Pending/retired/updated medical policy list

Deletions:

• Deleted I.B.21 - posterior nasal nerve ablation. This procedure is now considered medically necessary and addressed in new medical policy, 91653 – Posterior Nasal Nerve Ablation

Deletions:

• Removed benefit language for facial scar revision from medical necessity criteria section.
• Removed Blepharoptosis and Brow Ptosis Repair criteria, as applicable criteria are managed through InterQual.
• Removed the pediatric port wine stain (PWS) criterion for superficial PWS on head or neck for psychological or clinical prophylaxis.

Changes:

• Updated section title from Port Wine “Stains” to "Port Wine “Birthmarks” to reflect current terminology.
• Updated and clarified the clinical functional impairment documentation requirements require photographic documentation of the affected area.

Deletions:

• Removed the requirement for members to demonstrate compliance with equipment use, as applicable criteria are managed through InterQual.
• Removed preauthorization dollar-threshold language.

Additions:

• Added exclusion: Intermittent Pneumatic Compression devices (IPC)

Deletions:

• Deleted items 1-4 under I. A.

Additions:

• Updated table in section V. Regulatory (US Food and Drug Administration)

Deletions:

• Removed general exclusion for maternal complications in I.A, I.B, I.C and I.D
• Removed E.6.g exclusion for contraindications to surgery

Changes:

• Title changed to “Fetal Surgery”; types of procedures are now included in the policy scope 

Deletions:

• Removed prior authorization language in the medical necessity criteria section for home physician services.

Additions:

• Added examples of intermittent skilled nursing services, section to clarify services that may support medical necessity for home skilled nursing care.

Changes:

• Relocated non-covered service language to the applicable policy sections to improve clarity.

Deletions:

• A.: Deleted names of botulinum toxin preferred agents
• I. B.: Deleted benefit details

Additions:

• Added a definition of infertility.
• Added examples of medically necessary diagnostic testing and procedures for both female and male infertility evaluation.
• Added examples of medically necessary treatments for underlying causes of infertility in both females and males.
• Added examples of medically necessary assisted reproductive technology (ART) services when an applicable infertility rider or fertility benefit is present.

Changes:

• Reorganized infertility diagnostic services into separate female-factor and male-factor evaluation sections.
• Reorganized infertility treatment services into separate female-factor and male-factor treatment sections.
• Expanded and reorganized Assisted Reproductive Technology (ART) benefit requirements, inclusions, exclusions and limitations.

Clarifications:

• Clarified that coverage for infertility diagnostic, treatment, ART and fertility preservation services remains subject to member-specific benefits, riders and plan provisions.

Additions:

• Added a requirement that services meet generally accepted standards of safety and effectiveness to be considered medically necessary.
• Added Evidence-Based Standards section that describes the types of evidence utilized in medical necessity determinations.
• Added exclusions for the following: services lacking credible scientific evidence, convenience services, and non-medical services.

Clarifications:

• Clarified that medical necessity and coverage are separate determinations.
• Clarified that a provider's recommendation alone does not establish medical necessity.

Additions:

• Added annual quantity limits for therapeutic shoes and inserts for individuals with diabetes.
• Added criteria for replacement of pediatric orthopedic shoes, inserts, lifts, and related modifications when medically necessary due to growth, development, or changes in medical condition.

Changes:

• Relocated criteria for shoes, inserts, shoe lifts and modifications for leg length discrepancy and deformities in pediatrics.
• Updated leg length discrepancy criteria for members less than 18 years of age with no other congenital or neurologic abnormalities from ≥1 inch (2.54 cm) to 2-6cm.

Clarifications:

• Panniculectomy is considered medically necessary when applicable InterQual criteria are met.
• Abdominoplasty is considered medically necessary when applicable Priority Health criteria are met.

Deletions:

• Removed the limitation regarding concurrent use of botulinum toxin (Botox) and total parenteral nutrition (TPN) for gastroparesis.

