Medical Policy Update for July 12, 2022

Medical Guidelines	Reason for Update
Ablative Techniques for the Myolysis of Uterine Fibroids (PDF)	Added coverage for Acessa and Sonata. Policy Guidelines updates. References updated. Medical Director review 6/2022
Adaptive Behavioral Treatment for Autism Spectrum Disorders (PDF)	Update made to When Covered section to remove following criteria: “There is an established and current (within 5 years) DSM-5 diagnosis of Autism Spectrum Disorder using one or more validated assessment tool (e.g., Autism Diagnostic Observation Schedule (ADOS), Autism Diagnostic Interview (ADI-R), Childhood Autism Rating Scale (CARS), Social Communication Questionnaire (SCQ), Social Reciprocity Scale (SRS), Gilliam Autism Rating Scale (GARS);” Specialty Matched Consultant Advisory Panel Review 6/2022. Medical Director Review 6/2022. References added.
Artificial Pancreas Device Systems (PDF)	Related policies added. References added. Specialty Matched Consultant Advisory Panel review 6/2022. Medical Director review 6/2022. No change to policy statement.
Cardiac (Heart) Transplantation	Minor update to description section. Specialty Matched Consultant Advisory Panel review 6/2022. Medical Director review 6/2022.
Carotid Artery Angioplasty/Stenting (CAS)	Specialty Matched Consultant Advisory Panel review 6/2022. Medical Director review 6/2022.
Congenital Heart Defect, Repair Devices (PDF)	Specialty Matched Consultant Advisory Panel review 6/2022. Medical Director review 6/2022.
Continuous Monitoring of Glucose in the Interstitial Fluid (PDF)	References updated. Specialty Matched Consultant Advisory Panel review 6/2022. Medical Director review 6/2022. Added codes G0308 and G0309 to Billing/Coding section, effective 7/1/2022. Updated FDA approved device list to include Freestyle Libre 3. No change to policy statement.
Diagnosis of Vaginitis including Multi-target PCR Testing AHS – M2057 (PDF)	Added the following statement to When Not Covered section “Reimbursement is not allowed for all other tests for vaginitis not addressed above.” to align with Avalon
Heart-Lung Transplantation (PDF)	Minor updates only. Specialty Matched Consultant Advisory Panel review 6/2022. Medical Director review 6/2022.
Implantable Cardioverter Defibrillator (PDF)	Specialty Matched Consultant Advisory Panel review 6/2022. Medical Director review 6/2022.
Insulin Therapy, Chronic Intermittent Intravenous (CIIIT) (PDF)	References added. Specialty Matched Consultant Advisory Panel review 6/2022. Medical Director review 6/2022. No changes to policy statement or intent.
Islet Cell Transplantation (PDF)	References added. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 6/2022. Medical Director review 6/2022. No changes to policy statement or intent.
Neurostimulation, Electrical (PDF)	Updated CPT code under “Other Electrical Stimulation Devices” section for Percutaneous electrical nerve stimulation (PENS) (Code 64999; HCPCS Code E1399) and added the following statement “Providers may submit claims for these services using the unlisted code 64999. Providers should not be using 64553-64565, or 64590 to bill this service as these codes are not appropriate.” No change to policy statement. Medical Director Review 6/2022.
Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF)	Description including regulatory status updated. Added “or Amplatzer Amulet” to both the Covered and Non-Covered sections. Added “, including the Lariat and Amplatzer Cardiac Plug devices,” to the second non-covered statement for clarity. No change to policy intent. Policy guidelines updated. Specialty Matched Consultant Advisory Panel review 6/2022. Medical Director review 6/2022.
Quantitative Electroencephalography as a Diagnostic Aid for Attention Deficit/Hyperactivity Disorder (PDF)	Updated Description section. References added. Specialty Matched Consultant Advisory Panel review 6/2022. Medical Director review 6/2022. No change to policy statement.
Sensory Integration Therapy and Auditory Integration Therapy (PDF)	Description updated. References added. Specialty Matched Consultant Advisory Panel review 6/202. Medical Director review 6/2022. No change to policy statement.
Surgical Management of Transcatheter Heart Valves	Minor updates to regulatory status and policy guidelines. Specialty Matched Consultant Advisory Panel review 6/2022. Medical Director review 6/2022.
Surgical Ventricular Restoration (PDF)	Specialty Matched Consultant Advisory Panel review 6/2022. Medical Director review 6/2022.
TENS (Transcutaneous Electrical Nerve Stimulator) (PDF)	Removed code 64550. Added codes 97014 and 97032. No changes to policy statement or intent
Transcatheter Closure of Ventricular Septal Defects (PDF)	Specialty Matched Consultant Advisory Panel review 6/2022. Medical Director review 6/2022.
Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders (PDF)	Related policies added. References added. Specialty Matched Consultant Advisory Panel review 6/2022. Medical Director review 6/2022. No change to policy statement.
Treatment For Opioid Use Disorder in Opioid Treatment Programs (OTPs) (PDF)	References added. Specialty Matched Consultant Advisory Panel review 6/2022. Medical Director review 6/2022. No change to policy statement.

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