The Medical Management Guidelines and corresponding update bulletins for UnitedHealthcare West are listed below.
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A monthly notice of recently approved and/or revised Medical Management Guidelines (MMGs) 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 Management Guideline 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 Management Guideline Update Bulletin and the posted guideline, the provisions of the posted guideline will prevail.
Last Published 07.01.2021
This bulletin provides complete details on recently approved, revised, and/or retired UnitedHealthcare West Medical Management Guidelines.
Last Published 08.01.2021
This bulletin provides complete details on recently approved, revised, and/or retired UnitedHealthcare West Medical Management Guidelines.
Last Published 09.01.2021
This bulletin provides complete details on recently approved, revised, and/or retired UnitedHealthcare West Medical Management Guidelines.
Last Published 09.01.2021
UnitedHealthcare has developed Medical Management Guidelines to assist us in administering health benefits. These 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 Management Guidelines express our determination of whether a health service (e.g., test, drug, 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. The Medical Management Guidelines are also used to determine whether a service falls within a benefit category or is excluded from coverage. They may address such matters as whether services are skilled versus custodial, or reconstructive versus cosmetic.
Benefit coverage for health services is determined by the member specific benefit plan document, such as an Evidence of Coverage or Schedule of Benefits, 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 guidelines. The Medical Management Guidelines do not replace an individualized case-by-case review and medical necessity determination for each UnitedHealthcare® West member.
Medical Management 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 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 Management 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. Health Plan coverage is provided by or through UnitedHealthcare of California, UnitedHealthcare Benefits Plan of California, UnitedHealthcare of Oklahoma, Inc., UnitedHealthcare of Oregon, Inc., UnitedHealthcare Benefits of Texas, Inc., and UnitedHealthcare of Washington, Inc.
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Last Published 08.01.2021
Effective Date: 02.01.2021 – This policy addresses thermal radiofrequency ablation and other facet joint nerve ablation procedures for spinal pain. Applicable Procedure Codes: 22899, 27299, 64625, 64633, 64634, 64635, 64636, 64999.
Last Published 07.01.2021
Effective Date: 07.01.2021 – 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 07.01.2021
Effective Date: 07.01.2021 – 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, E1399.
Last Published 04.15.2021
Effective Date: 02.01.2021 – This policy addresses apheresis/therapeutic apheresis. Applicable Procedure Codes: 0342T, 36511, 36512, 36513, 36514, 36516, 36522, S2120.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses autologous chondrocyte transplantation (ACT), osteochondral autograft and allograft transplantation, microfracture repair of the knee, and focal articular cartilage repair. Applicable Procedure Codes: 27412, 27415, 27416, 28446, 29866, 29867, 29879, J7330, S2112.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses surgical repair for treating athletic pubalgia. Applicable Procedure Codes: 49659, 49999.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses home sleep apnea testing, attended full-channel nocturnal polysomnography performed in a healthcare facility or laboratory setting, daytime sleep studies, and attended PAP titration. Applicable Procedure Codes: 95782, 95783, 95800, 95801, 95803, 95805, 95806, 95807, 95808, 95810, 95811, G0398, G0399, G0400.
Last Published 04.18.2021
Effective Date: 10.01.2020 – This policy addresses autologous cellular therapy. Applicable Procedures Codes: 0263T, 0264T, 0265T, 0489T, 0490T, 0565T, 0566T, 27599.
Last Published 08.01.2021
Effective Date: 08.01.2021 – This policy addresses balloon sinus ostial dilation. Applicable Procedure Codes: 31295, 31296, 31297, 31298, 31299.
Last Published 04.15.2021
Effective Date: 12.01.2020 – This policy addresses bariatric surgical procedures, including gastric bypass, gastric banding, sleeve gastrectomy, biliopancreatic bypass, and biliopancreatic diversion with duodenal switch.
Last Published 04.15.2021
Effective Date: 04.01.2021 – 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 04.15.2021
Effective Date: 08.01.2020 – This policy addresses bone or soft tissue healing and fusion enhancement products/systems. Applicable Procedure Codes: 20930, 20931, 20932, 20933, 20934, 22558, 22585, 22899.
