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Provider Manual

Medical Policies

Last Updated on April 22, 2019

Policy changes effective April 1, 2019:

Annual policy 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
    • N/A
    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 Incontinence
    New Policies
    • N/A 

    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 December 2018:

    Reviewed with changes made to medical criteria

    • Experimental or Investigational
    • Breast Reconstruction Post-Mastectomy
    • Treatment of Autism Spectrum Disorders

    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 November 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