Medical Policy Updates

Notification of Policy Revisions Effective January 1, 2022 (Posted October 19, 2021)

Medical Policy	Revision
Cosmetic and Reconstructive Surgery “Notification”	When Cosmetic and Reconstructive Surgery is covered section updated to state “Treatment of a keloid is considered medically necessary when there is documented evidence of significant functional impairment related to the keloid and the treatment can be reasonably expected to improve the functional impairment. Treatment of a keloid with superficial radiation therapy up to 3 fractions is considered medically necessary as adjunct therapy following surgical excision initiated within 3 days when the medically necessary criteria for keloid removal are met.” Billing/Coding section updated to include code 77401. Medical Director review 9/2021. Notification given 10/19/2021 for effective date 1/1/2022.
Cryoablation for Chronic Rhinitis “Notification”	New policy issued. Cryoablation for Chronic Rhinitis is considered investigational. Policy noticed 10/19/2021 for policy effective date 1/1/2022.
Facet Joint Denervation “Notification”	Updated Policy Guidelines item # 2c. Removed “and that documents the presence of facet disease;” Updated Policy Guidelines item #4.” A trial of two controlled medial branch block or facet injection with either a local anesthetic or combined local anesthetic and steroid under live fluoroscopic guidance that has resulted in at least a 70% reduction in pain for the duration of the expected injection”. Notification 10/19/2021 for effective date 1/1/2022.
Lumbar Spine Fusion Surgery “Notification”	Medical Director review. Reference added. The following note added to the When Covered section: “For non-emergent procedures that include fusion, it is required that the surgical candidate refrain from smoking/nicotine for at least six weeks prior to surgery and during the time of healing. Attestation from the performing provider is required”. Notification given 10/19/2021 for policy effective date 1/1/2022.
Spinal Cord and Dorsal Root Ganglion Stimulation “Notification”	Reference added. Policy Guidelines updated. Policy statement updated to add Dorsal Root Ganglion Stimulation trial to criteria for permanent coverage. Dorsal Root Ganglion Stimulation added to item B. in When Not Covered section. Policy noticed 10/19/2021 for effective date 1/1/2022.