The Coverage Summaries, corresponding update bulletins, and related Medical Benefit Injectable Policies for UnitedHealthcare Medicare Advantage plans are listed below.
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A monthly notice of recently approved and/or revised UnitedHealthcare Medicare Advantage Coverage Summaries is provided below for your review. We publish a new announcement on the first calendar day of every month.
The appearance of a health service (e.g., test, drug, device or procedure) in the Coverage Summary Update Bulletin does not imply that UnitedHealthcare provides coverage for the health service. In the event of an inconsistency or conflict between the information provided in the Medicare Advantage Coverage Summary Policy Update Bulletin and the posted policy, the provisions of the posted policy will prevail.
Last Published 01.01.2021
This bulletin provides complete details on recently approved, revised, and/or retired UnitedHealthcare Medicare Advantage Coverage Summaries.
Last Published 02.01.2021
This bulletin provides complete details on recently approved, revised, and/or retired UnitedHealthcare Medicare Advantage Coverage Summaries.
Last Published 02.01.2021
This bulletin provides complete details on recently approved, revised, and/or retired UnitedHealthcare Medicare Advantage Coverage Summaries.
Last Published 02.01.2021
These policies provide additional information on medical benefit injectables addressed in the UnitedHealthcare Medicare Advantage Coverage Summaries.
Last Published 01.01.2021
Effective Date: 01.01.2021 - This policy addresses Medicare Part B step therapy programs for erythropoietic agents, infliximab products, colony stimulating factors, and hyaluronic acid polymers.
These UnitedHealthcare Coverage Summaries are applicable to UnitedHealthcare Medicare Advantage Plans offered by UnitedHealthcare and its affiliates.
General Statements
The Coverage Summaries are policies based on existing current Medicare National Coverage Determinations, Local Coverage Determinations, UnitedHealthcare Medical Policies, and applicable UnitedHealthcare Medicare Advantage Plans EOCs and SOBs intended to provide benefit coverage information and guidelines specific to UnitedHealthcare Medicare Advantage Plans. The Coverage Summaries are developed and reviewed by the UnitedHealthcare Medicare Benefit Interpretation Committee. Benefit interpretations for UnitedHealthcare Medicare Advantage Plan members are made on a case-by-case basis using the guidelines in the Coverage Summaries. The Coverage Summaries are subject to change based upon changes in Medicare's coverage requirements, changes in scientific knowledge and technology and evolving practice patterns. Providers are responsible for reviewing the CMS Medicare Coverage Center guidance and in the event that there is a conflict between the Coverage Summaries and the CMS Medicare Coverage Center guidance, the CMS Medicare Coverage Center guidance will govern.
Covered benefits, limitations and exclusions are specified in the UnitedHealthcare Medicare Advantage Plan Evidence of Coverage (EOC) and Summary of Benefits (SOB) only. If there are any differences between the member's UnitedHealthcare Medicare Advantage Plan EOC or SOB and the Coverage Summaries, the member's UnitedHealthcare Medicare Advantage Plan EOC or SOB shall govern. Nothing in the Coverage Summaries is intended to be construed as an expansion of benefits beyond the benefits specified in the UnitedHealthcare Medicare Advantage Plan EOC or SOB or as a basis for payment of any benefits under the UnitedHealthcare Medicare Advantage Plans.
Nothing in the Coverage Summaries is intended to be construed as establishing any guidelines for the practice of medicine or a standard of care for the practice of medicine. UnitedHealthcare does not practice medicine and does not make medical decisions for UnitedHealthcare Medicare Advantage Plan Members. Medical decisions for UnitedHealthcare Medicare Advantage Plan Members are made by the treating physician in conjunction with the member.
The information contained within the Coverage Summaries is strictly proprietary to UnitedHealthcare. The information is not to be copied in whole or part; nor is the information to be distributed without express written consent of UnitedHealthcare.
The Coverage Summaries are based upon: (1) Medicare publications relating to coverage determinations; (2) laws and regulations which may be applicable to UnitedHealthcare Medicare Advantage Plans; and (3) research, studies and evidence from other sources including, but not limited to, the U.S. Food and Drug Administration (FDA).
Many of the benefit interpretations in the Coverage Summaries require a determination of medical necessity to establish coverage. Medical necessity determinations must be made by trained and/or licensed professional medical personnel only.
