Pending/retired/updated medical policy list

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.

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.

August 2023 policy updates

Medical policy Details
Autologous Chondrocyte Implant / Meniscal Allograft (91443)

Clarification: Revised language describing procedures (I. A through F).

Addition: Added Carticel and MACI as examples of Autologous chondrocyte implants
Behavioral Health Residential Treatment (91625) Addition: Nursing services requirements specified according to facility type
Bronchial Thermoplasty (91577) Deletion: Replaced “asthma case management” with “care management”
Carotid and Intracranial Artery Stenting (91495) Deleted the following criterion for carotid artery stenting: “Patient must have a reference vessel diameter within the range of 4.0 mm and 9.0 mm at the target lesion”
Cellular and Gene Therapy (91638)

NEW policy

This new policy is applicable only to Commercial and Medicare to address questions around cellular and gene therapies, including CAR T cell class. The policy documents existing processes and criteria. There are no changes to current operations or criteria.
Detoxification (91104) Addition: There must be a licensed physician staffed and on-call around the clock. Nursing/medical services to include on-site nursing services 24-hours-per-day for those beneficiaries who are in the detoxification process, and who require medications to manage the current crisis
Durable Medical Equipment (91110) Addition: Non-pneumatic compression devices are not medically necessary due to insufficient evidence of effectiveness in improving long-term health outcomes
End Stage Renal Disease (91526) Addition: Both the Ellipsys™ Vascular Access System (Medtronic) and the WavelinQ™ EndoAVF System (BD) may now be considered medically necessary.
Genetics: Counseling Testing Screening (91540)
 Clarification: Distinguished that eviCore manages prior authorization of PGD genetic tests while and embryo biopsy (CPT codes 89290 and 89291) is through Priority Health. No change in prior authorization or process.
Home Care (91023) Addition: Expanded allowable practitioners who can establish and review a care plan
Home Prothrombin Time or INR Monitoring (91507) Clarification: Prothrombin time (PT) monitoring or International Normalized Ratio (INR) for direct oral anticoagulants or low molecular weight heparin is not medically necessary. This is not a new restriction. It is a clarification of appropriate use.
Infertility Diagnosis and Treatment / Assisted Reproduction / Artificial Conception (91163) Clarification: Replaced “covered benefit” with “medically necessary” where appropriate.
Intravascular Lithotripsy (91639)

NEW policy

Effective 10/23/2023. Service codes C9764-C9767 (limb perfusion in the proximal lower extremities) are covered for all plan types. Service codes C9772-C9775 (interventions in the distal aspect of the lower extremity) are not medically necessary and will not be separately payable for Commercial and Medicaid.
Obstructive Sleep Apnea (OSA) (91333) Addition: Unattended sleep study/sleep apnea testing/sleep monitoring using a device that measures 3 or more channels that include pulse oximetry, actigraphy, and peripheral arterial tone (e.g., WatchPAT™ device) may be considered medically necessary.
Orthotics: Shoe Inserts, Orthopedic Shoes (91420)

Addition:

  • Therapeutic shoes and inserts for persons without diabetes are requested/billed using “L” codes. (Specific “L” codes may be non-covered for certain products—see product limitations at bottom of section VI. CODING INFORMATION.)
  • Added parentheticals: Orthopedic shoes (1 pair per plan year) and inserts (3 pair per plan year) may be covered if any of the following applies.
Prostatic Urethral Lift & Transurethral Water Vapor Therapy for BPH (91626)
 Addition: Medical necessity criteria for transurethral waterjet ablation/Aquablation. Prior authorization is not required. Aquablation is currently covered by Medicare through an existing WPS LCD. This change impacts Commercial, which previously did not cover this procedure.
Rehabilitative & Habilitative Medicine Services (91318) Clarification: Moved maintenance therapy exclusions to I.E and clarified rehabilitative services exclusion. The change is only to clarify that exclusion language is specific to Commercial plans and not intended to reflect Medicaid or Medicare positions on maintenance therapy. No process changes, current exclusions remain the same.
Surgical Treatment Lymphedema and Lipedema (91631) Addition: The use of bioimpedance spectroscopy in the detection, diagnosis, or surveillance of primary lymphedema or non-cancer related lymphedema is not medically necessary.
Surgical Treatment of Obesity (91595) Deletion: Removed reference to Medicaid in criteria specific to medical weight management program requirement.
Transurethral Radiofrequency Micro-Remodeling (Renessa) For Stress Urinary Incontinence (91578) RETIRED
Vitamin Testing (91624) Addition: Policy was previously limited in scope to serum vitamin D testing (25-hydroxyvitamin D; [25(OH) D]; calcidiol). Scope has now been expanded to include serum vitamin B-12 testing (cyanocobalamin). Title of policy has been changed to reflect broader scope.
Autism Spectrum Disorders (91615) Clarification: The diagnostic evaluation for ABA autism treatment should include evidence of a multimodal assessment that contains caregiver(s) reports, record, collateral reports, data gathered from utilization of standardized psychological tools, and an observational assessment to determine diagnostic and clinical impressions.

