The Medical Policies, Medical Benefit Drug Policies, Coverage Determination Guidelines, Utilization Review Guidelines and corresponding update bulletins for UnitedHealthcare Community Plan of Louisiana are listed below.
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A monthly notice of recently approved and/or revised Medical Policies, Medical Benefit Drug Policies, Coverage Determination Guidelines (CDGs), and Utilization Review Guidelines (URGs) 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 10.01.2023
This bulletin provides complete details on recently approved, revised, and/or retired UnitedHealthcare Community Plan of Louisiana Medical Policies, Medical Benefit Drug Policies, Coverage Determination Guidelines (CDG), and/or Utilization Review Guidelines (URG).
Last Published 11.01.2023
This bulletin provides complete details on recently approved, revised, and/or retired UnitedHealthcare Community Plan of Louisiana Medical Policies, Medical Benefit Drug Policies, Coverage Determination Guidelines (CDG), and/or Utilization Review Guidelines (URG).
Last Published 12.01.2023
This bulletin provides complete details on recently approved, revised, and/or retired UnitedHealthcare Community Plan of Louisiana Medical Policies, Medical Benefit Drug Policies, Coverage Determination Guidelines (CDG), and/or Utilization Review Guidelines (URG).
Last Published 12.01.2023
A listing of the Medical Policy Update Bulletins for the past two rolling years.
Please read the terms and conditions below carefully.
UnitedHealthcare has developed Medical Policies, Medical Benefit Drug Policies, Coverage Determination Guidelines, and Utilization Review Guidelines to assist us in administering health benefits. These policies and guidelines 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.
Coverage Determination Guidelines are used to determine whether a service falls within a benefit category or is excluded from coverage. Coverage Determination Guidelines may address such matters as whether services are skilled versus custodial, or reconstructive versus cosmetic.
Utilization Review Guidelines apply clinical practice guidelines to determine whether the health care services provided or planned for an individual member are the most appropriate and cost-effective services under the specific circumstances.
Benefit coverage for health services is determined by the member specific benefit plan document, such as a Certificate of Coverage, Schedule of Benefits, or Summary Plan Description, and applicable laws that may require coverage for a specific service. The member specific benefit plan document identifies which services are covered, which are excluded, and which are subject to limitations. In the event of a conflict, the member specific benefit plan document supersedes these policies and guidelines.
Medical Policies, Medical Benefit Drug Policies, Coverage Determination Guidelines, and Utilization Review Guidelines are developed as needed, are regularly reviewed and updated, and are subject to change. They represent a portion of the resources used to support UnitedHealthcare coverage decision making. The information presented in these policies and guidelines 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. The InterQual® criteria 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, Medical Benefit Drug Policies, Coverage Determination Guidelines, and Utilization Review Guidelines 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 03.01.2023
Effective Date: 03.01.2023 – This policy addresses the use of levonorgestrel-releasing intrauterine devices (LNG-IUD), uterine artery embolization (UAE), magnetic resonance-guided focused ultrasound ablation (MRgFUS), and ultrasound-guided radiofrequency ablation. Applicable Procedure Codes: 0071T, 0072T, 0404T, 37243, 58578, 58674, 58999, J7296, J7297, J7298, J7301, J7306, S4981.
Last Published 04.01.2023
Effective Date: 04.01.2023 – This policy addresses airway clearance devices, such as high-frequency chest wall oscillation systems, acoustical or mechanical percussor, positive expiratory pressure and aerosol drug delivery system combination device, and intrapulmonary percussive ventilation (IPV) devices. Applicable Procedure Codes: A7025, A7026, E0481, E0483.
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 04.01.2023
Effective Date: 04.01.2023 – This policy addresses emergency ambulance (ground, water, or air) and non-emergency ambulance (ground or air) services.
Last Published 05.01.2023
Effective Date: 05.01.2023 – This policy addresses the use of Amondys 45™ (casimersen) for the treatment of Duchenne muscular dystrophy (DMD). Applicable Procedure Code: J1426.
Last Published 03.01.2023
Effective Date: 03.01.2023 – This policy addresses apheresis/therapeutic apheresis. Applicable Procedure Codes: 0342T, 36511, 36512, 36513, 36514, 36516, 36522, S2120.
Last Published 06.01.2023
Effective Date: 06.01.2023 – This policy addresses autologous chondrocyte transplantation (ACT), osteochondral autograft and allograft transplantation, and microfracture repair of the knee. Applicable Procedure Codes: 0737T, 27412, 27415, 27416, 28446, 29866, 29867, 29879, J7330, S2112.
Last Published 09.01.2023
Effective Date: 09.01.2023 – This policy addresses surgical repair for treating athletic pubalgia. Applicable Procedure Codes: 49659, 49999.
Last Published 07.01.2023
Effective Date: 07.01.2023 – This policy addresses augmentative and alternative communication (AAC) devices. Applicable Procedure Codes: E2500, E2502, E2504, E2506, E2508, E2510, E2512, E2599.
Last Published 01.01.2023
Effective Date: 01.01.2023 – This policy addresses autologous cellular therapy. Applicable Procedures Codes: 0263T, 0264T, 0265T, 0489T, 0490T, 0565T, 0566T, 0717T, 0718T, 27599.
Last Published 04.01.2023
Effective Date: 04.01.2023 – This policy addresses bariatric surgical procedures, including gastric bypass, gastric banding, sleeve gastrectomy, biliopancreatic bypass, and biliopancreatic diversion with duodenal switch.
Last Published 11.01.2022
Effective Date: 11.01.2022 – This policy addresses hospital beds, mattresses, and accessories.
Last Published 10.01.2023
Effective Date: 10.01.2023 – 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.