Last Published 04.15.2021
Effective Date: 10.01.2020 – 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. Applicable Procedure Codes: 0422T, 76376, 76377, 76391, 76498, 76499, 76641, 76642, 77046, 77047, 77048, 77049, 77065, 77066, 77067, S8080.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses breast reconstruction post-mastectomy and for treatment of Poland syndrome. Applicable Procedure Codes: 11920, 11921, 11922, 11970, 11971, 15271, 15272, 15771, 15772, 15777, 19301, 19302, 19303, 19305, 19306, 19307, 19316, 19318, 19325, 19330, 19340, 19342, 19350, 19355, 19357, 19361, 19364, 19367, 19368, 19369, 19380, 19396, 19499, L8600, S2066, S2067, S2068, S8950.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses breast reduction surgeries. Applicable Procedure Code: 19318.
Last Published 04.15.2021
Effective Date: 01.01.2021 – This policy addresses breast repair/reconstruction not following mastectomy. Applicable Procedure Codes: 19328, 19330, 19355, 19370, 19371, 19380.
Last Published 08.01.2021
Effective Date: 08.01.2021 – This policy addresses bronchial thermoplasty. Applicable Procedure Codes: 31660, 31661.
Last Published 07.01.2021
Effective Date: 07.01.2021 – 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 04.15.2021
Effective Date: 03.01.2021 – 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, 0423T, 82172, 83695, 83698, 83701, 83704, 93050, 93799, 93895, 93998.
Last Published 09.01.2021
Effective Date: 09.01.2021 – This policy addresses the Ashkenazi Jewish carrier screening and expanded carrier screening panel testing. Applicable Procedure Codes: 81412, 81443, 81479.
Last Published 09.01.2021
Effective Date: 09.01.2021 – This policy addresses catheter ablation for atrial fibrillation. Applicable Procedure Codes: 93653, 93655, 93656, 93657.
Last Published 08.01.2021
Effective Date: 08.01.2021 – This policy addresses DNA-based noninvasive prenatal tests. Applicable Procedure Codes: 0060U, 0168U, 81420, 81422, 81479, 81507.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses chelation therapy. Applicable Procedure Codes: J0470, J0600, J0895, J3490, J8499, M0300, S9355.
Last Published 04.15.2021
Effective Date: 11.01.2020 – This policy addresses chemosensitivity and chemoresistance assays in cancer. Applicable Procedure Codes: 0083U, 0564T, 81535, 81536, 86849, 89240.
Last Published 05.06.2021
Effective Date: 05.01.2021 – This policy addresses chemotherapy observation or inpatient stay.
Last Published 06.01.2021
Effective Date: 06.01.2021 – This policy addresses genome-wide comparative genomic hybridization microarray testing or single nucleotide polymorphism (SNP) chromosomal microarray analysis. Applicable Procedure Codes: 0156U, 0209U, 81228, 81229, 81479, S3870.
Last Published 09.01.2021
Effective Date: 09.01.2021 – This policy addresses the evidenced-based clinical guidelines from nationally recognized sources used to guide our quality and health management programs.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses clinical trials. Applicable Procedure Codes: G0276, G0293, G0294, G2000, S9988, S9990, S9991, S9992, S9994, S9996.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses non-hybrid and hybrid cochlear implantation. Applicable Procedure Codes: 69930, L8614, L8615, L8616, L8617, L8618, L8619, L8627, L8628, V5273.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses cognitive rehabilitation and coma stimulation. Applicable Procedure Codes: 97129, 97130, S9056.
Last Published 04.15.2021
Effective Date: 04.01.2021 – This policy addresses serum or urine collagen crosslinks or biochemical markers. Applicable Procedure Code: 82523.
Last Published 04.15.2021
Effective Date: 01.01.2021 – This policy addresses computed tomographic colonography. Applicable Procedure Codes: 74261, 74262, 74263.
