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Provider Manual

Medical Policies

Last Updated on March 11, 2019

Policy changes effective February 1, 2019:

Annual policy review for the month of February 2019:

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
  • Ivor Lewis Procedure
Policies reviewed with no changes made to medical criteria
  • Medtronic IN.PACT Admiral Paclitaxel-coated PTA Balloon
  • Urinary Incontinence
New policies
  • Off Label Coverage Determination

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