The Medical Policies, Medical Benefit Drug Policies, and corresponding update bulletins for UnitedHealthcare Community Plan of Indiana are listed below.
A monthly notice of recently approved and/or revised Medical Policies and Medical Benefit Drug Policies 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 Medical Policy 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 Medical Policy Update Bulletin and the posted policy, the provisions of the posted policy will prevail.
Last Published 08.01.2024
This bulletin provides complete details on recently approved, revised, and/or retired UnitedHealthcare Community Plan of Indiana Medical Policies and/or Medical Benefit Drug Policies.
Last Published 09.01.2024
This bulletin provides complete details on recently approved, revised, and/or retired UnitedHealthcare Community Plan of Indiana Medical Policies and/or Medical Benefit Drug Policies.
Last Published 10.01.2024
This bulletin provides complete details on recently approved, revised, and/or retired UnitedHealthcare Community Plan of Indiana Medical Policies and/or Medical Benefit Drug Policies.
Last Published 10.01.2024
A listing of the Medical Policy Update Bulletins.
Please read the terms and conditions below carefully.
UnitedHealthcare has developed Medical Policies and Medical Benefit Drug Policies to assist us in administering health benefits. These policies are provided for informational purposes and do not constitute medical advice. Treating physicians and health care providers are solely responsible for determining what care to provide to their patients. Members should always consult their physician before making any decisions about medical care.
Our Medical Policies and Medical Benefit Drug Policies express our determination of whether a health service (e.g., test, device, or procedure) is proven to be effective based on the published clinical evidence. They are also used to decide whether a given health service is medically necessary. Services determined to be experimental, investigational, unproven, or not medically necessary by the clinical evidence are typically not covered.
Benefit coverage for health services is determined by the specific benefit plan. When deciding coverage, the federal, state, or contractual requirements for benefit plan coverage must be referenced. In the event of a conflict, the federal, state, or contractual requirements for benefit plan coverage supersede these policies.
Medical Policies and Medical Benefit Drug Policies are developed as needed, regularly reviewed and updated, and subject to change. They represent a portion of the resources used to support UnitedHealthcare coverage decision making. The information presented in these policies is believed to be accurate and current as of the date of publication and is provided on an "AS IS" basis. Additionally, UnitedHealthcare may use tools developed by third parties, such as the InterQual® criteria, to assist us in administering health benefits. UnitedHealthcare Medical Policies and Medical Benefit Drug Policies are intended to be used in connection with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice.
Medical Policies and Medical Benefit Drug Policies are the property of UnitedHealthcare. Unauthorized copying, use, and distribution of this information are strictly prohibited. The InterQual® criteria are proprietary to Change Healthcare and are not published on this website.
When these policies are used to determine medical necessity, clinical guidelines will be applied in the following order:
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Last Published 08.01.2024
Effective Date: 08.01.2024 – This policy addresses intraosseous radiofrequency ablation, ablation for treating sacroiliac pain, and other facet joint nerve ablation procedures for spinal pain. Applicable Procedure Codes: 22899, 27299, 64625, 64628, 64629, 64999.
Last Published 07.01.2024
Effective Date: 07.01.2024 – This policy addresses the use of Adzynma (ADAMTS13, recombinant-krhn) for the treatment of congenital thrombotic thrombocytopenic purpura (cTTP). Applicable Procedure Code: J7171.
Last Published 11.01.2023
Effective Date: 11.01.2023 – This policy addresses alpha1-proteinase inhibitors (Aralast NP™, Glassia™, Prolastin®-C, and Zemaira®) for chronic augmentation and maintenance therapy of emphysema due to congenital deficiency of alpha1-proteinase inhibitor (A1-PI)/alpha1-antitrypsin (AAT) deficiency. Applicable Procedure Codes: J0256, J0257.
Last Published 11.01.2023
Effective Date: 11.01.2023 – This policy addresses the use of Benlysta® (belimumab) injection for intravenous infusion for the treatment of systemic lupus erythematosus (SLE) and active lupus nephritis (LN). Applicable Procedure Code: J0490.
Last Published 04.01.2024
Effective Date: 04.01.2024 – This policy addresses the use of botulinum toxin types A and B, including Dysport® (abobotulinumtoxinA), Xeomin® (incobotulinumtoxinA), Botox® (onabotulinumtoxinA), and Myobloc® (rimabotulinumtoxinB). Applicable Procedure Codes: J0585, J0586, J0587, J0588, J0589.
