Medical Policies

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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 (40KB PDF)
• Abortion, Recurrent Spontaneous - 91156 (39KB PDF)
• Allergy Testing/Immunotherapy - 91037 Reviewed 12/2009 (50KB PDF)
• Apnea Monitors - 91497 Reviewed 12/2009 (42KB PDF)
• Artificial Intervertebral Discs - 91493 Reviewed 08/2009 (126KB PDF)
  
• Assisted Reproduction/Artificial Conception: See Infertility Diagnosis & Treatment/Assisted Reproduction/Artificial Conception - 91163
  
• Augmentative Communications / Speech-Generating Devices (ACD) for Medicaid Members - 91499 Reviewed 12/2009 (35KB PDF)
  
• Augmentative Communication Device PA form (Medicaid only) (117KB PDF)
  
• Autologous Chondrocyte Implant/Meniscal Allograft - 91443 Updated 08/2009 (137KB PDF)
• Automated Percutaneous Lumbar Discectomy - 91519 Reviewed 08/2009 (131KB PDF)
  
• Autopsy - 91054 Reviewed 12/2009 (37KB PDF)
  
• AxialIF^TM Axial Lumbar Interbody Fusion - 91549 Updated 07/2009 (142KB PDF)
  

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B

• Bariatric Surgery: See Obesity - 91435 (133KB PDF)
• Biofeedback - 91002 Reviewed 12/2009 (45KB PDF)
  
• Blepharoptosis/Brow Ptosis Repair - 91376 Reviewed 02/2010 (55KB PDF)
  
• Blood Pressure Monitors for Medicaid Members - 91503 Reviewed 12/2009 (33KB PDF)
  
• Bone Density Studies - 91494 Updated 01/2010 (70KB PDF)
  As of 01/01/2010, Priority Health limits coverage for BMD studies to central DXA only. Central DXA is the only study covered in any setting.
  
• Bone Marrow/Peripheral Stem Cell or Blood Cell Transplantation - 91066 Updated 10/2009 (282KB PDF)
  
• Botulinum Toxin - 91455 Updated 04/2009 (69KB PDF)
  
• Breast Related Procedures - 91545 Updated 10/2009 (284KB PDF)
  
• Bilateral Reduction Mammoplasty PA form Updated 04/2009 (4KB PDF)
  

• Breast Specific Gamma Imaging - 91568 Added 09/2009 (109KB PDF)
  

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C

• Capsule Endoscopy - 91476 Reviewed 04/2009 (131KB PDF)
  
• Cardiac Loop Recorder, Implantable - 91496 Reviewed 12/2009 (48KB PDF)
  
• Cardiovascular Risk Markers - 91559 Reviewed 12/2009 (56KB PDF)
  
• Cardioverter Defibrillators - 91410 Reviewed 08/2009 (75KB PDF)
  
• Implantable Cardioverter Defibrillator (ICD) PA form
• Carotid and Intracranial Artery Stenting - 91495 Reviewed 06/2008 (152KB PDF)
  
• Catheter Ablation for Cardiac Arrhythmias - 91314 Reviewed 04/2009 (140KB PDF)
  
• Chelation Therapy - 91077 Reviewed 12/2009 (39KB PDF)
  
• Chemosensitivity Assays - 91566 Added 09/2009 (122KB PDF)
  
• Cingulotomy - 91475 Reviewed 12/2009 (40KB PDF)
  
• Clinical Trials for Cancer Care - 91448 Reviewed 08/2009 (164KB PDF)
  
• Colorectal Cancer Screening - 91547 Reviewed 04/2009 (140KB PDF)
  
• Complications to Non-Covered Care - 91086 Reviewed 12/2009 (39KB PDF)
  
• Contact Lenses/Eyeglasses - 91425 Reviewed 04/2009 (122KB PDF)
• Continuous Glucose Monitoring - 91466 Updated 02/2010 (50KB PDF)
  
• Continuous Glucose Monitoring System PA form (241KB PDF)
  
• Coronary artery calcium score / EBCT: Policy removed See AIM website for clinical guidelines
  
• Coronary CT angiography: Policy removed See AIM website for clinical guidelines
• Cosmetic and Reconstructive Surgery Procedures - 91535 Updated 11/2009 (149KB PDF)
  Labial hypertrophy added to non-covered conditions.
  
• Cranial Helmets - 91504 Reviewed 08/2009 (124KB PDF)
  
• Craniosacral Therapy - 91095 Reviewed 12/2009 (37KB PDF)
  

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D

• Dental Extractions - 91523 Reviewed 02/2010 (39KB PDF)
  
• Detoxification - 91104 Reviewed 12/2009 (40KB PDF)
  
• Dialectical Behavior Therapy (DBT) - 91555 Updated 10/2009 (164KB PDF)
  Benefit limits have been removed. Prior authorization section updated to reflect "prior auth (by member only) required for initial evaluation."
  