Additions:

• Added exclusions for cannabinoid hyperemesis syndrome (CHS) and intravenous wellness, hydration, vitamin and nutrient infusion therapies.
• Added medical necessity criteria for intradialytic parenteral nutrition (IDPN), including end stage renal disease (ERSD)-related malnutrition, failure of appropriate nutritional interventions, and meeting applicable home parenteral nutrition criteria.
• Added exclusions for IDPN in members with acute kidney injury without end-stage renal disease (ESRD); and for concurrent IDPN and TPN therapy.

Changes:

• Updated home parenteral nutrition criteria by replacing the serum albumin requirement ( <3.4 g/dL) with provider-documented clinical evidence of malnutrition or nutritional risk.
• Increased the IDPN serum albumin threshold from <3.4 g/dL to <3.5 g/dL.

Clarifications:

• Clarified qualifying gastrointestinal condition criteria by separating malabsorptive disorders from gastrointestinal motility/anatomic disorders.
• Clarified requirements regarding failure of oral intake, enteral nutrition, and medical management prior to PN initiation.

Clarifications:

• SPRINT PNS is a unique device in that is intended for temporary (60-day) implantation to provide durable symptom relief. The FDA has uniquely classified this device. Sprint PNS has been moved from I. C. and is now addressed separately in I. E. Temporarily Implanted Peripheral Nerve Stimulators. It is considered not medically necessary.
• Updated Section III. BACKGROUND

Additions:

• Updated and expanded table in Section V. Regulatory (US Food and Drug Administration)

Additions:

• Expanded non-covered indications (e.g., dementia, lymphedema, and rheumatoid arthritis) and organized exclusions by clinical conditions.

Changes:

• Renamed the policy from Monochromatic Phototherapy (Anodyne/MIRE/LLLT) to Photobiomodulation (PBM) and Low-Level Light Therapy (LLLT).
• Revised coverage determination from investigational for all indications to medically necessary for prevention and treatment of oral mucositis when criteria are met.

Clarifications:

• Clarified that non-coverage for investigational indications applies regardless of terminology used, device type or treatment setting.

Deletions:

• I.B.1 and I.B.2 – Removed the requirement for completion of childbearing for prophylactic hysterectomy

Additions:

• I.C.1. – Added CHD1, PALB2, PTEN, STK11 and TP53 as genetic variants known to predispose a woman to breast cancer
• I.G – Added criteria for prophylactic proctocolectomy or colectomy

Additions:

• Scope
• Related Policies
• Guidelines / Position Statements
• Regulatory (US Food and Drug Administration)

Deletions:

• Removed Michigan-specific Medicaid and benefit coverage language.
• Removed the provider referral note allowing therapy services for up to 21 days or 10 treatments without a referral.

Additions:

• Updated cardiac rehabilitation criteria, defining stable chronic heart failure as left ventricular ejection fraction ≤35% with New York Heart Association (NYHA) Class II-IV symptoms.
• Updated cardiac rehabilitation criteria to specify that acute myocardial infarction must have occurred within the previous 12 months to qualify for cardiac rehabilitation.
• Added Heart-Lung transplantation as a qualifying diagnosis for cardiac rehabilitation.

Deletions:

• Deleted I.A.4.b – posterior nasal nerve ablation. This procedure is now considered medically necessary and addressed in PH Medical Policy 91653 – Posterior Nasal Nerve Ablation

Deletions:

• Removed the requirement for 15 or more lesions for chemical peel coverage.
• Removed the exclusions related to pregnancy/lactation and history of keloid formation.
• Removed specific medications listed for the treatment of rosacea.

Additions:

• Added medical necessity criteria and exclusions for photodynamic therapy (PDT), including treatment of actinic keratoses, cutaneous squamous cell carcinoma in situ (Bowen disease) and low-risk superficial basal cell carcinoma.
• Added medically necessary criteria for vulvar and labial surgical procedures, including treatment of malignancy and premalignant disease.
• Expanded exclusions for keloid treatment (platelet-rich plasma, regenerative medicine therapies, Botox and laser-assisted drug delivery).

