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Medical Policy Update for November 7, 2023
| Medical Guidelines | Reason for Update |
|---|---|
| Ambulatory Event Monitors (PDF) | Description section, Policy Guidelines and References updated. When Covered and Not Covered sections edited for clarity, no change to policy statement. Specialty Matched Consultant Advisory Panel review 10/2023. Medical Director review 10/2023 |
| Anesthesia Services (PDF) | References updated. Specialty Matched Consultant Advisory Panel review 10/2023. Medical Director Review 10/2023. No change to policy statement. |
| Artificial Intervertebral Disc (PDF) | References updated. Related policies added. FDA approved devices updated. Minor edits to Policy Guidelines. No change to policy intent. Specialty Matched Consultant Review 10/2023. Medical Director review 10/2023. |
| Autonomic Nervous System Testing (PDF) | References updated. Added related policy. Updated listing of U.S. FDA approved ANS testing devices. Specialty Matched Consultant Review 10/2023. Medical Director review 10/2023. |
| Bariatric Surgery (PDF) | Policy Guidelines section updated to remove “an assessment of thyroid levels is required” from A thorough preoperative evaluation. No change to coverage criteria. Medical Director Review. |
| Baroreflex Stimulation Devices (PDF) | Description, Policy Guidelines and References updated. No change to policy statement. Specialty Matched Consultant Advisory Panel review 10/2023. Medical Director review 10/2023. |
| Cardiac Monitoring Devices in the Outpatient Setting (PDF) | Description, Regulatory Status, Policy Guidelines and References updated. No change to policy statement. Specialty Matched Consultant Advisory Panel review 10/2023. Medical Director review 10/2023. |
| Carotid Intimal-Medial Thickness (PDF) | Description section, Policy Guidelines, and References updated. Specialty Matched Consultant Advisory Panel review 10/2023. Medical Director review 10/2023. |
| Computed Tomography to Detect Coronary Artery Calcification (PDF) | Description, Policy Guidelines and References updated. Specialty Matched Consultant Advisory Panel review 10/2023. Medical Director review 10/2023. |
| Decompression of the Intervertebral Disc Using Laser Energy (Laser Discectomy) or Radiofrequency Coblation (Nucleoplasty) (PDF) | Added Related Policies. References updated. Specialty Matched Consultant Advisory Panel review 10/2023. Medical Director review 10/2023. |
| Dental Criteria for use of Hospital Inpatient or Outpatient Facility Services or Ambulatory Surgery Center Facility Services (PDF) | Specialty Matched Consultant Advisory Panel review 10/2023. Medical Director Review 10/2023. No change to policy statement. |
| Dental Reconstructive Services (PDF) | References updated. Specialty Matched Consultant Advisory Panel review 10/2023. Medical Director Review 10/2023. Added the following statement to the Billing/Coding section: “Charges related to an accidental injury must be submitted within 2 years of the accident when stated in the member benefit booklet.” No change to policy statement. |
| Electrodiagnostic Studies (PDF) | Updated Description section, References, and title of Related Policy. Added Regulatory Status section. Updated Policy Guidelines. No change to policy intent. Specialty Matched Consultant Advisory Panel review 10/2023. Medical Director review 10/2023 |
| Enhanced External Counterpulsation (EECP) (PDF) | Policy Guidelines and References updated. When Covered section edited for clarity, no change to policy statement. Specialty Matched Consultant Advisory Panel review 10/2023. Medical Director review 10/2023. |
| Hyperbaric Oxygen Therapy (PDF) | Regulatory status updated. Updated “patients” to “individuals” in coverage criteria. References updated. Specialty Matched Consultant Advisory Panel review 10/2023. Medical Director review 10/2023. No change to policy statement |
| Injection Therapy for Headache (Migraine and Other) and Non-Spine Management (PDF) | Minor edits to Description section. References updated. Updated ICD 10 code from R51 to R51.0 and R51.9 in the Billing/Coding section. Specialty Matched Consultant Advisory Panel review 10/2023. Medical Director review 10/2023. |
| Interferential Stimulation (PDF) | Updated title of one Related Policy. References updated. Specialty Matched Consultant Advisory Panel review 10/2023. Medical Director review 10/2023. |
| Leadless Cardiac Pacemakers (PDF) | Description, Policy Guidelines and References updated, When Covered Section edited for clarity, no change to policy statement. Specialty Matched Consultant Advisory Panel review 10/2023. Medical Director review 10/2023. |
| MRI-guided Laser Interstitial Thermal Therapy for Neurological Indications (PDF) | Updated Description, Regulatory Status and references. Removed CPT code 64999. Specialty Matched Consultant Advisory Panel review 10/2023. Medical Director review 10/2023. |
| Navigated Transcranial Magnetic Stimulation (nTMS) (PDF) | Regulatory Status updated. Reference added. Specialty Matched Consultant Advisory Panel review 10/2023. Medical Director review 10/2023. |
| Orthodontics for Pediatric Patients (PDF) | References updated. Removed D8690 from Billing/Coding section. Specialty Matched Consultant Advisory Panel review 10/2023. Medical Director Review 10/2023. No change to policy statement. |
| Orthognathic Surgery (PDF) | References updated. Specialty Matched Consultant Advisory Panel review 10/2023. Medical Director Review 10/2023. No change to policy statement. |
| Progenitor Cell Therapy for the Treatment of Damaged Myocardium Due to Ischemia (PDF) | Policy Guidelines and References updated. Specialty Advisory Consultant Advisory Panel review 10/2023. Medical Director review 10/2023. |
| Quantitative Sensory Testing (PDF) | Updated FDA approved devices. Updated references. Medical Director review 10/2023. Specialty Matched Consultant Advisory Panel review 10/2023. |
| Signal-Averaged ECG (PDF) | Description section and References updated. Not Covered section edited for clarity, no change to policy statement. Specialty Matched Consultant Advisory Panel review 10/2023. Medical Director review 10/2023. |
| Spinal Cord and Dorsal Root Ganglion Stimulation (PDF) | Updated Description. Reformatted Regulatory Status and added an FDA approved device to the list. Removed terminated CPT code 95973 from Billing/Coding section. Specialty Matched Consultant Panel review 10/2023. Medical Director review 10/2023. |
| Spinal Manipulation Under Anesthesia (PDF) | References updated. Specialty Matched Consultant Advisory Panel Review 10/2023. Medical Director Review 10/2023. No change to policy statement. |
| Stem-Cell Therapy for Peripheral Arterial Disease (PDF) | Description section, Regulatory Status, Policy Guidelines and References updated. Specialty Matched Consultant Advisory Panel review 10/2023. Medical Director review 10/2023. |
| Temporomandibular Joint Dysfunction (TMJD) (PDF) | Benefits application section updated for clarity. When not covered updated for clarity. Policy guidelines updated. References updated. Specialty Matched Consultant Advisory Panel review 10/2023. Medical Director Review 10/2023. No change to policy statement. |
| Total Facet Arthroplasty (PDF) | Added and updated title of one Related Policy. Updated Regulatory Status. Policy Guidelines updated. No change to policy intent. References updated. Specialty Matched Consultant Advisory Panel review 10/2023. Medical Director review 10/2023. |
| Wearable Cardioverter Defibrillators (PDF) | Description section, Policy Guidelines and References updated. When Covered section edited for clarity, no change to policy statement. Specialty Matched Consultant Advisory Panel review 10/2023. Medical Director review 10/2023. |
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