Pending Medical Policy Updates

From time to time, we make changes to our medical policies. Priority Health makes them available here for your review before they go into effect.

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Medical policies effective March 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.
  
• NEW Gastroparesis Testing and Treatment - 91572 (42KB PDF)
  New policy outlining what is covered versus not covered for the evaluation and diagnosis of gastroparesis. Also contains coverage information regarding treatment of gastroparesis.
  
• NEW Patellofemoral Replacement for Isolated Osteoarthritis of the Knee - 91571 (48KB PDF)
  New policy reflecting the use of patellofemoral replacement for isolated patellofemoral osteoarthritis has not been proven to be effective. PFR is considered investigational/unproven in nature, and therefore, is not a covered benefit.
• NEW Pharmacogenomics Testing - 91570 (53KB PDF)
  New policy outlining various pharmacogenomic tests including what is covered and not covered.
  
• NEW Transcranial Magnetic Stimulation for Depression - 91563 (59KB PDF)
  New policy outlining coverage criteria for use of transcranial magnetic stimulation for depression. Policy also includes absolute contraindications, relative contraindications, limitations and exclusions and provider requirements.
  

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Medical policies effective February 25, 2010:

• Skin Conditions - 91456 (139KB 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).
  

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Medical policies effective February 23, 2010:

• Genetics: Counseling, Testing and Screening - 91540 (114KB PDF)
  Language added to clarify the intent of Prognostic Testing and who should be ordering.
• Levonorgestrel-Releasing IUD (Mirena®) - 91487 (54KB PDF)
  The levonorgestrel-releasing intrauterine system (Mirena®) is a covered benefit for menorrhagia. Previous language stating "when standard medical therapies for menorrhagia, including oral contraceptives, have failed" has been removed.
  
• Vagal Nerve Stimulation for Depression - 91524 (54KB PDF)
  Language updated to reflect that the use of vagal nerve stimulation is an FDA-approved treatment for treatment-resistant depression.
  

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Medical policies effective February 1, 2010:

• Genetics: Counseling, Testing & Screening - 91540 (114KB PDF)
  Our current medical policy covers genetic counseling but does not require pre-test counseling by a board-certified provider/genetic counselor. To align our policy with nationally established guidelines for appropriate testing protocols, this requirement has been added to medical policy 91540, Genetics: Counseling, Testing  and Screening, for certain tests, effective 02/01/2010. Please refer to the medical policy for more information.
• Stimulation Therapy and Devices - 91468 (181KB PDF)
  A two month trial for TENS for any diagnosis does not require prior authorization. Prior authorization beyond the two month trial is needed and will require documentation. Exceptions apply. Please refer to the medical policy for more information.
  

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Medical policies effective January 1, 2010:

• Bone Density Studies - 91494 (70KB PDF)
  Priority Health will limit coverage for BMD studies to central DXA only. Central DXA will now be the only study covered in any setting.
  

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Medical policies effective November 20, 2009:

• Cosmetic and Reconstructive Surgery Procedures - 91535 (149KB PDF)
  Labial hypertrophy added to non-covered conditions list in the policy.
  
• Obstructive Sleep Apnea & Upper Airway Resistance Syndrome - 91333 (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.
  
• Skin Conditions - 91456 (164KB PDF)
  Labial Hypertrophy added to the medical policy and is not a covered benefit.
  

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Medical policies effective October 19, 2009:

• Neuropsychological and Psychological Testing - 91537 (64KB PDF)
  Revised with changes to coverage language; additions and deletions to list of what is not covered; prior authorization requirement removed.
  
• Pervasive Developmental Disorders - 91543 (126KB PDF)
  Revised to add criteria for coverage and further explanation of criteria.
  
• NEW Tumor Markers - 91562 (152KB PDF)

Back to the listing of current Medical Policies


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