• Discectomy, Automated Percutaneous Lumbar - 91519 (114KB PDF)
• Durable Medical Equipment - 91110 Reviewed 06/2009 (114KB PDF)
  

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E

• Eating Disorders - 91007 Updated 08/2009 (108KB PDF)
  
• Electro-convulsive Therapy (ECT) - 91554 Reviewed 10/2009 (122KB PDF)
  
• Enclosed Bed Systems for Medicaid Members - 91498 Reviewed 12/2009 (33KB PDF)
  
• End Stage Renal Disease - 91526 Reviewed 02/10 (50KB PDF)
  
• Endometrial Ablation Procedures for Menorrhagia - 91539 Reviewed 02/2010 (52KB PDF)
• Endoscopic Treatment of GERD and Barrett's Esophagus - 91483 Updated 02/2010 (126PDF)
  
• Enhanced External Counterpulsation (EECP) - 91440 Reviewed 02/2010 (41KB PDF)
  
• Enteral Nutritional Therapy - 91278 Reviewed 04/2009 (140KB PDF)
  
  • Enteral formulas PA form (34KB PDF)
    
  • Enteral formulas PA form - Medicare (54KB PDF)
    
• Enuresis Therapy - 91418 Updated 02/2010 (37KB PDF)
  
• Experimental/Investigational/Unproven Care/Benefit Exceptions - 91117 Updated 04/2009 (146KB PDF)
  
• Extracorporeal Immunoadsorption (ECI) - 91118 Reviewed 10/2009 (107KB PDF)
  
• Extracorporeal Shock Wave Therapy (ECWT) - 91527 Reviewed 02/2010 (41KB PDF)

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F

• Facial Scar Revisions - 91442 Reviewed 02/2010 (39KB PDF)
• Feeding Disorders - 91469 Reviewed 10/2009 (118KB PDF)
  
• Female Erectile Dysfunction Therapy: see Sexual Dysfunction policy - 91160 (157KB PDF)
• Fetal Surgery - 91120 Reviewed 04/2009 (118KB PDF)
• Fluocinolone Implant - 91511 Reviewed 04/2009 (112KB PDF)
• Foot Care - 91121 Reviewed 02/2009 (164KB PDF)
  PENDING UPDATE 03/25/2010 Foot Care - 91121 (83KB PDF) Language updated to reflect that therapeutic injections of the same joint are limited to a maximum of three injections in a six-month period. Also, language added stating that surgery with tenotomy, whether one or multiple incisions, will be considered as one surgery. Added subtalar arthroereisis (subtalar implant) to the exclusion section. See the summary of changes on the policy for other minor updates.
  

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G

• Genetic Counseling, Testing and Screening - 91540 Updated 02/2010 (114KB PDF)
  To align our policy with nationally established guidelines for appropriate testing protocols, pre-test counseling requirements by a board-certified provider/genetic counselor have been added. Language added to clarify the intent of prognostic testing and who should be ordering.
  
  • Breast Cancer Treatment Assessment with Oncotype DX^TM PA form (254KB PDF)
  • Breast and Ovarian Cancer Screening by Molecular Testing PA form (320KB PDF)

• Growth Hormone Replacement in Adults - 91441 Reviewed 02/2010 (43KB PDF)
  
• Growth Hormone Therapy in Children - 91460 Reviewed 08/2009 (203KB PDF)
  

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H

• Hearing Augmentation - 91544 Reviewed 08/2009 (187KB PDF)
  
• Hip Resurfacing, Total - 91530 Updated 02/2008 (49KB PDF)
  
• Home Care - 91023 Updated 06/2009 (137KB PDF)
  
• Home Hemodialysis - 91512 Updated 12/2009 (136KB PDF)
  
• Home Prothrombin Time or INR Monitoring - 91507 Reviewed 04/2009 (119KB PDF)
  
• Hospice Care - 91520 Updated 08/2009 (134KB PDF)
  
• Hyperbaric Oxygen Therapy - 91151 Reviewed 06/2009 (137KB PDF)
• Hyperhidrosis - 91451 Reviewed 04/2009 (112KB PDF)

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I

• IDET and Other Thermal Intradiscal Procedures (TIPs) - 91438 Updated 02/2010 (44KB 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 Reviewed 12/2009 (38KB PDF)
  
• Infertility Diagnosis and Treatment/Assisted Reproduction/Artificial Conception - 91163 Reviewed 10/2009 (130KB PDF)
  
• Infusion Pumps - Implantable and External - 91414 Updated 02/2010 (53KB PDF)
  
