Medical Policy Updates

Medical Policy Update June 14, 2022

Medical Guidelines	Reason for Update
Automated Percutaneous and Endoscopic Discectomy	References added. Specialty Matched Consultant Advisory Panel review 5/18/2022.
Bariatric Surgery	Reference added. Specialty Matched Consultant Advisory Panel review 4/20/2022.
Complementary and Alternative Medicine	Added CPT code 0736T to Billing/Coding section. Effective 7/1/2022
Cranial Electrotherapy Stimulation (CES) and Auricular Electrostimulation	Reference added. Regulatory Status updated. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 5/18/2022.
Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate, or Dermatologic Tumors	Specialty Matched Consultant Advisory Panel review 4/20/2022.
Cryosurgical Ablation of Primary or Metastatic Liver Tumors	Reference added. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 4/20/2022.
Endovascular Procedures for Intracranial Arterial Disease	Specialty Matched Consultant Advisory Panel review 5/18/2022.
Endovascular Therapies for Extracranial Vertebral Artery Disease	Specialty Matched Consultant Advisory Panel review 5/18/2022.
Gender Affirmation Surgery and Hormone Therapy	Specialty Matched Consultant Advisory Panel review 4/20/2022.
Image-Guided Minimally Invasive Decompression (IG-MLD) for Spinal Stenosis	Specialty Matched Consultant Advisory Panel review 5/18/2022.
Interspinous Fixation (Fusion) Devices	Specialty Matched Consultant Advisory Panel review 5/18/2022.
Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers)	Specialty Matched Consultant Advisory Panel review 5/18/2022.
Intraoperative Neurophysiologic Monitoring	Specialty Matched Consultant Advisory Panel review 5/18/2022.
Liver Transplant and Combined Liver-Kidney Transplant	Reference added. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel 4/20/2022.
Lumbar Spine Fusion Surgery	Specialty Matched Consultant Advisory Panel review 5/18/2022
Neurostimulation, Electrical	Added CPT code 0720T to Billing/Coding section. Effective 7/1/2022.
Occipital Nerve Stimulation	Specialty Matched Consultant Advisory Panel review 5/18/2022.
Paraspinal Surface Electromyography (SEMG)	Specialty Matched Consultant Advisory Panel review 5/18/2022.
Percutaneous Electrical Nerve Stimulation (PENS) or Neuromodulation Therapy and Percutaneous Electrical Nerve Field Stimulation (PENFS)	Added CPT code 0720T to Billing/Coding section. Effective 7/1/2022
Percutaneous Intradiscal and Intraosseous Radiofrequency Procedures of the Spine	Policy Guidelines updated. Removed deleted codes C9752 and C9753 from Billing/Coding section. Specialty Matched Consultant Advisory Panel review 5/18/2022.
Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers	Specialty Matched Consultant Advisory Panel review 4/20/2022
Polysomnography for Non‒Respiratory Sleep Disorders	Specialty Matched Consultant Advisory Panel review 5/18/2022
Radioembolization for Primary and Metastatic Tumors of the Liver	Removed ICD-9 diagnoses codes (153.0, 153.1, 155.0, 155.1, 155.2, 197.7, 573.8, 573.9) from Billing/Coding section. No change to policy statement.
Sacroiliac Joint Fusion/Stabilization	Reference added. Description section updated. "Transiliac lacement" and "e.g., iFuse" added to the medically necessary statement on sacroiliac joint fusion. Policy Guidelines updated. Clinical Trials information updated. Specialty Matched Consultant Advisory Panel review 5/18/2022
Skin and Soft Tissue Substitutes	The following codes were added to the Billing/Coding section: Q4259, Q4260, Q4261 effective 7/1/2022.
Surgical Deactivation of Headache Trigger Sites	Specialty Matched Consultant Advisory Panel review 5/18/2022.
Three Dimensional Printed Orthopedic Implants	Specialty Matched Consultant Advisory Panel review 2/16/2022.
Topical Negative Pressure Therapy for Wounds	Reference added. Rationale section updated. Specialty Matched Consultant Advisory Panel review 4/20/2022.
Vagus Nerve Stimulation	Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 5/18/2022.
Vertebroplasty, Kyphoplasty, and Sacroplasty Percutaneous	References added. Specialty Matched Consultant Advisory Panel review 5/18/2022.