Last Published 12.01.2023
Effective Date: 12.01.2023 – This policy addresses breast imaging, including digital mammography, magnetic resonance imaging (MRI), ultrasound, automated breast ultrasound system, computer-aided detection (CAD), computer-aided tactile breast imaging, electrical impedance scanning (EIS), magnetic resonance elastography (MRE), and molecular breast imaging.
Last Published 01.01.2023
Effective Date: 01.01.2023 – This policy addresses breast reconstruction post-mastectomy. Applicable Procedure Codes: 11920, 11921, 11922, 11970, 11971, 15271, 15272, 15777, 19316, 19330, 19340, 19342, 19350, 19355, 19357, 19361, 19364, 19367, 19368, 19369, 19370, 19371, 19380, 19396, 19499, L8600, S2066, S2067, S2068, S8950.
Last Published 08.01.2023
Effective Date: 08.01.2023 – This policy addresses breast reduction surgeries. Applicable Procedure Code: 19316, 19318.
Last Published 08.01.2023
Effective Date: 08.01.2023 – This policy addreses the use of Brineura® (cerliponase alfa) in pediatric patients with late infantile neuronal ceroid lipofuscinosis (LINCL). Applicable Procedure Code: J0567.
Last Published 09.01.2023
Effective Date: 09.01.2023 – This policy addresses upper and lower eyelid blepharoplasty, upper eyelid blepharoptosis repair, brow ptosis, eyelid surgery with an anophthalmic socket, ectropion or punctal eversion, entropion, lid retraction surgery, canthoplasty/canthopexy, and repair of floppy eyelid syndrome (FES).
Last Published 09.01.2023
Effective Date: 09.01.2023 – This policy addresses cardiac event monitoring, including ambulatory event monitoring, outpatient cardiac telemetry, and implantable loop recorder. Applicable Procedure Codes: 0650T, 33285, 33286, 93224, 93225, 93226, 93227, 93228, 93229, 93241, 93242, 93243, 93244, 93245, 93246, 93247, 93248, 93268, 93270, 93271, 93272, 93285, 93291, 93298, E0616, G2066.
Last Published 10.01.2023
Effective Date: 10.01.2023 – This policy addresses arterial compliance testing using waveform analysis, carotid intima-media thickness (CIMT) measurement, advanced lipoprotein analysis, endothelial function assessment, and tests for lipoprotein-associated phospholipase A2 (Lp-PLA2) enzyme, other human A2 phospholipases, and long-chain omega-3 fatty acids. Applicable Procedure Codes: 0052U, 0308U, 0309U, 0377U, 82172, 83695, 83698, 83701, 83704, 84999, 93050, 93799, 93895, 93998.
Last Published 11.01.2023
Effective Date: 11.01.2023 – This policy addresses the Ashkenazi Jewish carrier screening and expanded carrier screening panel testing. Applicable Procedure Codes: 0400U, 81412, 81443, 81479.
Last Published 06.01.2023
Effective Date: 06.01.2023 – This policy addresses catheter ablation for atrial fibrillation. Applicable Procedure Codes: 93653, 93655, 93656, 93657.
Last Published 10.01.2023
Effective Date: 10.01.2023 – This policy addresses DNA-based noninvasive prenatal tests. Applicable Procedure Codes: 0060U, 0327U, 81420, 81422, 81479, 81507.
Last Published 10.01.2023
Effective Date: 10.01.2023 – This policy addresses chelation therapy. Applicable Procedure Codes: J0470, J0600, J0895, J3490, J3520, J8499, M0300, S9355.
Last Published 10.01.2023
Effective Date: 10.01.2023 – This policy addresses chemotherapy observation or overnight (inpatient) stay.
Last Published 01.01.2023
Effective Date: 01.01.2023 – This policy addresses clinical trials. Applicable Procedure Codes: G0276, G0293, G0294, G2000, S9988, S9990, S9991, S9992, S9994, S9996.
Last Published 09.01.2023
Effective Date: 09.01.2023 – This policy addresses non-hybrid and hybrid cochlear implantation. Applicable Procedure Codes: 69930, L8614, L8615, L8616, L8617, L8618, L8619, L8627, L8628, V5273.
Last Published 03.01.2023
Effective Date: 03.01.2023 – This policy addresses cognitive rehabilitation and coma stimulation. Applicable Procedure Codes: 97129, 97130, S9056.
Last Published 06.01.2023
Effective Date: 06.01.2023 – This policy addresses serum or urine collagen crosslinks or biochemical markers. Applicable Procedure Code: 82523.
Last Published 02.01.2023
Effective Date: 02.01.2023 – This policy addresses the use of Soliris® (eculizumab) and Ultomiris® (ravulizumab-cwvz). Applicable Procedure Codes: J1300, J1303.
Last Published 05.01.2023
Effective Date: 05.01.2023 – This policy addresses computed tomographic colonography. Applicable Procedure Codes: 74261, 74262, 74263.
Last Published 05.01.2023
Effective Date: 05.01.2023 – This policy addresses computer-assisted surgical navigation for musculoskeletal procedures and the use of intra-operative kinetic balance sensor for implant stability during knee replacement arthroplasty. Applicable Procedure Codes: 0054T, 0055T, 20985.
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 04.01.2023
Effective Date: 04.01.2023 – This policy addresses core decompression for avascular necrosis. Applicable Procedure Codes: 21299, 23929, 27299, 27599, 27899, S2325.
Last Published 09.01.2023
Effective Date: 09.01.2023 – This policy addresses corneal collagen cross-linking (C-CXL) for the treatment of progressive keratoconus and corneal ectasia. Applicable Procedure Codes: 0402T, J2787.
Last Published 12.01.2023
Effective Date: 12.01.2023 – This policy addresses cosmetic and reconstructive procedures.
