May 2025 medical policy updates

Our Medical Affairs Committee (MAC), comprised of Priority Health network physicians, met in May and approved the following medical policy updates. Unless otherwise noted, the updates are effective June 1, 2025.

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

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.
Capsule Endoscopy (#91476) The exclusion of capsule endoscopy for Crohn’s disease management will be removed. Capsule endoscopy will be considered medically necessary for Chron’s disease management, as in suspected recurrence.
Carotid and Intracranial Artery Stenting (#91495)
  • 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
Colorectal Cancer Screening (#91547)
  • 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.
Cosmetic and Reconstructive Surgery Procedures (#91535)
  • Removed dental congenital abnormalities
  • Removed specific timeframe for identification of congenital anomaly
Enteral Nutrition Therapy (#91278)
  • 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
High Intensity Focused Ultrasound (#91601)
  • 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
Implantable Heart Failure Monitors (#91610)
  • 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
Intraoperative Neurophysiological Monitoring (#91646) Effective Aug. 1, 2025: I.B: Intraoperative neurophysiological monitoring will not be considered medically necessary for lumbar spinal fusion procedures.
Osteoarthritis of the Knee (#91571)
  • 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
Palliative Care (#91558) Deleted Table 1 and 1.A.D
Speech Therapy (#91336) The Buffalo Model will be considered experimental and investigational for the evaluation and treatment of central auditory processing disorder (CAPD).
Stem Cell or Bone Marrow Transplantation (#91066) Autologous hematopoietic stem cell transplantation for the treatment of multiple sclerosis, previously considered experimental and investigational, will be considered medically necessary when criteria are met.
Stereotactic Radiosurgery (SRS) ad Stereotactic Body Radiotherapy (SBRT) (#91127) RETIRED. All procedures outlined in the policy are managed by EviCore’s radiation oncology program. For information on how to find EviCore’s clinical criteria, see Medical necessity criteria in our Provider Manual.
Termination of Pregnancy (#91000)
  • 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.
Thermal Capsulorrhaphy (#91551) RETIRED. All procedures outlined in the policy are managed by TurningPoint. For information on how to find TurningPoint’s clinical criteria, see Medical necessity criteria in our Provider Manual.
Transcatheter Closure of Septal Defects (#91528) I.C: Ventricular septal defects is no longer an exclusion and has been added as an indication.
Ventricular Assist Devices and Artificial Hearts (#91509)

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.