UnitedHealthcare Medicare Advantage Plan members have the right to appeal benefit decisions in accordance with Medicare guidelines as outlined in the UnitedHealthcare Medicare Advantage Plans EOC or SOB. Any questions regarding appeals should be directed to the UnitedHealthcare Medicare Advantage Plans Appeals Department identified on the members' identification card.
Hierarchy of References/Resources
The Coverage Summaries are developed and written using the following references/resources:
Coverage Summaries are the property of UnitedHealthcare. Unauthorized copying, use and distribution of this information are strictly prohibited.
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Last Published 11.01.2020
This policy addresses abortions, including health care associated with spontaneous or therapeutic pregnancy termination.
Last Published 11.01.2020
This policy addresses inpatient and outpatient alcohol and chemical/substance abuse detoxification and rehabilitation.
Last Published 02.01.2021
This policy addresses allergy testing, allergy immunotherapy to treat allergies, reasonable supply of antigen, and non-covered tests/services.
Last Published 02.01.2021
This policy addresses ambulance transportation by ground or air.
Last Published 08.15.2020
This policy addresses cervical and lumbar artificial disc replacement (LADR). Applicable Procedure Codes: 0095T, 0098T, 0163T, 0165T, 22856, 22857, 22858, 22861, 22862, 22864.
Last Published 07.01.2020
This policy addresses biofeedback for the re-education of muscle groups and for treatment of stress and/or urge urinary incontinence.
Last Published 02.01.2021
This policy addresses upper and lower eyelid blepharoplasty, brow ptosis repair, upper eyelid blepharoptosis repair, reduction of overcorrection ptosis, ectropion/entropion repair, lid retraction, correction of lagophthalmos, canthus repair, lid repair, floppy eyelid syndrome repair, and canthopexy. Applicable Procedure Codes: 15820, 15821, 15822, 15823, 21280, 21282, 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909, 67911, 67912, 67914, 67915, 67916, 67917, 67921, 67922, 67923, 67924, 67950, 67961, 67966.
Last Published 02.01.2021
This policy addresses blood components, clotting factors, platelets, and transfusions, including related products and services.
Last Published 04.01.2020
This policy addresses bone (mineral) density study/bone mass measurement (BMM).
Last Published 02.01.2021
This policy addresses brachytherapy, high-dose rate electronic brachytherapy, and implantable beta-emitting microspheres for treatment of malignant tumors. Applicable Procedure Codes: 0394T, 0395T.
Last Published 01.15.2021
This policy addresses reconstruction of the affected and the contralateral unaffected breast following mastectomy . Applicable Procedure Codes: 19328, 19330, 19340, 19342, 19350, 19357, 19361, 19364, 19366, 19367, 19368, 19369, 19370, 19371, 19380, 19396.
Last Published 09.01.2020
This policy addresses cardiac pacemakers and monitoring, defibrillators, pulmonary artery pressure measurements, anesthesia for cardiac pacemaker surgery, intraoperative ventricular mapping, and external counterpulsation (ECP) therapy. Applicable Procedure Codes: 33270, 33271, 33273, 33274, 33275, 33289, 93260, 93261, 93264, 93644, C2624.
Last Published 02.01.2021
This policy addresses diagnostic and therapeutic procedures. Applicable Procedure Codes: 37220, 37221, 37222, 37223, 37224, 37225, 37226, 37227, 37228, 37229, 37230, 37231, 37232, 37233, 37234, 37235, 75710, 75716, 92978, 92979, 93050, 93653, 93655, 93656, 93657.
Last Published 07.01.2020
This policy addresses carotid body resection and non-invasive test of carotid function (direct and indirect).
Last Published 11.01.2020
This policy addresses financial payment responsibility of covered services when a beneficiary changes membership status while hospitalized or receiving home health services, and continuation of care.
Last Published 02.01.2021
This policy addresses chelation therapy for lead poisoning, non-overload conditions, and the treatment or prevention of atherosclerosis.
Last Published 02.01.2021
This policy addresses chemotherapy agents, immunotherapy agents, hormonal agents, off-label use of drugs and biologicals in an anti-cancer chemotherapeutic regimen, national cancer institute (NCI) designated "Group C" drugs, medicare approved clinical trials, chemotherapy services, and shortage of Leucovorin. Applicable Procedure Code: J0640.
Last Published 04.01.2020
This policy addresses manual manipulation of the spine, power traction equipment/devices, and fluidized therapy dry heat.