Last Published 10.01.2023
Effective Date: 10.01.2023 – 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 11.01.2023
Effective Date: 11.01.2023 – This policy addresses breast ductal lavage, breast ductal fluid aspiration and cytology, and fiberoptic ductoscopy with or without ductal lavage. Applicable Procedure Code: 19499.
Last Published 06.01.2023
Effective Date: 06.01.2023 – This policy addresses deep brain and responsive cortical stimulation. Applicable Procedure Codes: 61850, 61860, 61863, 61864, 61867, 61868, 61885, 61886, 64999, L8679, L8680, L8682, L8685, L8686, L8687, L8688.
Last Published 10.01.2023
Effective Date: 10.01.2023 – This policy addresses the use of denosumab (Prolia® & Xgeva®). Applicable Procedure Code: J0897.
Last Published 07.01.2023
Effective Date: 07.01.2023 – 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 08.01.2023
Effective Date: 08.01.2023 – This policy addresses durable medical equipment (DME), orthotics, medical supplies, and repairs/replacements.
Last Published 07.01.2023
Effective Date: 07.01.2023 – This policy addresses planned elective inpatient admission for certain surgeries or procedures.
Last Published 03.01.2023
Effective Date: 03.01.2023 – This policy addresses the use of devices to generate electric tumor treatment fields (TTF). Applicable Procedure Codes: 77299, A4555, E0766.
Last Published 03.01.2023
Effective Date: 03.01.2023 – This policy addresses electrical and ultrasonic bone growth stimulators. Applicable Procedure Codes: 20974, 20975, 20979, E0747, E0748, E0749, E0760.
Last Published 09.01.2023
Effective Date: 09.01.2023 – This policy addresses electrical bioimpedance for cardiac output measurement. Applicable Procedure Code: 93701.
Last Published 07.01.2023
Effective Date: 07.01.2023 – This policy addresses electrical stimulation and electromagnetic therapy for ulcers or wounds. Applicable Procedure Codes: E0769, G0281, G0282, G0295, G0329.
Last Published 06.01.2023
Effective Date: 06.01.2023 – This policy addresses electrical stimulation for the treatment of pain and muscle rehabilitation. Applicable Procedure Codes: 0278T, 0720T, 0783T, 64555, A4556, A4557, A4558, A4595, A4630, E0720, E0730, E0731, E0744, E0745, E0762, E0764, E0770, E1399, K1023, L8678, L8679, L8680, L8682, L8685, L8686, L8687, L8688, S8130, S8131.
Last Published 07.01.2023
Effective Date: 07.01.2023 – This policy addresses embolization of the ovarian or internal iliac veins. Applicable Procedure Code: 37241.
Last Published 04.01.2023
Effective Date: 04.01.2023 – This policy addresses the use of Enjaymo™ (sutimlimab-jome) for the treatment of cold agglutinin disease (CAD). Applicable Procedure Code: J1302.
Last Published 10.01.2023
Effective Date: 10.01.2023 – This policy addresses oral and enteral nutrition. Applicable Procedure Codes: B4100, B4102, B4103, B4104, B4149, B4150, B4152, B4153, B4154, B4155, B4157, B4158, B4159, B4160, B4161, B4162, S9432, S9433, S9434, S9435.
Last Published 09.20.2023
Effective Date: 09.20.2023 – This policy addresses epidural steroid injections. Applicable Procedure Codes: 62320, 62321, 62322, 62323, 64479, 64480, 64483, 64484.
Last Published 01.01.2023
Effective Date: 01.01.2023 – 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 10.01.2023
Effective Date: 10.01.2023 – This policy addresses the use of Evenity® (romosozumab-aqqg) for the treatment of osteoporosis in postmenopausal patients at high risk for fracture. Applicable Procedures Code: J3111.
Last Published 12.01.2023
Effective Date: 12.01.2023 – This policy addresses extracorporeal shock wave therapy (ESWT) for musculoskeletal and soft tissue conditions. Applicable Procedure Codes: 0101T, 0102T, 0512T, 0513T, 28890.
Last Published 12.01.2023
Effective Date: 12.01.2023 – This policy addresses facet joint injections/medial branch blocks for spinal pain. Applicable Procedure Codes: 0213T, 0214T, 0215T, 0216T, 0217T, 0218T, 64490, 64491, 64492, 64493, 64494, 64495.
Last Published 10.01.2023
Effective Date: 10.01.2023 – This policy addresses fecal measurement of calprotectin. Applicable Procedure Code: 83993.
Last Published 09.01.2023
Effective Date: 09.01.2023 – This policy addresses fecal microbiota transplantation (FMT) via enema for prevention of the recurrence of clostridioides difficile infection (CDI). Applicable Procedure Codes: 0780T, 44705, G0455.
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 10.01.2023
Effective Date: 10.01.2023 – This policy addresses gastric electrical stimulation therapy; manometry, sensation, tone, and compliance testing; defecography; and electrogastrography/electroenterography. Applicable Procedure Codes: A9286, A9900, A9999, E1399, 0779T, 43647, 43648, 43881, 43882, 64590, 64595, 72195, 72196, 72197, 76496, 91117, 91120, 91122, 91132, 91133.
Last Published 11.01.2023
Effective Date: 11.01.2023 – This policy addresses gender dysphoria treatment, including surgical treatment and certain ancillary procedures.
Last Published 07.01.2023
Effective Date: 07.01.2023 – This policy addresses genetic testing for cardiac disease. Applicable Procedure Codes: 0237U, 0401U, 81410, 81411, 81413, 81414, 81439, 81479, 81493.
Last Published 04.01.2023
Effective Date: 04.01.2023 – This policy addresses hereditary breast and ovarian cancer (BRCA1, BRCA2) testing and multi-gene hereditary cancer panel testing.