Last Published 10.01.2024
Effective Date: 10.01.2024 – This policy addresses breast reconstruction post-mastectomy and for the treatment of Poland syndrome, removal of breast implants, and breast repair and reconstruction not post mastectomy. Applicable Procedure Codes: 11920, 11921, 11922, 11970, 11971, 15271, 15272, 15771, 15772, 15777, 19316, 19325, 19328, 19330, 19340, 19342, 19350, 19355, 19357, 19361, 19364, 19367, 19368, 19369, 19370, 19371, 19380, 19396, 19499, L8600, S2066, S2067, S2068, S8950.
Last Published 08.01.2024
Effective Date: 08.01.2024 – This policy addresses the use of Brineura® (cerliponase alfa) in pediatric patients with late infantile neuronal ceroid lipofuscinosis (LINCL). Applicable Procedure Code: J0567.
Last Published 12.01.2023
Effective Date: 12.01.2023 – This policy addresses brow ptosis, browpexy or internal browlift, eyelid surgery for correction of lagophthalmos, lid retraction surgery, and canthoplasty/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 04.01.2024
Effective Date: 04.01.2024 – This policy addresses the use of buprenorphine (Probuphine®) for the treatment of opioid dependence/opioid use disorder. Applicable Procedure Codes: J0577, J0578.
Last Published 07.01.2024
Effective Date: 07.01.2024 – This policy addresses chelation therapy. Applicable Procedure Codes: J0470, J0600, J0895, J3490, J3520, J8499, M0300, S9355.
Last Published 07.01.2024
Effective Date: 07.01.2024 – This policy addresses chemotherapy observation or overnight (inpatient) stay.
Last Published 07.01.2024
Effective Date: 07.01.2024 – This policy addresses the use of Soliris® (eculizumab) and Ultomiris® (ravulizumab-cwvz). Applicable Procedure Codes: J1300, J1303.
Last Published 08.01.2023
Effective Date: 08.01.2023 – This policy addresses insulin delivery and continuous glucose monitoring for diabetes management. Applicable Procedure Codes: 0446T, 0447T, 0448T, 95249, 95250, 95251, A4211, A4226, A4238, A4239, A9274, A9276, A9277, A9278, E0784, E0787, E1399, E2102, E2103, S1030, S1031, S1034, S1035, S1036, S1037.
Last Published 01.01.2024
Effective Date: 01.01.2024 – This policy addresses core decompression for avascular necrosis. Applicable Procedure Codes: 21299, 23929, 27299, 27599, 27899, S2325.
Last Published 06.01.2024
Effective Date: 06.01.2024 – This policy addresses the use of Crysvita®(burosumab-twza) for the treatment of X-linked hypophosphatemia (XLH) and Fibroblast Growth Factor 23 (FGF23)-related hypophosphatemia in tumor-induced osteomalacia (TIO). Applicable Procedure Code: J0584.
Last Published 04.01.2024
Effective Date 04.01.2024 – This policy addresses deep brain and responsive cortical stimulation. Applicable Procedure Codes: 61850, 61860, 61863, 61864, 61867, 61868, 61885, 61886, 61889, 61891, 64999, L8679, L8680, L8682, L8685, L8686, L8687, L8688.
Last Published 08.01.2024
Effective Date: 08.01.2024 – This policy addresses thermal intradiscal procedures (TIPs) and percutaneous discectomy and decompression procedures for treating discogenic pain, and annulus fibrosus repair following spinal surgery. Applicable Procedure Codes: 0627T, 0628T, 0629T, 0630T, 22526, 22527, 22899, S2348.
Last Published 08.01.2024
Effective Date: 08.01.2024 – This policy addresses durable medical equipment (DME), orthotics, ostomy supplies, medical supplies and repairs/replacements.
Last Published 03.01.2024
Effective Date: 03.01.2024 – This policy addresses planned elective inpatient admission for certain surgeries or procedures.
Last Published 03.01.2024
Effective Date: 03.01.2024 – This policy addresses the use of devices to generate electric tumor treatment fields (TTF). Applicable Procedure Codes: 77299, A4555, E0766.