Last Published 09.01.2020
This policy addresses cochleostomy with neurovascular transplant for the treatment of Ménière’s disease.
Last Published 10.01.2020
This policy addresses complementary and alternative therapies or services. Applicable Procedure Codes: 64999, A9270.
Last Published 12.01.2020
This policy addresses computed tomographic angiography (CTA), multidetector (multidetector-row/multislice) computed cardiac tomography (MDCT), and electron beam computed tomography (EBCT).
Last Published 02.01.2021
This policy addresses cosmetic surgery or expenses incurred in connection with such surgery, breast reconstruction, breast reduction surgery (reductive mammoplasty), blepharoplasty, treatment of actinic keratosis, panniculectomy/abdominal lipectomy, suction-assisted lipectomy, mastopexy, gynecomastia treatment, dermal injections for the treatment of facial lipodystrophy syndrome (LDS), tattooing to correct color defects of the skin, myocutaneous flaps for the head/neck/trunk/extremities, toe polydactyly reconstruction, pectus deformity repair, septoplasty, rhinoplasty, vestibular stenosis repair, balloon sinuplasty, surgery to correct moon face, gender dysphoria treatment, light and laser therapy for rosacea and rhinophyma, and insertion of tissue expander for other than breast. Applicable Procedure Codes: 11920, 11921, 11922, 11960, 15830, 15731, 15733, 15734, 15736, 15756, 15738, 15847, 15876, 15877, 15878, 15879, 19300, 19316, 19318, 21740, 21742, 21743, 28344.
Last Published 11.01.2020
This policy addresses court, attorney or agency requested services and paternity testing.
Last Published 06.01.2020
This policy addresses unilateral or bilateral thalamic ventralis intermedius nucleus (VIM) deep brain stimulation (DBS).
Last Published 09.01.2020
This policy addresses dental services or oral surgery, temporomandibular joint (TMJ), and orthognathic surgery. Applicable Procedure Codes: E0849, E0855, E1700, E1701, E1702.
Last Published 01.15.2021
This policy addresses diabetic self-management training, medical nutrition therapy, blood glucose monitors (including modified/special), continuous glucose monitoring, external continuous subcutaneous insulin infusion pump, closed-loop blood glucose control device, home health benefits to a blind diabetic, outpatient intravenous insulin treatment, insulin, and insulin delivery/testing supplies. Applicable Procedure Codes: 95249, 95250, 95251, A4233, A4234, A4235, A4236, A4244, A4245, A4246, A4247, A4250, A4253, A4255, A4256, A4257, A4258, A4259, A9276, A9277, A9278, E0607, E0784, E2100, E2101, K0553, K0554.
Last Published 02.01.2021
This policy addresses dialysis (peritoneal, hemofiltration, ultrafiltration and hemodialysis) services and medically necessary equipment/supplies used to furnish dialysis in a Medicare certified ESRD Facility, member’s home or inpatient hospital facility.
Last Published 02.01.2021
This policy addresses specific Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies. Applicable Procedure Codes: A4606, A4614, A9284, A9300, E0118, E0445, E0464, E0465, E0466, E0467, E0483, E1800, E1801, E1802, E1805, E1806, E1810, E1811, E1812, E1815, E1816, E1818, E1825, E1830, E1831, E1840, E1841, L8701, L8702.
Last Published 07.15.2020
This policy addresses durable medical equipment (DME) rental or purchase, prosthetic and corrective appliances/orthotics, supplies for DME, prosthetic devices and corrective appliances, medical supplies, repairs, maintenance, replacement, routine, periodic maintenance, and accessories to DME/corrective appliances/prosthetics that are primarily for the comfort or convenience of the member.
Last Published 09.01.2020
This policy addresses institutional or home care educational programs, educational activities not closely related to the care and treatment of the patient, nutritional counseling, and face-to-face kidney disease education (KDE) services.
Last Published 11.01.2020
This policy addresses emergency services, urgently-needed services, post-stabilization care services, follow-up care, and ambulance services.
Last Published 02.01.2020
This policy addresses evaluation and management services, including physician office in a facility, physician consultation with a patient’s family and associates, pronouncement of death, podiatrist consultation in a skilled nursing facility, and hospital and skilled nursing facility admission diagnostic procedures.
