February 2022 policy updates

The following policy changes were approved by the Medical Advisory Committee and are effective February 2022:

Policy Update
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