Last Published 10.01.2024
Effective Date: 10.01.2024 – This policy addresses functional electrical stimulation (FES) and neuromuscular electrical stimulation (NMES). Applicable Procedure Codes: 0278T, 0720T, 63650, 63655, 63663, 63664, 63685, 64555, 64999, A4556, A4543, A4544, A4557, A4595, E0720, E0721, E0730, E0731, E0743, E0744, E0745, E0764, E0770, E1399, L8679, L8680, L8682, L8685, L8686, L8687, L8688, S8130, S8131.
Last Published 08.01.2024
Effective Date: 08.01.2024 – This policy addresses electrical stimulation and electromagnetic therapy for wounds. Applicable Procedure Codes: G0281, G0282.
Last Published 08.01.2024
Effective Date: 08.01.2024 – This policy addresses electrical stimulation and electromagnetic therapy for wounds. Applicable Procedure Codes: E0769, G0295, G0329.
Last Published 05.01.2024
Effective Date: 05.01.2024 – This policy addresses the use of Enjaym® (sutimlimab-jome) for the treatment of cold agglutinin disease (CAD). Applicable Procedure Code: J1302.
Last Published 01.01.2024
Effective Date: 01.01.2024 – This policy addresses the use of erythropoiesis-stimulating agents (ESAs), including Aranesp® (darbepoetin alfa), Epogen® (epoetin alfa), Mircera® (methoxy polyethylene glycol-epoetin beta [MPG-epoetin beta]), Procrit® (epoetin alfa), and Retacrit™ (epoetin alfa). Applicable Procedure Codes: J0881, J0882, J0885, J0887, J0888, Q4081, Q5105, Q5106.
Last Published 12.01.2023
Effective Date: 12.01.2023 – This policy addresses the use of Gamifant® (emapalumab-lzsg) for the treatment of primary and secondary hemophagocytic lymphohistiocytosis (HLH). Applicable Procedure Code: J9210.
Last Published 09.01.2024
Effective Date: 09.01.2024 – This policy addresses gastric electrical stimulation therapy; manometry, sensation, tone, and compliance testing; defecography; and electrogastrography/electroenterography. Applicable Procedure Codes: 0779T, 0868T, 43647, 43648, 43881, 43882, 64590, 64595, 72195, 72196, 72197, 74270, 76496, 91117, 91120, 91122, 91132, 91133, A9286, A9900, A9999, E1399.
Last Published 06.01.2024
Effective Date: 06.01.2024 – This policy addresses gender dysphoria treatment, including surgical treatment and certain ancillary procedures.
Last Published 05.01.2024
Effective Date: 05.01.2024 – This policy addresses the use of Givlaari® (givosiran) for the treatment of acute hepatic porphyrias. Applicable Procedure Code: J0223.
Last Published 11.01.2023
Effective Date: 11.01.2023 – This policy addresses gonadotropin releasing hormone analog (GnRH analog) drug products. Applicable Procedure Codes: J1950, J1951, J1952, J1954, J3315, J3316, J9155, J9202, J9217, J9225, J9226.
Last Published 08.01.2024
Effective Date: 08.01.2024 – This policy addresses wearable, bone-anchored, and semi-implantable hearing aids and devices.
Last Published 11.01.2023
Effective Date: 11.01.2023 – This policy addresses the use of C1 esterace inhibitors (human), C1 esterace inhibitors (recombinant), and plasma kallikrein inhibitors (human) for the treatment and prophlaxis of hereditary angioedema (HAE). Applicable Procedure Codes: J0596, J0597, J0598, J1290.
Last Published 12.01.2023
Effective Date: 12.01.2023 – This policy addresses hospital services for observation versus inpatient level of care.
Last Published 11.01.2023
Effective Date: 11.01.2023 – This policy addresses the use of Ilaris®. Applicable Procedure Code: J0638.
Last Published 07.01.2024
Effective Date: 07.01.2024 – This policy addresses the use of intravenous (IV) and subcutaneous (SC) immune globulin (IG) products. Applicable Procedure Codes: 90283, 90284, J1459, J1551, J1554, J1555, J1556, J1557, J1558, J1559, J1561, J1566, J1568, J1569, J1572, J1575, J1576, J1599.
