Pending/retired/updated medical policy list

Deletion: Moved coverage information for prophylactic mastectomy to medical policy # 91508- Prophylactic Cancer Surgery.

Additions:

• Neurotization and nerve coaptation in conjunction with breast reconstruction procedures using autologous tissue are considered experimental and investigational.
• En bloc capsulectomy is only medically necessary for an established or suspected breast implant associated cancer.
• Breast implant removal is medically necessary according to InterQual criteria.
• Breast reconstruction procedures are medically necessary according to InterQual criteria.
• New sections - Related medical policies, Government Regulations, and Medical/Professional Society Guidelines/Position Statement sections.

Clarifications:

• Formatting changes
• Removed notations such as asterisks and added them into criteria or moved to applicable sections
• Reduction mammaplasty for unilateral gynecomastia is medically necessary according to InterQual criteria
• Replaced covered benefits language with “medically necessary” where applicable

• Addition:

• To be considered medically/clinically necessary, services and supplies must not be primarily for the convenience of the member or the health care provider.
• Medical devices and products, biologics, and drugs must have regulatory approval or clearance, when applicable.
• New sections: Government Regulations, and FDA/Regulatory.
• Exclusions: Cosmetic, experimental and/or investigational, or benefit excluded procedures.
• Deletion: Medicare coverage criteria will be used in the absence of medical policy, plan documents or technology review.

• Addition: Hysterectomy is medically necessary for the treatment of menorrhagia.
• Clarification:
• Deleted coverage specific information for IUD for contraception because it is outside the scope of this policy.
• Deleted exclusion for ELITT.

Effective Nov. 1, 2025

• Addition:
• For Medicare: Added reference to new policy: Tonic Motor Activation (TOMAC) peroneal nerve stimulation for restless leg syndrome (i.e., nidra™) – Medicare Advantage (#91648)
• Medical necessity criteria for IB-Stim (NeurAxis) auricular stimulation device

• Prophylactic simple mastectomy is medically necessary for members who have a history of chest radiation before 30 years of age, and members with confirmed pathogenic variants of breast cancer susceptibility genes.
• Added language from medical policy #91545 - Breast Related Procedures: Additional coverage for an initial procedure (reduction, augmentation or mastopexy) on the contralateral breast to produce symmetry between the affected and unaffected breasts for prophylactic simple mastectomy is medically necessary.
• Removed age limitations:
• Prophylactic mastectomy: Requirement of having a first, second-degree and/or third-degree relative who was diagnosed with breast cancer at age 50 or younger.
• Prophylactic total gastrectomy: Requirement of a positive family history of gastric cancer under the age of 50.

• Exclusion: Total Body Photography, cryotherapy for the treatment of acne, and salabrasion, are not medically necessary.
• Clarification:
• At home phototherapy (UVB) treatments for indications other than psoriasis including vitiligo is experimental and investigational and/or not medically necessary.
• At home UVB treatments may be medically necessary for members who are unable to travel for office-based treatment due to serious medical or physical conditions (e.g. confined to the home, severity and frequency of flares) or have a history of frequent psoriasis flares which require immediate treatment to control.

Effective Nov. 1, 2025

• Deletion: IB-Stim (NeurAxis) auricular stimulation device as an exclusion (medical necessity criteria for IB-Stim (NeurAxis) auricular stimulation device can now be found in medical policy 91634 – Peripheral Nerve Stimulation).

• Deletion:
• Section I. A. 1. Deleted the following inclusion criterion for liposuction for lipedema: Body Mass Index (BMI) ≤ 32 at time of surgery
• Section I A. 2. Deleted the following exclusion for liposuction for lipedema: Body Mass Index (BMI) > 32
• Change: Microsurgical procedures for lymphedema are considered medically necessary following a confirmed diagnosis of lymphedema. These procedures are still considered experimental, investigational or unproven when performed prophylactically.
• Clarification: Restructured section I. A. Lipedema

Effective Nov. 1, 2025

This new medical policy applies to Medicare plans only and establishes medical necessity criteria. Prior authorization will be required for the applicable code: E0743 – External lower extremity nerve stimulator for restless leg syndrome, each

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.