Last Published 04.15.2021
Effective Date: 01.01.2021 – 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 Procedures Codes: 0054T, 0055T, 20985.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses computerized dynamic posturography (CDP) testing. Applicable Procedure Codes: 92548, 92549.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses insulin delivery and continuous glucose monitoring for diabetes management. Applicable Procedure Codes: 0446T, 0447T, 0448T, 95249, 95250, 95251, A4211, A4226, A9274, A9276, A9277, A9278, E0784, E0787, E1399, K0553, K0554, S1030, S1031, S1034, S1035, S1036, S1037.
Last Published 04.15.2021
Effective Date: 12.01.2020 – This policy addresses core decompression avascular necrosis . Applicable Procedure Codes: 21299, 23929, 27299, 27599, 27899, S2325.
Last Published 08.01.2021
Effective Date: 08.01.2021 – This policy addresses measurement of corneal hysteresis, measurement of ocular blood flow, and monitoring of intraocular pressure. Applicable Procedure Codes: 0198T, 0329T, 66999, 67299, 92145.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses cosmetic and reconstructive procedures.
Last Published 09.01.2021
Effective Date: 09.01.2021 – 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 07.01.2021
Effective Date: 07.01.2021 – This policy addresses conventional deep brain stimulation 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 04.15.2021
Effective Date: 12.01.2020 – 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: 22526, 22527, 22899, 62287, 62380, S2348.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses planned elective inpatient admission for certain surgeries or procedures.
Last Published 04.15.2021
Effective Date: 03.01.2021 – This policy addresses the use of devices to generate electric tumor treatment fields (TTF). Applicable Procedure Codes: 77299, A4555, E0766.
Last Published 04.15.2021
Effective Date: 01.01.2021 – This policy addresses electrical and ultrasonic bone growth stimulators. Applicable Procedure Codes: 20974, 20975, 20979, E0747, E0748, E0749, E0760.
Last Published 09.01.2021
Effective Date: 09.01.2021 – This policy addresses electrical bioimpedance for cardiac output measurement. Applicable Procedure Code: 93701.
Last Published 04.15.2021
Effective Date: 04.01.2021 – This policy addresses electrical stimulation and electromagnetic therapy for treating ulcers or wounds. Applicable Procedure Codes: E0769, G0281, G0282, G0295, G0329.
Last Published 08.01.2021
Effective Date: 08.01.2021 – This policy addresses electrical stimulation for the treatment of pain and muscle rehabilitation. Applicable Procedure Codes: 0278T, 63650, 63655, 63663, 63664, 63685, 64555, 64566, 64999, E0744, E0745, E0762, E0764, E0770, E1399, L8679, L8680, L8682, L8685, L8686, L8687, L8688, S8130, S8131.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses electroencephalographic (EEG) monitoring and video recording. Applicable Procedure Codes: 95700, 95711, 95712, 95713, 95714, 95715, 95716, 95718, 95720, 95722, 95724, 95726.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses embolization of the ovarian or internal iliac veins. Applicable Procedure Code: 37241.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses outpatient emergency health care services, physician-ordered emergency department visits, and urgent care center services.
Last Published 08.01.2021
Effective Date: 05.01.2021 – This policy addresses epidural steroid injections for spinal pain. Applicable Procedure Codes: 62320, 62321, 62322, 62323, 64479, 64480, 64483, 64484.
Last Published 04.15.2021
Effective Date: 02.01.2021 – This policy addresses functional anesthetic discography (FAD), provocative discograph,y epiduroscopy (including spinal myeloscopy), and percutaneous and endoscopic epidural lysis of adhesions for the diagnosis or treatment of any type of neck, back, or spinal disorder. Applicable Procedure Codes: 62263, 62264, 62290, 62290, 64999, 72285, 72295.
Last Published 08.01.2021
Effective Date: 08.01.2021 – This policy addresses extracorporeal shock wave therapy (ESWT) for musculoskeletal and soft tissue conditions. Applicable Procedure Codes: 0101T, 0102T, 0512T, 0513T, 28890.
Last Published 08.01.2021
Effective Date: 05.01.2021 – 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 06.01.2021
Effective Date: 06.01.2021 – This policy addresses fecal measurement of calprotectin. Applicable Procedure Code: 83993.