Last Published 07.01.2023
Effective Date: 07.01.2023 – This policy addresses immunomodulator agents for inflammatory conditions. Applicable Procedure Codes: C9399, 96372, 96401, J0129, J0717, J1602, J2327, J3245, J3262, J3357, J3358, J3380. J3490, J3590.
Last Published 10.01.2024
Effective Date: 04.01.2024 – This policy addresses interspinous bony fusion devices and decompression systems. Applicable Procedure Codes: 22853, 22854, 22859, 22867, 22868, 22869, 22870, 22899, C1821.
Last Published 08.01.2024
Effective Date: 08.01.2024 – This policy addresses the use of specialty pharmacy medications administered by the intravitreal route for certain ophthalmologic conditions. Applicable Procedure Codes: J1096, J7311, J7312, J7313, J7314.
Last Published 09.01.2024
Effective Date: 09.01.2024 – This policy addresses intrauterine fetal surgery (IUFS) and fetoscopic endoluminal tracheal occlusion (FETO) . Applicable Procedure Codes: 59072, 59074, 59076, 59897, S2400, S2401, S2402, S2403, S2404, S2405, S2409, S2411.
Last Published 06.01.2024
Effective Date: 06.01.2024 – This policy addresses the use of intravenous enzyme replacement drug products for the treatment of Gaucher disease, including Cerezyme® (imiglucerase), Elelyso® (taliglucerase), and VPRIV® (velaglucerase). Applicable Procedure Codes: J1786, J3060, J3385.
Last Published 02.01.2024
Effective Date: 02.01.2024 – This policy addresses the use of Feraheme® (ferumoxytol), Injectafer® (ferric carboxymaltose), and Monoferric® (ferric derisomaltose) for intravenous iron replacement therapy. Applicable Procedure Codes: J1437, J1439, Q0138, Q0139.
Last Published 07.01.2024
Effective Date: 07.01.2024 – This policy addresses the use of Korsuva (difelikefalin) for the treatment of moderate-to-severe pruritus associated with chronic kidney disease in adults undergoing hemodialysis. Applicable Procedure Code: J0879.
Last Published 04.01.2024
Effective Date: 04.01.2024 – This policy addresses light and laser therapy, including light phototherapy, photodynamic therapy, intense pulsed light, pulsed dye laser, and laser hair removal. Applicable Procedure Codes: 17106, 17107, 17108, 17380.
Last Published 07.01.2024
Effective Date: 07.01.2024 – This policy addresses the use of Apretude (cabotegravir) to reduce the risk of sexually acquired HIV-1 infection and Cabenuva (cabotegravir/rilpivirine) for the treatment of a human immunodeficiency virus type-1 (HIV-1) in patients who are virologically suppressed. Applicable Procedure Codes: J0739, J0741, J1961.
Last Published 08.01.2024
Effective Date: 08.01.2024 – This policy addresses the maximum dosage per administration and dosing frequency for certain medications administered by a medical professional.
Last Published 12.01.2023
Effective Date: 12.01.2023 – This policy addresses the use of low-load prolonged-duration stretch devices, static progressive (SP) stretch splint devices, and patient actuated serial stretch (PASS) devices. Applicable Procedure Codes: E1399, E1800, E1801, E1806, E1810, E1811, E1812, E1815, E1816, E1818, E1830, E1831, E1841.
Last Published 08.01.2024
Effective Date: 08.01.2024 – This policy addresses drug products used as medical therapies for enzyme deficiency. Applicable Procedure Codes: J0180, J0218, J0219, J0217, J0221, J1203, J1322, J1458, J1743, J1931, J2508, J2840, J3397, J3490, J3590.
Last Published 10.01.2024
Effective Date: 08.01.2024 – This policy addresses minimally invasive spine surgery procedures. Applicable Procedure Codes: 0200T, 0201T, 0275T, 22586, 22630, 22899, 62287, 62380, G0276.
Last Published 10.01.2024
Effective Date: 10.01.2024 – This policy addresses the use of Rystiggo®, Vyvgart®, & Vyvgart® Hytrulo for the treatment of myasthenia gravis. Applicable Procedure Codes: J9332, J3490, J3590.
Last Published 04.01.2024
Effective Date: 04.01.2024 – This policy addresses nerve conduction studies and other neurophysiological testing.