May 2023 policy updates

Unless otherwise noted, the May 2023 medical policy updates go into effect May 2023.

Medical policy  Details
Panniculectomy / Abdominoplasty (#91605)
 Abdominoplasty (CPT 15847) will require prior authorization effective July 24, 2023.

Unless abdominal wall laxity interferes with activities of daily living and causes a functional impairment, abdominoplasty is considered cosmetic and not medically necessary.

Procedure was previously allowed if prior authorization was approved for the primary procedure, Panniculectomy.
Thyroid-Related Procedures (#91621)
 Thyroid molecular diagnostic tests (CPT codes 81546, 0026U, 0245U, 0204U, 0018U, 0287U and 81210) will require prior authorization effective July 24, 2023.
Computerized Dynamic Posturography (#91637)
 New medical policy created to support reduction of coverage for Computerized Dynamic Posturography (CPD).

CDP for the diagnosis of vestibular disorders is experimental and investigational due to insufficient evidence of efficacy. While CDP has been available for many years, no trials evaluated the accuracy of its diagnostic performance or impact on diagnostic decision-making or health outcomes for its use in the diagnosis of vestibular disorders.

CPT codes 92548 and 92549 will no longer be covered effective July 24, 2023.
Category III/T Current Procedural Terminology (CPT®) Codes (#91636)
 New policy to establish Priority Health’s default position: Category III "T" codes are not medically necessary unless addressed in another policy.

This policy is effective May 23, 2023.
Breast Related Procedures (#91545)
 The use of bioimpedance spectroscopy is medically necessary for secondary, subclinical (Stage 0 or 1) breast cancer related lymphedema. This change in position is based on the 2023 NCCN Survivorship guidelines. Medical necessity is limited to diagnosis of cancer, other indications remain not medically necessary; also remains as no prior authorization.
Gender Affirming Surgery (#91612)
 Specific procedures that may now be considered medically necessary, but only when performed as part of a component of a comprehensive facial feminization or facial masculinization service performed as an adjunct to gender affirming surgery (items I.A - C) following a diagnosis of gender dysphoria.

An isolated blepharoplasty, brow lift or rhinoplasty, not completed as a component of a comprehensive feminization or masculinization service, is subject to the terms, conditions, limitations and medical necessity criteria specified in Priority Health Medical Policy #91535 – Cosmetic and Reconstructive Surgery Procedures.
Markers for Digestive Disorders (#91583)
 Updated position on anti-drug antibodies to infliximab, adalimumab, vedolizumab or ustekinumab from experimental and investigation to medically necessary if criteria are met. Measurement of anti-drug antibodies are medically necessary for dose escalation. However, routine, or serial testing are not medically necessary.
Percutaneous Left Atrial Appendage Closure (#91605)
 Medical necessity criteria for Percutaneous Left Atrial Appendage Closure have changed from Priority Health criteria to InterQual® criteria. Effective July 10, 2023.
Implantable Loop Recorder (#91618)
 Medical necessity criteria for implantable loop recorders have changed from Priority Health criteria to InterQual® criteria. Effective July 10, 2023.
Cardiovascular Defibrillators (#91410) Deleted pacemakers and pacemaker from the policy scope.
Cosmetic and Reconstructive Surgery Procedures (#91535) Added abdominoplasty to the list of cosmetic procedures.
Enteral Nutrition Therapy (#91278) Clarification: Formulas, food products and supplements that do not require a physician’s order are a covered benefit (e.g., grocery products for a low-protein diet) only when said formula, food product or supplement is designed and intended solely for the dietary management of an inborn error of metabolism (IEM).
Experimental / Investigational / Unproven Care / Benefit Exceptions (#91117)

