Medical Policies
Last Updated on April 06, 2021
Policy changes effective April 1, 2021
Updated Policies- Varicose Vein Treatments Medical Policy
- Genetic Testing for Hereditary Cancer Susceptibility Syndromes Medical Policy
- Genetic Testing for Prenatal and Preconception Carrier Screening Medical Policy
- Genetic Testing for Prenatal Diagnosis (Via Amniocentesis or CVS) and Pregnancy Loss Medical Policy
- Genetic Testing: Non-invasive Prenatal Screening (NIPS)/Non-invasive Prenatal Testing (NIPT) Medical Policy
- Home Care Coverage Criteria Medical Policy
- Electroconvulsive Therapy Medical Policy
- Experimental and Investigation Medical Policy
- Urinary Incontinence Medical Policy
- Gastric Pacing and Gastric Electrical Stimulation Medical Policy
- Inpatient Rehab Facility (IRF) Medical Policy
- Long Term Acute Rehab (LTAC) Facility Medical Policy
- Genetic Testing for Lung Disorders Medical Policy
Policy changes effective March 1, 2021
Updated Policies- Cluster and Migraine Headache: Nonsurgical Management Medical Policy
- Cryoablation Medical Policy
- Experimental and Investigation Medical Policy
- Telehealth Medical Policy
- Implantable Hormone Pellet Replacement Therapy Medical Policy
- Ivor Lewis Procedure Medical Policy
- LINX for GERD Medical Policy
- Medtronic IN.PACT Admiral Paclitaxel-coated PTA Balloon Medical Policy
Policy changes effective February 1, 2021
Updated Policies- Back Surgical Procedure: Vertebroplasty-Inpatient and Outpatient Settings
- Back Surgical Procedures for Cervical and Thoracic Levels-Inpatient and Outpatient Settings
- Behavioral Health/AODA: Transitional Care Coverage – Medicare Advantage
- Hyperbaric Oxygen Therapy
- Radiofrequency Ablation to Treat Tumors
- Refractive Eye Surgery
- Tilt Table Testing
- Total Hip Replacement Surgical Precertification – Title changed to Total Hip Replacement Surgery
- Total Knee Replacement Surgical Precertification – Title also changed to Total Knee Replacement Surgery
- Genetic Testing for Cardiac Disorders
- Skin Substitutes, Chemical Peels, Dermabrasions, and other Skin Procedures
- Amino-Acid Based Oral Formulas for Infants
- Behavioral Health/AODA: Transitional Care Coverage
- Core Decompression of AVN of the Femoral Head
- Hyperthermic Intraperitoneal Chemotherapy
- Pancreas Transplant Alone (PTA) and Autologous Islet Cell Transplants
- Telehealth
- Wearable Hearing Aids
- Genetic Testing General Approach to Genetic Testing
- Genetic Testing for Aortopathies and Connective Tissue Disorders
- Hospice
Policy changes effective January 1, 2021
Updated Policies- Breast Reconstruction Post-Mastectomy Medical Policy
- Erectile Dysfunction Treatments Medical Policy
- Genetic Testing for Prenatal and Preconception Carrier Screening Medical Policy
- Experimental
- Behavioral Health/AODA: Transitional Care Coverage
- Abdominoplasty and Panniculectomy
- Breast Reduction Mammoplasty
- Inpatient Admission Prior to Surgery (Pre-op)
- Radiesse
- Treatment of Autism Spectrum Disorders
Policy changes effective December 1, 2020
Updated Policies- Contact Lenses and Other Eyewear
- Cellular Therapies
- COVID-19 Medical Policy
- Experimental and Investigation Policy
- Hyaluronic Acid
- Carpal Tunnel Repair Surgical Precertification
- Eyelid & Brow Repair
- Idiopathic Scoliosis
- Knee Arthroscopy Surgery Precertification
- Obesity Management, Surgical Approaches
- Varicose Vein Treatments
- Luxturna
- Imlygic
- Genetic Testing for Prenatal and Preconception Carrier Screening
- Prior authorization will be required for spinal muscular atrophy carrier screening starting March 1, 2021
Policy changes effective November 1, 2020
Updated Policies- Mitraclip Procedure
- Genetic Testing for Gastrointestinal (non-cancerous) Conditions
- Genetic Testing for Hereditary Hearing Loss
- Genetic Testing Oncology: Molecular Analysis of Solid Tumors and Hematologic Malignancies
