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Commercial Medical Policy Update for May 29, 2024
| Medical Guidelines | Reason for Update |
|---|---|
| Automated Percutaneous and Endoscopic Discectomy (PDF) | Added two related policies. References updated. Specialty Matched Consultant Advisory Panel review 5/2024. Medical Director review 5/2024. |
| Beta Amyloid Imaging With Positron Emission Tomography for Alzheimer’s Disease (PDF) | References updated. Specialty Matched Consultant Advisory Panel review 5/2024. Medical Director review 5/2024. Related policy removed. No change to policy statement. |
| Capsule Endoscopy, Wireless (PDF) | Not Covered section edited for clarity, no change to policy statement. Minor typographical edits made to Policy Guidelines. References updated. Specialty Matched Consultant Advisory Panel 5/2024. Medical Director review 5/2024 |
| Chemoembolization of the Hepatic Artery, Transcatheter Approach (PDF) | Description and Policy Guidelines updated. Updated Billing/Coding section to remove ICD-10 diagnosis codes. References added. Specialty Matched Consultant Advisory Panel review 5/2024. Medical Director review 5/2024. No change to policy statement. |
| Cranial Electrotherapy Stimulation (CES) and Auricular Electrostimulation | Regulatory Status and References updated. HCPCS code E0732 added to and terminated code K1002 deleted from Billing/Coding section. Specialty Matched Consultant Advisory Panel review 5/2024. Medical Director review 5/2024. |
| Electrogastrography, Cutaneous (PDF) | References updated. Specialty Matched Consultant Advisory Panel 5/2024. Medical Director review 5/2024. |
| Endovascular Procedures for Intracranial Arterial Disease (PDF) | When Covered section revised specific to intracranial flow diverting stents; moved anatomic criteria for intracranial flow diverting stents from the Policy Guidelines section. Policy Guidelines also updated. No change to policy intent. References updated. Specialty Matched Consultant Advisory Panel review 5/2024. Medical Director review 5/2024. |
| Enteral Nutrition (PDF) | Removed codes B4151 and B4156 from Billing/Coding section. Description and References sections updated. Specialty Matched Consultant Advisory Panel 5/2024. Medical Director review 5/2024. |
| Esophageal pH Monitoring (PDF) | Description and References sections updated. Specialty Matched Consultant Advisory Panel 5/2024. Medical Director review 5/2024. |
| Gastric Electrical Stimulation (PDF) | Description and References sections updated. Specialty Matched Consultant Advisory Panel 5/2024. Medical Director review 5/2024. |
| Image-Guided Minimally Invasive Decompression (IG-MLD) for Spinal Stenosis (PDF) | References updated. Specialty Matched Consultant Advisory Panel review 5/2024. Medical Director review. |
| Interspinous Fixation (Fusion) Devices (PDF) | Updated title of one Related Policy. References updated. Medical Director review 5/2024. Specialty Matched Consultant Advisory Panel review 5/2024. |
| Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers) (PDF) | Updated title of one Related Policy. Policy Guidelines updated. No change to intent of policy. References added. Medical Director review 5/2024. Specialty Matched Consultant Advisory Panel review 5/2024. |
| Laboratory Procedures Medical Policy AHS - R2162 (PDF) | Annual policy review. Code 0357U removed from Billing/Coding section. Policy Guidelines updated. No updates from lab benefit manager, no change to policy statement. |
| Lumbar Spine Procedures (PDF) | Description and Policy Guidelines updated. No change to policy intent. References updated. Specialty Matched Consultant Advisory Panel review 5/2024. Medical Director review 5/2024. |
| Magnetic Resonance Spectroscopy (PDF) | Minor updates made to Description for clarity. References added. Specialty Matched Consultant Advisory Panel review 5/2024. Medical Director Review 5/2024. No change to policy statement. |
| MRI-Guided Focused Ultrasound (MRgFUS) (PDF) | Regulatory Status and Policy Guidelines updated. References added. Specialty Matched Consultant Advisory Panel review 5/2024. Medical Director review 5/2024. No change to policy statement. |
| Myocardial Sympathetic Innervation Imaging (PDF) | References added. Specialty Matched Consultant Advisory Panel review 5/2024. Medical Director review 5/2024. No change to policy statement. |
| Occipital Nerve Stimulation (PDF) | Updated title of Related Policy. Billing/Coding section updated as follows: HCPCS code L8684 removed ICD10 codes G43.B09, G44.201, G44.209, G44.211, G44.219, G44.221, G44, 229, N94.3, N95.1, ICD10 code R51 removed and replaced with R51.0 and R51.9, and added the following ICD10 codes: G44.001, G44.009, G44.011, G44.019, G44.021, G44.029, G44.031, G44.039, G44.041, G44.049, G44.051, G44.059, G44.091, G44.099. Medical Director review 5/2024. Specialty Matched Consultant Advisory Panel review 5/2024. |
| Pancreas Transplant (PDF) | Description, Policy Guidelines and References sections updated. Specialty Matched Consultant Advisory Panel 5/2024. Medical Director review 5/2024. |
| Paraspinal Surface Electromyography (SEMG) (PDF) | References updated. Medical Director review 5/2024. Specialty Matched Consultant Advisory Panel review 5/2024. |
| Percutaneous Intradiscal and Intraosseous Radiofrequency Procedures of the Spine (PDF) | References updated. Medical Director review 5/2024. Specialty Matched Consultant Advisory Panel review 5/2024. |
| Peroral Endoscopic Myotomy for Treatment of Esophageal Achalasia (PDF) | Description, Policy Guidelines and References updated. Specialty Matched Consultant Advisory Panel 5/2024. Medical Director review 5/2024. |
| Polysomnography for Non‒Respiratory Sleep Disorders (PDF) | References updated. Medical Director review 5/2024. Specialty Matched Consultant Advisory Panel review 5/2024. |
| Positional Magnetic Resonance Imaging (MRI) (PDF) | References added. Specialty Matched Consultant Advisory Panel review 5/2024. Medical Director review 5/2024. No change in policy statement. |
| Professional Pathology Billing Requirements AHS – R2169 (PDF) | Annual policy review. No updates from lab benefit manager, no change to policy statement. |
| Screening for Vertebral Fracture with Dual X-ray Absorptiometry (DXA) (PDF) | References added. Specialty Matched Consultant Advisory Panel review 5/2024. Medical Director review 5/2024. No change to policy statement. |
| Small Bowel, Small Bowel with Liver, or Multivisceral Transplant (PDF) | References updated. Specialty Matched Consultant Advisory Panel 5/2024. Medical Director review 5/2024. |
| Therapeutic Radiopharmaceuticals in Oncology (PDF) | References added. Specialty Matched Consultant Advisory Panel review 5/2024. Medical Director review 2024. No change to policy statement. |
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