Additions:

  • The drug, device, treatment or procedure is not widely used and generally accepted as standard medical care for the condition, disease, illness or injury being treated as reported in nationally recognized peer-reviewed medical literature published in the English language are experimental, investigational or unproven.
  • Definition of peer-reviewed literature.
  • Category III code is considered experimental, investigational and unproven unless there is a Priority Health medical policy that specifically addresses coverage or medical necessity.

Deletion:

  • Appendix B. Moved the Appendix to Category III Procedural Terminology (CPT®) Codes policy #91636
Hemophilia Management (#91569)
 Updated language with pharmacy terminology to reduce ambiguity and misinterpretation.
Infusion Services & Equipment (#91414)
  • Removed outdated name of InterQual criteria set
  • Separated and more clearly described the medical necessity requirements by line of business
Irreversible Electroporation (IRE)-Nanoknife (#91599)
 Added clause, “due to insufficient evidence in the peer-reviewed literature” to explain why NanoKnife is considered experimentational and investigational.
Obstructive Sleep Apnea (#91333)
 Changed values of CPAP Titration Studies: OSA with severe desaturation (oxygen desaturations either a) continuous minutes with SaO2 ≤ 88% [formerly < 87%] or b) 5 total minutes with SaO2 ≤ 90% [formerly < 80%]). These new values align with current standard cutoffs.
Peripheral Nerve Stimulation (#91634)
 Addition: eTNS (external trigeminal nerve stimulation, e.g., Monarch eTNS System) is unproven for treatment of ADHDF and there considered not medically necessary.
Prosthetics / External Policy (#91306) Addition: An osseointegrated / osseoanchored lower limb prosthetic device (e.g., OPRA Implant System) is considered experimental, investigational or unproven.
Recurrent Pregnancy Loss (#91156)
 Changed policy’s name from “Recurrent Spontaneous Abortion” to “Recurrent Pregnancy Loss” to reflect current terminology. No criteria changes were made.
Septoplasty / Rhinoplasty (#91506)
 Addition: Repair of nasal valve collapse with low energy, temperature-controlled (e.g., radiofrequency) subcutaneous / submucosal remodeling (e.g., VivAer) is considered experimentational, investigational and unproven.
Telemedicine / Virtual Services (#91604)
Transcatheter Heart Valve Procedures (#91597)
 Medical necessity criteria and prior authorization requirement for transcatheter pulmonary valve implantation (CPT code 33477) have been removed.

February 2023 policy updates

Surgical Treatment of Obesity - #91595

  • Added single-anastomosis duodenoileal bypass with sleeve gastrectomy (SADI-S) as a bariatric procedure that is covered when the surgical criteria have been met
  • Added specificity around GERD as a qualifying criterion for corrective revisional bariatric surgery
  • Reduced the severities specified for each of the five associated qualifying comorbidities for 35 ≤ BMI < 40
  • Clarified requirements around supervision of the medical weight management program
  • Clarified what qualifies as active participation and compliance with medical weight management program
  • Specified that height and weight measurements, along with calculation of BMI, must be conducted by a provider.
  • Clarified that the BMI calculated from the height and weight obtained at the initial assessment for bariatric surgery will be used to determine medical necessity, regardless of later weight fluctuation.
  • Clarified that required criteria are based on BMI, not weight

Spinal Cord Column and Dorsal Root Ganglion Stimulation - #91635

  • This is a new stand-alone policy extracted from our existing Stimulation Therapy and Devices policy (#91468). This won’t impact providers as the content is unchanged.

