Medical Policy Updates

Medical Policy Update March 8, 2022

Medical Guidelines	Reason for Update
Ablation and Neural Therapy Procedures for Headache and Pain Management	Specialty Matched Consultant Advisory Panel review 2/16/2022.
Ambulance and Medical Transport Services	Specialty Matched Consultant Advisory Panel review 2/2022. Medical Director Review 2/2022. No change to policy.
Balloon Dilation of the Eustachian Tube	Code 69799 deleted. Specialty Matched Consultant Advisory Panel review 2/16/2022.
Balloon Ostial Dilation (Balloon Sinuplasty)	Specialty Matched Consultant Advisory Panel review 2/16/2022.
Bone Morphogenetic Protein	Specialty Matched Consultant Advisory Panel review 2/16/2022.
Chelation Therapy	References updated. Specialty Matched Consultant Advisory Panel review 2/2022. Medical Director Review 2/2022. No change to policy statement.
Clinical Trial Services	Specialty Matched Consultant Advisory Panel review 2/2022. Medical Director review 2/2022. No change to policy.
Colorectal Cancer Screening AHS-B0001	Description section updated with USPSTF reference for screening average risk adults aged 45 or older. Reference added.
Complementary and Alternative Medicine	References updated. Specialty Matched Consultant Advisory Panel review 02/2022. Medical Director review 2/2022. No change to policy statement.
Continuous Monitoring of Glucose in the Interstitial Fluid	Following statement was removed from “When Not Covered” section, The use of intermittently scanned (flash) CGM devices is considered investigational. Medical Director review 2/2022.
Dynamic Posturography	Reference added. Specialty Matched Consultant Advisory Panel review 2/16/2022.
Electrical Bone Growth Stimulation	References added. Specialty Matched Consultant Advisory Panel review 6/16/2021.
Electrical Stimulation for the Treatment of Arthritis	References updated. Description section updated. Specialty Matched Consultant Advisory Panel review 2/2022. Medical Director Review 2/2022. No change to policy statement.
Implantable Bone Conduction Hearing Aids	Specialty Matched Consultant Advisory Panel review 2/16/2022.
Infusion Therapy in the Home	Specialty Matched Consultant Advisory Panel review 2/2022. Medical Director review 2/2022. No change to policy.
Intravenous Antibiotic Therapy for Lyme Disease	Reference added. Specialty Matched Consultant Advisory Panel review 2/16/2022. Deleted codes 0041U, 0042U, 0043U, 0044U, 86617, and 87476 as these codes are for testing as opposed to antibiotic therapy. Updated policy statement on Lyme arthritis to change "antibiotic-refractory" to preferred terminology of "post-antibiotic". No change to policy intent.
Meniscal Allografts and Other Meniscal Implants	References added. Specialty Matched Consultant Advisory Panel review 6/16/2021.
Microprocessor-Controlled Prostheses for the Lower Limb	Specialty Matched Consultant Advisory Panel review 2/16/2022.
Molecular Markers in Fine Needle Aspirates of the Thyroid AHS - M2108	Updated description section, table of tests, policy guidelines and references. Added related policies section. Added CPT codes 81455 and 81546 to Billing/Coding section. Clarified Note 1 with statement “except for genomic expression classifiers.” No change to policy statement.
Observation Room Services	Specialty Matched Consultant Advisory Panel review 2/2022. Medical Director review 2/2022. No change to policy statement.
Orthopedic Applications of Stem Cell Therapy	Reference added. Specialty Matched Consultant Advisory Panel review 2/16/2022.
Orthotics	Reference added. Specialty Matched Consultant Advisory Panel review 2/16/2022.
Patient-Specific Instrumentation (e.g., Cutting Guides) for Joint Arthroplasty	Reference added. Related policy removed. Specialty Matched Consultant Advisory Panel review 6/16/2021.
Powered Exoskeleton for Ambulation in Patients with Lower Limb Disabilities	Specialty Matched Consultant Advisory Panel review 2/16/2022.
Semi-Implantable and Fully Implantable Middle Ear Hearing Aid	Reference added. Specialty Matched Consultant Advisory Panel review 2/16/2022.
Skilled Nursing Facility Care	Specialty Matched Consultant Advisory Panel review 2/2022. Medical Director review 2/2022. No change to policy statement.
Skilled Nursing Services	Specialty Matched Consultant Advisory Panel review 2/2022. Medical Director Review 2/2022. No change to policy statement.
Subtalar Arthroereisis	Specialty Matched Consultant Advisory Panel review 2/16/2022.
Surgery for Femoroacetabular Impingement	Reference added. Specialty Matched Consultant Advisory Panel review 6/16/2021.
Synthetic Cartilage Implants for Joint Pain	Specialty Matched Consultant Advisory Panel review 2/16/2022.
Treatment For Opioid Use Disorder in Opioid Treatment Programs (OTPs)	Billing/Coding section updated to include “HCPCS code G2216 is limited to being billed 10 units once per calendar month, however, exceptions to this limit are allowed in the case where the member uses the initial supply of naloxone dispensed by the OTP to the extent that it is medically reasonable and necessary to provide additional naloxone. If an additional supply of naloxone is needed within 30 days of the original supply being provided, OTPs must document in the medical record the reason for the exception”. Medical Director review 2/2022.
Ultrasound Accelerated Fracture Healing Device	Specialty Matched Consultant Advisory Panel review 2/16/2022.
Vertebral Axial Decompression (VAD-X)	Reference added. Specialty Matched Consultant Advisory Panel review 6/16/2021.
Vestibular Function Testing	Reference added. Code 92700 deleted from Billing/Coding section. Specialty Matched Consultant Advisory Panel review 2/16/2022.