- Ambulance: Land and Air Transportation
- Back Surgical Procedures for Lumbar Spinal Level - Inpatient and Outpatient Settings
- Eye Movement Desensitization and Reprocessing (EMDR)
- Home Health Care- Medicare Advantage
- Left Atrial Appendage Closure
- Medicare Advantage Chiropractor
- Sleep Studies
Policy changes effective October 1, 2020
Updated Policies- Lung Volume Reduction Surgery
- Septoplasty/Rhinoplasty
- Genetic Testing for Hereditary Cancer Susceptibility Syndromes Medical Policy
- Genetic Testing - Oncology: Molecular Analysis of Solid Tumors and Hematologic Malignancies
- Genetic Testing Oncology: Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy)
- Cluster and Migraine Headaches
- Genetic Testing for Hematologic Conditions (non-cancerous)
- Genetic Testing for Epilepsy, Neurodegenerative, and Neuromuscular Conditions
- Medicare Advantage Skilled Nursing Facility Coverage Criteria
- Private Duty Nursing in the Home Setting
- Repetitive Transcranial Magnetic Stimulation
- Spravato
- Swing Bed
- Zolgensma
- Synagis Injections
Policy changes effective September 1, 2020
Updated Policies- Experimental or Investigational
- Vagus Nerve Stimulation for Epilepsy and Depression
- Complementary and Alternative Medicine
- Genetic Testing
- Intrastromal Corneal Ring Segments
- MAZE Procedure
- Outpatient and Inpatient Chemotherapy Administration
- Spinal Cord Stimulation
- Zika Virus
Policy changes effective August 1, 2020
Updated Policies- Bone and Tendon Graft Substitutes and Adjuncts Medical Policy
- Cosmetic Surgery/Treatments Medical Policy
- Gender Reassignment Services and Surgical Procedures Medical Policy
- Home Infusion Medical Policy
- Intravenous Iron Therapy - Commercial/Exchange Medical Policy
- Experimental Investigation Medical Policy
- Cellular Therapies Medical Policy
- Vagus Nerve Stimulation for Epilepsy and Depression Medical Policy
- Telehealth PolicyGenetic Testing: Genetic Testing: Non-invasive Prenatal Screening (NIPS)/Non-invasive Prenatal Testing (NIPT) Medical Policy
- Healthcheck "Other Services" Medical Policy
- Intravenous Iron Therapy - Medicare Medical Policy
- Transcatheter Aortic Valve Replacement (TAVR) Medical Policy
- Dupilumab (Dupixent®) Medical Policy
- Hyaluronic Acid Derivatives Medical Policy
- Fractional Flow Reserve CT Medical Policy
- Genetic Testing for Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay
Policy changes effective July 1, 2020
Updated Policies- Abnormal Vascular Lesion Removal Medical Policy
- Femoro-Acetabular Surgery for Hip Impingement Syndrome Medical Policy
- Infuse Bone Graft (Bmp-2) Procedure Medical Policy
- Physical, Occupational and Speech Therapy Exclusions Medical Policy
- Skin Substitutes, Chemical Peels, Dermabrasions, and other Skin Procedures Medical Policy
- Gender Reassignment Medical Policy
- Home Care Coverage Criteria Medical Policy
- Behavioral Health-AODA: Transitional Care Coverage-Medicare Advantage Medical Policy
- Electroencephalography (EEG) Procedures Medical Policy
- TMJ Benefit Review Medical Policy
- Chelation Therapy Medical Policy
- C1 esterase inhibitor (Haegarda®) Medical Policy
- Crysvita ® (burosumab-twza) Medical Policy
- Durvalumab (Imfinzi®) Medical Policy
- Fosnetupitant and palonosetron (Akynzeo®) Medical Policy
- Genetic Testing: Whole Exome and Whole Genome Sequencing for the Diagnosis of Genetic Disorders Medical Policy
Policy changes effective June 1, 2020
Updated Policies- Implantable Cardioverter-Defibrillator (ICD) Insertion Procedures
- Oral Appliances for the Treatment of Obstructive Sleep Apnea
- Peripheral Vascular Stent
- Acute Inpatient Rehab
- Telehealth Policy
- Bone Growth Stimulator for the 5th Metatarsal
- Botulinum Toxin Injections
- Implantable Loop Recorder
- Lipectomy or Suction-Assisted Lipectomy
- Total Ankle Replacement
- Fecal Transplant
- Fractional Flow Reserve CT
- COVID-19
