Medical Policy Update for October 10, 2023

References updated. Specialty Matched Consultant Advisory Panel review 9/2023. Medical Director review 9/2023.

Added Related Policy. Updated FDA approved device in Description section.  Criteria in the When Covered section expanded as follows: Unilateral cochlear implantation of a FDA approved non-hybrid cochlear implant device may be considered medically necessary in individuals who meet these criteria: 5 years of age and older, and limited or no benefit after a minimum one-month trial wearing a Contra Lateral Routing of Signal (CROS) hearing aid or other relevant device, and one of the following: profound sensorineural hearing loss in one ear and normal hearing or mild sensorineural hearing loss in the other ear, or profound sensorineural hearing loss in one ear and mild to moderately severe sensorineural hearing loss in the other ear, with a difference of at least 15 dB in PTAs between ears. When Not Covered section updated as follows:  Cochlear implantation as a treatment for individuals with tinnitus is considered investigational when the criteria above are not met.  Additional criteria added to the When Not Covered section specific to SSD/ASHL as follows:  A cochlear implant should not be implanted in individuals with single-sided deafness or asymmetrical hearing loss with any of the following: Profound hearing loss for more than ten years, or acoustic neuroma.  Expanded on definition of hearing loss ratings and defined limited benefit from unilateral amplification in adults and children in Policy Guidelines section. References updated.  Medical Director Review 8/2023.  Specialty Matched Consultant Advisory Panel review 8/2023.

References updated. Code 99201 removed from Billing/Coding section. Specialty Matched Consultant Advisory Panel 9/2023. Medical Director review 9/2023.

Description, Policy Guidelines and References updated. Specialty Matched Consultant Advisory Panel review 09/2023. Medical Director review. 09/2023.

Specialty Matched Consultant Advisory Panel 9/2023. Medical Director review 9/2023.

Policy title changed from “Gender Affirmation Surgery and Hormone Therapy” to “Gender Affirmation Surgery”. Under “When Covered” section removed Hormonal Therapy. Hormone therapy is addressed by Corporate Pharmacy Clinical Management. Added related policies Gonadotropin Releasing Hormone Therapy, Estrogens, and Androgens – NC Standard. Removed codes C1813, C2622, J1950, J3315, J9217, J9219, J9226 from billing section. Under “Benefits Application” section added statement When benefits for gender affirmation surgery are available coverage and availability of services may vary by State. Under “Not Covered” section added statement Gender Affirmation Surgery is not covered when prohibited by law. Medical Director review 09/2023.

References updated. Specialty Matched Consultant Advisory Panel review 9/2023. Medical  Director review 9/2023.

References updated. Specialty Matched Consultant Advisory Panel 9/2023. Medical Director review 9/2023

Updated #12 under When Covered to read as follows: “The member/caregiver must complete an assessment with the Blue Cross and Blue Shield of North Carolina case management team to evaluate for current and ongoing needs.” Medical Director review 10/2023.

References and Billing/Coding section updated. Specialty Matched Consultant Advisory Panel review 9/2023. Medical Director review 9/2023.

Previous code range E2201-E2399 updated to E2201-E2398 under Billing/Coding section. References updated. Specialty Matched Consultant Advisory Panel 9/2023. Medical Director review 9/2023.