| Medical Guidelines |
Reason for Update |
| Absorbable Nasal Implant for Treatment of Nasal Valve Collapse |
Specialty Matched Consultant Advisory Panel review 8/18/2021. |
| Balloon Ostial Dilation (Balloon Sinuplasty) |
Specialty Matched Consultant Advisory Panel review 2/17/2021. Medical Director review. Removed “mucosal thickening of at least 3 mm” from When Covered section. Added “The Plan may require submission of, or access to, the CT images for review” to Policy Guidelines. |
| Cochlear Implant |
Reference added. Specialty Matched Consultant Advisory Panel review 8/18/2021. |
| Erectile Dysfunction AHS - G2132 |
Specialty Matched Consultant Advisory Panel review 11/17/2021. |
| Focal Treatments for Prostate Cancer |
Reference added. Regulatory Status updated. Specialty Matched Consultant Advisory Panel review 11/17/2021. |
| Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence |
Reference added. Description, Regulatory Status, and Policy Guidelines updated. Polyacrylamide hydrogel added to list of covered periurethral bulking agents. Specialty Matched Consultant Advisory Panel review 11/17/2021. |
| Intensity Modulated Radiation Therapy (IMRT) of the Chest |
Under “When Covered” section, added medically necessary indication for partial breast irradiation: “Intensity-modulated radiation therapy (IMRT), up to 5 fractions, may be considered medically necessary as a technique of partial breast irradiation after breast conserving surgery when it has been determined that use of 3D conformal radiation would result in unacceptable toxicity.” Medical Director review 11/2021. |
| Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence |
Reference added. Specialty Matched Consultant Advisory Panel review 11/17/2021. |
| Percutaneous Tibial Nerve Stimulation for Voiding Dysfunction |
Reference added. Specialty Matched Consultant Advisory Panel review 11/17/2021 |
| Rhinoplasty |
Specialty Matched Consultant Advisory Panel review 8/18/2021. |
| Sacral Nerve Neuromodulation/Stimulation for Pelvic Floor Dysfunction |
Reference added. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 11/17/2021. |
| Septoplasty |
Specialty Matched Consultant Advisory Panel review 8/18/2021. |
| Surgery for Obstructive Sleep Apnea and Upper Airway Resistance Syndrome |
Reference added. Specialty Matched Consultant Advisory Panel review 8/18/2021. |
| Surgical Treatment of Sinus Disease |
Specialty Matched Consultant Advisory Panel review 8/18/2021. Added Fungal ball or mycetoma to list of covered indications. |
| Tinnitus Treatment |
Reference added. Specialty Matched Consultant Advisory Panel review 8/18/2021. |
| Transurethral Water Vapor Thermal Therapy for Benign Prostatic Hyperplasia |
Reference added. Specialty Matched Consultant Advisory Panel review 11/17/2021. |
| Urinary Tumor Markers for Bladder Cancer AHS – G2125 |
Specialty Matched Consultant Advisory Panel review 11/17/2021. |
| Vesicoureteral Reflux, Treatment with Periureteral Bulking Agents |
Reference added. Specialty Matched Consultant Advisory Panel review 11/17/2021. |
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