- Genetic Testing Oncology: molecular analysis of solid tumors and hematologic malignancies
- Genetic Testing Oncology Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy)
- Genetic Testing: Whole Exome and Whole Genome Sequencing for the Diagnosis of Genetic Disorders
- Genetic Testing: Pharmacogenetics
- Genetic Testing Oncology: Prognostic/Algorithmic Testing
Policy changes effective May 1, 2020
Policies reviewed with changes made to medical criteria:
- Cochlear Implant
- Spravato
- Infuse Bone Graft
- Complementary and Alternative Medicine
- Ambulance Policy
- Cluster and Migraine Headache
- Acute Inpatient Rehab
- Experimental or Investigational
- Autologous Cultured Chondrocytes
- Biofeedback for Physical Conditions
- Cardiomems
- Electroconvulsive Therapy
- Fractional Flow Reserve CT
- Total Disc Arthroplasty
Archived policies:
- 72 Hour Subcutaneous Continuous Glucose Monitoring (CGM)
- Cologuard DNA stool testing
- Genetic Testing Oncology Cancer Screening
Policy changes effective April 1, 2020
Policies reviewed with changes made to medical criteria:
- Libtayo® (cemiplimab-rwlc) - Managed by Magellan
- Lumoxiti™ (moxetumomab pasudotox-tdfk) – Managed by Magellan
- Telehealth policy
- Home Care Coverage Criteria
- Acute Inpatient Rehab Facility (IRF)
- Long Term Acute Rehab (LTAC) Facility
- Radicava
Policy changes effective March 1, 2020
Policies reviewed with changes made to medical criteria:
- Cluster and Migraine Headache: Nonsurgical Management
- Cryoablation
- Fecal Microbiota Transplantation (FMT)
- Gastric Pacing and Gastric Electrical Stimulation
- Implantable Hormone Pellet Replacement Therapy
- Urinary Incontinence
- Hyaluronic Acid Derivatives
- Experimental/Investigational Policy
- Genetic Policy – Two policies were broken out of the main Genetic Policy
- Genetic Testing for Hereditary Cancer
- Genetic Testing for Prenatal, Preimplantation, and Preconception Carrier Screening
- Ivor Lewis Procedure
- Medtronic IN.PACT Admiral Paclitaxel-coated PTA Balloon
- Linx for GERD
- Zoledronic Acid Policy
Policy changes effective Feb. 1, 2020
Policies reviewed with changes made to medical criteria:
- Back Surgical Procedure: Vertebroplasty-Inpatient and Outpatient Settings
- Back Surgical Procedure for Cervical and Thoracic levels -Inpatient and Outpatient Settings
- Cologuard DNA
- Core Decompression of AVN of the Femoral Head
- Hospice
- Hyperbaric Oxygen Therapy
- Hyperthermic Intraperitoneal Chemotherapy
- Pancreas Transplant Aline (PTA) and Autologous Islet Cell Transplants
- Radiofrequency Ablation to Treat Tumors
- Refractive Eye Surgery
- Telehealth
- Tilt Table Testing
- Total Hip Replacement Surgical Precertification
- Total Knee Replacement Surgical Precertification
- Experimental/Investigational Policy Changes
- Complementary and Alternative Policy
- Amino-Acid Based Oral Formulas for Infants – reviewed by Northwood
- Behavioral Health AODA: Transitional Care Coverage
- Wearable Hearing Aids
- None
- Low Back Pain Consultation with Orthopedic or Neurosurgical Specialist
- Hysterectomy Surgical Procedures
Policy changes effective Jan. 1, 2020
Policies reviewed with changes made to medical criteria:
- Abdominoplasty and Panniculectomy Policy
- Breast Reconstruction Post Mastectomy
- Breast Reduction Mammoplasty
- Erectile Dysfunction Treatments
- Radiesse
- Hyaluronic Acid Derivatives
- Intravenous Iron Therapy Commercial/Exchange
- Dupixent
- Inpatient Admission Prior to Surgery (Pre-op)
- Treatment of Autism Spectrum Disorder
- None
- None
Policy changes effective Dec. 1, 2019
Policies reviewed with changes made to medical criteria:
- Eyelid & Brow Repair Medical Policy
- Contact Lenses and Other Eyewear Medical Policy
- Hysterectomy Surgical Procedures Medical Policy
- Idiopathic Scoliosis Medical Policy
- Knee Arthroscopy Surgery Precertification
- Obesity Management, Surgical Approaches Medical Policy
- Varicose Vein Treatments Medical Policy