Last Published 09.01.2020
This policy addresses experimental and investigational procedures/items/medications, investigational device exemption (IDE), and clinical trials.
Last Published 06.01.2020
This policy addresses extracorporeal photopheresis, including palliative treatment of skin manifestations of cutaneous T-cell lymphoma (CTCL) that has not responded to other therapy, patients with acute cardiac allograft rejection or chronic graft versus host disease whose disease is refractory to standard immunosuppressive drug treatment, treatment of bronchiolitis obliterans syndrome (BOS), and treatment of bullous pemphigoid and pemphigus vulgaris.
Last Published 08.01.2020
This policy addresses extracranial-intracranial (EC-IC) arterial bypass surgery.
Last Published 08.01.2020
This policy addresses fabric wrap for abdominal aneurysms.
Last Published 12.01.2020
This policy addresses family planning for prevention of pregnancy, including office visits, routine pregnancy testing, sterilization, Birth control devices and procedures, over-the-counter supplies or prescription devices or drugs for birth control, non-prescription contraceptive supplies, and reversal of sterilization procedures.
Last Published 12.01.2020
This policy addresses routine foot care, supportive devices for feet, diabetic sensory neuropathy with loss of protective sensation, consultation services rendered by a podiatrist in a skilled nursing facility, subluxation of the foot, and treatment of flat foot.
Last Published 02.01.2021
This policy addresses gastroesophageal and gastrointestinal (GI) services, procedures, and related devices. Applicable Procedure Codes: 0184T, 43257, 43284, 43647, 43648, 43881, 43882, 46601, 46607, 64590, 64595, 74261, 74262, 74263, 76497, 76498, 83993, 91110, 91111.
Last Published 12.01.2020
This policy addresses genetic testing and counseling, including tumor markers, cytogenetic studies, and molecular diagnostic genetic tests.
Last Published 11.15.2020
This policy addresses insertion of aqueous drainage devices, implantation of glaucoma drainage devices, canaloplasty, and viscocanalostomy. Applicable Procedure Codes: 0191T, 0253T, 0376T, 0449T, 0450T, 0474T, 66174, 66175, 66183.
Last Published 12.01.2020
This policy addresses surgically implanted auditory devices (including cochlear implants, auditory brainstem implants, and osseointegrated implants), hearing aids, totally implanted hearing systems, cochlear hybrid implants, ultrasonic ablative surgery, and oxygen to treat hearing loss.
Last Published 08.01.2020
This policy addresses hearing screening services performed in the physician's office, audiology services, computerized dynamic posturography (CDP), and hearing examinations for the prescription/fitting/adjustment of standard hearing aids.
Last Published 01.01.2021
This policy addresses home health, skilled care, and related services and supplies.
Last Published 06.01.2020
This policy addresses hospice care.
Last Published 01.01.2021
This policy addresses inpatient and outpatient hospital services, religious nonmedical health care institutions (RNHCIs), long term care hospitals (LTCH), and never events.
Last Published 11.01.2020
This policy addresses hyperbaric oxygen (HBO) therapy and topical application of oxygen.
Last Published 09.01.2020
This policy addresses diagnosis and treatment of sexual impotency and erectile function. Applicable Procedure Codes: L7900, L7902.
Last Published 12.15.2020
This policy addresses conservative treatments of urinary incontinence, mechanical/hydraulic incontinence control devices, urodynamic studies (uroflowmetry/cystometrogram), biofeedback therapy, collagen implant therapy, sacral nerve stimulation (SNS), non-implantable pelvic floor electrical stimulator, electrical continence aid, bladder stimulators (pacemakers), posterior tibial nerve stimulation (PTNS), Solesta® for fecal incontinence, and botulinum toxin type a for overactive bladder/urinary incontinence. Applicable Codes: 64566, L8605.
Last Published 09.01.2020
This policy addresses tests and treatments for infertility.
Last Published 02.01.2021
This policy addresses external infusion pumps and implantable infusion pumps.
Last Published 08.01.2020
This policy addresses core decompression for avascular necrosis, hip resurfacing arthroplasty (HRA), hip/knee/elbow/shoulder replacement surgery (arthroplasty), unicompartmental knee arthroplasty, surgical treatment for femoroacetabular impingement (FAI) syndrome, and arthroscopic lavage and debridement for osteoarthritis of the knee. Applicable Procedure Codes: 21299, 23470, 23472, 23929, 24360, 24361, 24362, 24363, 27120, 27122, 27130, 27132, 27134, 27137, 27138, 27299, 27445, 27446, 27447, 27486, 27487, 27599, 27899, 29914, 29915, 29916, S2118, S2325.