• Intranasal Flu Vaccine - 91480  Reviewed 10/2009 (111KB PDF)
  
• Intraoperative Radiation Therapy (IORT) - 91556 Reviewed 12/2009 (46KB PDF)
  
• Intraperitoneal Hyperthermic Chemotherapy - 91548 Reviewed 02/2010 (96KB PDF)
  
• Intravascular Brachytherapy - 91536 Reviewed 06/2009 (255KB PDF)
• Intravenous Immunoglobulin (IVIG) - 91514 Updated 08/2009 (162KB PDF)
  
• IVIG PA form (56KB PDF)
  

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J

K

• Knee Arthroscopy for Osteoarthritis - 91564 Reviewed 03/2010 (54KB PDF)
  

L

• Levonorgestrel-Releasing IUD (Mirena®) IUD - 91487 Updated 02/2010 (54KB PDF)
  
• Lipoprotein Testing  Discontinued 1/16/2009. See Cardiovascular Risk Markers - 91559 (140KB PDF)
  
• Lung Volume Reduction Surgery - 91472 Reviewed 10/2009 (125KB PDF)
  

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M

• MRI of the breast: Policy removed See AIM website for clinical guidelines
• Medical Necessity Determination - 91447 Reviewed 12/2009 (29KB PDF)
  
• Monochromatic Phototherapy (Anodyne Therapy/MIRE Therapy/Low Level Light Therapy) - 91486 Reviewed 06/2009 (115KB PDF)
  

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N

• Neocate: see Enteral Nutrition Therapy - 91278 (60KB PDF)
• Neuropsychological and Psychological Testing - 91537 Updated 10/2009 (64KB PDF)
  Revised with changes to coverage language; additions and deletions to list of what is not covered; prior authorization requirement removed.
  
• Never Events/Medical Errors - 91516  Updated 10/2009 (256KB PDF)
  Medicare Category of Conditions Table replaced by Medicare Hospital Acquired Conditions Table. Added new table titled: CMS Initiative Addressing Never Events. Present on Admission Indicators added to the coding information.
  
• Non-Acute Inpatient Services - 91332 Reviewed 10/2009 (127KB PDF)
  

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O

• Obesity - 91435  Updated 07/2009 (222KB PDF)
  
  • Bariatric Surgery Evaluation Authorization form Updated 12/2009 (891KB PDF)
  • Bariatric Surgery Authorization Form Updated 12/2009 (254KB PDF)
  • Medical Weight Loss Program PA form Updated 12/2009 (273KB PDF)
• Obstructive Sleep Apnea & Upper Airway Resistance Syndrome - 91333 Updated 11/2009 (145KB PDF)
  A consult must now be performed by a specialist at an "ABSM certified" sleep center. If polysomnogram or SMLT is not performed at a sleep center, referral for a "certified" sleep specialist consult is required.
  
• Oral Surgery - 91542 Reviewed 02/2010 (67KB PDF)
  
• Orthognathic Surgery - 91273 Reviewed 12/2009 (46KB PDF)
  
• Orthoptic and Pleoptic Training for Medicaid Members - 91500 Reviewed 12/2009 (31KB PDF)
  
• Orthotics: Shoe Inserts, Orthopedic Shoes - 91420 Reviewed 02/2010 (68KB PDF)
  
• Orthotics/Support Devices Policy - 91339 Updated 07/2009 (159KB PDF)
  

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P

• Palliative Care - 91558 Added 09/2009 (192KB PDF)
  
• PET scans: Policy removed See AIM website for clinical guidelines
  
• Brain imaging
• Cardiac imaging
• Oncology
  
• Panniculectomy/Abdominoplasty - 91444 Updated 02/2010 (43KB PDF)
  
• Parenteral Nutrition Therapy in the Home - 91517 Updated 09/21/2009 (137KB PDF)
  Revised with deletion to policy criteria; additions to specific malabsorptive conditions list.
  
• Pervasive Development Disorders, Including Autistic Spectrum Disorders - 91543 Updated 10/2009 (127KB PDF)
  Revised to add criteria for coverage and further explanation of criteria.
  
• Platelet Rich Plasma/Platelet Rich Fibrin Matrix - 91553 Reviewed 06/2009 (106KB PDF)
  

• Port Wine Stains and Vascular Malformations - 91413 Reviewed 02/2010 (107KB PDF)
• Prolotherapy - 91301 Reviewed 04/2009 (105KB PDF)
• Prophylactic Cancer Risk Reduction Surgery - 91508 Reviewed 02/2010 (61KB PDF)
  
• Prosthetics, External - 91306 Updated 04/2009 (182KB PDF)
  
• Psychological Evaluation and Management of Non-Mental Health Disorders - 91546 Updated 10/2009 (173KB PDF)
  Services will now be billed with a primary medical diagnosis in 15 minute units. Visit limits were deleted from the medical policy.
  