Last Published 04.15.2021
Effective Date: 02.01.2021 – This policy addresses functional endoscopic sinus surgery (FESS). Applicable Procedure Codes: 31240, 31253, 31254, 31255, 31256, 31257, 31259, 31267, 31276, 31287, 31288.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses gastric electrical stimulation therapy; manometry, sensation, tone, and compliance testing; defecography; and electrogastrography/electroenterography. Applicable Procedure Codes: 43647, 43648, 43881, 43882, 64590, 64595, 72195, 72196, 72197, 76496, 91117, 91120, 91122, 91132, 91133.
Last Published 04.15.2021
Effective Date: 03.01.2021 – This policy addresses multiplex polymerase chain reaction (PCR) panel testing of gastrointestinal pathogens. Applicable Procedure Codes: 0097U, 87505, 87506, 87507.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses gender dysphoria treatment, including surgical treatment and certain ancillary procedures.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses genetic testing for cardiac disease. Applicable Procedure Codes: 0237U, 81410, 81411, 81413, 81414, 81439, 81479, 81493.
Last Published 04.15.2021
Effective Date: 01.01.2021 – This policy addresses hereditary breast and ovarian cancer (BRCA1, BRCA2) testing and multi-gene hereditary cancer panel testing.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses multi-gene panel testing for the diagnosis of neuromuscular disorders. Applicable Procedure Codes: 0216U, 0217U, 81440, 81460, 81465, 81479.
Last Published 04.15.2021
Effective Date: 04.01.2021 – This policy addresses genitourinary pathogen nucleic acid detection panel testing to evaluate symptomatic women for vaginitis. Applicable Procedure Codes: 0068U, 87480, 81513, 81514, 87481, 87482, 87510, 87511, 87512, 87660, 87661, 87797, 87798, 87799, 87800, 87801.
Last Published 08.01.2021
Effective Date: 08.01.2021 – This policy addresses glaucoma drainage devices/stents, canaloplasty, and gonioscopy-assisted transluminal trabeculotomy. Applicable Procedure Codes: 0191T, 0253T, 0376T, 0449T, 0450T, 0474T, 65820, 66174, 66175, 66179, 66180, 66183, 66184, 66185, C1889, L8612.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses mastectomy or suction lipectomy for the treatment of benign gynecomastia. Applicable Procedure Code: 19300.
Last Published 08.01.2021
Effective Date: 08.01.2021 – 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 04.15.2021
Effective Date: 10.14.2020 – This policy addresses hepatitis screening. Applicable Procedure Codes: 86704, 86705, 86706, 86707, 86708, 86709, 86803, 86804, 87340, 87341, 87350, 87902, 87912, G0472, G0499.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses home hemodialysis (HHD). Applicable Procedure Codes: 90963, 90964, 90965, 90966, 90967, 90968, 90969, 90970, 90989, 90993, 99512, S9335.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses home traction therapy. Applicable Procedure Codes: E0830, E0840, E0849, E0850, E0855, E0856, E0860, E0941.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses hysterectomy. Applicable Procedure Codes: 58150, 58152, 58180, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58285, 58290, 58291, 58292, 58294, 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573.
Last Published 06.01.2021
Effective Date: 06.01.2021 – This policy addresses hospital outpatient facility infusion services for intravenous immune globulin (IVIG) and subcutaneous immune globulin (SCIG) therapy. Applicable Procedure Codes: 90283, 90284, J1459, J1554, J1555, J1556, J1557, J1558, J1559, J1561, J1566, J1568, J1569, J1572, J1575, J1599, J3590.
Last Published 08.01.2021
Effective Date: 08.01.2021 – 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 08.01.2021
Effective Date: 07.01.2021 – 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 04.15.2021
Effective Date: 03.01.2021 – This policy addresses the use of inhaled nitric oxide (iNO) for treating term or near-term infants with hypoxic respiratory failure or echocardiographic evidence of persistent pulmonary hypertension of the newborn (PPHN). Applicable Procedure Code: 94799.
Last Published 09.01.2021
Effective Date: 09.01.2021 – 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 04.15.2021
Effective Date: 12.01.2020 – This policy addresses intensive behavioral therapy for autism spectrum disorder.