Last Published 10.01.2023
Effective Date: 10.01.2023 – This policy addresses glaucoma drainage devices/stents, canaloplasty, and gonioscopy-assisted transluminal trabeculotomy. Applicable Procedure Codes: 0253T, 0449T, 0450T, 0474T, 0671T, 65820, 66174, 66175, 66179, 66180, 66183, 66989, 66991, C1889, L8612.
Last Published 09.01.2023
Effective Date: 09.01.2023 – This policy addresses mastectomy or suction lipectomy for the treatment of benign gynecomastia. Applicable Procedure Code: 19300.
Last Published 06.01.2023
Effective Date: 06.01.2023 – This policy addresses wearable air conduction, bone-anchored, semi-implantable hearing aids (SEHA), intraoral bone conduction, and laser or light based hearing aids, and totally implanted middle ear hearing systems.
Last Published 10.01.2023
Effective Date: 10.01.2023 – This policy addresses hepatitis screening. Applicable Procedure Codes: 86704, 86705, 86706, 86707, 86708, 86709, 86803, 86804, 87340, 87341, 87350, 87467, 87902, 87912, G0472, G0499.
Last Published 04.01.2023
Effective Date: 04.01.2023 – This policy addresses home health care services.
Last Published 06.01.2023
Effective Date: 06.01.2023 – This policy addresses home traction therapy. Applicable Procedure Codes: E0830, E0840, E0849, E0850, E0855, E0856, E0860, E0941.
Last Published 01.01.2023
Effective Date: 01.01.2023 – This policy addresses hospital services for observation versus inpatient level of care.
Last Published 06.01.2023
Effective Date: 06.01.2023 – This policy addresses hysterectomy. Applicable Procedure Codes: 58150, 58152, 58180, 58260, 58262, 58263, 58267, 58270, 58275, 58290, 58291, 58292, 58294, 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573.
Last Published 12.01.2023
Effective Date: 12.01.2023 – 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 11.01.2023
Effective Date: 11.01.2023 – This policy addresses transarterial radioembolization (TARE) using yttrium-90 (90Y) microspheres for the treatment of malignant tumors. Applicable Procedure Codes: 37243, 79445, S2095.
Last Published 06.01.2023
Effective Date: 06.01.2023 – This policy addresses implanted electrical stimulator for spinal cord. Applicable Procedure Codes: 63650, 63655, 63685, 63688, C1767, C1778, C1816, C1820, C1822, C1823, C1883, C1897, L8679, L8680, L8682, L8685, L8686, L8687, L8688, L8695.
Last Published 06.01.2023
Effective Date: 06.01.2023 – This policy addresses the use of intensity-modulated radiation therapy (IMRT). Applicable Procedure Codes: 77301, 77338, 77385, 77386, 77387, 77520, 77522, 77523, 77525, G6015, G6016, G6017.
Last Published 07.01.2023
Effective Date: 07.01.2022 – This policy addresses surgical treatment for spine pain.
Last Published 09.01.2023
Effective Date: 09.01.2023 – This policy addresses measurement of corneal hysteresis, measurement of ocular blood flow, and monitoring of intraocular pressure. Applicable Procedure Codes: 0198T, 0329T, 66999, 67299.
Last Published 02.01.2023
Effective Date: 02.01.2023 – This policy addresses intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC). Applicable Procedure Code: 96549.
Last Published 10.01.2023
Effective Date: 10.01.2023 – This policy addresses intrauterine fetal surgery. Applicable Procedure Codes: 59072, 59074, 59076, 59897, S2400, S2401, S2402, S2403, S2404, S2405, S2409, S2411.
Last Published 10.01.2023
Effective Date: 10.01.2023 – 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 12.01.2023
Effective Date: 12.01.2023 – This policy addresses the use of intravenous iron replacement therapy with Feraheme® (ferumoxytol), Injectafer® (ferric carboxymaltose), and Monoferric® (ferric derisomaltose) for the treatment of iron deficiency anemia (IDA) with and without chronic kidney disease (CKD). Applicable Procedure Codes: J1437, J1439, Q0138.
Last Published 08.01.2023
Effective Date: 08.01.2023 – This policy addresses the use of specialty pharmacy medications administered by the intravitreal route for certain ophthalmologic conditions. Applicable Procedure Codes: J7311, J7312, J7313, J7314.
Last Published 07.01.2023
Effective Date: 07.01.2023 – 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 11.01.2022
Effective Date: 11.01.2022 – This policy addresses the use of Krystexxa® (pegloticase) for treatment of chronic gout refractory to conventional therapy. Applicable Procedure Code: J2507.
Last Published 05.01.2023
Effective Date: 05.01.2023 – This policy addresses closure (occlusion) of the left atrial appendage (LAA). Applicable Procedure Codes: 33267, 33268, 33269, 33340, 33999.
Last Published 03.01.2023
Effective Date: 03.01.2023 – 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 07.01.2023
Effective Date: 07.01.2023 – This policy addresses liposuction for lipedema when used to treat functional impairment. Applicable Procedure Codes: 15877, 15878, 15879.
Last Published 03.01.2023
Effective Date: 03.01.2023 – This policy addresses extracorporeal shock wave lithotripsy (ESWL) and endoscopic intracorporeal laser lithotripsy for treating salivary stones. Applicable Procedure Code: 42699.
Last Published 08.01.2023
Effective Date: 08.01.2023 – This policy addresses lower extremity prosthetics.
Last Published 12.01.2022
Effective Date: 12.01.2022 – This policy addresses the use of Luxturna® (voretigene neparvovec-rzyl) for the treatment of inherited retinal dystrophies (IRD) caused by mutations in the retinal pigment epithelium-specific protein 65kDa (RPE65) gene. Applicable Procedure Code: J3398.
