Medical policies

Pending/retired/updated medical policies

Go to the recent and upcoming policy changes list.

Current medical policies

Jump down to a specific section by clicking a letter.

A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | Q | R | S | T | U | V | W | X | Y | Z

A

• Abortion: see Termination of Pregnancy, Elective - 91000 (41KB PDF)
• Abortion, Recurrent Spontaneous - 91156 Reviewed 09/2010 (39KB PDF)
• Allergy Testing/Immunotherapy - 91037 Reviewed 12/2011 (43KB PDF)
• Apnea Monitors - 91497 Reviewed 12/2011 (37KB PDF)
• Artificial Intervertebral Discs: See Spine Procedures - 91581
• Assisted Reproduction/Artificial Conception: See Infertility Diagnosis & Treatment/Assisted Reproduction/Artificial Conception - 91163
• Augmentative Communications / Speech-Generating Devices (ACD) for Medicaid Members - 91499 Reviewed 12/2011 (33KB PDF)
  • Augmentative Communication Device PA form (Medicaid only) (117KB PDF)
• Autologous Chondrocyte Implant/Meniscal Allograft - 91443 Reviewed 06/2011 (46KB PDF)
• Automated Percutaneous Lumbar Discectomy: See Spine Procedures - 91581 (151KB PDF)
• Autopsy - 91054 Reviewed 12/2011 (33KB PDF)
• AxialIF^TMAxial Lumbar Interbody Fusion: See Spine Procedures - 91581 (151KB PDF)

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B

• NEW Balloon Sinus Ostial Dilation - 91596 (KB PDF) Effective 01/2012
  New policy on the use of balloon sinus ostial dilation, e.g. Balloon Sinuplasty™, as investigational and not medically necessary for the treatment of any sinus condition, including but not limited to sinusitis.
• Bariatric Surgery: See Obesity - 91435 (133KB PDF)
• Biofeedback - 91002 Reviewed 12/2011 (37KB PDF)
• Blepharoptosis/Brow Ptosis Repair: See Cosmetic and Reconstructive Surgery Procedures - 91535 (128KB PDF)
• Blood Pressure Monitors & Ambulatory Blood Pressure Monitoring - 91503 Revised 12/2011 (40KB PDF) 
• Bone Density Studies - 91494 Reviewed 10/2011 (67KB PDF)
• Bone Marrow/Peripheral Stem Cell or Blood Cell Transplantation - 91066 Revised 06/2011 (187KB PDF)
• Botulinum Toxin - 91455 Retired 04/2011 
• Breast Related Procedures - 91545 Revised 09/2011 (104KB PDF)
  • Bilateral Reduction Mammoplasty PA form Revised 08/2010 (508KB PDF)
• Breast Specific Gamma Imaging - 91568 Reviewed 08/2011 (38KB PDF)
• Bronchial Thermoplasty - 91577 Revised 02/2012 (46KB PDF)
  Summary of change: Coverage criteria for bronchial thermoplasty added to the policy. Previously it was not covered.

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C

• Capsule Endoscopy - 91476 Reviewed 04/2012 (53KB PDF)
• Cardiovascular Risk Markers - 91559 Revised 02/2012 (49KB PDF)
  Summary of change: Lipoprotein particle size and concentration/density measurement (previously covered) and natriuretic peptides added to the list of tests that are not covered for the screening, management or diagnosis of CVD.
• Cardioverter Defibrillators - 91410 Revised 08/2011 (419KB PDF)
  
