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Provider Manual

Medical Policies

Last Updated on June 22, 2020

Policy changes effective June 1, 2020

Updated Policies
  • Implantable Cardioverter-Defibrillator (ICD) Insertion Procedures
  • Oral Appliances for the Treatment of Obstructive Sleep Apnea
  • Peripheral Vascular Stent
  • Acute Inpatient Rehab
  • Telehealth Policy
No changes to policies
  • Bone Growth Stimulator for the 5th Metatarsal
  • Botulinum Toxin Injections
  • Implantable Loop Recorder
  • Lipectomy or Suction-Assisted Lipectomy
  • Total Ankle Replacement
Archive
  • Fecal Transplant
  • Fractional Flow Reserve CT
New effective 6/1/20
  • COVID-19
New effective 8/1/20
  • Genetic Testing Oncology: molecular analysis of solid tumors and hematologic malignancies
  • Genetic Testing Oncology Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy)
  • Genetic Testing: Whole Exome and Whole Genome Sequencing for the Diagnosis of Genetic Disorders
  • Genetic Testing: Pharmacogenetics
  • Genetic Testing Oncology: Prognostic/Algorithmic Testing

Policy changes effective May 1, 2020

Policies reviewed with changes made to medical criteria:

  • Cochlear Implant
  • Spravato 
  • Infuse Bone Graft
  • Complementary and Alternative Medicine
  • Ambulance Policy
  • Cluster and Migraine Headache
  • Acute Inpatient Rehab
  • Experimental or Investigational
Policies reviewed with no changes made to medical criteria:
  • Autologous Cultured Chondrocytes
  • Biofeedback for Physical Conditions
  • Cardiomems
  • Electroconvulsive Therapy
  • Fractional Flow Reserve CT 
  • Total Disc Arthroplasty 

Archived policies:

  • 72 Hour Subcutaneous Continuous Glucose Monitoring (CGM)
  • Cologuard DNA stool testing
New policy effective July 1, 2020
  • Genetic Testing Oncology Cancer Screening 

Policy changes effective April 1, 2020

Policies reviewed with changes made to medical criteria:

  • Libtayo® (cemiplimab-rwlc)  - Managed by Magellan
  • Lumoxiti™ (moxetumomab pasudotox-tdfk) – Managed by Magellan
  • Telehealth policy
Policies reviewed with no changes made to medical criteria:
  • Home Care Coverage Criteria
  • Acute Inpatient Rehab Facility (IRF) 
  • Long Term Acute Rehab (LTAC) Facility 
Retired Policy
  • Radicava

Policy changes effective March 1, 2020

Policies reviewed with changes made to medical criteria:

  • Cluster and Migraine Headache: Nonsurgical Management
  • Cryoablation
  • Fecal Microbiota Transplantation (FMT)
  • Gastric Pacing and Gastric Electrical Stimulation
  • Implantable Hormone Pellet Replacement Therapy
  • Urinary Incontinence
  • Hyaluronic Acid Derivatives
  • Experimental/Investigational Policy
  • Genetic Policy – Two policies were broken out of the main Genetic Policy
  • Genetic Testing for Hereditary Cancer
  • Genetic Testing for Prenatal, Preimplantation, and Preconception Carrier Screening
Policies reviewed with no changes made to medical criteria:
  • Ivor Lewis Procedure
  • Medtronic IN.PACT Admiral Paclitaxel-coated PTA Balloon 
 New Policy
  • Linx for GERD
Retired Policy
  • Zoledronic Acid Policy

Policy changes effective Feb. 1, 2020

Policies reviewed with changes made to medical criteria:

  • Back Surgical Procedure: Vertebroplasty-Inpatient and Outpatient Settings
  • Back Surgical Procedure for Cervical and Thoracic levels -Inpatient and Outpatient Settings
  • Cologuard DNA 
  • Core Decompression of AVN of the Femoral Head
  • Hospice
  • Hyperbaric Oxygen Therapy
  • Hyperthermic Intraperitoneal Chemotherapy
  • Pancreas Transplant Aline (PTA) and Autologous Islet Cell Transplants
  • Radiofrequency Ablation to Treat Tumors
  • Refractive Eye Surgery
  • Telehealth
  • Tilt Table Testing
  • Total Hip Replacement Surgical Precertification
  • Total Knee Replacement Surgical Precertification
  • Experimental/Investigational Policy Changes
  • Complementary and Alternative Policy
Policies reviewed with no changes made to medical criteria:
  • Amino-Acid Based Oral Formulas for Infants – reviewed by Northwood
  • Behavioral Health AODA: Transitional Care Coverage
  • Wearable Hearing Aids 
 New Policies
  • None
Retired Policies
  • Low Back Pain Consultation with Orthopedic or Neurosurgical Specialist 
  • Hysterectomy Surgical Procedures