Last Published 11.01.2023
Effective Date: 11.01.2023 – This policy addresses implantable miniature telescope (IMT), conjunctival incision with posterior extrascleral placement of a pharmacologic agent, epiretinal radiation therapy, and laser photocoagulation. Applicable Procedure Codes: 0308T, 67036, 67299, 92499.
Last Published 07.01.2023
Effective Date: 07.01.2023 – This policy addresses manipulation under anesthesia (MUA). Applicable Procedure Codes: 21073, 22505, 23700, 25259, 26340, 27198, 27275, 27570, 27860, D7830.
Last Published 10.01.2023
Effective Date: 10.01.2023 – This policy addresses manipulative therapy. Applicable Procedure Codes: 98925, 98926, 98927, 98928, 98929, 98940, 98941, 98942, 98943, S8990.
Last Published 09.01.2023
Effective Date: 09.01.2023 – This policy addresses the maximum dosage per administration and dosing frequency for certain medications administered by a medical professional.
Last Published 06.01.2023
Effective Date: 06.01.2023 – 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, E1802, E1805, E1806, E1810, E1811, E1812, E1815, E1816, E1818, E1825, E1830, E1831, E1840, E1841.
Last Published 12.01.2023
Effective Date: 12.01.2023 – This policy addresses drug products used as medical therapies for enzyme deficiency. Applicable Procedure Codes: C9399, J0180, J0218, J0219, J0221, J1322, J1458, J1743, J1931, J2840, J3397, J3490, J3590.
Last Published 01.01.2023
Effective Date: 01.01.2023 – This policy addresses meniscus allograft transplantation with human cadaver tissue and collagen meniscus implants. Applicable Procedure Codes: 29868, G0428.
Last Published 03.01.2023
Effective Date: 03.01.2023 – This policy addresses minimally invasive endoscopic procedures and devices for treating gastroesophageal reflux disease (GERD). Applicable Procedure Codes: 43210, 43257, 43284, 43289, 43497, 43499, 43999.
Last Published 07.01.2023
Effective Date: 07.01.2023 – This policy addresses surgical treatment for spine pain.
Last Published 10.01.2023
Effective Date: 10.01.2023 – This policy addresses molecular oncology testing for cancer indications, including breast cancer, thyroid cancer, hematological cancer, and lung cancer.
Last Published 10.01.2023
Effective Date: 10.01.2023 – This policy addresses motorized spinal traction devices. Applicable Procedure Code: S9090.
Last Published 10.01.2023
Effective Date: 10.01.2023 – This policy addresses negative pressure wound therapy. Applicable Procedure Codes: 97605, 97606, 97607, 97608, A6550, A9272, E2402.
Last Published 03.01.2023
Effective Date: 03.01.2023 – This policy addresses autologous (sural) and allogenic nerve grafts to restore erectile function during or after radical prostatectomy. Applicable Procedure Codes: 55899, 64999.
Last Published 06.01.2023
Effective Date: 06.01.2023 – This policy addresses nerve conduction studies and other neurophysiological testing. Applicable Procedure Codes: 0106T, 0107T, 0108T, 0109T, 0110T, 0464T, 0533T, 0534T, 0535T, 0536T, 0778T, 0788T, 95860, 95861, 95863, 95864, 95865, 95866, 95867, 95868, 95869, 95870, 95872, 95873, 95874, 95885, 95886, 95887, 95905, 95907, 95908, 95909, 95910, 95911, 95912, 95913, 95937, 95999, 96002, 96003, 96004, A9279, A9280, G0255, S3900.
Last Published 02.01.2023
Effective Date: 02.01.2023 – This policy addresses neuropsychological testing and computerized cognitive testing under the medical benefit. Applicable Procedure Codes: 96116, 96121, 96132, 96133, 96136, 96137, 96138, 96139, 96146.
Last Published 11.01.2023
Effective Date: 11.01.2023 – This policy addresses warming therapy, noncontact normothermic wound therapy, and low frequency ultrasound for treating wounds. Applicable Procedure Codes: 0598T, 0599T, 97610, A6000, E0231, E0232.
Last Published 10.01.2023
Effective Date: 10.01.2023 – This policy addresses nonsurgical and surgical treatment of obstructive sleep apnea (OSA). Applicable Procedure Codes: 0424T, 0425T, 0426T, 0427T, 0428T, 0429T, 0430T, 0431T, 0432T, 0433T, 0434T, 0435T, 0436T, 21142, 21199, 21206, 21685, 41512, 41530, 41599, 42145, 42299, 64553, 64568, 64569, 64570, 64582, 64583, 64584, A7049, E0485, E0486, E1399, K1001, K1027, K1028, K1029, L8679, L8680, L8686, S2080, S2900.
Last Published 10.01.2023
Effective Date: 10.01.2023 – 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, 64633, 64634, 64722, 64744, 64771, 64999, K1023, L8679, L8680, L8685.
Last Published 07.01.2023
Effective Date: 07.01.2023 – This policy addresses off-label and unproven indications of FDA-approved injectable specialty drugs.
Last Published 10.01.2023
Effective Date: 10.01.2023 – This policy addresses multiple services/procedures.
Last Published 04.01.2023
Effective Date: 04.01.2023 – This policy addresses parameters for coverage of injectable oncology medications. Applicable Procedure Codes: A9513, A9590, A9606, A9607, A9699, J0640, J0641, J0642, J9035, J9198, J9199, J9201, J9310, J9311, J9312, J9355, J9356, Q5107, Q5112, Q5113, Q5114, Q5115, Q5116, Q5117, Q5118, Q5119, Q5123, Q5126, Q5129.