- Lung Volume reduction Medical Policy
- Behavioral Health/AODA: Transitional Care Coverage Medical Policy
- Hypoglossal Nerve Neurostimulation Medical Policy
- Experimental Investigation Medical Policy
Policies reviewed with no changes made to medical criteria:
- Carpal Tunnel Repair Surgical Precertification
- Disabled Dependent Coverage
New Policies
- Luxturna
- Imlygic
Retired Policy
- Home Infusion Policy
Policy changes effective Nov. 1, 2019
Policies reviewed with changes made to medical criteria:
- Back Surgical Procedures for Lumbar Spinal Level - Inpatient and Outpatient Settings
- Eye Movement Desensitization and Reprocessing (EMDR)
- Left Atrial Appendage Closure to Reduce the Risk of Stroke
- Mitraclip Procedure
- Experimental/Investigational
Policies reviewed with no changes made to medical criteria:
- Ambulance: Land and Air Transportation
- Cellular Therapies
- Home Health Care- Medicare Advantage
- Medicare Advantage Chiropractor
- Takhzyro® (lanadelumab-flyo)
Retired Policies
- Intravenous Immune Globulins (immune globulin) - home infusion
- IV Antibiotic/Antifungal Prior Authorization Policy
- C1 esterase inhibitor (Haegarda®)
Policy changes effective Oct. 1, 2019
Policies reviewed with changes made to medical criteria:
- Lung Volume Reduction System
- Septoplasty/Rhinoplasty
- Sleep Studies
- Synagis
Policies reviewed with no changes made to medical criteria:
- Medicare Advantage Skilled Nursing Facility Coverage Criteria
- Private Duty Nursing Duty
- Repetitive Transcranial Magnetic Stimulation
- Swing Bed
New Policies
- Spravato
- Zolgensma
Retired Policies
- Medicare Advantage Part C Drug Bundled Medication
Policy changes effective Sept. 1, 2019
Policies reviewed with changes made to medical criteria:
- Complementary/Alternative Medicine
- Experimental/Investigational
- Intrastromal Corneal Rings Segments
- Spinal Cord Stimulation
- Vagus Nerve Stimulation for Epilepsy and Depression
- Zika virus
Policies reviewed with no changes made to medical criteria:
- Genetic Testing
- Home, outpatient and inpatient chemotherapy
- Maze Procedure
Policy changes effective August 1, 2019
- Reviewed with changes made to medical criteria
- Bone and tendon graft substitutes and adjuncts
- Cosmetic surgery/treatments
- Gender reassignment services and surgical procedures
- Healthcheck “other services”
- Home infusion
- Intravenous iron therapy – commercial/exchange
- Intravenous iron therapy – Medicare
- Transcatheter aortic valve replacement (TAVR)
- Crysvita
- Dupilumab
- Durvalumab
- Fosnetupitant and palonosetron
- Hyaluronic acid derivatives
- Zoledronic acid
Policy changes effective July 1, 2019
Reviewed with no changes made to medical criteria
- Behavioral Health – AODA: Transitional Care Coverage-Medicare Advantage
- Femoro-Acetabular Surgery for Hip Impingement Syndrome
- Infuse Bone Graft (Bmp-2) Procedure
- Physical, Occupational and Speech Therapy Exclusions
Reviewed with changes made to medical criteria
- Experimental and Investigational
- Abnormal Vascular Lesion Removal
- Chelation Therapy
- Electroencephalography (EEG) Procedures
- Skin Substitutes, Chemical Peels, Dermabrasions and other Skin Procedures
- TMJ Benefit Review
New Policies
- Gamifant
- Revcovi
- Somatuline (lanreotide)
Policy changes effective June 1, 2019
Policies reviewed with changes made to medical criteria
- Botulinum Toxin Injections
- Implantable Cardioverter-Defibrillator (ICD) Insertion Procedures
- Implantable Loop Recorder
- Lipectomy or Suction-Assisted Lipectomy
- Oral Appliances for the Treatment of Obstructive Sleep Apnea
- Peripheral Vascular Stent
- Total Ankle Replacement
- Treatment of Chronic Skin Conditions
- Experimental and Investigational
- Cellular Therapies
- Health Check Other Services
- Telehealth
- Total Knee Replacement Surgical Procedures
- Total Hip Replacement Surgical Procedures
- Carpal Tunnel Repair Surgical Procedures