Last Published 07.01.2024
Effective Date: 07.01.2024 – This policy addresses the use of Nplate® (romiplostim) for the treatment of chronic immune thrombocytopenic purpura (ITP). Applicable Procedure Code: J2796.
Last Published 05.01.2024
Effective Date: 03.01.2024 – This policy addresses nonsurgical and surgical treatment of obstructive sleep apnea (OSA). Applicable Procedure Codes: 21142, 21199, 21206, 21685, 33276, 33277, 33278, 33279, 33280, 33281, 33287, 33288, 41512, 41530, 41599, 42140, 42145, 42299, 64570, 64582, 64583, 64584, 93150, 93151, 93513, EE0485, E0486, E0492, E0493, E0530, E1399, K1027, L8679, L8680, L8686, S2080, S2900.
Last Published 10.01.2024
Effective Date: 10.01.2024 – This policy addresses occipital neuralgia and headache treatments, including occipital nerve blocks and occipital nerve ablation. Applicable Procedure Codes: 63185, 63190, 64405, 64553, 64555, 64568, 64570, 64575, 64590, 64596, 64597, 64598, 64633, 64634, 64722, 64744, 64771, 64999, A4540, L8679, L8680, L8685.
Last Published 07.01.2024
Effective Date: 07.01.2024 – This policy addresses off-label and unproven indications of FDA-approved specialty drugs.
Last Published 08.01.2024
Effective Date: 07.01.2024 – This policy addresses multiple services/procedures.
Last Published 08.01.2024
Effective Date: 08.01.2024 – This policy addresses parameters for coverage of injectable oncology medications. Applicable Procedure Codes: J0640, J0641, J0642, J9198, J9199, J9201.
Last Published 04.01.2024
Effective Date: 04.01.2024 – This policy addresses the use of Izervay™ (avacincaptad pegol) and Syfovre™ (pegcetacoplan injection) for the treatment of geographic atrophy (GA) secondary to age-related macular degeneration (AMD). Applicable Procedure Codes: J2781, J2782.
Last Published 10.01.2024
Effective Date: 10.01.2024 – This policy addresses the use of vascular endothelial growth factor (VEGF) inhibitors. Applicable Procedure Codes: J0177, J0178, J0179, J2777, J2778, J2779, J9035, Q5124, Q5128.
Last Published 07.01.2024
Effective Date: 07.01.2024 – This policy addresses the use of Oxlumo ® (lumasiran) and Rivfloza ™ (nedosiran) for the treatment of primary hyperoxaluria type 1 (PH1). Applicable Procedure Codes: J0224, J3490.
Last Published 04.01.2024
Effective Date: 04.01.2024 – This policy addresses the use of Parsabiv® (etelcalcetide) for the treatment of secondary hyperparathyroidism with chronic kidney disease. Applicable Procedure Code: J0606.
Last Published 10.01.2024
Effective Date: 10.01.2024 – This policy addresses prostate surgeries and interventions, including transurethral ablation, cryoablation, surgical prostatectomy, prostatic urethral lift (PUL), high-energy water vapor thermotherapy, and transperineal placement of biodegradable material. Applicable Procedure Codes: 0421T, 0582T, 0619T, 0655T, 0714T, 0738T, 0739T, 0867T, 37243, 52441, 52442, 53850, 53852, 53854, 53855, 55873, 55874.
Last Published 04.01.2024
Effective Date: 04.01.2024 – This policy addresses proton beam radiation therapy. Applicable Procedure Codes: G6015, G6016, G6017, 77301, 77338, 77385, 77386, 77387, 77520, 77522, 77523, 77525.
Last Published 09.01.2024
Effective Date: 09.01.2024 – This policy addresses the use of Qalsody® (tofersen) for the treatment of amyotrophic lateral sclerosis (ALS). Applicable Procedure Code: J1304.
Last Published 08.01.2024
Effective Date: 08.01.2024 – This policy addresses the use of Radicava® (edaravone) for the treatment of amyotrophic lateral sclerosis (ALS). Applicable Procedure Code: J1301.
Last Published 01.01.2024
Effective Date: 01.01.2024 – This policy addresses the use of Rebyota™ (fecal microbiota, live-jslm) for prevention of the recurrence of clostridioides difficile infection (CDI). Applicable Procedure Codes: G0455, J1440.