Last Published 06.01.2023
Effective Date: 06.01.2023 – This policy addresses oral and enteral nutrition. Applicable Procedure Codes: B4100, B4102, B4103, B4104, B4149, B4150, B4152, B4153, B4154, B4155, B4157, B4158, B4159, B4160, B4161, B4162, B9002, S9432, S9433, S9434, S9435.
Last Published 09.01.2023
Effective Date: 09.01.2023 – This policy addresses orthognathic (jaw) surgery.
Last Published 12.01.2023
Effective Date: 12.01.2023 – This policy addresses the use of Oxlumo® (lumasiran) for the treatment of primary hyperoxaluria type 1 (PH1). Applicable Procedures Code: J0224.
Last Published 10.01.2023
Effective Date: 10.01.2023 – This policy addresses panniculectomy, abdominoplasty, lipectomy, repair of diastasis recti, and suction-assisted lipectomy. Applicable Procedure Codes: 15830, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15847, 15876, 15877, 15878, 15879.
Last Published 04.01.2023
Effective Date: 04.01.2023 – This policy addresses the use of Parsabiv® (etelcalcetide) for the treatment of secondary hyperparathyroidism with chronic kidney disease. Applicable Procedure Code: J0606.
Last Published 10.01.2023
Effective Date: 10.01.2023 – This policy addresses patient lifts. Applicable Procedure Codes: E0621, E0630, E0635, E0636, E0639, E0640, E1035, E1036.
Last Published 10.01.2023
Effective Date: 10.01.2023 – This policy addresses surgical repair of pectus excavatum and pectus carinatum. Applicable Procedure Codes: 21740, 21742, 21743.
Last Published 10.01.2023
Effective Date: 10.01.2023 – This policy addresses pediatric gait trainers and standing systems. Applicable Procedure Codes: E0637, E0638, E0641, E0642, E8000, E8001, E8002.
Last Published 06.01.2023
Effective Date: 06.01.2023 – This policy addresses percutaneous patent foramen ovale closure for the prevention of recurrent ischemic stroke. Applicable Procedure Code: 93580.
Last Published 10.01.2023
Effective Date: 05.01.2023 – This policy addresses percutaneous vertebroplasty and kyphoplasty for treating spinal pain. Applicable Procedure Codes: 22510, 22511, 22512, 22513, 22514, 22515.
Last Published 10.01.2023
Effective Date: 10.01.2023 – This policy addresses pharmacogenetic multi-gene panel testing. Applicable Procedure Codes: 0029U, 0078U, 0173U, 0175U, 0286U, 0290U, 0291U, 0292U, 0293U, 0345U, 0347U, 0348U, 0349U, 0350U, 0380U, 0392U, 0411U, 0419U, 81479.
Last Published 05.01.2023
Effective Date: 05.01.2023 – This policy addresses the use of cranial orthotic devices for treating infants following craniosynostosis surgery or for nonsynostotic (nonfusion) deformational or positional plagiocephaly. Applicable Procedure Codes: D5924, L0112, L0113, S1040.
Last Published 10.01.2023
Effective Date: 10.01.2023 – This policy addresses pneumatic compression devices. Applicable Procedure Codes: A4600, E0650, E0651, E0652, E0655, E0660, E0665, E0666, E0667, E0668, E0669, E0670, E0671, E0672, E0673, E0675, E0676.
Last Published 04.01.2023
Effective Date: 04.01.2023 – This policy addresses prolotherapy and platelet rich plasma. Applicable Procedure Codes: 0232T, G0460, G0465, M0076, P9020.
Last Published 09.01.2023
Effective Date: 09.01.2023 – This policy addresses prostrate 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, 0655T, 0738T, 0739T, 37243, 52441, 52442, 53850, 53852, 53854, 53855, 55866, 55873, 55874.
Last Published 06.01.2023
Effective Date: 06.01.2023 – This policy addresses proton beam radiation therapy. Applicable Procedure Codes: 77301, 77338, 77385, 77386, 77387, 77520, 77522, 77523, 77525, G6015, G6016, G6017.
Last Published 11.01.2023
Effective Date: 11.01.2023 – This policy addresses outpatient hospital facility-based intravenous medication infusion. Applicable Procedure Codes: 90283, 90284, J0129, J1426, J1427, J1428, J1429, J1459, J1551, J1554, J1555, J1556, J1557, J1558, J1559, J1561, J1566, J1568, J1569, J1572, J1575, J1576, J1599, J1602, J1745, J3245, J3262, J3380, J3590, Q5103, Q5104, Q5121.
Last Published 12.01.2023
Effective Date: 12.01.2023 – This policy addresses the use of Qalsody™ (tofersen) for the treatment of amyotrophic lateral sclerosis (ALS). Applicable Procedure Codes: C9157, J3490, J3590.
Last Published 06.01.2023
Effective Date: 06.01.2023 – This policy addresses radiation therapy fractionation, image-guided radiation therapy (IGRT), and special radiation therapy services. 77014, 77331, 77370, 77385, 77386, 77387, 77399, 77401, 77402, 77407, 77412, 77470, 77520, 77522, 77523, 77525, G6001, G6002, G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014, G6015, G6016, G6017.
Last Published 04.01.2023
Effective Date: 04.01.2023 – This policy addresses the use of Radicava® (edaravone) for the treatment of amyotrophic lateral sclerosis (ALS). Applicable Procedure Code: J1301.
Last Published 05.01.2023
Effective Date: 05.01.2023 – This policy addresses Reblozyl® (luspatercept-aamt) for the treatment of anemia in adult patients with beta thalassemia and symptomatic anemia in patients with myelodysplastic syndromes or myelodysplastic/myeloproliferative neoplasms. Applicable Procedure Code: J0896.