  • Implantable Cardioverter Defibrillator (ICD) PA form
• Carotid and Intracranial Artery Stenting - 91495 Reviewed 06/2011 (54KB PDF)
• Catheter Ablation for Cardiac Arrhythmias - 91314 Revised 04/2012 (53KB PDF)
  Summary of change: Language updated to reflect all covered therapies and specific criteria for coverage.
• Chelation Therapy - 91077 Revised 12/2011 (37KB PDF)
• Chemosensitivity Assays - 91566 Reviewed 08/2011 (37KB PDF)
• Cingulotomy - 91475 Reviewed 12/2011 (35KB PDF)
• Clinical Trials for Cancer Care - 91448 Reviewed 04/2012 (65KB PDF)
• Colorectal Cancer Screening - 91547 Revised 02/2012 (50KB PDF)
  Summary of change: Computer tomography colonography (CTC) added to list of standard tests covered for general colon cancer screening. CTC will still require prior authorization.
• Complications to Non-Covered Care - 91086 Reviewed 12/2011 (34KB PDF)
• NEW Computed Tomography Scanning for Lung Cancer Screening - 91600 Effective 03/2012 (39KB PDF)
  New policy addressing the non-coverage of spiral computed tomography (CT) scanning, also known as helical CT or low-dose CT scanning, for screening for lung cancer for average risk or high risk groups (e.g., smokers) because it is not recommended by the United States Preventive Services Task Force (www.uspstf.gov).
• Continuous Glucose Monitoring - 91466 Updated 05/2012 (45KB PDF)
  Summary of change: Language added to reflect that mySentry^TM Remote Glucose Monitor, a MiniMed accessory, has not been FDA approved and is not a covered benefit.
• Coronary artery calcium score / EBCT: See AIM website for clinical guidelines
• Coronary CT angiography: See AIM website for clinical guidelines
• Cosmetic and Reconstructive Surgery Procedures - 91535 Reviewed 02/2012 (128KB PDF)
  Cranial Helmets - 91504 Reviewed 08/2011 (44KB PDF)

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D

• Dental Extractions: See Oral Surgery & Dental Extractions - 91542 (75KB PDF)
• Detoxification - 91104 Revised 12/2011 (36KB PDF)
• Dialectical Behavior Therapy (DBT) - 91555 Reviewed 10/2011 (105KB PDF)
• Discectomy, Automated Percutaneous Lumbar: See Spine Procedures - 91581 (151KB PDF)
• Drug-Eluting Stents for Ischemic Heart Disease - 91580 Effective 11/2011
• Durable Medical Equipment - 91110 Revised 09/2011 (47KB PDF)

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E

• Eating Disorders - 91007 Reviewed 08/2011 (33KB PDF)
• Electro-convulsive Therapy (ECT) - 91554 Reviewed 10/2011 (44KB PDF)
• Enclosed Bed Systems for Medicaid Members - 91498 Reviewed 12/2011 (28KB PDF)
• End Stage Renal Disease: See Home Hemodialysis - 91526 (41KB PDF)
• Endometrial Ablation Procedures for Menorrhagia: See Menorrhagia Treatment - 91575 (43KB PDF)
• Endoscopic Treatment of GERD and Barrett's Esophagus - 91483 Reviewed 04/2011 (115PDF)
• Enteral Nutritional Therapy - 91278 Revised 04/2012 (52KB PDF)
  Summary of change: Coverage clarified, and language also added to reflect that oral 100% hydrolyzed amino acids infant formulas are covered up to 24 months of age when specific criteria are met.
  
  • Enteral formulas PA form (34KB PDF)
  • Enteral formulas PA form - Medicare (54KB PDF)
• Enuresis Therapy - 91418 Reviewed 02/2012 (33KB PDF)
• Experimental/Investigational/Unproven Care/Benefit Exceptions - 91117 Reviewed 04/2012 (98KB PDF)
• Extracorporeal Immunoadsorption (ECI) - 91118: Retired 10/01/2011. Claims will adjudicate per Medicare criteria.
• Extracorporeal Shock Wave Therapy (ECWT) - 91527 Reviewed 02/2012 (37KB PDF)

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F

• Facial Scar Revisions: See Cosmetic and Reconstructive Surgery Procedures - 91535 (128KB PDF)
• Feeding Disorders - 91469 Reviewed 10/2011 (165KB PDF)
• Female Erectile Dysfunction Therapy: See Sexual Dysfunction policy - 91160 (157KB PDF)
• Fetal Surgery - 91120 Revised 08/2011 (198KB PDF) 
• Fluocinolone Implant - 91511 Reviewed 04/2012 (37KB PDF)
• Foot Care - 91121 Reviewed 02/2012 (375KB PDF)