- Hysterectomy Surgical Procedures
Policies reviewed with no changes made to medical criteria
- Bone Growth Stimulator for the 5th Metatarsal
- Electrical Stimulation and Electromagnetic Therapy for the Treatment of Wounds
New Policies
- Rezum Therapy
- Gamifant
- Revcovi
Policy changes effective May 1, 2019
Policies reviewed with changes made to medical criteria
- Biofeedback for Physical Conditions
- Electroconvulsive Therapy (ECT)
- Swing Bed
Policies reviewed with no changes made to medical records
- 72 Hour Subcutaneous Continuous Glucose Monitoring (CGM)
- Autologous Cultured Chondrocytes
- Cardiomems
- Cochlear Implant
- Fractional Flow Reserve CT
- Total Disc Arthroplasty
Policy changes effective April 1, 2019
Reviewed with no changes made to medical criteria
- Home Health Criteria
Reviewed with no changes made to medical criteria
- Intravenous Iron Therapy – Commercial/Exchange
- Intravenous Iron Therapy – Medicare
- Radicava – beginning 4/1/19, Evicore will review
- Breast Reconstruction Post Mastectomy
- Hyperthermic Intraperitoneal Chemotherapy
New policies
- Hypoglossal Nerve Neurostimulation
- Libtayo
- Lumoxiti
- Acute Rehab Facility
- Long Term Acute Rehab
Policy changes effective March 1, 2019
Reviewed with no changes made to medical criteria - none
Reviewed with changes made to medical criteria
- Cluster and Migraine Headache Non-Surgical Management
- Cryoablation
- Fecal Microbiota Transplantation
- Gastric Pacing and Gastric Electrical Stimulation
- Implantable Hormone Pellet Replacement Therapy
- Ivor Lewis Procedure
- Medtronic IN.PACT Admiral Paclitaxel-coated PTA Balloon
- Urinary
New Policies - none
Policy changes effective January 1, 2019
Policies reviewed with changes made to medical criteria
- Back Surgical Procedures for Cervical and Thoracic Levels-Inpatient and Outpatient Settings
- Back Surgical Procedure: Vertebroplasty-Inpatient and Outpatient Settings
- Cologuard DNA-Stool Testing
- Core Decompression of AVN of the Femoral Head
- Hospice Coding and Packaging Guidelines
- Hyperbaric Oxygen Therapy
- Hyperthermic Intraperitoneal Chemotherapy
- Total Knee Replacement Surgical Precertification Coding and Packaging Guidelines
- Pancreas Transplant Alone (PTA) and Autologous Islet Cell Transplants
- Radiofrequency Ablation to Treat Tumors
- Refractive Eye Surgery
- Telehealth
- Tilt Table Testing
- Total Hip Replacement Surgical Precertification
Policies reviewed with no changes made to medical criteria
- Amino-Acid Based oral Formulas
- Behavioral Health/AODA: Transitional Care Coverage
- Chronic Hip Pain-Osteoarthritis Specialty Consult
- Hospice
- Knee Replacement Surgical Precertification
- Low Back Pain (LBP) Consultation with Orthopedic or Neurosurgical Specialist
- Wearable Hearing Aids
New policies - none
Policy changes effective December 1, 2018
Reviewed with changes made to medical criteria
- Experimental or Investigational
- Breast Reconstruction Post-MastectomyTreatment of Autism Spectrum Disorder
Policies reviewed with no changes made to medical criteria
- Abdominoplasty and Panniculectomy
- Erectile Dysfunction Treatments
- Inpatient Admission Prior to Surgery (Pre-op)
- Radiesse
- Experimental or Investigational
- Blepharoplasty, Blepharoptosis Repair
- Contact Lenses and Other Eyewear
- Idiopathic Scoliosis
- Varicose Vein Treatments
New policies - none
Policy changes effective November 1, 2018
Reviewed with changes made to medical criteria - none
Reviewed with no changes made to medical criteria
- Carpal Tunnel Repair Surgical Precertification
- Carpal Tunnel Syndrome-Median Neuropathy Specialty Consult
- Chronic Knee Pain-Osteoarthritis or Meniscal Degeneration Specialty Consult
- Disabled Dependent Coverage
- Hysterectomy Surgical Procedures
- Knee Arthroscopy Surgery Precertification
- Obesity Management, Surgical Approaches Obesity Management
- Dupixent
New policies - none