• Pulse Oximetry for Home Use - 91452 Reviewed 10/2009 (104KB PDF)
  

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Q

• QEEG - Quantitative Electroencephalogram - 91510 Reviewed 08/2009 (118KB PDF)
  

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R

• Radiofrequency Ablation for Back Pain - 91541 Reviewed 02/2010 (47KB PDF)
• Radiosurgery - 91127 Reviewed 08/2009 (129KB PDF)
  
• Recurrent Spontaneous Abortion - 91156 Reviewed 10/2009 (116KB PDF)
  
• Refractive Keratoplasty/Lasik - 91529 Reviewed 06/2009 (140KB PDF)
  
• Rehabilitative Medicine Services - 91318 Updated 01/2010 (158KB PDF)
  Updated due to a change in the law related to chiropractors.
  
• Renal Artery Stenosis - 91561 Reviewed 12/2009 (144KB PDF)
• Respite Care - 91321 Updated 10/2009 (123KB PDF)
  
• Robotically Assisted Surgeries - 91522 Reviewed 06/2009 (51KB PDF)

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S

• Septoplasty/Rhinoplasty - 91506 Reviewed 02/2010 (49KB PDF)
• Sexual Dysfunction and Impotence - 91160 Reviewed 02/2010 (61KB PDF)
• Skin Conditions - 91456 Updated 02/2010 (164KB PDF)
  Coverage of treatment for psoriasis updated to include phototherapy criteria; previously only addressed home phototherapy. Changed percentage under "covered when unresponsive to conventional treatment for severe disabling psoriasis (>30% of body)" to (>10% of body).
  
• Skin Substitutes - 91560 Updated 08/2009 (132KB PDF))
• Sleep Apnea-Obstructive - 91333 (131KB PDF)
• Speech Therapy - 91336 Reviewed 02/2010 (53KB PDF)
  
• Sperm and Oocyte Retrieval and Storage - 91393 Reviewed 10/2009 (119KB PDF)
  
• Spine Centers of Excellence - 91531 Reviewed 06/2009 (167KB PDF)
  
• Sterilization for Medicaid Members - 91501 Reviewed 12/2009 (31KB PDF)
  
• Stereotactic Radiosurgery: See Radiosurgery - 91127 (129KB)
• Stimulation Therapy and Devices - 91468 Updated 02/2010 (181KB PDF)
  A two-month trial for TENS for any diagnosis does not require prior authorization. Beyond the two-month trial, you will need prior authorization and must provide documentation. Exceptions apply.
  
• Synagis®/Palivizumab - 91429 Updated 10/2009 (153KB PDF)
  Criteria and tables added to reflect modified recommendations from the American Academy of Pediatrics Committee on Infectious Diseases.
  

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T

• Technology Assessment - 91430 Reviewed 06/2009 (111KB)
• Temporomandibular Joint Disorders (TMJD) - 91353 Reviewed 04/2009 (109KB PDF)
• Termination of Pregnancy, Elective - 91000 Reviewed 04/2009 (105KB PDF)
• Thermal Capsulorrhaphy - 91551 Reviewed 04/2009 (106KB PDF)
• Thermography - 91355 Reviewed 10/2009 (106KB PDF)
• Titanium Rib - 91505 Reviewed 02/2010 (53KB PDF)
• Tinnitus Retraining Therapy - 91482 Reviewed 06/2009 (107KB PDF)
• Total Hip Resurfacing - 91530 Reviewed 02/2010 (49KB PDF)
  
• Transcatheter Closure of Septal Defects - 91528 Reviewed 04/2009 (115KB PDF)
  
• Transplantation of Solid Organs - 91272 Updated 10/2009 (277KB PDF)
  
• Tumor Markers - 91562 Added 10/2009 (55KB PDF)
  

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U

• Umbilical Cord Blood Testing and Storage - 91459 Reviewed 06/2009 (100KB 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 - 91524 Updated 02/2010 (54KB PDF)
• Varicose Vein Treatment - 91326 Reviewed 06/2009 (137KB PDF)
• Ventricular Assist Devices (VADs) and Artificial Hearts - 91509 Updated 10/2009 (146KB PDF)
  Criteria for artificial hearts has been added to the policy. Medical policy name has been updated to include artificial hearts.
  
• Vertebroplasty/Kyphoplasty - 91479 Reviewed 06/2009 (52KB PDF)
• Virtual Colonoscopy: Policy retired 4/23/2008; see Colorectal Cancer Screening - 91547 (140KB PDF)
• Vision Care/Eye Exam - 91538 Reviewed 04/2009 (180KB PDF)

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W

X

Y

Z

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