| Medical Guidelines | Reason for Update |
|---|---|
| Abdominoplasty and Panniculectomy | References updated. Specialty Matched Consultant Review 8/2025. Medical Director review 8/2025. No change to policy statement. |
| Absorbable Nasal Implant for Treatment of Nasal Valve Collapse | References updated. Specialty Matched Consultant Advisory Panel review 8/2025. Medical Director review 8/2025. |
| Breast Surgeries | Updated References. Specialty Matched Consultant Advisory Panel review 8/2025. Medical Director review 8/2025. No change to policy statement. |
| Cochlear Implant | When Covered section updated for clarity. No change to policy intent. Policy Guidelines updated with respect to defining limited benefit and now reads, “In adults, limited benefit from hearing aids is defined as scores 60% correct or less in the ear to be implanted …” References updated. Specialty Matched Consultant Advisory Panel review 8/2025. Medical Director review 8/2025. |
| Composite Allotransplantation of the Hand and Face | References updated. Specialty Matched Consultant Advisory Panel 8/2025. Medical Director review 8/2025. No change to policy statement. |
| Cosmetic and Reconstructive Surgery | References updated. Specialty Matched Consultant Advisory Panel 8/2025. Medical Director review 8/2025. No change to policy statement. |
| Cryoablation, Radiofrequency Ablation, and Laser Ablation for Treatment of Chronic Rhinitis | Updated the Description and Policy Guidelines sections with minimal edits for clarity. No change to policy intent. References updated. Medical Director Review 8/2025. Specialty Matched Consultant Advisory Panel review 8/2025. |
| Extracorporeal Photopheresis | Specialty Matched Consultant Advisory Panel review 8/20/2025. Reference added. No change to policy statement. |
| Hematopoietic Cell Transplantation | Specialty Matched Consultant Advisory Panel review 8/20/2025. References added. No change to policy statement. |
| Intensity Modulated Radiation Therapy for Tumors of the Central Nervous System | Specialty Matched Consultant Advisory Panel review 5/21/2025. References updated. Per Medical Director/CAP review: Under “when not covered” section, added non-covered criteria: “Intensity Modulated Radiation Therapy (IMRT) is considered not medically necessary for prophylactic cranial irradiation in individuals with small cell lung cancer (SCLC).” Notification given 7/1/2025 for effective date 9/10/2025. |
| Laser Treatment of Port Wine Stains | References updates. Specialty Matched Consultant Advisory Panel review 8/2025. Medical Director review 8/2025. No change to policy statement. |
| Quantitative Electroencephalography | Updated description, policy guidelines, and references added. Updated When Not Covered with the following: “Quantitative electroencephalographic (EEG)-based assessment of the theta:beta ratio is considered investigational as a diagnostic aid for for cognitive impairment and all mental health diagnosis, including but not limited to: Major depressive disorder; Substance use disorder diagnoses; Post-traumatic stress disorder; Conversion disorder with seizures or convulsions; Anxiety disorder/generalized anxiety disorder; Postconcussional syndrome; Autism spectrum disorders. Specialty Matched Consultant Advisory Panel review 6/2025. Medical Director review 6/2025. Notification given 7/16/2025 for effective date 9/10/2025. |
| Reconstructive Eyelid Surgery and Brow Lift | Specialty Matched Consultant Advisory Panel review 8/2025. Medical Director review 8/2025. References updated. No change to policy statement. |
| Rhinoplasty | Updated When Covered section with minimal edits for clarity. Policy Guidelines updated. No change to policy intent. Updated references. Medical Director Review 8/2025. Specialty Matched Consultant Advisory Panel 8/2025. |
| Septoplasty | Updated When Covered section with minimal edits for clarity. No change to policy intent. Updated references. Specialty Matched Consultant Advisory Panel review 8/2025. Medical Director review 8/2025. |
| Skin and Soft Tissue Substitutes | Description updated to include the following statement: “This policy only addresses use of amniotic membrane and placenta products for non-ophthalmologic indications. This policy does not address the use of amniotic or placenta products for ophthalmic indications. Please see related policy for ophthalmic indications. This policy does not address cadaveric tendon repair products. Updated When Covered section to include lists of products for 2nd and 3rd degree burns and added “Cadaver-derived skin grafts may be considered medically necessary for the management of traumatic skin wounds and burn wounds if the wound is too large for autograft.” References updated. Specialty Matched Consultant Advisory Panel review 8/2025. Medical Director review 8/2025. |
| Surgical Treatment for Lipedema | References updated. Medical Director review 8/2025. Specialty Matched Consultant Advisory Panel Review 8/2025. No change to policy statement. |
| Surgical Treatment of Chest Wall Deformities (Congenital or Acquired | Specialty Matched Consultant Advisory Panel 8/2025. Medical Director review 8/2025. References updated. No change to policy statement. |
| Tinnitus Treatment | Description section updated. Updated listing of FDA-approved devices. References updated. Specialty Matched Consultant Advisory Panel review 8/2025. Medical Director review 8/2025. |
| Tumor Treatment Fields Therapy | Specialty Matched Consultant Advisory Panel review 8/20/25. References added. No change to policy statement. |
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