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G

• Gastroparesis Testing and Treatment - 91572 Reviewed 02/2012 (38KB PDF)
• Genetics: Counseling, Testing and Screening - 91540 Updated 12/2011 (573KB PDF)
  
  • Breast and Ovarian Cancer Screening by Molecular Testing PA form (320KB PDF)

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H

• Hearing Augmentation - 91544 Effective 09/2010 (133KB PDF)
• Hemophilia Management - 91569 Reviewed 02/2012 (36KB PDF)
• Hip Resurfacing, Total - 91530 Revised 02/2008 (49KB PDF)
• Home Care - 91023 Reviewed 06/2011 (49KB PDF)
• Home Hemodialysis - 91526 (Formerly End Stage Renal Disease & Home Hemodialysis) Revised 01/2012 (41KB PDF)
  Summary of change: ESRD and intradialytic parenteral nutrition (IDPN) criteria and descriptions were removed; IDPN criteria were added to Parenteral Nutritional Therapy Policy 91517.
• Home Prothrombin Time or INR Monitoring - 91507 Reviewed 04/2012 (46KB PDF)
• Hospice Care - 91520 Revised 08/2011 (228KB PDF)
  Hyperbaric Oxygen Therapy - 91151 Reviewed 06/2011 (49KB PDF)
• Hyperhidrosis - 91451 Reviewed 04/2012 (44KB PDF)

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I

• IDET and Other Thermal Intradiscal Procedures (TIPs): See Spine Procedures - 91581 (151KB PDF)
• Implantable Cardioverter Defibrillator (ICD): See Cardioverter Defibrillator - 91410 (179KB PDF)
• Impotence: See Sexual Dysfunction policy - 91160 (61KB PDF)
• Incontinence Supplies for Medicaid Members - 91502 Revised 12/2011 (38KB PDF)
• Infertility Diagnosis and Treatment/Assisted Reproduction/Artificial Conception - 91163 Revised 07/2010 (66KB PDF)
• Infusion Pumps - Implantable and External - 91414 Reviewed 04/2012 (44KB PDF)
• Intraoperative Radiatherapy (IORT) - 91556 Revised 01/2012 (46KB PDF)
  Summary of change: Criteria added for the coverage of intraoperative radiation therapy (IORT) as part of clinical care for breast cancer if certain criteria are met. Language updated to reflect that IORT would also be covered as part of a clinical trial for breast cancer if criteria for coverage as part of clinical care is not met.
• Intraperitoneal Hyperthermic Chemotherapy - 91548 Reviewed 02/2012 (103KB PDF)
• Intracoronary Brachytherapy - 91536 Revised 06/2011 (106KB PDF)
• Intravenous Immunoglobulin (IVIG) - 91514: Retired 09/2011. Use the updated IVIG drug authorization form (68KB PDF) in place of the policy.
• NEW Irreversible Electroporation (IRE) or Nanoknife - 91599 Effective 04/2012 (35KB PDF)
  New policy addressing the non-coverage of Irreversible Electroporation (IRE) or Nanoknife for the ablation of cancer as it is considered experimental and investigational.

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K

• New: Knee Arthroscopy - 91587 Effective 07/16/2012 (58KB PDF)
  New policy developed and approved through the Medical Affairs Committee and support evidence based guidelines. Beginning July 16, 2012 this procedure must meet criteria and will require prior authorization.
• Retiring: Knee Arthroscopy for Osteoarthritis - 91564 Reviewed 02/2012 (131KB PDF)
  Use the new Knee Arthroscopy - 91587 policy effective 07/16/12.