Last Published 04.15.2021
Effective Date: 09.01.2020 – This policy addresses intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC). Applicable Procedure Code: 96549.
Last Published 09.01.2021
Effective Date: 09.01.2021 – This policy addresses intrauterine fetal surgery. Applicable Procedure Codes: 59072, 59074, 59076, 59897, S2400, S2401, S2402, S2403, S2404, S2405, S2409, S2411.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses laser interstitial thermal therapy. Applicable Procedure Codes: 19499, 20999, 27599, 32999, 53899, 55899, 64999.
Last Published 04.15.2021
Effective Date: 11.01.2020 – 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 04.15.2021
Effective Date: 11.01.2020 – This policy addresses extracorporeal shock wave lithotripsy (ESWL) and endoscopic intracorporeal laser lithotripsy for treating salivary stones. Applicable Procedure Code: 42699.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses lower extremity vascular angiography and endovascular revascularization procedures. Applicable Procedure Codes: 37220, 37221, 37222, 37223, 37224, 37225, 37226, 37227, 37228, 37229, 37230, 37231, 37232, 37233, 37234, 37235, 75710, 75716.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses implantable miniature telescope (IMT), conjunctival incision with posterior extrascleral placement of a pharmacologic agent, laser photocoagulation, and radiation therapy. Applicable Procedure Codes: 0308T, 67036, 67299, 92499.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses magnetic resonance spectroscopy (MRS). Applicable Procedure Code: 76390.
Last Published 04.15.2021
Effective Date: 04.01.2021 – This policy addresses manipulation under anesthesia (MUA). Applicable Procedure Codes: 21073, 22505, 25259, 27275, 27860, 23700, 24300, 26340, 27198, 27570, D7830.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses manipulative therapy. Applicable Procedure Codes: 98925, 98926, 98927, 98928, 98929, 98940, 98941, 98942, 98943, S8990.
Last Published 04.15.2021
Effective Date: 01.01.2021 – 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 09.01.2021
Effective Date: 09.01.2021 – This policy addresses meniscus allograft transplantation with human cadaver tissue and collagen meniscus implants. Applicable Procedure Codes: 29868, G0428.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses minimally invasive endoscopic procedures and devices for treating gastroesophageal reflux disease (GERD) and the Per Oral Endoscopic Myotomy (POEM) procedure for achalasia or diffuse esophageal spasm. Applicable Procedure Codes: 43210, 43257, 43284, 43289, 43499, 43999.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses molecular oncology testing for cancer indications, including breast cancer, thyroid cancer, hematological cancer, and lung cancer.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses motorized spinal traction devices. Applicable Procedure Code: S9090.
Last Published 04.15.2021
Effective Date: 03.01.2021 – This policy addresses negative pressure wound therapy. Applicable Procedure Codes: 97605, 97606, 97607, 97608, A6550, A9272, E2402.
Last Published 04.15.2021
Effective Date: 01.01.2021 – 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 04.15.2021
Effective Date: 01.01.2021 – This policy addresses nerve conduction studies and other neurophysiological testing.
Last Published 09.01.2021
Effective Date: 09.01.2021 – 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 05.01.2021
Effective Date: 05.01.2021 – This policy addresses observation services in a hospital setting.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses nonsurgical and surgical treatment of obstructive sleep apnea (OSA). Applicable Procedure Codes: 0466T, 0467T, 0468T, 21199, 21206, 21685, 41512, 41530, 41599, 42145, 42299, 64553, 64568, 64569, 64570, E0485, E0486, K1001, L8679, L8680, L8686, S2080, S2900.
Last Published 08.01.2021
Effective Date: 08.01.2021 – 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, L8679, L8680, L8685.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses multiple services/procedures.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses parameters for coverage of injectable oncology medications. Applicable Procedure Code: C9078, C9080, J0640, J0641, J0642, J1950, J3315, J9035, J9155, J9198, J9199, J9201, J9202, J9217, J9218, J9219, J9310, J9312, J9316, J9348, J9353, J9355, J9356, Q5107, Q5112, Q5113, Q5114, Q5115, Q5116, Q5117, Q5118, Q5119.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses orthognathic (jaw) surgery.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses neonatal hearing screening, auditory screening, and diagnostic testing using otoacoustic emissions (OAEs). Applicable Procedure Codes: 92558, 92587, 92588.