Blood Pressure Monitors and Ambulatory Blood Pressure Monitoring - #91503

  • Removed age restriction for manual and automatic blood pressure monitors with uncontrolled blood pressure to reflect changes made in MDHHS Provider Manual version 10/1/22. Affects Medicaid only.

Durable Medical Equipment - #91110

  • Added clarification that pneumatic compression devices are not medically necessary for lymphedema of the head and neck. Update made to ease administrative review burden and doesn’t represent a coverage change since we defer to InterQual criteria for DME, and head / neck aren’t included in InterQual’s recommendation.

Hearing Augmentation - #91544

  • Commercial: Clarified indication for cochlear implants. No change to the criteria since it goes through InterQual for review. Just clarifying the policy.
  • Medicaid: Updated with MDHHS criteria for cochlear implants as MDHHS expanded coverage.

Orthotics Support Devices - #91339

  • Clarified in the text that MyoPro isn’t covered. Code for MyoPro was already set to not covered. New language clarifies existing position and doesn’t impact coverage.

Stimulation Therapy and Devices - #91468

  • Extracted sections related to spinal cord column and dorsal root ganglion stimulations for a standalone policy (referenced above).

End Stage Renal Disease - #91526

  • Clarified that the use of the EMMI tool is recommended but not required.

Vision Care - #91538

  • Clarified that artificial iris devices for congenital aniridia are considered experimental and investigational and are not a covered benefit.

Breast Related Procedures - #91545

  • Clarified that the use of bioimpedance isn’t medically necessary for lymphedema monitoring as conventional measurement methods remain the standard of care.

November 2022 policy updates

Autism Spectrum Disorders - 91615

Added an exclusion for Artificial intelligence (AI) devices, prescription digital diagnostics or mobile medical applications (MMA) for the diagnosis of ASD (e.g., Canvas Dx, Cognoa)

Biofeedback - 91002

Added prescription digital therapeutic devices (e.g., Freespira) as experimental, investigational, or unproven

Continuous Glucose Monitoring - 91466

Clarified prior authorization requirements by line of business – no change to criteria

Gender Affirming Surgery - 91612

  • Removed criteria that the procedure be recommended by two qualified professionals
  • Removed requirement that procedure be completed by surgeon with training and active practice in gender-affirming surgical procedures
  • Added criteria for gonadectomy for documentation of permanence resultant proposed GAS
  • Added note regarding reproductive services, referencing other Priority Heath medical policies
  • Noted that reversal of gender affirming surgery isn’t a covered benefit
  • Updated policy title from “Gender Reassignment Surgery”
  • Updated terminology throughout to reflect the latest conventions in the Standards of Care for the Health of Transgender and Gender Diverse People
  • Reduced documentation of continuous hormonal therapy for gender incongruence from 12 months to 6 months
  • Clarified qualifying diagnosis of gender incongruence
  • Removed exclusions for facial reconstruction, trachea shave and reduction thyroid chondroplasty

Gender Dysphoria and/or Incongruence, Non-Surgical Treatment - 91622

  • Updated terminology throughout to reflect the latest conventions in the Standards of Care for the Health of Transgender and Gender Diverse People
  • Changed criteria for hormone therapy requiring at least 3 months of mental health therapy
  • Clarified evidence needed to demonstrate gender diversity / incongruence has been sustained over time
  • Removed voice therapy exclusion

Genetics: Counseling, Testing and Screening - 91540

  • Replaced “covered” with “medically necessary” where appropriate
  • Formatting changes

Intensity Modulated Radiation Therapy - 91633

Removed criteria: "D4. Radiation oncologist review of dose-volume histograms for all targets and critical structures." Change made because completing a histogram required simulation that’s not typically completed until after plan approval is provided.

Markers for Digestive Disorders - 91583

  • Replaced “covered” with “medically necessary” where appropriate
  • Formatting changes

Peripheral Nerve Stimulation - 91634

Added criteria from existing “Stimulation Therapy and Devices” policy (91648) on TENS, PENS and permanently implanted peripheral nerve stimulation and devices, and added specific examples of those devices.

