Pending/retired/updated medical policy list
From time to time, we make changes to our medical policies. Priority Health makes changes available here for your review before they go into effect.
Our Medical Affairs Committee (MAC), comprised of network practitioners contracted with Priority Health, review and approve all new medical policies and changes to existing medical policies.
May 2025 policy updates
Unless otherwise noted, the May 2025 medical policy updates noted below go into effect June 1, 2025.
Medical policy | Details |
Autologous Chondrocyte Implant / Meniscal Allograft / Osteochondral Replacement (#91443) |
RETIRED. All procedures outlined in the policy are managed by TurningPoint, except for autologous cellular implant derived from adipose tissue, autologous adipose derived regenerative cell therapy, or autologous microfragmented adipose injection (e.g., Lipogems) for any musculoskeletal indication. This criterion will be moved to medical policy #91571 – Osteoarthritis of the Knee. For information on how to find TurningPoint’s clinical criteria, see Medical necessity criteria in our Provider Manual. |
Capsule Endoscopy (#91476) |
The exclusion of capsule endoscopy for Crohn’s disease management will be removed. Capsule endoscopy will be considered medically necessary for Chron’s disease management, as in suspected recurrence. |
Carotid and Intracranial Artery Stenting (#91495) |
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Colorectal Cancer Screening (#91547) |
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Cosmetic and Reconstructive Surgery Procedures (#91535) |
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Enteral Nutrition Therapy (#91278) |
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High Intensity Focused Ultrasound (#91601) |
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Implantable Heart Failure Monitors (#91610) |
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Intraoperative Neurophysiological Monitoring (#91646) |
Effective Aug. 1, 2025: I.B: Intraoperative neurophysiological monitoring will not be considered medically necessary for lumbar spinal fusion procedures. |
Osteoarthritis of the Knee (#91571) |
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Palliative Care (#91558) |
Deleted Table 1 and 1.A.D |
Speech Therapy (#91336) |
The Buffalo Model will be considered experimental and investigational for the evaluation and treatment of central auditory processing disorder (CAPD). |
Stem Cell or Bone Marrow Transplantation (#91066) |
Autologous hematopoietic stem cell transplantation for the treatment of multiple sclerosis, previously considered experimental and investigational, will be considered medically necessary when criteria are met. |
Stereotactic Radiosurgery (SRS) ad Stereotactic Body Radiotherapy (SBRT) (#91127) | RETIRED. All procedures outlined in the policy are managed by EviCore’s radiation oncology program. For information on how to find EviCore’s clinical criteria, see Medical necessity criteria in our Provider Manual. |
Termination of Pregnancy (#91000) |
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Thermal Capsulorrhaphy (#91551) |
RETIRED. All procedures outlined in the policy are managed by TurningPoint. For information on how to find TurningPoint’s clinical criteria, see Medical necessity criteria in our Provider Manual. |
Transcatheter Closure of Septal Defects (#91528) |
I.C: Ventricular septal defects is no longer an exclusion and has been added as an indication. |
Ventricular Assist Devices and Artificial Hearts (#91509) |
Effective Aug. 1, 2025: I.: Real-time at-home or remote monitoring of vitals (i.e., INR, blood pressure, weight, temperature, oxygen saturation) through Bluetooth or similarly-enabled or enhanced meters, blood pressure cuffs, scales, thermometers, pulse oximeters or similar devices will be considered not medically necessary, as such enhancements are for convenience. Priority Health will not reimburse for any additional costs or premiums associated with such enhancements over more conventional instruments not so equipped. |
February 2025 policy updates
Unless otherwise noted, the February 2025 medical policy updates noted below go into effect Mar. 1, 2025.
Medical policy | Details |
Allergy Testing / Immunotherapy (#91037) |
Note: The changes below were made for clarity and consistency with Priority Health’s current position on FDA-approved SLIT tablets. Additions:
Changes:
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Autism Spectrum Disorders (#91615) |
Note: The addition below does not represent a change. Language was added to the policy to clarify an existing Priority Health position. Additions:
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Digital Therapeutics (#91645) |
Additions:
Clarifications:
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End Stage Renal Disease (ESRD): Renal Dialysis (#91526) |
Deletions:
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Extracorporeal Shock Wave Therapy (ESWT) (#91527) |
Note: The update below isn’t a change in coverage. ESWT is currently not covered for any indication. Addition:
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Foot Care (#91121) |
Note: The change below isn’t a change in coverage. Clarification:
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Genetics: Counseling, Testing and Screening (#91540) |
Addition:
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Hearing Augmentation (#91544) |
Addition:
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Infusion Services & Equipment (#91414) |
Addition:
Deletion:
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Intraoperative Neurophysiological Monitoring (#91646) |
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Laster Interstitial Thermal Therapy (LITT) (#91640) |
Change:
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Markers for Digestive Disorders (#91583) |
Policy changes effective May 1, 2025 Addition / clarification:
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Medical Management of Obesity (#91594) | Retiring medical policy |
Multi-marker Tumor Panels (#91609) |
Retiring medical policy. Moving criteria to Genetics: Counseling, Testing and Screening (#91540) policy. Changes:
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Neuroablation for Pain Management (#91647) |
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Rehabilitative & Habilitative Medicine Services (#91318) |
Note: The addition below does not represent a change. Language was added to the policy to clarify an existing Priority Health position. Addition:
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Spine Procedures (#91581) |
Additions:
Deletions:
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Stimulation Therapy and Devices (#91468) |
Note: The additions below do not represent a change. Language was added to the policy to clarify Priority Health’s current position. Additions:
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Transcatheter Heart Valve Procedures (#91597) |
Clarifications:
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