Last Published 12.01.2023
Effective Date: 12.01.2023 – 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 11.27.2023
Effective Date: 11.01.2023 – This policy addresses review of certain new to market medications that are healthcare provider administered. Applicable Procedure Codes: C9399, J3490, J3590.
Last Published 01.01.2023
Effective Date: 01.01.2023 – This policy addresses lysis intranasal synechia, repair of nasal vestibular stenosis or alar collapse, rhinoplasty, rhinophyma, septal dermatoplasty, and nasal polypectomy. Applicable Procedure Codes: 30117, 30120, 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, 30465, 30468, 30560, 30999, 31237, L8699.
Last Published 10.01.2023
Effective Date: 10.01.2023 – This policy addresses the use of Riabni® (rituximab-arrx), Rituxan® (rituximab), Ruxience® (rituximab-pvvr), and Truxima® (rituximab-abbs). Applicable Procedure Codes: J3590, J9311, J9312, J9999. Q5115, Q5119, Q5123.
Last Published 09.01.2023
Effective Date: 09.01.2023 – 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: J0222, J0225.
Last Published 03.03.2023
Effective Date: 03.01.2023 – This policy addresses Ryplazim® (plasminogen, human-tvmh) for the treatment of plasminogen deficiency type 1 (hypoplasminogenemia). Applicable Procedure Codes: J2998.
Last Published 06.01.2023
Effective Date: 06.01.2023 – This policy addresses sacral nerve stimulation for urinary and fecal indications. Applicable Procedure Codes: 64561, 64581, 64585, 64590, 64595, L8679, L8680, L8682, L8685, L8686, L8687, L8688.
Last Published 12.01.2023
Effective Date: 12.01.2023 – This policy addresses Scenesse® (afamelanotide) for the treatment of erythropoietic protoporphyria (EPP). Applicable Procedure Code: J7352.
Last Published 10.01.2023
Effective Date: 10.01.2023 – This policy addresses medications that are determined to be self-administered and excluded from medical coverage.
Last Published 06.01.2023
Effective Date: 03.09.2022 – This policy addresses sinus procedures. Applicable Procedure Codes: 31240, 31253. 31254, 31255, 31256, 31257, 31259, 31267, 31276, 31287, 31288, 31295, 31296, 31297, 31298, 31299.
Last Published 06.01.2021
Effective Date: 07.01.2019 – This policy addresses skilled care and custodial care services. Applicable Procedure Codes: 99509, S5100, S5101, S5102, S5105, S5120, S5121, S5125, S5126, S5130, S5131, S5135, S5136, S5140, S5141, S5150, S5151, S5170, S5175, S9125, T1005, T1019, T1020.
Last Published 12.01.2023
Effective Date: 12.01.2023 – This policy addresses skin and soft tissue substitutes.
Last Published 05.01.2023
Effective Date: 05.01.2023 – This policy addresses skin and soft tissue substitutes for the treatment of partial- and full-thickness diabetic lower extremity ulcers. Applicable Procedure Codes: Q4101, Q4106, Q4121, Q4154, Q4160, Q4186, Q4195, Q4196.
Last Published 06.01.2023
Effective Date: 06.01.2023 – This policy addresses intra-articular injections of sodium hyaluronate. Applicable Procedure Codes: 20605, 20606, 20610, 20611, J3490, J7318, J7320, J7321, J7322, J7323, J7324, J7325, J7326, J7327, J7328, J7329, J7331, J7332.
Last Published 10.01.2023
Effective Date: 10.01.2023 – This policy addresses the use of somatostatin analogs, including Sandostatin® (octreotide acetate), Sandostatin® LAR (octreotide acetate LAR), Signifor® (pasireotide diaspartate), Signifor® LAR (pasireotide), and Somatuline® Depot (lanreotide). Applicable Procedure Codes: J1930, J1932, J2353, J2354, J2502.
Last Published 06.01.2023
Effective Date: 06.01.2023 – This policy addresses the use of Spevigo® (spesolimab-sbzo) for the treatment of generalized pustular psoriasis (GPP). Applicable Procedure Code: J1747.
Last Published 12.01.2023
Effective Date: 12.01.2023 – This policy addresses spinal fusion and bone healing enhancement products. Applicable Procedure Codes: 20930, 20931, 20939, 22899.
Last Published 10.01.2023
Effective Date: 10.01.2023 – This policy addresses spinal fusion and decompression procedures, laminectomy, isolated facet fusion, dynamic stabilization systems, and total facet joint arthroplasty.
Last Published 06.01.2023
Effective Date: 06.01.2023 – This policy addresses stereotactic radiation therapy, including stereotactic radiosurgery (SRS) and stereotactic body radiation therapy (SBRT). Applicable Procedures Codes: 32701, 61796, 61797, 61798, 61799, 61800, 63620, 63621, 77301, 77371, 77372, 77373, 77432, 77435, G0339, G0340.
Last Published 01.01.2023
Effective Date: 01.01.2023 – This policy addresses the use of compounded implantable drug pellets. Applicable Procedure Codes: 11981, 11982, 11983, J3490, J7999.
Last Published 03.01.2023
Effective Date: 03.01.2023 – This policy addresses surgery of the elbow. Applicable Procedure Codes: 24360, 24361, 24362, 24363, 24365, 24366, 24370, 24371, 29830, 29834, 29835, 29836, 29837, 29838.
Last Published 03.01.2023
Effective Date: 03.01.2023 – This policy addresses surgery of the hip and femoroacetabular impingement (FAI) syndrome. Applicable Procedure Codes: 27120, 27125, 27130, 27132, 27134, 27137, 27138, 27299, 29860, 29861, 29862, 29863, 29914, 29915, 29916, 29999, S2118.
Last Published 03.01.2023
Effective Date: 03.01.2023 – This policy addresses surgery of the knee. Applicable Procedure Codes: 27437, 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447, 27486, 27487, 29870, 29871, 29873, 29874, 29875, 29876, 29877, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889.