Rehabilitative, Habilitative Medicine Services - 91318

Clarified policy to include exclusionary criteria for osteopathic manipulative treatment (OMT) used in the following, as it’s considered experimental and investigational or not medically necessary:

  • Craniosacral therapy
  • Non-somatic internal organ disorders
  • Non-musculoskeletal disorders
  • Scoliosis
  • Temporomandibular joint (TMJ) disorder
  • Prevention of the indications above
  • Condition has returned to pre-symptom state
  • Little or no improvement is demonstrated within 30 days of the initial visit despite modification of the treatment plan

Stem Cell or Bone Marrow Transplantation - 91066

Stem Cell Transplant for Neuroblastoma: Updated neuroblastoma risk strata to Children’s Oncology Group (COG) Neuroblastoma Risk Classifier Version 2

Stimulation Therapy and Devices - 91468

Deleted the sections on TENS, PENS, PNT and Peripherally Implanted Nerve Stimulators, which have moved to new Priority Health medical policy, Peripheral Nerve Stimulators (91634).

Telemedicine / Virtual Services - 91604

Behavioral health telemedicine services completed through asynchronous technologies are generally not payable

Thermography - 91355

Clarified that Siren Socks is considered experimental and investigational

August 2022 policy updates

May 2022 policy updates

  • Prostatic Artery Embolization - 91620
    Expanded coverage to cover a CTA of the pelvis prior to a prosthetic artery embolization (PAE) after the criteria for PAE have been met. Prior authorization for CTA of the pelvis (CPT code 72191) is required through eviCore.
  • Stereotactic Radiosurgery and Stereotactic Body Radiotherapy - 91127
    Specified documentation requirements for stereotactic body radiation therapy (SBRT). Updated medical necessity criteria for SBRT to include pre-service review of prior authorization requests
  • Arthroscopy and Arthroscopically Assisted Surgery for Knee, Hip, and Shoulder - 91628
    Added new exclusion – the use of biodegradable subacromial balloon spacer (e.g., InSpace, Stryker) is considered experimental, investigational and unproven
  • Continuous Glucose Monitoring - 91466
    Added new exclusion: software or hardware for downloading data to a device, such as a personal computer, smart phone or tablet, to aid in the self-management of diabetes mellitus is considered not medically necessary
  • Experimental/Investigational/Unproven Care/Benefit Exceptions - 91117
    Updated Appendices B & D to remove outdated exemptions. Added exemption for Tether, a vertebral body tethering system for skeletally immature patients with progressive idiopathic scoliosis, which is only covered for Commercial products
  • Hearing Augmentation - 91544
    Updated language to reflect MDHHS Medicaid Provider Manual guidance allowing for non-implantable BAHA. Updated audiology criteria language to mirror MDHHS Medicare Provider Manual language
  • High-Intensity Focused Ultrasound - 91601
    Edited language for HIFU for prostate cancer to reflect NCCN language. Added language from medical policy #91314 which states that HIFU is experimental and investigation for a stand-alone ablative procedure for atrial fibrillation.
  • Infusion Services and Equipment - 91414
    These updates will align the medical policy with our Pharmacy department's process and will go into effect on July 1, 2022. We'll post the updated medical policy before the effective date and will include:
    • Removal of site of service exemption for cancer diagnosis
    • Adding site of service exemption for pediatric members 17 years old or younger
    • Adding criteria exemption review for members living 30 miles from the nearest approved site that administers oncology drugs
  • Moderate Sedation for Interventional Pain Management - 96132
    New medical policy. Goes into effect July 25, 2022. Denies anesthesia and moderate sedation services when not deemed medically necessary. This edit will apply to claims for our commercial members and for any provider for a patient 18 years of age or older.
  • Skin Conditions - 91456
    Simplified language and reformatted
  • Spine Procedures - 91581
    Added that Tether is medically necessary when used according to its FDA HDE approval
  • Transcatheter Heart Valve Procedures - 91597
    Updated limitations and exclusions to transcatheter aortic valve replacement
  • Varicose Vein Treatment - 91326
    Expanded coverage to include endoluminous radiofrequency ablation (ERFA) for accessory veins by removing it from the list of procedures considered unproven and not medically necessary