Last Published 04.15.2021
Effective Date: 11.01.2020 – 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 07.01.2021
Effective Date: 07.01.2021 – This policy addresses surgical repair of pectus excavatum and pectus carinatum. Applicable Procedure Codes: 21740, 21742, 21743.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses pediatric outpatient intensive feeding programs. Applicable Procedure Code: 92526.
Last Published 04.15.2021
Effective Date: 04.01.2021 – This policy addresses percutaneous patent foramen ovale closure for the prevention of recurrent ischemic stroke. Applicable Procedure Code: 93580.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses the use of pharmacogenetic multi-gene panel testing for genetic polymorphisms. Applicable Procedure Codes: 0029U, 0078U, 0173U, 0175U, 81479.
Last Published 08.01.2021
Effective Date: 08.01.2021 – 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: 21175, D5924, L0112, L0113, S1040.
Last Published 07.01.2021
Effective Date: 07.01.2021 – 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 07.01.2021
Effective Date: 07.01.2021 – This policy addresses preimplantation genetic testing (PGT). Applicable Procedure Codes: 0254U, 81228, 81229, 81479.
Last Published 09.01.2021
Effective Date: 09.01.2021 – This policy addresses preventive care services.
Last Published 08.01.2021
Effective Date: 08.01.2021 – This policy addresses prolotherapy and platelet rich plasma. Applicable Procedure Codes: 0232T, 0481T, G0460, M0076, P9020, S9055.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses the use of oral propranolol for the treatment of infantile hemangiomas (IH).
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses proton beam radiation therapy. Applicable Procedure Codes: 77301, 77338, 77385, 77386, 77387, 77520, 77522, 77523, 77525, G6015, G6016, G6017.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses outpatient hospital facility-based intravenous medication infusion, including eculizumab (Soliris®). Applicable Procedure Code: J1300.
Last Published 05.06.2021
Effective Date: 05.01.2021 – This policy addresses pulmonary rehabilitation. Applicable Procedure Codes: 94669, S9473, G0424.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses lysis intranasal synechia, repair of nasal vestibular stenosis or alar collapse, rhinoplasty, rhinophyma, septal dermatoplasty, and nasal polypectomy. Applicable Procedure Codes: 30120, 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, 30465, 30468, 30560, 30620, 31237.
Last Published 04.15.2021
Effective Date: 12.01.2020 – This policy addresses sensory integration therapy and auditory integration training. Applicable Procedure Code: 97533.
Last Published 07.01.2021
Effective Date: 07.01.2021 – 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 08.01.2021
Effective Date: 08.01.2021 – This policy addresses skin and soft tissue substitutes.
Last Published 04.15.2021
Effective Date: 04.01.2021 – 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 07.01.2021
Effective Date: 07.01.2021 – This policy addresses the use of Soliris® (eculizumab). Applicable Procedure Code: J1300.
Last Published 04.15.2021
Effective Date: 09.01.2020 – This policy addresses spinal and paraspinal ultrasonography. Applicable Procedure Code: 76800.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses surgery of the elbow. Applicable Procedure Codes: 24360, 24361, 24362, 24363, 24366, 24370, 24371, 29830, 29834, 29837, 29838.
Last Published 09.01.2021
Effective Date: 09.01.2021 – This policy addresses surgery of the foot. Applicable Procedure Codes: 28285, 28289, 28291, 28292, 28295, 28297, 28298, 28299, 28296, 28299, 29893.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses surgery of the hip and femoroacetabular impingement (FAI) syndrome. Applicable Procedure Codes: 27120, 27122, 27125, 27130, 27132, 27134, 27137, 27138, 27299, 29860, 29861, 29862, 29863, 29914, 29915, 29916, 29999, S2118.
Last Published 09.01.2021
Effective Date: 09.01.2021 – This policy addresses surgery of the knee. Applicable Procedure Codes: 27437, 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447, 27486, 27487, 29850, 29851, 29855, 29856, 29870, 29871, 29873, 29874, 29875, 29876, 29877, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889.