L

• Levonorgestrel-Releasing IUD (MirenaÆ) IUD: See Menorrhagia Treatment - 91575 (43KB PDF)
• Lipoprotein Testing discontinued 1/16/2009. See Cardiovascular Risk Markers - 91559 (140KB PDF)
• New: Lumbar Fusion - 91590 Effective 07/16/2012 (51KB PDF)
  New policy developed and approved through the Medical Affairs Committee and support evidence based guidelines. Beginning July 16, 2012 this procedure must meet criteria and will require prior authorization.
• New: Lumbar Laminectomy - 91591 Effective 07/16/2012 (50KB PDF)
  New policy developed and approved through the Medical Affairs Committee and support evidence based guidelines. Beginning July 16, 2012 this procedure must meet criteria and will require prior authorization.
• Lung Volume Reduction Surgery - 91472 Reviewed 10/2011 (181KB PDF)

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M

• Markers for Digestive Disorders - 91583 Revised 02/2012 (113KB PDF)
  Summary of change: Criteria expanded to clarify testing that is considered experimental and investigational, and to reflect that genetic testing as an initial screening in symptomatic or in asymptomatic individuals is considered to be experimental and investigational (i.e. MyCeliacID, PROMETHEUS® Celiac Genetics).
• Medical Errors: Serious Reportable Events/Hospital Acquired Conditions - 91516 Renamed 10/2011 (339KB PDF)
• Medical Management of Obesity - 91594 (104KB PDF) Effective 04/01/2012
  Summary of change: Criteria has significantly changed. New policy requirements are Age ≥ 16 years, BMI ≥ 30, and an intake assessment that shows a patient is in the contemplation or action phase of readiness for change. The new policy allows for the medical weight management program to be provided by a credentialed physician with a declared interest in the medical management of obesity, the member's primary care physician (PCP) or other managing physician. Medical management is no longer required to be prior authorized or provided by a Weight Loss Center of Excellence.
• Medical Necessity Determination - 91447 Reviewed 12/2011 (23KB PDF)
• Menorrhagia Treatment - 91575 Reviewed 08/2011 (45KB PDF)
• Monochromatic Phototherapy (anodyne therapy/MIRE therapy/low level light therapy) - 91486 Reviewed 06/2011 (34KB PDF)
• MRI of the breast: See AIM website for clinical guidelines

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N

• Neocate: See Enteral Nutrition Therapy - 91278 (60KB PDF)
• Neuropsychological and Psychological Testing - 91537 Reviewed 08/2011 (53KB PDF)
• Never Events/Medical Errors - 91516, see "Medical Errors"
• Non-Acute Inpatient Services - 91332 Reviewed 10/2011 (47KB PDF)

O

• Obesity - 91435 (137KB PDF) Effective 04/01/2012
  Summary of change: Effective 04/01/12, this policy will only apply to requests for prior authorization to contracted Priority Health Weight Loss Centers of Excellence through 05/31/12. It will be retired effective 06/01/12.
  
  • Bariatric Surgery Evaluation Authorization form Revised 04/2012 (891KB PDF)
  • Bariatric Surgery Authorization form Revised 04/2012 (254KB PDF)
  • Medical Weight Loss Program PA form Revised 01/2012 (273KB PDF)
• Obesity, medical management: See Medical Management of Obesity - 91594 (104KB PDF)
• Obesity, surgical treatment: See Surgical Treatment of Obesity - 91595 (118KB PDF)
• Obstructive Sleep Apnea & Upper Airway Resistance Syndrome - 91333 Revised 04/2012 (58KB PDF) 
• Oral Surgery & Dental Extractions - 91542 Reviewed 02/2012 (426KB PDF)
• Orthognathic Surgery - 91273 Reviewed 12/2011 (42KB PDF)
• Orthoptic and Pleoptic Training for Medicaid Members - 91500 Reviewed 12/2011 (29KB PDF)
• Orthotics: Shoe Inserts, Orthopedic Shoes - 91420 Reviewed 02/2012 (61KB PDF)
• Orthotics/Support Devices Policy - 91339 Reviewed 06/2011 (74KB PDF)