Last Published 03.01.2023
Effective Date: 03.01.2023 – This policy addresses surgery of the shoulder. Applicable Procedure Codes: 23470, 23472, 23473, 23474, 29805, 29806, 29807, 29819, 29820, 29822, 29823, 29824, 29825, 29826, 29827, 29828, 29999.
Last Published 10.01.2023
Effective Date: 10.01.2023 – This policy addresses varicose vein ablative and stripping procedures and ligation procedures. Applicable Procedure Codes: 0744T, 36465, 36466, 36468, 36470, 36471, 36473, 36474, 36475, 36476, 36478, 36479, 36482, 36483, 37500, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785, 37799.
Last Published 04.01.2023
Effective Date: 04.01.2023 – 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 12.01.2023
Effective Date: 12.01.2023 – This policy addresses the use of Syfovre™ (pegcetacoplan injection) for the treatment of geographic atrophy (GA) secondary to age-related macular degeneration (AMD). Applicable Procedure Code: J2781.
Last Published 06.01.2023
Effective Date: 06.01.2023 – 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 10.01.2023
Effective Date: 10.01.2023 – This policy addresses the use of Tepezza® (teprotumumab-trbw) for the treatment of thyroid eye disease. Applicable Procedure Code: J3241.
Last Published 03.01.2023
Effective Date: 03.01.2023 – 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 08.01.2023
Effective Date: 08.01.2023 – This policy addresses thermography, including digital infrared thermal imaging, temperature gradient studies, and magnetic resonance (MR) thermography. Applicable Procedure Codes: 76498, 93740.
Last Published 06.01.2023
Effective Date: 06.01.2023 – This policy addresses cervical and lumbar artificial total disc replacement. Applicable Procedure Codes: 0098T, 0165T, 22856, 22857, 22858, 22860, 22861, 22862, 22899.
Last Published 03.01.2023
Effective Date: 03.01.2023 – This policy addresses the SynCardia™ temporary Total Artificial Heart. Applicable Procedure Codes: 33927, 33928, 33975, 33976, 33979, 33981, 33982, 33983, 33995, 33997.
Last Published 09.20.2023
Effective Date: 09.01.2023 – This policy addresses transanal endoscopic microsurgery for the excision of small tumors localized to the rectum. Applicable Procedure Code: 0184T.
Last Published 07.01.2023
Effective Date: 07.01.2023 – This policy addresses transcatheter heart valve (aortic, pulmonary, mitral) procedures. Applicable Procedure Codes: 0345T, 0483T, 0484T, 0543T, 0544T, 0545T, 0569T, 0570T, 0646T, 33361, 33362, 33363, 33364, 33365, 33366, 33367, 33368, 33369, 33418, 33419, 33477, 33999, 93799.
Last Published 06.01.2023
Effective Date: 06.01.2023 – This policy addresses transcranial magnetic stimulation and navigated transcranial magnetic stimulation (nTMS). Applicable Procedure Codes: 64999, 90867, 90868, 90869.
Last Published 08.01.2023
Effective Date: 08.01.2023 – This policy addresses transpupillary thermotherapy. Applicable Procedure Codes: 67299, 92499.
Last Published 03.01.2023
Effective Date: 03.01.2023 – This policy addresses unicondylar spacer devices for treating knee joint pain or disability from any cause. Applicable Procedure Code: 27599.
Last Published 08.01.2023
Effective Date: 08.01.2023 – 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 06.01.2023
Effective Date: 06.01.2023 – This policy addresses implantable vagus nerve stimulators and transcutaneous (non-implantable) vagus and trigeminal nerve stimulators. Applicable Procedure Codes: 61885, 61886, 64553, 64568, 64570, E0770, E1399, K1016, K1017, K1020, L8679, L8680, L8682, L8683, L8685, L8686, L8687, L8688.
Last Published 05.01.2023
Effective Date: 05.01.2023 – This policy addresses vertebral body tethering for the treatment of scoliosis. Applicable Procedure Codes: 0656T, 0657T, 22899.
Last Published 03.01.2023
Effective Date: 03.01.2023 – This policy addresses virtual upper gastrointestinal endoscopy. Applicable Procedure Codes: 76497, 76498.
Last Published 05.01.2023
Effective Date: 05.01.2023 – This policy addresses occlusion therapy, pharmacologic penalization therapy, orthoptic or vision therapy, prism adaptation therapy, visual perception therapy, vision restoration therapy, and the use of visual information processing evaluations to diagnose reading or learning disabilities. Applicable Procedure Codes: 0687T, 0688T, 0704T, 0705T, 0706T, 92065, 92499.
Last Published 03.01.2023
Effective Date: 03.01.2023 – This policy addresses the use of Vyvgart™ (efgartigimod alfa-fcab) for the treatment of myasthenia gravis. Applicable Procedure Code: J9332.
Last Published 07.01.2023
Effective Date: 07.01.2023 – This policy addresses walkers. Applicable Procedure Codes: E0130, E0135, E0140, E0141, E0143, E0144, E0147, E0148, E0149, E1054, E1055, E0156, E1057, E0158, E0159.
Last Published 07.01.2023
Effective Date: 07.01.2023 – This policy addresses whole exome and whole genome sequencing. Applicable Procedure Codes: 0036U, 0094U, 0212U, 0213U, 0214U, 0215U, 0265U, 0335U, 0336U, 81415, 81416, 81417, 81425, 81426, 81427.
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 08.01.2023
Effective Date: 08.01.2023 – This policy addresses the use of Zolgensma® (onasemnogene abeparvovec-xioi) for the treatment of spinal muscular atrophy (SMA). Applicable Procedure Code: J3399.
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