| Medical Guidelines | Reason for Update |
|---|---|
| Abdominoplasty and Panniculectomy | References updated. Specialty Matched Consultant Review 8/2024. Medical Director review 8/2024. No change to policy statement. |
| Absorbable Nasal Implant for Treatment of Nasal Valve Collapse | References updated. Specialty Matched Consultant Advisory Panel review 8/2024. Medical Director review 8/2024. |
| Breast Surgeries | Updated References. Updated Section II description, Section III Policy Guidelines, and Section IV Policy Guidelines. Specialty Matched Consultant Advisory Panel review 8/2024. Medical Director review 8/2024. No change to policy statement. |
| Cochlear Implant | Description and Regulatory Status sections updated. When Covered section updated for clarity by rearranging bullets contained in the second coverage indication, added subsection headers, and clarified hearing aids under Bilateral Sensorineural Deafness to read, “appropriately fit, conventional hearing aids”. Policy Guidelines updated. No change to policy intent. References updated. Specialty Matched Consultant Advisory Panel review 8/2024. Medical Director review 8/2024. |
| Composite Allotransplantation of the Hand and Face | References updated. Specialty Matched Consultant Advisory Panel 8/2024. Medical Director review 8/2024. No change to policy statement. |
| Cosmetic and Reconstructive Surgery | Related Policies updated. References updated. Specialty Matched Consultant Advisory Panel 8/2024. Medical Director review 8/2024. No change to policy statement. |
| Cryoablation, Radiofrequency Ablation, and Laser Ablation for Treatment of Chronic Rhinitis | Description and Policy Guidelines sections updated. No change to policy intent. Regulatory Status and References updated. Medical Director Review 8/2024. Specialty Matched Consultant Advisory Panel review 8/2024. |
| Extracorporeal Photopheresis | Specialty Matched Consultant Advisory Panel review 8/21/2024. Updated description section. References added. No change to policy statement. |
| Hematopoietic Cell Transplantation | Specialty Matched Consultant Advisory Panel review 8/21/2024. References added. No change to policy statement. |
| Infertility Diagnosis and Treatment – B0006 | Description updated to further define infertility for clarification. Minor changes made to when not covered section for clarity. No changes to policy statement. Medical Director review 8/2024. |
| Laser Treatment of Port Wine Stains | References updates. Specialty Matched Consultant Advisory Panel review 8/2024. Medical Director review 8/2024. No change to policy statement. |
| Reconstructive Eyelid Surgery and Brow Lift | Specialty Matched Consultant Advisory Panel review 8/2024. Medical Director review 8/2024. References updated. No change to policy statement. |
| Septoplasty | Added Related Policy. When Septoplasty is Covered section updated as follows: removed the following “The ethmoid bone is the bone in the nose through which the olfactory nerves pass. Olfactory nerves are connected with the sense of smell” as this statement is more definitional in nature. Added additional coverage bullet: “A deviated septum that precludes access for functional endoscopic surgery”. Updated references. Specialty Matched Consultant Advisory Panel review 8/2024. Medical Director review 8/2024. |
| Skin and Soft Tissue Substitutes | References updated. Specialty Matched Consultant Advisory Panel review 8/2024. Updated coverage criteria to remove tables and utilized list format. Replaced “patient” with “individual” throughout policy. Added TheraSkin® to approved products for treatment of diabetic ulcers when criteria are met. Removed CPT code C1762 from Billing/Coding section. Medical Director review 8/2024 |
| Surgical Treatment for Lipedema | References updated. Medical Director review 8/2024. Specialty Matched Consultant Advisory Panel Review 8/2024. No change to policy statement. |
| Surgical Treatment of Chest Wall Deformities (Congenital or Acquired) | Specialty Matched Consultant Advisory Panel 8/2024. Medical Director review 8/2024. References updated. No change to policy statement. |
| Surgical Treatment of Sinus Disease | Description and Regulatory Status updated. Added two related policies. Policy Guidelines updated. No change to policy intent. Medical Director review 8/2024. Specialty Matched Consultant Advisory Panel review 8/2024. |
| Tinnitus Treatment | Description section updated. Regulatory Status section header added. Updated listing of FDA-approved devices. Policy Guidelines updated without change to policy intent. Removed terminated CPT code 96152 from Billing/Coding section. Specialty Matched Consultant Advisory Panel review 8/2024. Medical Director review 8/2024. |
| Tumor-Treatment Fields Therapy | Specialty Matched Consultant Advisory Panel review 8/21/2024. Updated description section and references added. No change to policy statement. |
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