• Changed terminology from “cover” to “medically necessary” for alignment with the purpose of this medical policy and to distinguish from benefit level plan documents.
• Updated to include a statement that percutaneous transcatheter placement of extracranial vertebral or intrathoracic carotid artery stent(s) is managed by TurningPoint

• Added link to EviCore, where applicable
• The Cologuard Plus™ (Exact Sciences Corp.) in vitro diagnostic test is managed by EviCore
• The Shield™ (Guardant Health, Inc.) blood test for colorectal cancer screening is managed by EviCore, effective July 1, 2025
• Computer or artificial intelligence assisted reading tools intended to help endoscopists detect polyps and adenomas during colonoscopy (i.e., GI Genius Intelligent Endoscopy Module) may be used to support clinicians’ standard methods of detection. However, such use won’t be separately payable.

• Removed dental congenital abnormalities
• Removed specific timeframe for identification of congenital anomaly

• I.C.2: RELiZORB is now indicated for use in pediatric (ages 1 and above) and adult patients to hydrolyze fats in enteral formula (previously ages 2 and above) to reflect new labeling effective Jan. 15, 2025
• Section for Medicaid/Healthy MI members: Removed sections A-D and replaced with a link to the Medicaid Provider Manual

• I.B: Magnetic resonance-guided focused ultrasound (MRgFUS) will be considered medically necessary for medication refractory essential tremor and medication refractory, tremor dependent Parkinson’s Disease when InterQual® criteria are met
• II / III / V: New policy sections: Government Relations section, listing applicable CMS NCDs or LCDs; FDA / Regulatory; Medical / Professional Society Guidelines

• Reader is directed to the following document for coverage for Medicare members: National Coverage Analysis (NCA) CAG-00466N. Implantable Pulmonary Artery Pressure Sensors for Heart Failure Management (Centers for Medicare & Medicaid Services)
• Selection inclusion criteria in section I.A.1 have been clarified

• Added a new policy section: ”Related policies”
• Autologous cellular implant derived from adipose tissue, bone marrow aspirate concentrate (BMAC), platelet rich plasma (PRP) injections and mesenchymal stem cell injections are considered experimental and investigational for the indications listed in this policy and aren’t prior authorized by TurningPoint

• I.A. 1- 2: Updated language regarding applicable laws and regulations, and associated coverage criteria
• I.B: Replaced Medicaid specific criteria with reference to MDHHS Provider Manual.

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.

Note: The changes below were made for clarity and consistency with Priority Health’s current position on FDA-approved SLIT tablets.

Additions:

• I. Notes: Reference to the Priority Health Billing & Coding Policy entitled Allergy Injections / Immunotherapy has been added. Recent changes to this billing & coding policy were made to in vitro testing:
  
  - In vitro testing isn’t payable when a skin test is also performed for the same antigen with the exception of latex sensitivity, Hymenoptera and nut/peanut sensitivity.
  - In vitro testing must be supported within the medical record as a substitute for in vivo testing (skin testing) and, effective Nov. 11, 2024, will be limited to 30 allergens over a 12-month period.

Changes:

• I. B.: In the prior revision (R9), all sublingual immunotherapy (SLIT) was listed as not medically necessary. With this revision (R10), only SLIT tablets that have not been approved by the FDA, as well as all aqueous SLIT formulations, are not medically necessary. Reader is now referred to Priority Health’s current Pharmacy Benefit regarding coverage for FDA-approved SLIT tablets.

Note: The addition below does not represent a change. Language was added to the policy to clarify an existing Priority Health position.

Additions:

• Exclusions: B. 13. Equine-assisted activities therapies (e.g., hippotherapy, therapeutic riding) has been added as an exclusion

Additions:

• The d-Nav® System (Hygieia, Inc.) is considered medically necessary when used by adults with Type 2 diabetes as an aid in optimizing insulin management. Use of the d-Nav® System is limited to Health Care Providers who have been trained by Hygieia or a Hygieia trained person on the use of the d-Nav® System, including setup of the patient’s Phone App. Use of the d-Nav® System requires a prescription.

Clarifications:

• Policy was restructured to first specify any digital therapeutics that may be considered medically necessary (inclusions), and second to indicate that all other digital therapeutics not expressly named as inclusions are considered not medically necessary for any indication or use, and are experimental, investigational, or unproven (exclusions).

