| Medical Guidelines | Reason for Update |
|---|---|
| Automated Percutaneous and Endoscopic Discectomy | References updated. Specialty Matched Consultant Advisory Panel review 5/2025. Medical Director review 5/2025. |
| Beta Amyloid Imaging with Positron Emission Tomography for Alzheimer’s Disease | Regulatory status, policy guidelines, and references updated. Specialty Matched Consultant Advisory Panel review 5/2025. Medical Director review 5/2025. No change to policy statement. |
| Chemoembolization of the Hepatic Artery, Transcatheter Approach | Description and Policy Guidelines updated. References added. Specialty Matched Consultant Advisory Panel review 5/2025. Medical Director review 5/2025. No change to policy statement. |
| Cranial Electrotherapy Stimulation (CES) and Auricular Electrostimulation | Regulatory Status and References updated. Specialty Matched Consultant Advisory Panel review 5/2025. Medical Director review 5/2025. |
| Electrogastrography, Cutaneous | References updated. Specialty Matched Consultant Advisory Panel 5/2025. Medical Director review 5/2025. |
| Endovascular Procedures for Intracranial Arterial Disease | References updated. Specialty Matched Consultant Advisory Panel review 5/2025. Medical Director review 5/2025. |
| Enteral Nutrition | References updated. Specialty Matched Consultant Advisory Panel 5/2025. Medical Director review 5/2025. |
| Esophageal pH Monitoring | Description, Policy Guidelines and References sections updated. Specialty Matched Consultant Advisory Panel 5/2025. Medical Director review 5/2025. |
| Gastric Electrical Stimulation | Policy Guidelines and References updated, Specialty Matched Consultant Advisory Panel 5/2025. Medical Director review 5/2025. |
| Image-Guided Minimally Invasive Decompression (IG-MLD) for Spinal Stenosis | References updated. Specialty Matched Consultant Advisory Panel review 5/2025. Medical Director review 5/2025. |
| Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers) | Policy Guidelines updated without change to policy intent. References updated. Medical Director review 5/2025. Specialty Matched Consultant Advisory Panel review 5/2025. |
| Interspinous Fixation (Fusion) Devices | Policy Guidelines updated. No change to policy intent. References updated. Medical Director review 5/2025. Specialty Matched Consultant Advisory Panel review 5/2025. |
| Intraoperative Neurophysiologic Monitoring | References updated. Removed one archived Related Policy “Navigated Transcranial Magnetic Stimulation (nTMS). Medical Director review 5/2025. Specialty Matched Consultant Advisory Panel review 5/2025. |
| Lumbar Spine Procedures | Added one Related Policy. Policy Guidelines updated without change to policy intent. References updated. Specialty Matched Consultant Advisory Panel review 5/2025. Medical Director review 5/2025. |
| Magnetic Resonance Spectroscopy | Minor updates made to Description for clarity. References added. Specialty Matched Consultant Advisory Panel review 5/2025. Medical Director Review 5/2025. No change to policy statement. |
| MRI-Guided Focused Ultrasound (MRgFUS) | Description, Regulatory Status, and Policy Guidelines updated. References added. Specialty Matched Consultant Advisory Panel review 5/2025. Medical Director review 5/2025. No change to policy statement. |
| Myocardial Sympathetic Innervation Imaging | References added. Policy Guidelines and description updated. Specialty Matched Consultant Advisory Panel review 5/2025. Medical Director review 5/2025. No change to policy statement. |
| Occipital Nerve Stimulation | Description, Regulatory Status, and Policy Guidelines updated. No change to policy intent. References updated. Medical Director review 5/2025. Specialty Matched Consultant Advisory Panel review 5/2025. |
| Pancreas Transplant | Description, Policy Guidelines and References sections updated. Specialty Matched Consultant Advisory Panel 5/2025. Medical Director review 5/2025. |
| Paraspinal Surface Electromyography (SEMG) | References updated. Medical Director review 5/2025. Specialty Matched Consultant Advisory Panel review 5/2025. |
| Peroral Endoscopic Myotomy for Treatment of Esophageal Achalasia | Description, Policy Guidelines and References updated. When Covered section edited for clarity, no change to policy statement. Specialty Matched Consultant Advisory Panel 5/2025. Medical Director review 5/2025. |
| Polysomnography for Non‒Respiratory Sleep Disorders | References updated. Medical Director review 5/2025. Specialty Matched Consultant Advisory Panel review 5/2025. |
| Positional Magnetic Resonance Imaging (MRI) | References added. Specialty Matched Consultant Advisory Panel review 5/2025. Medical Director review 5/2025. No change in policy statement. |
| Sacroiliac Joint Fusion/Stabilization | Regulatory Status and References updated. Policy Guidelines updated without changes to policy intent. Removed information related to unpublished and ongoing clinical trials from Policy Guidelines. Medical Director review 5/2025. Specialty Matched Consultant Advisory Panel review 5/2025. |
| Screening for Vertebral Fracture with Dual X-ray Absorptiometry (DXA) | References added. Specialty Matched Consultant Advisory Panel review 5/2025. Medical Director review 5/2025. No change to policy statement. |
| Small Bowel, Small Bowel with Liver, or Multivisceral Transplant | References updated. Specialty Matched Consultant Advisory Panel 5/2025. Medical Director review 5/2025. |
| Surgical Deactivation of Headache Trigger Sites | References updated. Medical Director review 5/2025. Specialty Matched Consultant Advisory Panel review 5/2025. |
| Therapeutic Radiopharmaceuticals in Oncology | References added. Specialty Matched Consultant Advisory Panel review 5/2025. Medical Director review 2025. No change to policy statement. |
| Trigger Point and Tender Point Injections | Updated When Covered section for clarity. Updated When Not Covered to remove “Ultrasound and other imaging guidance of trigger point injections are considered investigational” and add “Trigger point injections using botulinum toxin or botulinum toxin derivatives are not covered.” Added the following statement to Billing/Coding section: “Separate reimbursement is not allowed for image guidance.” Medical director review 5/2025. |
| Vagus Nerve Stimulation | References updated. Medical Director review 5/2025. Specialty Matched Consultant Advisory Panel review 5/2025. |
| Vertebroplasty, Kyphoplasty, and Sacroplasty Percutaneous | Regulatory Status and Policy Guidelines updated. No change to policy intent. References updated. Specialty Matched Consultant Advisory Panel review 5/2025. Medical Director review 5/2025. |
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