Last Published 04.01.2024
Effective Date: 04.01.2024 – This policy addresses the use of repository corticotropin injections (Acthar® Gel and Purified Cortophin Gel). Applicable Procedure Codes: J0801, J0802.
Last Published 10.01.2024
Effective Date: 07.01.2024 – This policy addresses review of certain new to market medications that are healthcare provider administered. Applicable Procedure Codes: C9399, J3490, J3590.
Last Published 07.01.2024
Effective Date: 07.01.2024 – This policy addresses rhinoplasty and other nasal surgeries. Applicable Procedure Codes: 30117, 30120, 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, 30465, 30468, 30469, 30999, 31237, 31242, 31243, 64999, L8699.
Last Published 06.01.2024
Effective Date: 06.01.2024 – This policy addresses the use of Riabni® (rituximab-arrx), Rituxan® (rituximab), Ruxience® (rituximab-pvvr), and Truxima® (rituximab-abbs). Applicable Procedure Codes: J3590, J9311, J9312, J999, Q5115, Q5119, Q5123.
Last Published 08.01.2024
Effective Date: 08.01.2024 – This policy addresses the use of Onpattro® (patisiran) and Amvuttra® (vutrisiran) for the treatment of polyneuropathy of hereditary transthyretin-mediated (hATTR) amyloidosis. Applicable Procedure Codes: C9399, J0222, J3490, J3590.
Last Published 04.01.2024
Effective Date: 04.01.2024 – This policy addresses the use of Ryplazim® (plasminogen, human-tvmh) for the treatment of plasminogen deficiency type 1 (hypoplasminogenemia). Applicable Procedure Code: J2998.
Last Published 07.01.2024
Effective Date: 07.01.2024 – This policy addresses the use of Saphnelo® (Anifrolumab-Fnia) for the treatment of moderate to severe systemic lupus erythematosus (SLE). Applicable Procedure Code: J0491.
Last Published 07.01.2024
Effective Date: 07.01.2024 – This policy addresses Scenesse® (afamelanotide) for the treatment of erythropoietic protoporphyria (EPP). Applicable Procedures Code: J7352.
Last Published 08.01.2024
Effective Date: 08.01.2024 – This policy addresses medications that are determined to be self-administered and excluded from medical coverage.
Last Published 06.01.2024
Effective Date: 06.01.2024 – This policy addresses the use of sodium hyaluronate products. Applicable Procedure Codes: 20605, 20606, 20610, 20611, J3490, J7318, J7320, J7321, J7322, J7323, J7324, J7325, J7326, J7327, J7328, J7329, J7331, J7332.
Last Published 10.01.2024
Effective Date: 06.01.2024 – This policy addresses surgical treatment for spine pain.
Last Published 01.01.2024
Effective Date: 01.01.2024 – This policy addresses the use of compounded implantable drug pellets. Applicable Procedure Codes: 11981, 11982, 11983, J3490, J7999.
Last Published 11.01.2023
Effective Date: 11.01.2023 – This policy addresses surgery of the shoulder. Applicable Procedure Codes: 23470, 23472, 23473, 23474, 29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827, 29828, 29999.
Last Published 08.01.2024
Effective Date: 08.01.2024 – This policy addresses varicose vein ablative and stripping procedures, ligation procedures, ambulatory phlebectomy, sclerotherapy, and endovascular embolization. Applicable Procedure Codes: 0744T, 36465, 36466, 36468, 36470, 36471, 36473, 36474, 36475, 36476, 36478, 36479, 36482, 36483, 37500, 37700, 37718, 37722, 37735, 37765, 37766, 37780, 37785, 37799.
Last Published 02.01.2024
Effective Date: 02.01.2024 – This policy addresses surgical procedures for the treatment or prevention of lymphedema. Applicable Procedure Codes: 15830, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15847, 15876, 15877, 15878, 15879, 38999, 49906.
Last Published 10.01.2024
Effective Date: 10.01.2024 – This policy addresses the use of Tepezza® (teprotumumab-trbw) for the treatment of thyroid eye disease. Applicable Procedure Code: J3241.