Changes:

• Updated chemical peel criteria by replacing topical therapy failure requirement with broader language, allowing treatment when conventional therapies are not feasible, contraindicated or have failed.
• Renamed “Labial Hypertrophy” section to “Vulvar and Labial Surgical Procedures”.

Clarifications:

• Clarified limitations, exclusions and age-specific requirements for psoriasis phototherapy, office-based phototherapy, and targeted UVB therapy.
• Clarified that pulsed dye laser is medically necessary only for nail psoriasis.

Deletions:

• Removed age limitation for RECELL® treatment of burns to align with current FDA indications.

Changes:

• Reclassified Kerecis® as medically necessary for diabetic foot ulcers when medical necessity criteria are met.
• Reclassified SkinTE® from "Not Separately Payable" to "Not Medically Necessary”.

Clarifications:

• Clarified that covered Grafix® products include Grafix PL Core™ and Grafix PL Prime™ in addition to Grafix Core® and Grafix Prime®.

Deletions:

• Deleted redundant exclusions in Non-Covered Electrical Stimulation Therapies

Additions:

• Added Policy scope.
• Added section II. Centers for Medicare & Medicaid Services (CMS) Coverage Determination
• Added section IV. Guidelines / Position Statements
• Added section V. Regulatory (US Food and Drug Administration)
• Added formal citations for guidelines and position statements to section IX. References

Changes:

• Updated related policies

Changes:

• I.A.1. – changed the age range from 22-70 years to ≥18 to align with new American Academy of Sleep Medicine guideline recommendation

Deletions:

• I.B.1 and 1.C.1 – Removed the requirement for the fibroid to be palpable in the abdomen
• I.C.6 – Removed the requirement for provider training and certification on Sonata

Additions:

• Policy scope
• Background: Added discussion of corneal collagen cross linking (CXL)
• Guidelines/Position Statements: Added three guidelines that address corneal collagen cross linking
• Regulatory: Updated table. Added FDA labeling for EPIOXA™ HD and EPIOXA™
• References: Added references for corneal collagen cross-linking

Clarifications:

• Moved refractive keratoplasy from Exclusions to its own section, referencing medical policy 91529 Refractive Keratoplasty

Additions:

• Added Section I. C. Exclusions (comprehensive micronutrient panels, intracellular micronutrient analysis, and similar)

Updated:

• III BACKGROUND: Comprehensive Micronutrient or Intracellular Nutrient Testing

Retired policy

This medical policy will be retired and its content will be migrated into a billing policy.

Deleted:

• Removed tobacco use as exclusion for Eustachian tube balloon dilation (ETBD)

Added:

• Medical necessity criteria for recurrent acute rhinosinusitis
• Medically necessity criteria for chronic obstructive Eustachian tube dysfunction in pediatrics

Changed: 

• Removed age criteria of 18 and up for eustachian tube dysfunction (New section addresses pediatric members age 8-17).
• Removed the strict ≥3‑month predefined medical therapy regimen requirement for chronic rhinosinusitis, allowing individualized, patient‑centered medical management prior to surgery
• Symptom duration threshold for ETBD (6 → 3 months)

Retired policy

This policy is being retired as Bronchial Thermoplasty (BT) is sunsetting as a treatment option for severe asthma due to device discontinuation, declining clinical utilization, and a shift in asthma management toward precision based medical therapy including biologic (anti-IgE, anti-IL5/5R, anti-IL4R) and pharmacologic therapies (small molecule therapies (e.g., JAK1 inhibitors).

Changed:

• Carotid artery stenting: Priority Health considers stenting of the carotid artery medically necessary when the applicable InterQual® criteria are met
• Intracranial angioplasty and stenting: Priority Health considers intracranial angioplasty and stenting medically necessary when the applicable InterQual® criteria are met
• Priority Health considers intracranial balloon angioplasty, including transcatheter of placement of intracranial intravascular stents, medically necessary when applicable InterQual® criteria are met

Changed: 

• VI. CODING: The table now lists only active Category III “T” codes that do not appear in another Priority Health or utilization management delegate medical policy or guideline.

