Medical policy updates

Below are links to updated or new policies. Remember, you can always find the latest updates to policies, as well as brief descriptions of what changed, in the Medical Policies section of the Provider Manual in the "Pending/retired/updated medical policy list. "

Effective January 1, 2018

Criteria updated to reflect treatment for drug and alcohol use is a covered benefit with limitations and restrictions as defined in the plan documents and Behavioral Health policies. Sub-acute detoxification and substance use disorder residential treatment must be certified by the Behavioral Health Department.

Prior authorization requirement removed for Transcatheter Closure of Septal Defects when patient is greater than 17 year old and for Transcatheter Closure of Patent Foramen Ovale.

Language added to clarify sclerosant itself is included as part of the surgical procedure code(s) for sclerotherapy and is therefore not separately payable. Language also updated to reflect coverage for Venaseal/cyanoacrylate embolization (CAE).

Prior authorization rules will apply to Medicare members for the following services effective 1/1/18:

  • Continuous glucose monitors
  • Dialysis
  • Insulin pumps
  • Outpatient requests for knee arthroscopy, kyphoplasty, vertebroplasty, lumbar fusion, lumbar laminectomy and orthopedic surgery (lumbar or cervical spine surgery, joint arthroscopy, hip, shoulder, knee replacement, shoulder repair) – prior to 1/1/18 authorization only required for inpatient requests.