February 2022 policy updates

  • Balloon Sinus Ostial Dilation for Chronic Sinusitis and Eustachian Tube Dilation - 91596
    Added medical necessity criteria for balloon dilation of eustachian tube dysfunction. Expanded the title of the policy. Changed position on balloon dilation for eustachian tube dysfunction to medically necessary when criteria are met.
  • Spine Procedures -91581
    Added inclusion and exclusion criteria for intraosseous basivertebral radiofrequency nerve ablation. CPT codes 64628 and 64629 are associated with this procedure. Currently no prior authorization requirement.
  • Surgical Treatments for Lipedema and Lymphedema - 91631
    Added new policy that contains detailed medical necessity criteria for surgical treatment of lipedema. Clarifies surgical treatments for lymphedema considered experimental, investigational or unproven.
  • Durable Medical Equipment - 91110
    Clarified coverage for pneumatic compression devices.
    Added requests for calibrated gradient pressure devices require documentation of treatment failure with non-calibrated gradient pressure devices.
  • Incontinence Supplies for Medicaid Members - 91502
    Updated criteria for short-term and long-term pull-on briefs. Added example of what MDHHS considers "measurable progress". Expanded medical conditions that MDHSS considers allowable for long-term use.
  • Infertility Diagnosis and Treatment/Assisted Reproduction/Artificial Conception - 91163
    Add Sperm & Oocyte Retrieval and Storage (#91393) policy language to this policy and retiring #91393 policy. Added term gestational carrier to page 3 of the policy.
  • Lung Volume Reduction (Surgical and Non-Surgical) - 91472
    Deleted distinction between intrabronchial vs. endobronchial valves. Deleted spiration valve as an exclusion. Added fissure integrity of less than 85% as an exclusion for endobronchial valve placement.
  • Surgical Treatment of Obesity - 91595
    Clarified that the reported BMI should be based upon measurement of height and weight within one month of beginning the medical weight management program.

November 2021 policy updates

  • Autism Spectrum Disorders - 91615
    Expanding coverage by eliminating age restrictions on Applied Behavioral Analysis (ABA) services
  • Colorectal Cancer Screening - 91547
    Expanding Commercial and Medicaid coverage by lowering age for average risk adults to being screening to 45 years old
  • Platelet Rich Plasma/ Platelet Rich Fibrin Matrix - 91553
    Expanding coverage due to a national coverage determination (NCD) 270.3 which allows coverage for platelet rich plasma for chronic non-healing diabetic wounds up to 20 weeks. This was previously limited to coverage with evidence development (CED).
  • Genetic Counseling Testing Screening - 91540
    Non-invasive prenatal testing (NIPT) no longer requires prior authorization.
  • Stimulation Therapy Devices - 91468
    We're separating out dorsal root ganglion stimulators from spinal cord/dorsal column stimulators.
  • Breast Related Procedures - 91545
    Clarified final stage of reconstruction and revision as the achievement of symmetry.
  • Spine Procedures - 91581
    Decreasing the list of procedures that will require prior authorization in 2022.
  • Orthotic Shoe Inserts - 91420
    Prior authorization is not required for therapeutic shoes and inserts for Medicare members with diabetes.
  • Spine Center of Excellence - 91531
    Policy will retire on Jan. 1, 2022.

Effective Sep. 1, 2021

  • Home Care - 91023
    Home health authorizations for wound care after the first 60 days are reviewed monthly. Dieticians are not a covered service for Medicaid members. Medical social services are covered only when specified in the member's coverage document.

Effective May 14, 2020

  • Prophylactic Cancer Risk Reduction Surgery - 91508
    Added family history as additional risk criteria when considering prophylactic simple mastectomy. This information was obtained from Comprehensive Cancer Network (NCCN) Guidelines for Genetic/Familial High-Risk Assessment: Breast and Ovarian. Prior authorization is no longer required for the following procedures:
    • Prophylactic gastrectomy
    • Prophylactic hysterectomy
    • Prophylactic mastectomy
    • Prophylactic oophorectomy
    • Prophylactic salpingo-oophorectomy
    Prior authorization is still required for prophylactic thyroidectomy.