Last Published 02.01.2021
This policy addresses laboratory tests and services (inpatient or outpatient). Applicable Procedure Codes: 82306, 83880.
Last Published 04.01.2020
This policy addresses laser procedures, including using lasers for ablation of the prostate, ocular surgery, and treatment of psoriasis.
Last Published 06.01.2020
This policy addresses lung volume reduction surgery (LVRS), including bilateral excision of a damaged lung with stapling performed via median sternotomy or video-assisted thoracoscopic surgery.
Last Published 04.01.2020
This policy addresses maternity and newborn care services.
Last Published 02.15.2021
This policy addresses outpatient medications/drugs, unlabeled use of Part B drugs, examples of covered and not covered medications/drugs, review at launch (RAL), step therapy programs, and shortage of Leucovorin. Applicable Procedure Codes: 11980, J0596, J0597, J0598, J0640, J1290, J3490.
Last Published 12.15.2020
This policy addresses mental health services and procedures, including inpatient and outpatient services, partial hospitalization care, and vagus nerve stimulation for intractable depression. Applicable Procedure Codes: 90880, 97154, 97155, 97156, E0203.
Last Published 11.01.2020
This policy addresses mobility assistive equipment (MAE), battery replacement, repairs, replacements and maintenance, and non-covered items/services. Applicable Procedure Codes: E0144, K0813, K0814, K0815, K0816, K0820, K0821, K0822, K0823, K0824, K0825, K0826, K0827, K0828, K0829, K0830, K0831, K0835, K0836, K0837, K0838, K0839, K0840, K0841, K0842, K0843, K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862, K0863, K0864, K0868, K0869, K0870, K0871, K0877, K0878, K0879, K0880, K0884, K0885, K0886, K0890, K0891, K0898.
Last Published 01.15.2021
This policy addresses septoplasty, rhinoplasty, vestibular stenosis repair, balloon sinus ostial dilation, and functional endoscopic sinus surgery (FESS). Applicable Procedure Codes: 31240, 31253, 31254, 31255, 31256, 31257, 31259, 31267, 31276, 31287, 31288, 31295, 31296, 31297, 31298.
Last Published 12.01.2020
This policy addresses neurologic services and procedures, including but not limited to monitoring, testing/studies, surgical procedures, cranial treatments, and seizure treatments.
Last Published 09.01.2020
This policy addresses evoked response tests and intraoperative neurophysiology monitoring.
Last Published 12.15.2020
This policy addresses neuropsychological testing.
Last Published 11.15.2020
This policy addresses non-covered items/services and services as a result of services that are not covered.
Last Published 12.01.2020
This policy addresses enteral and parenteral nutritional therapy.
Last Published 01.15.2021
This policy addresses non-surgical services (supplemental fasting and intensive behavioral therapy for obesity), surgical treatment (bariatric surgery), second bariatric surgeries, and examples of non-covered services.
Last Published 09.01.2020
This policy addresses outpatient hospital observation services.
Last Published 10.01.2020
This policy addresses collagen and non-collagen meniscus implant, extracorporeal shock wave therapy (ESWT), bone/soft tissue healing and fusion enhancement products, manipulation under anesthesia (MUA), unicondylar spacer devices, athletic pubalgia surgery, autologous chondrocyte transplantation (knee), osteochondral grafting (knee), and open osteochondral autograft (talus).
Last Published 11.01.2020
This policy addresses oxygen for home use indications and limitations of coverage, overnight oximetry studies, conditions in which home oxygen therapy is not covered, portable oxygen system, emergency or standby oxygen, home oxygen for COPD, home oxygen use to treat cluster headaches (CH), and oxygen services provided by an airline.
Last Published 02.15.2021
This policy addresses pain management, inpatient and outpatient pain rehabilitation programs, and related services. Applicable Procedure Codes: 20526, 20550, 20551, 20552, 20553, 20612, 27096, 28899, 62263, 62264, 62287, 62320, 62321, 62322, 62323, 62324, 62325, 62326, 62327, 64405, 64479, 64480, 64483, 64484, 64490, 64491, 64492, 64493, 64494, 64495, 64625, 64633, 64634, 64635, 64636, 64722, 64744, G0260.
