July 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, under Authorizations > Medical policies > Policy changes list.
Effective August 31, 2018
Obstructive Sleep Apnea 91333
Criteria for the coverage of an attended sleep study or polysomnogram (PSG) for periodic limb movement disorder (PLMD) updated. Updated criteria requires complaints by the patient or an observer, of repetitive limb movement during sleep, and a) frequent awakenings, or b) fragmented sleep, or c) difficulty maintaining sleep, or d) excessive daytime sleepiness. Additionally, the patient must have at least one additional risk factor for PMLD including, but not limited to, the following: a) iron deficiency anemia, b) renal disease, c) medication that cannot be discontinued, d) spinal injury, e) peripheral neuropathy or f) diabetes mellitus. If the patient is currently being treated for diagnosed OSA, the criterion for an additional risk factor for PLMD does not apply. Also, individual currently being treated with a dental appliance with moderate to severe OSA (AHI>15) at baseline removed as a qualifier for PSG for individuals with suspected OSA as determined by clinical symptoms.
Effective July 11, 2018
Spine Centers of Excellence 91531
There is no change to the medical policy but the criteria in Clear Coverage has been updated to gather additional information related to the authorization request for a Spine Referral for Neurosurgeon or Orthopedic Surgeon Evaluation. All supporting clinical documentation must be attached, including but not limited to, H&P, complete neuro exam, MRI, PM&R and surgical consultation notes regardless of whether the request is auto approved or pends for medical review. Lack of supporting documentation may result in denial secondary to inability to verify clinical criteria. Note: This criteria is not meant to be used for conditions requiring emergent surgical intervention.
Effective July 1, 2018
Mental Health Residential Treatments: Child and Adolescent 91607
Residential treatment criteria updated to reflect residential treatment takes place in a structured facility-based setting.
Multi-Maker Tumor Panels 91609
This policy was retired in June 2017 and is being reinstated effective July 1, 2018. The updated policy more clearly defines the coverage criteria for multi-marker tumor panels using next generation sequencing in the diagnosis and treatment of cancer and reflects broader coverage. The authorization process will continue to be managed by eviCore utilizing the criteria in this policy.
Skin Substitutes and Soft Tissue Grafts 91560
Criteria added for the coverage of Grafix® CORE Multipotent Cellular Repair Cryopreserved Chorion Matrix and Grafix® PRIME Multipotent Cellular Repair Cryopreserved Amnion Matrix for use in the treatment of partial and full-thickness neuropathic diabetic foot ulcer.