Clarified: 

• I. MEDICAL NECESSITY CRITERIA
• Moved titles of relevant American Medical Association guidance to IV. GUIDELINES / POSITION STATEMENTS.

Clarifications: 

• Updated website links to Pharmacy drug webpage and site of service information webpage

Clarified:

• Blood-based assays that detect SEPT9 (Septin9) DNA promoter methylation (e.g., colorectal cancer): Managed by EviCore (already indicated in Priority Health Medical Policy 91540 Genetics: Counseling, Testing, Screening).
• Additional genetic colorectal cancer tests are managed by EviCore (Lab Management Program), as indicated in Priority Health Medical Policy No. 91540 - Genetics: Counseling, Testing, Screening. Any test may or may not be considered medically necessary for colorectal cancer screening (already indicated in Priority Health Medical Policy 91540 Genetics: Counseling, Testing, Screening).
• BeScreened™-CRC (Beacon Biomedical Inc) blood-based colorectal cancer screening test, is considered experimental and investigational (already indicated in Priority Health Medical Policy 91540 Genetics: Counseling, Testing, Screening).

Added: 

• Exclusions for ENT, cranial / maxillofacial and neurosurgery procedures

Deleted: 

• Outdated references

Added:

• Computerized dynamic posturography for vestibular rehabilitation applications is considered E/I/U
• Updated background information and references

Added: 

• ICD-10: L91.0 - Hypertrophic scar for fractional ablative laser treatment as medically necessary  diagnosis under “V. Coding Information” section

Changes:

• Updated language to clarify Section “E”: Scar Revisions and Removal, specifically facial scar revision and post-burn hypertrophic and traumatic scars. Prior Authorization will be required.
• Moved the statement regarding fractional ablative laser treatment for keloid scars from the Hypertrophic and traumatic scars section (E.3) to the keloid section (E.2)

Deleted:

• Removed Medicaid‑specific language under exclusions for self‑help and adaptive aids.

Added:

• Added HCPCS A7523 (tracheostomy shower protector) to the not medically necessary coding section.
• Added billing policies and related policies for cross‑reference.

Changes:

• Moved continuous passive motion (CPM) devices for total knee arthroplasty and rotator cuff repair from medically necessary to not medically necessary for all indications.
• Updated the background and references to reflect current evidence and professional society guidelines.

Added:

• Site specific exclusions per society guidelines
• Robotic assisted/computer enhanced ESD platforms are explicitly classified as experimental/investigational

Changed:

• Gastric region: updated indications as they were broad and aligned them with society guidelines
• Colon/rectum: updated criteria from size-alone to morphology + suspected SMI
• Duodenum/small bowel: eliminated broad coverage and aligned with society guidelines.
• Replaced broad indications with guideline-style inclusion features (size + histology + ulceration + invasion depth) for Esophagus site. Split into two distinct pathways with specific thresholds and staging language for Esophageal squamous cell carcinoma / esophageal dysplasia and Early-stage (T1) esophageal adenocarcinoma / Barrett’s dysplasia

Clarified:

• Reorganized criteria into general requirements plus detailed site-specific criteria (esophagus, stomach, colorectal, duodenal/small bowel).
• Replaced vague indications (e.g., “polyps not removable by snare,” “submucosal masses,” “recurrent lesions”) with explicit guideline-based thresholds (size, histology, ulceration status, depth of invasion, need for en bloc resection).

Changed: 

• Digestive enzyme (lipase) cartridge (e.g., RELiZORB Immobilized Lipase Cartridge, Alcresta Therapeutics): Labeling has expanded to include neonates and infants. Accordingly, 1 year age limitation has been removed.

