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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.

Medical policies effective September 17, 2010

  • Genetics: Counseling, Testing and Screening - 91540 (99KB PDF)
    Added the specific tests that will be covered for chromosomal analysis or molecular testing, i.e. chromosomal microarray (CMA) or comparative genomic hybridization (CGH). Specific criteria added for the coverage of CADASIL Genetic Testing, which is considered experimental and investigational for most indications.
  • Hearing Augmentation - 91544 (133KB PDF)
    Added criteria for non-coverage of fully implantable middle ear hearing aids (i.e. Esteem®). They are considered experimental and investigational.
  • NEW Menorrhagia Treatment - 91575 (43KB PDF)
    This policy incorporates two previously separate policies: Endometrial Ablation Procedures for Menorrhagia - 91539 and Levongestrel-Releasing IUD (MIRENA®) for Menorrhagia - 91487
  • Skin Substitutes - 91560 (49KB PDF)
    Endoform Dermal Template® added to the list of skin substitute products that are considered experimental, investigational or unproven and are not a covered benefit.

Medical policies effective August 23, 2010:

Medical policies effective August 18, 2010:

  • Breast Related Procedures - 91545 (112KB PDF)
    If evaluation is needed for Bilateral Reduction Mammoplasty, it can now be done by a physician (no longer limited to just physiatrists). Removed the criteria indicating one of the following therapeutic measures must be completed: chiropractic care/physical therapy/exercises/posturing maneuvers/osteopathic manipulation.
  • Eating Disorders - 91007 (38KB PDF)
    Language added to clarify that behavioral health inpatient treatment requires prior authorization.
  • Hospice Care - 91520 (51KB PDF)
    Inpatient respite care for Medicaid members section updated.
  • Oral Surgery - 91542 (68KB PDF)
    Language added to clarify the intent of the policy related to treatment to correct congenital abnormalities of oral and or facial bones present from birth, i.e. cleft lip and or cleft palate. Treatments include Alveolar ridge closure and appliance for palatal expansion in preparation for bone graft surgery of the alveolar cleft.
  • Panniculectomy/Abdominoplasty - 91444 (42KB PDF)
    Documentation can now be completed by a treating physician, no longer only a dermatologist or infectious disease specialist. Medicaid criteria added to policy.
  • Pervasive Developmental Disorders, including Autistic Spectrum Disorders - 91543 (44KB PDF)
    "Member must be evaluated by the primary care physician" language deleted and replaced with "Member must be evaluated by a physician or specialist." Language indicating "*Prior auth (by member only) required for Initial Evaluation" was removed, as this is no longer a requirement.
  • Refractive Keratoplasty/LASIK - 91529 (48KB PDF)
    Intrastromal corneal ring segments (INTACS) removed from list of refractive surgeries that are not a covered benefit and criteria for coverage added.

    Medical policy effective August 11, 2010:

    • Transplantation of Solid Organs - 91272 (121KB PDF)
      Language related to the use of marijuana for medical purposes has been added to the policy/criteria section. Language also added to clarify the intent of the policy related to coverage of an ablative procedure (chemo or radiofrequency) for Hepatocellular Carcinoma (HCC) under Liver Transplants.

    Medical policies effective July 16, 2010:

    • Breast Related Procedures - 91545 (124KB PDF)
      Summary of addition: Microsurgical Lymph Node Transplantation for Postmastectomy Lymphedema, although considered experimental and investigational, may be covered if specific criteria are met. Requires prior authorization.
    • Infertility Diagnosis and Treatment/Assisted Reproduction/Artificial Conception - 91163 (66KB PDF)
      Summary of addition: Chemotherapeutic (drug) intervention (for infertility treatment) replaced with pharmacologic intervention which is limited and is outlined in the policy. Benefit plan descriptions, formularies, etc., need to be checked for details on which medications are covered, if any.
    • Transplantation of Solid Organs - 91272 (82KB PDF)
      Summary of additions: 1. Drug testing may be required at the discretion of Priority Health for patients with a history of substance abuse requesting approval for a transplant. 2. Much of the criteria in the policy have been removed and replaced with a statement that transplants are eligible for coverage when the transplanting institution’s selection criteria is met. 3. Liver Transplant criteria updated. 4. Intestinal Transplantation now reads:  Intestinal Transplantation, Small Bowel/Liver or Multivisceral (small bowel/liver and or stomach, pancreas, colon) Transplant. 5. Xenotransplantation language moved to a new location within the policy.
    • NEW Uterine Fibroid Treatment - 91573 (44KB PDF)

    Medical policies effective June 16, 2010:

    Medical policies effective May 20, 2010:

    Medical policies effective May 17, 2010:

    Medical policies effective May 1, 2010:

    Medical policies effective April 21, 2010:

    • Breast Related Procedures - 91545 (123KB PDF)
      Language deleted that breast reconstruction using the deep inferior epigastric perforator (DIEP) flap is not considered to be standard of care.
    • Endoscopic Treatment of GERD and Barrett's Esophagus - 91483 (135KB PDF)
      Criteria for non-coverage of Thermal Ablation Treatment for Barrett’s Esophagus deleted and criteria for coverage added.
    • Enteral Nutritional Therapy - 91278 (63KB PDF)
      Food thickeners that are medically necessary are now a covered benefit. Medicaid coverage updated to reflect Medicaid guidelines related to Enteral Nutritional Therapy. Several formatting changes made to make the coverage criteria clearer.
    • IVIG - 91514 (79KB PDF)
      Updated criteria related to common variable immunodeficiency (CVID). Updated the Standard Dosing Recommendations table. 
    • Obesity - 91435 (133KB PDF)
      Specific additional criteria previously required to be considered for a sleeve gastrectomy has been removed.

    Medical policies effective April 1, 2010:

    • Continuous Glucose Monitoring - 91466 (52KB PDF)
      The criteria for the use of continuous glucose monitoring systems (CGMS) has been changed. The prior auth requirement for CGMS has been removed. CGMS is not covered for Medicaid or Medicare members.

    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.

    Medical policies effective March 1, 2010:

    • Infusion Pumps - 91414 (56KB PDF)
      The criteria for Insulin pumps – ambulatory has been changed.  The prior auth requirement has been removed however, InterQual® criteria must be met and claims may be reviewed retrospectively. Pumps must be ordered by a participating provider.

    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).

    Medical policies effective February 23, 2010:

    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.

    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.

    Back to the listing of current Medical Policies


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    Last modified 08/23/10