Medical Policy Updates

Medical Policy Update for June 15, 2021

Medical Guidelines	Reason for Update
BioZorb®	Specialty Matched Consultant Advisory Panel review 5/19/2021. No change to policy statement.
Brachytherapy, Intracavitary Balloon Catheter for Brain Cancer	Specialty Matched Consultant Advisory Panel review 5/19/2021. Reference added. No change to policy statement.
Charged Particle Radiotherapy	Specialty Matched Consultant Advisory Panel review 5/19/2021. No change to policy statement. Reference added.
Dental Reconstructive Services	Updated Policy Guidelines item 3 for clarification by adding “labial or buccal frenectomy, frenotomy, frenuloplasty”. No change to policy statement.
Electronic Brachytherapy for Nonmelanoma Skin Cancer	Specialty Matched Consultant Advisory Panel review 5/19/2021. Reference added. No change to policy statement.
Intensity Modulated Radiation Therapy for Tumors of the Central Nervous System	Specialty Matched Consultant Advisory Panel review 5/19/2021. Reference added. No change to policy statement.
Intensity Modulated Radiation Therapy (IMRT) for Sarcoma of the Extremities	Specialty Matched Consultant Advisory Panel review 5/19/2021. Reference added. No change to policy statement.
Intensity Modulated Radiation Therapy (IMRT) of Abdomen and Pelvis	Specialty Matched Consultant Advisory Panel review 5/19/2021. Reference added. No change to policy statement.
Intensity Modulated Radiation Therapy (IMRT) of Head and Neck	Specialty Matched Consultant Advisory Panel review 5/19/2021. Reference added. No change to policy statement.
Intensity Modulated Radiation Therapy (IMRT) of the Chest	Specialty Matched Consultant Advisory Panel review 5/19/2021. Reference added. No change to policy statement.
Intensity-Modulated Radiation Therapy (IMRT) of the Prostate	Specialty Matched Consultant Advisory Panel review 5/19/2021. Reference added. No change to policy statement.
Paraspinal Surface Electromyography (SEMG)	Reference added. Specialty Matched Consultant Advisory Panel review 5/19/2021.
Percutaneous Intradiscal and Intraosseous Radiofrequency Procedures of the Spine	Reference added. Specialty Matched Consultant Advisory Panel review 5/19/2021.
Perirectal Spacer Use During Radiotherapy for Prostate Cancer	Specialty Matched Consultant Panel review 5/19/2021. Updated Description and Policy Guidelines sections. Reference added. Under Description section, clarified statement that hydrogel maintains the space for 3-6 months.
Polysomnography for Non‒Respiratory Sleep Disorders	Reference Added. Specialty Matched Consultant Advisory Panel Review 5/19/2021.
Radioembolization for Primary and Metastatic Tumors of the Liver	Specialty Matched Consultant Advisory Panel review 5/19/2021. Reference added. No change to policy statement.
Radiosurgery, Stereotactic Approach	Specialty Matched Consultant Advisory Panel review 5/19/2021. Reference added. No change to policy statement. Updated Policy Guidelines section.
Sacroiliac Joint Fusion/Stabilization	Reference added. New implants added. Policy Guidelines updated. Clinical Trials information updated. Specialty Matched Consultant Advisory Panel review 5/19/2021.
Serum Testing for Evidence of Mild Traumatic Brain Injury AHS – G2151	Specialty Matched Consultant Advisory Panel review 5/19/2021.
Surgical Deactivation of Headache Trigger Sites	Reference added. Specialty Matched Consultant Advisory Panel review 5/19/2021.
Vagus Nerve Stimulation	Reference added. Policy Guidelines updated. Policy statement unchanged. Specialty Matched Consultant Advisory Panel review 5/19/2021.
Vertebroplasty, Kyphoplasty, and Sacroplasty Percutaneous	References added. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 5/19/2021.