Removed:

• 0108U, as this code is located in specific policy: Gastroesophageal Reflux Disease (GERD) and Barrett’s Esophagus.
• 52284, as this code is located in specific policy: Benign Prostatic Hyperplasia (BPH) Treatments and Urethral Stricture Treatments - 91642

Added:

• 0248U: Oncology, spheroid cell culture in 3D microenvironment, 12-drug panel, brain- or brain metastasis-response prediction for each drug
• 0249U: Oncology (breast), semiquantitative analysis of 32 phosphoproteins and protein analytes, includes laser capture microdissection, with algorithmic analysis and interpretative report

Added:

• Extracorporeal Shock Wave Lithotripsy as a medically necessary for treatment of  pancreatic duct stones, gallbladder stones, common bile duct stones
• Salivary Gland or Salivary Duct Stones indication

Updated: 

• Background and references section

Clarified: 

• Section “B”- Updated for clarification: Tumor In Vitro Chemoresistance and Chemosensitivity Assays are considered experimental and investigational and not medically necessary for brain- or brain metastasis and breast cancer. Other In Vitro Chemoresistance and Chemosensitivity Assays are vendor managed (EviCore).

Additions: 

• Added in Section “II” (Centers for Medicare & Medicaid Services (CMS) Coverage Determination) section: Advanced Diagnostic Laboratory tests under Medicare Clinical Laboratory Fee Schedule.
• Appendix A added back to policy

Deleted: 

• Removed “B” regarding clinical trial information: “Intraperitoneal hyperthermic chemotherapy (IPHC) also known as Hyperthermic Intraperitoneal Chemotherapy (HIPEC) not recommended by NCCN may be covered as part of a clinical trial when the criteria of the Clinical Trials medical policies #91606 or #91448 are met."

Added: 

• Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC)- E/I/U

Changed: 

• Updated name to capture inclusion of pressurized intraperitoneal aerosol chemotherapy
• Updated policy scope to include PIPAC

Deleted: 

• Statement that NanoKnife is not FDA approved for cancer treatment

Updated: 

• Background and references, including information on the PRESERVE study

Changed:

• Moved Section “C” (Anesthesia and moderate sedation for all other pain management services are not covered unless done with a surgical procedure) and combined with section “B”
• Updated background section for clarity

Removed:

• Removed the following under medical necessity: “RFA procedures are limited to two per year. RFA procedures beyond two per year require medical review.”

Changed:

• Moving conventional sacroiliac (SI) Joint Radiofrequency from E/I/U to medically necessary when criteria is met. Prior Authorization required.
• Updated E/I/U: Cooled radiofrequency ablation (e.g., Coolief) for all indications (except Knee OA. See Priority Health medical policy #91571: Osteoarthritis of the Knee)

Added:

• Medical necessity criteria for repeat RFA for back and neck pain
• Expanded not medically necessary to include nerve cryoablation (such as intercostal nerve cryoablation) and cryodenervation.

Changed: 

• Genicular nerve RFA moving from not medically necessary to medically necessary when criteria is met. Prior Authorization Required.

Added: 

• Covered treatments for OA of the knee: Partial or total knee arthroscopy
• Additional non medically necessary treatments for knee OA-Transcutaneous electrical nerve stimulation (TENS), Neuroablative therapies (e.g.,cryoneurolysis), biomechanical shoe‑based devices, implanted shock absorbers (e.g., MISHA®), synthetic cartilage implants, low‑level laser therapy, and prolotherapy.

Deleted: 

• Related policy that was retired (Autologous Chondrocyte Implant/Meniscal Allograft).

Retired policy

This medical policy will be retired, and its content will be migrated into a billing policy.

Deleted:

• Outdated references

Added:

• Expanded policy scope to include POEM for: Zenker’s Diverticulum and select non-achalasia spastic motility disorders, with medical necessity criteria.

