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 January 1, 2010:

• Bone Density Studies - 91494 (173KB 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)

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Medical policies effective September 21, 2009:

• NEW Breast Specific Gamma Imaging - 91568 (109KB PDF)
• NEW Chemosensitivity Assays - 91566 (43KB PDF)
• Genetic Counseling, Testing, Screening - 91540 (216KB PDF)
  Revised to add further description of genetic counseling, genetic testing criteria, and genetic carrier testing criteria.
  
• NEW Palliative Care - 91558 (95KB PDF)
• Parenteral Nutritional Therapy in Home - 91517 (59KB PDF)
  Revised with deletion to policy criteria; additions to specific malabsorptive conditions list.
  
  

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Medical policies effective July 1, 2009:

• AxiaLif Axial Lumbar Interbody Fusion - 91549 (51KB PDF)
  Revised. Criteria for coverage removed and language for non-coverage added.
• Endoscopic Treatment of GERD and Barrett’s Esophagus - 91483 (134KB PDF)
  Revised. Clarifications added for what Priority Health does and does not cover for GERD and for Barrett’s Esophagus. Therapies for Barrett’s Esophagus explained; photodynamic therapy and thermal ablation descriptions added.
• IDET and Other Thermal Intradiscal Procedures (TIPs) - 91438 (52KB PDF)
  Revised. Description expanded; coverage removed for IDET and other TIPS for low back pain based on a lack of evidence of clinical improvement.
• NEW Knee Arthroscopy for Osteoarthritis - 91564 (54KB PDF)
• Orthotics: Shoe Inserts and Orthotic Shoes - 91420 (70KB PDF)
  Certain benefits now limited to members age 18 or less.
• Orthotics/Support Devices - 91339 (116KB PDF)
  Removed commercial and self-funded products pre-auth requirement.  Pre-auth still required for Medicaid and Medicare.

Back to the listing of current Medical Policies


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