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Provider Manual

Medical Policies

Last Updated on July 12, 2019

Policy changes effective July 1, 2019

Annual policy review for the month of  June 2019

Reviewed with no changes made to medical criteria

  • Behavioral Health – AODA: Transitional Care Coverage-Medicare Advantage
  • Femoro-Acetabular Surgery for Hip Impingement Syndrome
  • Infuse Bone Graft (Bmp-2) Procedure
  • Physical, Occupational and Speech Therapy Exclusions

Reviewed with changes made to medical criteria

  • Experimental and Investigational
  • Abnormal Vascular Lesion Removal
  • Chelation Therapy
  • Electroencephalography (EEG) Procedures
  • Skin Substitutes, Chemical Peels, Dermabrasions and other Skin Procedures
  • TMJ Benefit Review

New Policies

  • Gamifant
  •  Revcovi
  • Somatuline (lanreotide)

Policy changes effective June 1, 2019

Annual policy review for the month of May 2019

Policies reviewed with changes made to medical criteria

  • Botulinum Toxin Injections
  • Implantable Cardioverter-Defibrillator (ICD) Insertion Procedures
  • Implantable Loop Recorder
  • Lipectomy or Suction-Assisted Lipectomy
  • Oral Appliances for the Treatment of Obstructive Sleep Apnea
  • Peripheral Vascular Stent
  • Total Ankle Replacement
  • Treatment of Chronic Skin Conditions
  • Experimental and Investigational
  • Cellular Therapies
  • Health Check Other Services
  • Telehealth
  • Total Knee Replacement Surgical Procedures
  • Total Hip Replacement Surgical Procedures
  • Carpal Tunnel Repair Surgical Procedures
  • Hysterectomy Surgical Procedures

Policies reviewed with no changes made to medical criteria

  • Bone Growth Stimulator for the 5th Metatarsal
  • Electrical Stimulation and Electromagnetic Therapy for the Treatment of Wounds

New Policies

  • Rezum Therapy
  • Gamifant
  • Revcovi

Policy changes effective May 1, 2019

Annual policy review for the month of April 2019

Policies reviewed with changes made to medical criteria

  • Biofeedback for Physical Conditions
  • Electroconvulsive Therapy (ECT)
  • Swing Bed

Policies reviewed with no changes made to medical records

  • 72 Hour Subcutaneous Continuous Glucose Monitoring (CGM)
  • Autologous Cultured Chondrocytes
  • Cardiomems
  • Cochlear Implant
  • Fractional Flow Reserve CT
  • Total Disc Arthroplasty

Policy changes effective April 1, 2019

Annual policy review for the month of March 2019

Reviewed with no changes made to medical criteria

  •  Home Health Criteria

Reviewed with no changes made to medical criteria

  • Intravenous Iron Therapy – Commercial/Exchange
  • Intravenous Iron Therapy – Medicare
  • Radicava – beginning 4/1/19, Evicore will review
  • Breast Reconstruction Post Mastectomy
  • Hyperthermic Intraperitoneal Chemotherapy

New policies

  • Hypoglossal Nerve Neurostimulation
  • Libtayo
  • Lumoxiti
  • Acute Rehab Facility
  • Long Term Acute Rehab

Policy changes effective March 1, 2019

Annual Policy review for the month of February 2019

Reviewed with no changes made to medical criteria - none

Reviewed with changes made to medical criteria

  • Cluster and Migraine Headache Non-Surgical Management
  • Cryoablation
  • Fecal Microbiota Transplantation
  • Gastric Pacing and Gastric Electrical Stimulation
  • Implantable Hormone Pellet Replacement Therapy
  • Ivor Lewis Procedure
  • Medtronic IN.PACT Admiral Paclitaxel-coated PTA Balloon
  • Urinary

New Policies - none

Policy changes effective January 1, 2019

Annual policy review for the month of January 2019

Policies reviewed with changes made to medical criteria

  • Back Surgical Procedures for Cervical and Thoracic Levels-Inpatient and Outpatient Settings
  • Back Surgical Procedure: Vertebroplasty-Inpatient and Outpatient Settings
  • Cologuard DNA-Stool Testing
  • Core Decompression of AVN of the Femoral Head
  • Hospice Coding and Packaging Guidelines
  • Hyperbaric Oxygen Therapy
  • Hyperthermic Intraperitoneal Chemotherapy
  • Total Knee Replacement Surgical Precertification Coding and Packaging Guidelines
  • Pancreas Transplant Alone (PTA) and Autologous Islet Cell Transplants
  • Radiofrequency Ablation to Treat Tumors
  • Refractive Eye Surgery
  • Telehealth
  • Tilt Table Testing
  • Total Hip Replacement Surgical Precertification

Policies reviewed with no changes made to medical criteria

  • Amino-Acid Based oral Formulas
  • Behavioral Health/AODA: Transitional Care Coverage
  • Chronic Hip Pain-Osteoarthritis Specialty Consult
  • Hospice
  • Knee Replacement Surgical Precertification
  • Low Back Pain (LBP) Consultation with Orthopedic or Neurosurgical Specialist
  • Wearable Hearing Aids

New policies - none

Policy changes effective December 1, 2018

Annual policy review for the month of November 2018

Reviewed with changes made to medical criteria

  • Experimental or Investigational
  • Breast Reconstruction Post-MastectomyTreatment of Autism Spectrum Disorder

Policies reviewed with no changes made to medical criteria

  • Abdominoplasty and Panniculectomy
  • Erectile Dysfunction Treatments
  • Inpatient Admission Prior to Surgery (Pre-op)
  • Radiesse
  • Experimental or Investigational
  • Blepharoplasty, Blepharoptosis Repair
  • Contact Lenses and Other Eyewear
  • Idiopathic Scoliosis
  • Varicose Vein Treatments

New policies - none

Policy changes effective November 1, 2018

Annual policy review for the month of October 2018

Reviewed with changes made to medical criteria - none

Reviewed with no changes made to medical criteria

  • Carpal Tunnel Repair Surgical Precertification
  • Carpal Tunnel Syndrome-Median Neuropathy Specialty Consult
  • Chronic Knee Pain-Osteoarthritis or Meniscal Degeneration Specialty Consult
  • Disabled Dependent Coverage
  • Hysterectomy Surgical Procedures
  • Knee Arthroscopy Surgery Precertification
  • Obesity Management, Surgical Approaches Obesity Management
  • Dupixent

New policies - none