Changed: 

• Revised select exclusions in Section 1.3 (e.g., prior esophageal surgery or irradiation) from absolute exclusions to case‑by‑case clinical considerations

Clarified:

• Language added/removed/changed to better explain criteria guidelines
• Updated layout for inclusions, exclusions, limitations sections.

Removed:

• Removed MI Medicaid-specific language

Clarified:

• Use of InterQual criteria for medical necessity determination of: Lower extremity prosthetics; Electrically powered, externally powered, and/or microprocessor controlled

Added:

• Medically necessary tests / studies / indications for evaluation and treatment of recurrent pregnancy loss (RPL)
• Not medically necessary tests / studies for evaluation and treatment of RPL

New policy

This new policy outlines the medical necessity criteria required to support providing medical procedures in a hospital outpatient department (HOPD) vs an ambulatory surgery center (ASC) or physician office. Note: this policy doesn’t address medical necessity for individual medical procedures, and it doesn’t apply to emergency services or inpatient procedures.

Removed:

• Cymetra when used for treatment of vocal cord paralysis. This product is discontinued.

Added:

• Skin substitutes for Burns-Biobrane- glove; Integra® Meshed Bilayer Wound Matrix (MBWM), ReCell
• Skin substitutes for DFU- AlloPatch Pliable, AmnioBand®
• Skin substitutes for VLU- AmnioBand®
• Diagnosis: Dystrophic Epidermolysis Bullosa and medical necessity criteria

Changed:

• Reorganized the policy to an indication-based structure with medical necessity criteria. Prior Authorization required.
• Moved Integra® Omnigraft Dermal Regeneration Matrix to ulcer indications only, as this product is FDA indicated for ulcers.
• Moved Integra® Bilayer Matrix Wound Dressing (“Integra® Bilayer Wound Matrix”) from severe burn treatment to second degree burn treatment, per FDA guidelines
• Moved Integra Meshed Bilayer Wound Matrix from severe burn treatment to second degree burn treatment, per FDA guidelines
• Reclassified application of skin cell suspension (15011-15018, C8002) from not covered, to medically necessary for burn indications when medical criteria is met.

New policy

This new policy applies to Medicare Advantage (MA) plans only. It addresses SSBCI – supplemental benefits that aren’t primarily health-related and may be offered to eligible members. The policy:

• Lists comorbid and medically complex chronic conditions considered to be life threatening or that significantly limit overall health or function
• Specifies when an MA member is at high risk of hospitalization of other adverse health outcomes
• Specifies when an MA member requires intensive care coordination

Added: 

• Not medically necessary (E/I/U) indication: Central Auditory Processing Disorder

Changed: 

• Removed required number threshold for therapy services related to acquired hearing loss to align with society guidelines..

Clarified: 

• Updated layout of policy and language for clarity

Removed:

• I.A.2.a.: Removed exclusion for persistent or active substance or alcohol abuse
• Stem Cell Transplant for Autoimmune Diseases: removed lower age limit of 18 for autologous hematopoietic stem cell transplantation for the treatment of multiple sclerosis

Added:

• Stem Cell Transplant for Multiple Myeloma, Amyloidosis or Polyneuropathy, Organomegaly, Endocrinopathy, Monoclonal gammopathy and skin changes (POEMS syndrome): added risk-adapted criteria for tandem therapy for multiple myeloma

New policy

This policy outlines medical necessity criteria, limitations, and exclusions for surgical dressings and surgical wound care supplies, when a qualifying wound is present.

Removed:

• Copay specifications

Changed: 

• Percutaneous transcatheter closure of congenital atrial septal defect is considered medically necessary when InterQual® criteria have been met

Clarified: 

• Clarified exclusions to transcatheter closure of septal defects

Deleted: 

• 1.A.5 Removed length of time (3 month) requirement for patients with a history of substance abuse prior to transplant approval

Changed: 

• Updated the policy title to reflect a comprehensive tinnitus management framework.