Policy changes effective Jan. 1, 2020 

Policies reviewed with changes made to medical criteria: 

  • Abdominoplasty and Panniculectomy Policy 
  • Breast Reconstruction Post Mastectomy 
  • Breast Reduction Mammoplasty 
  • Erectile Dysfunction Treatments 
  • Radiesse 
  • Hyaluronic Acid Derivatives 
  • Intravenous Iron Therapy Commercial/Exchange 
  • Dupixent 
Policies reviewed with no changes made to medical criteria: 
  • Inpatient Admission Prior to Surgery (Pre-op) 
  • Treatment of Autism Spectrum Disorder 
New Policies 
  • None 
Retired Policies 
  • None 

Policy changes effective Dec. 1, 2019

Policies reviewed with changes made to medical criteria:

  • Eyelid & Brow Repair Medical Policy
  • Contact Lenses and Other Eyewear Medical Policy
  • Hysterectomy Surgical Procedures Medical Policy
  • Idiopathic Scoliosis Medical Policy
  • Knee Arthroscopy Surgery Precertification
  • Obesity Management, Surgical Approaches Medical Policy
  • Varicose Vein Treatments Medical Policy
  • Lung Volume reduction Medical Policy
  • Behavioral Health/AODA: Transitional Care Coverage Medical Policy
  • Hypoglossal Nerve Neurostimulation Medical Policy
  • Experimental Investigation Medical Policy

Policies reviewed with no changes made to medical criteria:

  • Carpal Tunnel Repair Surgical Precertification
  • Disabled Dependent Coverage

New Policies

  • Luxturna
  • Imlygic

Retired Policy

  • Home Infusion Policy

Policy changes effective Nov. 1, 2019

Policies reviewed with changes made to medical criteria:

  • Back Surgical Procedures for Lumbar Spinal Level - Inpatient and Outpatient Settings
  • Eye Movement Desensitization and Reprocessing (EMDR)
  • Left Atrial Appendage Closure to Reduce the Risk of Stroke
  • Mitraclip Procedure
  • Experimental/Investigational

    Policies reviewed with no changes made to medical criteria:

  • Ambulance: Land and Air Transportation
  • Cellular Therapies
  • Home Health Care- Medicare Advantage
  • Medicare Advantage Chiropractor
  • Takhzyro® (lanadelumab-flyo)

    Retired Policies

  • Intravenous Immune Globulins (immune globulin) - home infusion
  • IV Antibiotic/Antifungal Prior Authorization Policy
  • C1 esterase inhibitor (Haegarda®)

Policy changes effective Oct. 1, 2019

Policies reviewed with changes made to medical criteria:

  • Lung Volume Reduction System
  • Septoplasty/Rhinoplasty
  • Sleep Studies
  • Synagis

Policies reviewed with no changes made to medical criteria:

  • Medicare Advantage Skilled Nursing Facility Coverage Criteria
  • Private Duty Nursing Duty
  • Repetitive Transcranial Magnetic Stimulation
  • Swing Bed

New Policies

  • Spravato
  • Zolgensma

Retired Policies

  • Medicare Advantage Part C Drug Bundled Medication

Policy changes effective Sept. 1, 2019

Policies reviewed with changes made to medical criteria:

  • Complementary/Alternative Medicine
  • Experimental/Investigational
  • Intrastromal Corneal Rings Segments
  • Spinal Cord Stimulation
  • Vagus Nerve Stimulation for Epilepsy and Depression
  • Zika virus

Policies reviewed with no changes made to medical criteria:

  • Genetic Testing
  • Home, outpatient and inpatient chemotherapy
  • Maze Procedure

Policy changes effective August 1, 2019

 
  • Reviewed with changes made to medical criteria
  • Bone and tendon graft substitutes and adjuncts
  • Cosmetic surgery/treatments
  • Gender reassignment services and surgical procedures
  • Healthcheck “other services”
  • Home infusion
  • Intravenous iron therapy – commercial/exchange
  • Intravenous iron therapy – Medicare
  • Transcatheter aortic valve replacement (TAVR)
  • Crysvita
  • Dupilumab
  • Durvalumab
  • Fosnetupitant and palonosetron
  • Hyaluronic acid derivatives
  • Zoledronic acid

Policy changes effective July 1, 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

 

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

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

 

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

 

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

 

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

 

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

 

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