Last Published 09.01.2021
Effective Date: 09.01.2021 – This policy addresses surgery of the shoulder. Applicable Procedure Codes: 23412, 23470, 23472, 23473, 23474, 29805, 29806, 29807, 29819, 29820, 29822, 29823, 29824, 29825, 29826, 29827, 29828.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses varicose vein ablative and stripping procedures and ligation procedures. Applicable Procedure Codes: 36465, 36466, 36473, 36474, 36475, 36476, 36478, 36479, 36482, 36483, 37500, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785, 37799.
Last Published 09.01.2021
Effective Date: 09.01.2021 – This policy addresses surgical treatment for spine pain.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses treatment of temporomandibular joint (TMJ) disorders. Applicable Procedure Codes: 20552, 20553, 20605, 20606, 21010, 21050, 21060, 21070, 21085, 21089, 21110, 21198, 21209, 21240, 21242, 21243, 21247, 21299, 21499, 29800, 29804, 90901, 97039, 97139, E0746, E1399, E1700, E1701, E1702.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses thermography, including digital infrared thermal imaging, temperature gradient studies, and magnetic resonance (MR) thermography. Applicable Procedure Codes: 76498, 93740.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses cervical and lumbar artificial total disc replacement. Applicable Procedure Codes: 0095T, 0098T, 0163T, 0164T, 0165T, 22856, 22857, 22858, 22861, 22862, 22864, 22865, 22899.
Last Published 05.01.2021
Effective Date: 05.01.2021 – This policy addresses the SynCardia™ temporary Total Artificial Heart. Applicable Procedure Codes: 33927, 33928, 33975, 33976, 33979, 33981, 33982, 33983, 33995, 33997.
Last Published 09.01.2021
Effective Date: 09.01.2021 – 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 04.15.2021
Effective Date: 04.01.2021 – This policy addresses transcranial magnetic stimulation and navigated transcranial magnetic stimulation (nTMS). Applicable Procedure Codes: 64999, 90867, 90868, 90869.
Last Published 06.01.2021
Effective Date: 06.01.2021 – This policy addresses transpupillary thermotherapy. Applicable Procedure Codes: 67299, 92499.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses collection and storage of umbilical cord blood. Applicable Procedure Codes: 38205, 38206, 38207, 88240, S2140.
Last Published 04.15.2021
Effective Date: 10.01.2020 – This policy addresses unicondylar spacer devices for treating knee joint pain or disability from any cause. Applicable Procedure Code: 27599.
Last Published 04.15.2021
Effective Date: 04.01.2021 – This policy addresses implantable vagus nerve stimulators and transcutaneous (non-implantable) vagus and trigeminal nerve stimulators. Applicable Procedure Codes: 61885, 64553, 64568, 64570, E0770, E1399, K1016, K1017, K1020, L8679, L8680, L8682, L8683, L8685, L8686, L8687, L8688.
Last Published 07.01.2021
Effective Date: 07.01.2021 – This policy addresses vertebral body tethering for the treatment of scoliosis. Applicable Procedure Code: 0656T, 0657T, 22899.
Last Published 04.15.2021
Effective Date: 12.01.2020 – This policy addresses virtual upper gastrointestinal endoscopy. Applicable Procedure Codes: 76497, 76498.
Last Published 05.01.2021
Effective Date: 05.01.2021 – 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: 92065, 92499.
Last Published 04.18.2021
Effective Date: 01.01.2021 – This policy addresses warming therapy, noncontact normothermic wound therapy, and low frequency ultrasound for treating wounds. Applicable Procedure Codes: 97610, A6000, E0221, E0231, E0232.
Last Published 04.15.2021
Effective Date: 01.01.2021 – This policy addresses whole exome and whole genome sequencing. Applicable Procedure Codes: 0012U, 0013U, 0014U, 0036U, 0094U, 0212U, 0213U, 0214U, 0215U, 81415, 81416, 81417, 81425, 81426, 81427.
For questions, please contact your local Network Management representative or call the Provider Services number on the back of the member’s ID card.
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