Last Published 04.01.2020
This policy addresses percutaneous transluminal angioplasty (PTA) for the treatment of atherosclerotic obstructive lesions, concurrent with carotid stent placement, and concurrent with intracranial stent placement.
Last Published 03.01.2020
This policy addresses physician/practitioner services. Applicable Procedure Codes: 99291, 99292, 99341, 99342, 99343, 99344, 99345, 99346, 99347, 99348, 99349, 99350.
Last Published 02.01.2021
This policy addresses positron emission tomography (PET) procedures.
Last Published 05.01.2020
This policy addresses Medicare covered preventive services and screening, kidney disease education (KDE), routine physical examination, vaccines and immunizations for international travel, imaging for screening asymptomatic persons, counseling for vitamin D supplementation, and cytological examination of breast fluids. Applicable Procedure Code: 77063.
Last Published 12.15.2020
This policy addresses prostate cancer screening, cryosurgery of prostate, temporary prostatic stent, fluid jet system for treatment of benign prostatic hyperplasia (BPH), and prostate rectal spacers placement. Applicable Procedure Codes: 0421T, 53855, 55874.
Last Published 02.01.2021
This policy addresses diagnostic radiological services (inpatient and outpatient).
Last Published 02.01.2021
This policy addresses percutaneous transluminal coronary interventions (interventional cardiology), proton beam therapy (PBT), intensity modulated radiation therapy (IMRT), stereotactic radiosurgery/stereotactic body radiation therapy (SBRT), local hyperthermia, computer-assisted surgical navigation for musculoskeletal procedures, tumor treatment field therapy (TTFT), and magnetic resonance image guided high intensity focused ultrasound (MRgFUS). Applicable Procedure Codes: 0398T, 20985, A4555, E0766.
Last Published 07.01.2020
This policy addresses cardiac rehabilitation exercise programs, intensive cardiac rehabilitation, cardiac rehabilitation services for patients with congestive heart failure, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD).
Last Published 11.01.2020
This policy addresses outpatient rehabilitation therapy (physical and occupational therapy and speech-language pathology services), inpatient rehabilitation services, cognitive therapy, melodic intonation therapy, passive rehabilitation therapy for mandibular hypomobility, comprehensive computer-based motion analysis, supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD), and rehabilitation services for vision impairment. Applicable Procedure Codes: 93668, 96000, 96001, 96002, 96003, 96004, 97024, 97035.
Last Published 10.01.2020
This policy addresses treatment of kidney stones, therapeutic embolization, and face-to-face kidney disease education (KDE). Applicable Procedure Codes: G0420, G0421.
Last Published 11.01.2020
This policy addresses pulmonary rehabilitation, postural drainage and pulmonary exercises, high frequency chest wall oscillation (HFCWO) devices, nebulized beta adrenergic agonist therapy, exhaled breath condensate (EBC) pH, heat treatment, and bronchial thermoplasty. Applicable Procedure Code: 83987.
Last Published 07.01.2020
This policy addresses second and third physician opinions.
Last Published 12.01.2020
This policy addresses services provided in a correctional facility or prisons.
Last Published 10.01.2020
This policy addresses shoes and foot orthotics, including orthopedic shoe, prosthetic shoe, and therapeutic shoe.
Last Published 11.01.2020
This policy addresses skilled nursing facility (SNF) care and exhaustion of SNF benefits.
Last Published 12.15.2020
This policy addresses treatment of psoriasis, hemorheograph services, destruction of actinic keratoses, skin substitutes, infrared therapy services, intravenous immunoglobulin (IVIG), debridement services, and treatment of decubitus ulcers.
Last Published 02.01.2021
This policy addresses diagnosis and treatment of obstructive sleep apnea (OSA). Applicable Procedure Codes: 0466T, 0467T, 0468T, 41530, 64568, 64569, 64570, 95800, 95801, 95806, G0398, G0399, G0400.
Last Published 03.01.2020
This policy addresses speech generating devices.
Last Published 02.01.2021
This policy addresses lumbar spinal fusion, cervical spinal fusion, thermal intradiscal procedures, interspinous process decompression, arthrodesis, spinal stabilization, percutaneous decompression procedures, percutaneous vertebroplasty and vertebral augmentation, stereotactic computer assisted volumetric and/or navigational procedures, percutaneous minimally invasive fusion, and interlaminar lumbar instrumented fusion. Applicable Procedure Codes: 0200T, 0201T, 0202T, 0219T, 0220T, 0221T, 0222T, 22510, 22511, 22512, 22513, 22514, 22515, 22586, 27279, 22842, 22843, 22844, 22849, 22867, 22868, 22869, 22870, 62287.
