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Medical Policy Update June 14, 2022
| Medical Guidelines | Reason for Update |
|---|---|
| Automated Percutaneous and Endoscopic Discectomy (PDF) | References added. Specialty Matched Consultant Advisory Panel review 5/18/2022. |
| Bariatric Surgery (PDF) | Reference added. Specialty Matched Consultant Advisory Panel review 4/20/2022. |
| Complementary and Alternative Medicine (PDF) | 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 (PDF) | Specialty Matched Consultant Advisory Panel review 4/20/2022. |
| Cryosurgical Ablation of Primary or Metastatic Liver Tumors (PDF) | Reference added. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 4/20/2022. |
| Endovascular Procedures for Intracranial Arterial Disease (PDF) | Specialty Matched Consultant Advisory Panel review 5/18/2022. |
| Endovascular Therapies for Extracranial Vertebral Artery Disease (PDF) | Specialty Matched Consultant Advisory Panel review 5/18/2022. |
| Gender Affirmation Surgery and Hormone Therapy (PDF) | Specialty Matched Consultant Advisory Panel review 4/20/2022. |
| Image-Guided Minimally Invasive Decompression (IG-MLD) for Spinal Stenosis (PDF) | Specialty Matched Consultant Advisory Panel review 5/18/2022. |
| Interspinous Fixation (Fusion) Devices (PDF) | Specialty Matched Consultant Advisory Panel review 5/18/2022. |
| Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers) (PDF) | Specialty Matched Consultant Advisory Panel review 5/18/2022. |
| Intraoperative Neurophysiologic Monitoring (PDF) | Specialty Matched Consultant Advisory Panel review 5/18/2022. |
| Liver Transplant and Combined Liver-Kidney Transplant (PDF) | 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 (PDF) | Added CPT code 0720T to Billing/Coding section. Effective 7/1/2022. |
| Occipital Nerve Stimulation (PDF) | Specialty Matched Consultant Advisory Panel review 5/18/2022. |
| Paraspinal Surface Electromyography (SEMG) (PDF) | Specialty Matched Consultant Advisory Panel review 5/18/2022. |
| Percutaneous Electrical Nerve Stimulation (PENS) or Neuromodulation Therapy and Percutaneous Electrical Nerve Field Stimulation (PENFS) (PDF) | Added CPT code 0720T to Billing/Coding section. Effective 7/1/2022 |
| Percutaneous Intradiscal and Intraosseous Radiofrequency Procedures of the Spine (PDF) | 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 (PDF) | Specialty Matched Consultant Advisory Panel review 4/20/2022 |
| Polysomnography for Non‒Respiratory Sleep Disorders (PDF) | Specialty Matched Consultant Advisory Panel review 5/18/2022 |
| Radioembolization for Primary and Metastatic Tumors of the Liver (PDF) | 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 (PDF) | Reference added. Description section updated. "Transiliac placement" 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 (PDF) | The following codes were added to the Billing/Coding section: Q4259, Q4260, Q4261 effective 7/1/2022. |
| Surgical Deactivation of Headache Trigger Sites (PDF) | Specialty Matched Consultant Advisory Panel review 5/18/2022. |
| Three Dimensional Printed Orthopedic Implants (PDF) | Specialty Matched Consultant Advisory Panel review 2/16/2022. |
| Topical Negative Pressure Therapy for Wounds (PDF) | Reference added. Rationale section updated. Specialty Matched Consultant Advisory Panel review 4/20/2022. |
| Vagus Nerve Stimulation (PDF) | Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 5/18/2022. |
| Vertebroplasty, Kyphoplasty, and Sacroplasty Percutaneous (PDF) | References added. Specialty Matched Consultant Advisory Panel review 5/18/2022. |
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