| Medical Guidelines |
Reason for Update |
| Aqueous Shunts and Devices for Glaucoma |
Added CPT code 0671T to Billing/Coding section for effective date 1/1/22. |
| Capsule Endoscopy, Wireless |
Regulatory status within the Description section updated with magnetic capsule and the Pill cam SB 3 Capsule Endoscopy System FDA approvals. Item #4 under the When Not Covered section added as follows: “Magnetic capsule endoscopy is considered investigational for the evaluation of patients with unexplained upper abdominal complaints and all other indications.” Policy guidelines and references updated. Medical Director review 12/2021 |
| Wheelchairs (Manual and Power Operated) |
Under the When Covered section, Item III. Criteria for Specific Types of Power Wheelchairs (PWC): item #1. Group 1 PWC - removed item c. as follows: “The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the member.” Under the When Not Covered section, added item #4 as follows: “Items used to support activities of daily living (ADLs) that do not address a mobility limitation such as robotic arms (e.g.: KINOVA JACO® assistive arm) are considered not medically necessary. Items used for assistance with ADLs are considered self-help or convenience items that are not primarily medical in nature. Custodial or self-help care is not covered.” Table 1 under Policy Guidelines updated with addition of KINOVA JACO assistive robotic arm along with associated indications. Policy noticed 11/30/21 with effective date of 1/25/22. Medical Director review. 11/2021. |
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