Last Published 12.01.2020
This policy addresses neuromuscular electrical stimulator (NMES), spinal cord stimulators, implanted peripheral nerve stimulators, transcutaneous electrical nerve stimulator (TENS), phrenic nerve stimulators, electrical stimulation for the treatment of motor function disorders and dysphagia, electrotherapy for the treatment of facial nerve paralysis (Bell's palsy), percutaneous electrical nerve stimulation (PENS), and pecutaneous neuromodulation therapy (PNT). Applicable Procedure Codes: 63650, L8680.
Last Published 10.01.2020
This policy addresses electrical osteogenic stimulator and ultrasonic osteogenic stimulator. Applicable Procedure Codes: E0747, E0748, E0749, E0760.
Last Published 11.01.2020
This policy addresses telemedicine/telehealth services.
Last Published 08.01.2020
This policy addresses thermogenic therapy.
Last Published 11.01.2020
This policy addresses transcatheter aortic valve replacement (TAVR), transcatheter mitral valve repair, transcatheter pulmonary valve replacement, and percutaneous left atrial appendage (LAA) closure therapy. Applicable Procedure Codes: 33340, 33477.
Last Published 04.01.2020
This policy addresses transmyocardial revascularization (TMR) and partial ventriculectomy.
Last Published 02.01.2021
This policy addresses heart and heart lung transplants, kidney, kidney-pancreas, pancreas transplants, adult liver transplants, pediatric liver transplants, intestinal and multi-visceral transplantation, stem cell transplantation and bone marrow transplantation, islet cell transplantation in the context of a clinical trial, immunosuppressive drugs, and transplant-related services.
Last Published 08.01.2020
This policy addresses transvenous (catheter) pulmonary embolectomy.
Last Published 12.15.2020
This policy addresses diagnostic pap smear, Gravlee Jet Washer, Vabra aspirator, therapeutic embolization, uterine artery embolization, magnetic resonance imaging (MRI)-guided focused ultrasound ablation, hysterectomy for benign conditions, and use of intrauterine devices (IUD) for treatment of endometrial hyperplasia. Applicable Procedure Codes: 0071T, 0072T, 37243, 58999.
Last Published 02.15.2021
This policy addresses treatment of varicose veins in lower extremities, including ligation and excision (stripping), endovenous radiofrequency ablation or endovenous laser ablation, compression and microfoam sclerotherapy, endomechanical ablation of incompetent extremity veins, and embolization of the ovarian and iliac veins for pelvic congestion syndrome. Applicable Procedure Codes: 36470, 36471, 36473, 36474, 36475, 36476, 36478, 36479, 36482, 36483, 37241, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785, 37799.
Last Published 02.01.2021
This policy addresses ventricular assist devices, artificial hearts, and device replacements.
Last Published 04.01.2020
This policy addresses partial ventriculectomy, also known as ventricular reduction, ventricular remodeling, or heart volume reduction surgery.
Last Published 11.01.2020
This policy addresses vertebral artery surgery to relieve obstructions to vertebral artery blood flow.
Last Published 07.01.2020
This policy addresses services involving Veteran Administration (VA) eligible members and/or Veteran Administration (VA) facilities and services provided by Indian Health Services (IHS).
Last Published 02.01.2021
This policy addresses vision services, including examinations, testing, surgical procedures, therapy, and rehabilitation. Applicable Procedure Codes: 0100T, 0308T, 0378T, 0379T, 76514, 92025, 92065, 92132, 92133, 92134, 92145, 92227, 92228, 92250, C1840.
Last Published 10.01.2020
This policy addresses wound and ulcer treatments, including skin substitutes, electrical stimulation (ES) or electromagnetic therapy, hyperbaric oxygen, negative pressure wound therapy (NPWT), wound care suction device (non-electric powered, disposable), wound care suction pump therapy, blood-derived products for chronic non-healing wound, noncontact normothermic wound therapy, and infrared therapy devices.
For questions, please contact your local Network Management representative or call the Provider Services number on the back of the member’s health ID card.