Deletions:

• I. A. 2.: Deleted a significantly shortened life expectancy from list of absolute contraindications to renal transplantation as there is no universally accepted life expectancy below which an individual is ineligible for kidney transplantation.

Note: The update below isn’t a change in coverage. ESWT is currently not covered for any indication.

Addition:

• Low intensity ESWT for the treatment of erectile dysfunction is considered experimental and investigational.

Note: The change below isn’t a change in coverage.

Clarification:

• I.A.3.c.iii – Deleted hyaluronic acid as an example of conservative therapy
• I.A.8.c – Deferred to Pharmacy documents for coverage and prior authorization rules for anti-fungal agents.
• I.B.2 – Added cross reference to related medical policy: Extracorporeal Shock Wave Therapy (ESWT) # 91527

Addition:

• I.A.3. a – Directions on how to access third party delegated clinical guidelines
• I.K.2.: Criteria on multi-marker tumors panel from retired Multi-Marker Tumor Panels policy # 91609

Addition:

• D – Added cross reference to the Digital Therapeutics medical policy # 91645
• I. H – The Buffalo Model is experimental and investigational.

Addition:

• I.C.: Site of service exceptions for starting doses with multiple administrations, complexity of infusion, and when receiving immune checkpoint inhibitors in combination with provider-administered chemotherapy on the same day

Deletion:

• I.C.: Deletion: Removed age exemption from site of service review; exceptions are made based on complexity of infusion.

• New medical policy
• Puts information currently available in our Provider Manual into a medical policy. No changes were made.

Change:

• LITT is considered is medically necessary for primary and recurrent brain tumors or relapsed brain metastases when criteria are met.

Policy changes effective May 1, 2025

Addition / clarification:

• I.A 6.e. – Proactive therapeutic drug monitoring to predict therapeutic response in the management of IBD or UC (e.g., PredictrPK IFX) is not medically necessary.
• I.C. – Methane and hydrogen breath tests are medically necessary for the diagnosis of suspected lactose intolerance. At-home breath tests (e.g., TrioSmart) are not medically necessary.

Retiring medical policy. Moving criteria to Genetics: Counseling, Testing and Screening (#91540) policy.

Changes:

• Coverage for drug therapy recommended by next-generation sequencing results shall be determined by pharmacy drug coverage policies and requirements.

• New medical policy
• Consolidated criteria which currently exist across multiple medical policies, e.g. radiofrequency ablation (RFA) for back pain from the Spine Procedures policy # 91581 into one policy.
• Addresses currently non-covered experimental & investigational procedures (e.g., Coolief, iovera, pulsed RFA) which are billed with codes which could be applicable to covered and established procedures

Note: The addition below does not represent a change. Language was added to the policy to clarify an existing Priority Health position.

Addition:

• I.A.6 – Equine therapy (e.g., hippotherapy, therapeutic riding) is considered experimental and investigation or not medically necessary.

Additions:

• Reference to Neuroablation for Pain Management (#91647) medical policy
• Directions for providers to find TurningPoint medical necessity criteria

Deletions:

• I.G. – Moved radiofrequency ablation for back pain criteria to Neuroablation for Pain Management (#91647) medical policy.

Note: The additions below do not represent a change. Language was added to the policy to clarify Priority Health’s current position.

Additions:

• P. ELECTRIC TUMOR TREATMENT FIELDS (ETTF) DEVICES: Added the following text (italics): ETTF devices for all other indications are considered experimental and not covered, including, but not limited to, the following: Intrabuccal devices that deliver systemic amplitude-modulated radiofrequency electromagnetic field stimulation (AM RF EMF) for treatment of cancer (e.g., TheraBionic P1 device (TheraBionic, Inc.)).
• J. INCONTINENCE STIMULATOR: added section e. Transcutaneous Tibial Nerve Stimulation (TTNS) . Transcutaneous tibial nerve stimulation for treatment of overactive bladder and its associated symptoms is considered not medically necessary.

Clarifications:

• Utilization management and medical necessity criteria around transcatheter cardiac valve replacements and repairs have been clarified.
• Any procedures or interventions that are outside the scope of transcatheter heart valve procedures have been removed.