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P

• Palliative Care - 91558 Reviewed 04/2011 (87KB PDF)
• PET scans: See AIM website for clinical guidelines
  • Brain imaging
  • Cardiac imaging
  • Oncology
• Panniculectomy/Abdominoplasty - 91444 Revised 09/2011 (149KB PDF)
• Parenteral Nutrition Therapy - 91517 Revised 01/2012 (56KB PDF)
  Summary of change: Policy title changed from Parenteral Nutritional Therapy in the Home. Intradialytic parenteral nutrition (IDPN) criteria, formerly part of the Home Hemodialysis Medical Policy 91526, has been added. Medical necessity review section updated: Prior authorization is only required for home parenteral nutrition.
• Patellofemoral Replacement for Isolated Osteoarthritis of the Knee - 91571 Reviewed 02/2012 (163KB PDF)
• Pervasive Developmental Disabilities - 91543 Revised 08/2011 (62KB PDF)
• Pharmacogenomics Testing - 91570 Revised 02/2012 (63KB PDF)
  Summary of change: All non-covered testing moved from the criteria section of the policy to an appendix; several new non-covered tests added.
• Platelet Rich Plasma/Platelet Rich Fibrin Matrix - 91553 Reviewed 06/2011 (34KB PDF)
• Port Wine Stains and Vascular Malformations: See Cosmetic and Reconstructive Surgery Procedures - 91535 (128KB PDF)
• Prophylactic Cancer Risk Reduction Surgery - 91508 Reviewed 02/2012 (54KB PDF)
• Prosthetics, External - 91306 Reviewed 04/2012 (75KB PDF)
• Psychological Evaluation and Management of Non-Mental Health Disorders - 91546 Revised 06/2011 (59KB PDF)
• Pulse Oximetry for Home Use - 91452 Reviewed 10/2011 (152KB PDF)

Q

• QEEG - Quantitative Electroencephalogram - 91510 Reviewed 08/2011 (44KB PDF)

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R

• Radiofrequency Ablation for Back Pain: See Spine Procedures - 91581 (151KB PDF)
• Radiosurgery - 91127 Reviewed 08/2011 (47KB PDF)
• Recurrent Spontaneous Abortion - 91156 Reviewed 10/2011 (162KB PDF)
• Refractive Keratoplasty/Lasik - 91529 Reviewed 08/2011 (44KB PDF)
• Rehabilitative Medicine Services - 91318 Reviewed 02/2012 (70KB PDF)
• Renal Artery Stenosis - 91561 Reviewed 12/2011 (46KB PDF)
• Respite Care - 91321 Reviewed 04/2012 (31KB PDF)
• Robotically Assisted Surgeries - 91522 Reviewed 06/2011 (43KB PDF)

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S

• Septoplasty/Rhinoplasty - 91506 Reviewed 02/2012 (43KB PDF)
• Sexual Dysfunction and Impotence - 91160 Revised 04/2012 (57KB PDF)
  Summary of change: Stem cell therapy for erectile dysfunction was added to the list of non-covered services as it is experimental and investigational.
• Skin Conditions - 91456 Revised 04/2012 (122KB PDF)
  Summary of change: Criteria added to reflect additional consideration for home therapy (for those who are able to travel) for the treatment of psoriasis may be made if the treatment has been continuous and long term, > 1 year in duration, has shown to be effective for the member, and is expected to continue long term.
• Skin Substitutes - 91560 Revised 08/2011 (230KB PDF) 
• Sleep Apnea-Obstructive - 91333 Revised 04/2011 (131KB PDF)
• Speech Therapy - 91336 Reviewed 02/2012 (45KB PDF)
• Sperm and Oocyte Retrieval and Storage - 91393 Reviewed 10/2011 (164KB PDF)
• Spine Centers of Excellence - 91531 Revised 02/2012 (60KB PDF)
  Summary of change: Medicare referral requirements will change from notification only to prior authorization.
• Spine Procedures - 91581 Reviewed 04/2012 (183KB PDF)
• Sterilization for Medicaid Members - 91501 Reviewed 12/2011 (30KB PDF)
• Stereotactic Radiosurgery: See Radiosurgery - 91127 (46KB PDF)
• Stimulation Therapy and Devices - 91468 Effective 04/02/2012 (180KB PDF)
  Summary of change: Criteria updated to reflect that vagal nerve stimulation for the treatment of depression is not a covered benefit. Only covered for the treatment of seizures when criteria is met. The Vagal Nerve Stimulation for Depression medical policy will be retired effective 04/02/2012.
• Surgical Treatment of Obesity - 91595 (118KB PDF) Effective 04/01/2012
  Summary of change: Criteria has significantly changed. New policy requirements are:  a) BMI ≥ 35, participation in a medical weight management program and at least one obesity-related co-morbidity, or b) BMI ≥ 40, co-morbidity is not required, however, participation in a medical weight management program is, or c) BMI ≥ 50, no co-morbidity or participation in medical weight loss program. See policy for additional requirements.