Added:

• Inclusions and exclusions
• Exclusions include acupuncture, biofeedback, brain implant, cognitive behavioral therapy, deep brain stimulation (DBS) neuromodulation, psychedelic- assisted therapy, sound therapy, including transmeatal laser irradiation

• Insertion of an extracorporeal left ventricular assist device is considered medically necessary when the applicable InterQual® criteria are met.

• Insertion of an intracorporeal left ventricular assist device is considered medically necessary when the applicable InterQual® criteria are met:
• Criteria for insertion of a percutaneous left ventricular assist device have been modified

Additions:

• Updated the policy name to include urethral stricture treatment
• Urethral Stricture: cystourethroscopy with mechanical urethral dilation and urethral therapeutic drug delivery by drug-coated balloon (Optilume) catheter for recurrent bulbar strictures is considered medically necessary when specified criteria are met

Added non-covered services:

• Electrical stimulation therapy (e.g., TENS, PTNS)
• Acupuncture (e.g., Laser acupuncture (LAT)
• Tuina (Massage) therapy
• Artificial Intelligence (AI) wearable devices
• Hypnotherapy
• Psychotherapy
• Chiropractic treatment

• Added Extracorporeal Shock Wave Lithotripsy as medically necessary for the treatment of urolithiasis
• Clarification: Policy was restructured to specify the addition of extracorporeal shock therapy (lithotripsy) may be considered medically necessary, and to indicate extracorporeal shock wave therapy conditions that are considered not medically necessary
• Added non-covered services:
  • Coronary Artery Disease
  • Peripheral Artery Disease
  • Lymphedema
  • Multiple Sclerosis
  • Spasticity
  • Stress Urinary Incontinence

• Deletion: Removed “History of Barrett’s Esophagus” as an exclusion for the Magnetic sphincter augmentation (MSA) with the LINX procedure
• Clarification: Added non-covered treatments for GERD Including the following: acupuncture, non-Invasive post -prandial anti-reflux devices, lower esophageal sphincter (LES) electrical stimulation, antireflux mucosal intervention (ARMI) procedures (i.e., antireflux mucosectomy (ARMS) and antireflux mucosal ablation (ARMA))

• Removed exclusion of gastric peroral endoscopic pyloromyotomy or myotomy (G-POEM). The G-POEM procedure for refractory gastroparesis is considered medically necessary when medical policy criteria are met.
• Added G-POEM to the background section

New policy

• This medical policy addresses histotripsy (i.e., non-thermal ablation via acoustic energy delivery) for the treatment of malignant tumors (including the Edison Histotripsy System (HistoSonics)).
• Histotripsy is considered medically necessary when medical policy criteria are met

• Clarification: Added in conditions for clarification that external infusion pumps may be covered for
• Deletion: Deleted exemptions for site of service review, as they’re being moved to a pharmacy policy

Clarifications:

• Restructured Medical Necessity Criteria section for clarity
• Genioplasty is considered NOT medically necessary:
  • When NOT associated with obstructive apnea, or
  • When performed for the sole purpose of improving individual appearance and profileException: Genioplasty may be considered medically necessary when performed as a component of a comprehensive facial feminization or facial masculinization service performed as an adjunct to gender affirming surgery following a diagnosis of gender dysphoria: (see Priority Health Medical Policy Gender Affirming Surgery – 91612).

• Clarification: Powered upper extremity range of motion assist devices (includes microprocessor, sensors, all components and accessories), custom fabricated (myoelectric devices), are excluded.
• Change: Medical necessity for the following will be assessed by applying InterQual® CP:Durable Medical Equipment criteria:
  • Orthoses, Lower Extremity, Knee-Ankle-Foot (KAFO) and Ankle-Foot (AFO)
  • Orthoses, Thoracic, Lumbar, and Sacral Spine
  • Orthoses, Upper Extremity
• Clarification: Medical necessity for the following is assessed by applying InterQual® CP:Durable Medical Equipment criteria:
  • Orthoses, Cranial Remodeling
  • Orthoses, Lower Extremity, Knee