Last Published 07.01.2024
Effective Date: 07.01.2024 – This policy addresses the use of injectable testosterone and testosterone pellets for replacement therapy in conditions associated with a deficiency or absence of endogenous testosterone. Applicable Procedure Codes: 11980, J1071, J3121, J3145, S0189.
Last Published 05.01.2024
Effective Date: 05.01.2024 – This policy addresses transcatheter heart valve (aortic, mitral, pulmonary) procedures. Applicable Procedure Codes: 0345T, 0483T, 0484T, 0543T, 0544T, 0545T, 0569T, 0570T, 0646T, 0805T, 0806T, 33361, 33362, 33363, 33364, 33365, 33366, 33367, 33368, 33369, 33370, 33418, 33419, 33477, 33999, 93799.
Last Published 05.01.2024
Effective Date: 03.01.2024 – This policy addresses treatment of temporomandibular joint (TMJ) disorders. Applicable Procedure Codes: 20552, 20553, 20605, 20606, 21010, 21050, 21060, 21070, 21085, 21089, 21110, 21240, 21242, 21243, 21247, 21299, 21499, 29800, 29804, 90901, 97039, 97139, E0746, E1399, E1700, E1701, E1702.
Last Published 07.01.2024
Effective Date: 07.01.2024 – This policy addresses the use of Trogarzo® (ibalizumab-uiyk) for the treatment of multi-drug resistant human immunodeficiency virus (HIV). Applicable Procedure Code: J1746.
Last Published 09.01.2024
Effective Date: 09.01.2024 – This policy addresses collection and storage of umbilical cord blood. Applicable Procedure Codes: 38205, 38206, 38207, 88240, S2140.
Last Published 06.01.2024
Effective Date: 06.01.2024 – This policy addresses Uplizna® (inebilizumab-cdon) for the treatment of neuromyelitis optica spectrum disorder (NMOSD). Applicable Procedures Code: J1823.
Last Published 06.01.2024
Effective Date: 06.01.2024 – This policy addresses upper extremity myoelectric prosthetic devices. Applicable Procedure Codes: L6026, L6611, L6621, L6629, L6632, L6677, L6680, L6682, L6686, L6687, L6688, L6694, L6695, L6696, L6697, L6698, L6715, L6880, L6881, L6882, L6883, L6884, L6890, L6925, L6935, L6945, L6955, L6975, L7007, L7008, L7009, L7045, L7180, L7181, L7190, L7191, L7259, L7360, L7364, L7366, L7367, L7368, L7400, L7401, L7403, L7404, L8465.
Last Published 06.01.2024
Effective Date: 06.01.2024 – This policy addresses the use of Veopoz™ (pozelimab-bbfg) for the treatment of CD55-deficient protein-losing enteropathy (PLE) (i.e., CHAPLE disease). Applicable Procedure Codes: C9399, J3490, and J3590.
Last Published 04.01.2024
Effective Date: 04.01.2024 – This policy addresses vertebral body tethering for the treatment of scoliosis. Applicable Procedure Codes: 0656T, 0657T, 22836, 22837, 22899.
Last Published 11.01.2023
Effective Date: 11.01.2023 – This policy addresses virtual upper gastrointestinal endoscopy. Applicable Procedure Codes: 76497, 76498.
Last Published 07.01.2024
Effective Date: 07.01.2024 – This policy addresses the use of white blood cell colony stimulating factors (CSFs), including the drug products Fulphila, Granix, Leukine, Neulasta, Neupogen, Nivestym, Nyvepria, Releuko, Udenyca, Zarxio, and Ziextenzo. Applicable Procedure Codes: J1442, J1447, J1449, J2506, J2820, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122, Q5125, Q5127, Q5130.
Last Published 12.01.2023
Effective Date: 12.01.2023 – This policy addresses the use of Xiaflex® (collagenase clostridium histolyticum) for the treatment of Dupuytren’s contracture and Peyronie’s disease. Applicable Procedure Codes: 20527, 26341, J0775.
Last Published 06.01.2024
Effective Date: 06.01.2024 – This policy addresses the use of Xolair® (omalizumab). Applicable Procedure Code: J2357.
Last Published 11.01.2023
Effective Date: 11.01.2023 – This policy addresses the use of Zulresso® (brexanolone) for the treatment of postpartum depression (PPD) in adults. Applicable Procedure Code: J1632.