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T

• Technology Assessment - 91430 Revised 06/2011 (43KB)
  Temporomandibular Joint Disorders (TMJD) - 91353 Reviewed 04/2012 (37KB PDF)
• Termination of Pregnancy, Elective - 91000 Reviewed 04/2012 (36KB PDF)
• Thermal Capsulorrhaphy - 91551 Reviewed 04/2012 (34KB PDF)
• Thermography - 91355 Reviewed 10/2011 (153KB PDF)
• Titanium Rib - 91505 Reviewed 02/2012 (125KB PDF)
• Tinnitus Retraining Therapy - 91482 Reviewed 06/2011 (36KB PDF)
• Total Hip Resurfacing - 91530 Reviewed 02/2012 (136KB PDF)
• Transcatheter Closure of Septal Defects - 91528 Reviewed 04/2012 (45KB PDF)
• NEW Transcatheter Heart Valves - 91597 Effective 05/28/2012 (99KB PDF)
  New policy addressing the criteria for coverage of transcatheter aortic valve implantation (TAVI) and transcatheter pulmonary valve implantation (TPVI).
• Transcranial Magnetic Stimulation for Depression - 91563 Reviewed 02/2012 (42KB PDF) 
• Transcutaneous Electrical Acustimulation (TEAS) for Hyperemesis - 91576 Effective 11/2011 (39KB PDF)
• Transplantation of Solid Organs - 91272 Revised 06/2011 (71KB PDF)
• Transurethral Radiofrequency Micro-Remodeling (Renessa) for Female Incontinence - 91578 Reviewed 10/2011 (36KB PDF)
• Tumor Markers - 91562 Revised 02/2012 (66KB PDF)
  Summary of change: A listing of non-covered tumor markers added as Appendix II.  The list is not all-inclusive and any tumor marker not listed is still subject to the main policy criteria.

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U

• Umbilical Cord Blood Testing and Storage - 91459 Reviewed 06/2011 (34KB PDF)
• Uterine Fibroid Treatment - 91573 Reviewed 06/2011 (40KB PDF)
• Uvulopalatopharyngoplasty (UPPP) & Laser-Assisted Uvulopalatoplasty (LAUP): See Obstructive Sleep Apnea - 91333 (131KB PDF)

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V

• Vagal Nerve Stimulation as a Treatment of Depression: See Stimulation Therapy and Devices - 91468 (180KB PDF) 
• Varicose Vein Treatment - 91326 Revised 10/2011 (50KB PDF)
• Ventricular Assist Devices (VADs) and Artificial Hearts - 91509 Revised 11/2011 (308KB PDF)
  Virtual Colonoscopy: See Colorectal Cancer Screening - 91547 (140KB PDF)
• Vision Care - 91538 Revised 04/2011 (86KB PDF)
  PENDING Vision Care/Eye Exam - 91538 Effective 05/28/2012 (86KB PDF)
  Summary of change: Criteria added to reflect office-based vision therapy/orthoptics covered only as a treatment for convergence insufficiency (CI) in children. Use of this treatment/therapy for any other indication/diagnosis is considered to be experimental and investigational and is not a covered benefit.

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