel review 8/2023. Medical Director review 8/2023. References updated. No change to policy statement.

Rhinoplasty

Updated references. Added Related Policy.  Minor edit to the Policy Guidelines.  No change to policy intent.  Deleted terminated code C9749 from Billing/Coding section.  Medical Director Review 8/2023.  Specialty Matched Consultant Advisory Panel 8/2023.

Septoplasty

Specialty Matched Consultant Advisory Panel review 8/2023. Medical Director review 8/2023.  Updated references. Added Related Policy.

Skin and Soft Tissue SubstitutesReferences updated. Specialty Matched Consultant Advisory Panel review 8/2023. Medical Director review 8/2023. No changes to policy statement.
Sleep Apnea: Diagnosis and Medical Management

When covered section updated for clarity. References added. Specialty Matched Consultant Advisory Panel review 8/2023. Medical Director review 8/2023. No change to policy statement.

Surgery for Obstructive Sleep Apnea and Upper Airway Resistance Syndrome

References updated. Specialty Matched Consultant Advisory Panel review 8/2023. Medical Director review 8/2023. No change to policy statement.

Surgical Treatment for Lipedema

References updated. Medical Director review 8/2023. Specialty Matched Consultant Advisory Panel Review 8/2023. No change to policy statement.

Surgical Treatment of Chest Wall Deformities (Congenital or Acquired)

Specialty Matched Consultant Advisory Panel 8/2023. Medical Director review 8/2023. References updated.  No change to policy statement.

Tinnitus TreatmentReference added. Description section updated to include related policies, Minor edits to Policy Guidelines. No change to policy intent.  Specialty Matched Consultant Advisory Panel review 8/2023. Medical Director review 8/2023.
Tumor-Treatment Fields Therapy

Specialty Matched Consultant Advisory Panel review 8/16/2023. Updated description policy guidelines and references. No change to policy statement.