May 2026 medical policy updates

Retired policy 

This medical policy will be retired and its content will be migrated into a billing policy. 

Deleted: 

• Removed tobacco use as exclusion for Eustachian tube balloon dilation (ETBD)

Added: 

• Medical necessity criteria for recurrent acute rhinosinusitis 
• Medically necessity criteria for chronic obstructive Eustachian tube dysfunction in pediatrics

Changed:  

• Removed age criteria of 18 and up for eustachian tube dysfunction (New section addresses pediatric members age 8-17).
• Removed the strict ≥3‑month predefined medical therapy regimen requirement for chronic rhinosinusitis, allowing individualized, patient‑centered medical management prior to surgery
• Symptom duration threshold for ETBD (6 → 3 months)

Retired policy 

This policy is being retired as Bronchial Thermoplasty (BT) is sunsetting as a treatment option for severe asthma due to device discontinuation, declining clinical utilization, and a shift in asthma management toward precision based medical therapy including biologic (anti-IgE, anti-IL5/5R, anti-IL4R) and pharmacologic therapies (small molecule therapies (e.g., JAK1 inhibitors).  

Changed: 

• Carotid artery stenting: Priority Health considers stenting of the carotid artery medically necessary when the applicable InterQual® criteria are met
• Intracranial angioplasty and stenting: Priority Health considers intracranial angioplasty and stenting medically necessary when the applicable InterQual® criteria are met
• Priority Health considers intracranial balloon angioplasty, including transcatheter of placement of intracranial intravascular stents, medically necessary when applicable InterQual® criteria are met

Changed:  

• VI. CODING: The table now lists only active Category III “T” codes that do not appear in another Priority Health or utilization management delegate medical policy or guideline.

Clarified:  

• I. MEDICAL NECESSITY CRITERIA
• Moved titles of relevant American Medical Association guidance to IV. GUIDELINES / POSITION STATEMENTS.

Clarifications:  

• Updated website links to Pharmacy drug webpage and site of service information webpage

Clarified: 

• Blood-based assays that detect SEPT9 (Septin9) DNA promoter methylation (e.g., colorectal cancer): Managed by EviCore (already indicated in Priority Health Medical Policy 91540 Genetics: Counseling, Testing, Screening).
• Additional genetic colorectal cancer tests are managed by EviCore (Lab Management Program), as indicated in Priority Health Medical Policy No. 91540 - Genetics: Counseling, Testing, Screening. Any test may or may not be considered medically necessary for colorectal cancer screening (already indicated in Priority Health Medical Policy 91540 Genetics: Counseling, Testing, Screening).
• BeScreened™-CRC (Beacon Biomedical Inc) blood-based colorectal cancer screening test, is considered experimental and investigational (already indicated in Priority Health Medical Policy 91540 Genetics: Counseling, Testing, Screening).

Added:  

• Exclusions for ENT, cranial / maxillofacial and neurosurgery procedures

Deleted:  

• Outdated references

Added: 

• Computerized dynamic posturography for vestibular rehabilitation applications is considered E/I/U
• Updated background information and references

Added:  

• ICD-10: L91.0 - Hypertrophic scar for fractional ablative laser treatment as medically necessary  diagnosis under “V. Coding Information” section

Changes: 

• Updated language to clarify Section “E”: Scar Revisions and Removal, specifically facial scar revision and post-burn hypertrophic and traumatic scars. Prior Authorization will be required. 
• Moved the statement regarding fractional ablative laser treatment for keloid scars from the Hypertrophic and traumatic scars section (E.3) to the keloid section (E.2)

Deleted:  

• Removed Medicaid‑specific language under exclusions for self‑help and adaptive aids.

Added: 

• Added HCPCS A7523 (tracheostomy shower protector) to the not medically necessary coding section.
• Added billing policies and related policies for cross‑reference.

Changes: 

• Moved continuous passive motion (CPM) devices for total knee arthroplasty and rotator cuff repair from medically necessary to not medically necessary for all indications.
• Updated the background and references to reflect current evidence and professional society guidelines.

Added: 

• Site specific exclusions per society guidelines 
• Robotic assisted/computer enhanced ESD platforms are explicitly classified as experimental/investigational

Changed: 

• Gastric region: updated indications as they were broad and aligned them with society guidelines
• Colon/rectum: updated criteria from size-alone to morphology + suspected SMI
• Duodenum/small bowel: eliminated broad coverage and aligned with society guidelines.
• Replaced broad indications with guideline-style inclusion features (size + histology + ulceration + invasion depth) for Esophagus site. Split into two distinct pathways with specific thresholds and staging language for Esophageal squamous cell carcinoma / esophageal dysplasia and Early-stage (T1) esophageal adenocarcinoma / Barrett’s dysplasia

Clarified: 

• Reorganized criteria into general requirements plus detailed site-specific criteria (esophagus, stomach, colorectal, duodenal/small bowel).
• Replaced vague indications (e.g., “polyps not removable by snare,” “submucosal masses,” “recurrent lesions”) with explicit guideline-based thresholds (size, histology, ulceration status, depth of invasion, need for en bloc resection).

Changed:  

• Digestive enzyme (lipase) cartridge (e.g., RELiZORB Immobilized Lipase Cartridge, Alcresta Therapeutics): Labeling has expanded to include neonates and infants. Accordingly, 1 year age limitation has been removed.

Removed: 

• 0108U, as this code is located in specific policy: Gastroesophageal Reflux Disease (GERD) and Barrett’s Esophagus.
• 52284, as this code is located in specific policy: Benign Prostatic Hyperplasia (BPH) Treatments and Urethral Stricture Treatments - 91642

Added: 

• 0248U: Oncology, spheroid cell culture in 3D microenvironment, 12-drug panel, brain- or brain metastasis-response prediction for each drug
• 0249U: Oncology (breast), semiquantitative analysis of 32 phosphoproteins and protein analytes, includes laser capture microdissection, with algorithmic analysis and interpretative report

Added: 

• Extracorporeal Shock Wave Lithotripsy as a medically necessary for treatment of  pancreatic duct stones, gallbladder stones, common bile duct stones 
• Salivary Gland or Salivary Duct Stones indication

Updated:  

• Background and references section

Clarified:  

• Section “B”- Updated for clarification: Tumor In Vitro Chemoresistance and Chemosensitivity Assays are considered experimental and investigational and not medically necessary for brain- or brain metastasis and breast cancer. Other In Vitro Chemoresistance and Chemosensitivity Assays are vendor managed (EviCore).

Additions:  

• Added in Section “II” (Centers for Medicare & Medicaid Services (CMS) Coverage Determination) section: Advanced Diagnostic Laboratory tests under Medicare Clinical Laboratory Fee Schedule. 
• Appendix A added back to policy 

Deleted:  

• Removed “B” regarding clinical trial information: “Intraperitoneal hyperthermic chemotherapy (IPHC) also known as Hyperthermic Intraperitoneal Chemotherapy (HIPEC) not recommended by NCCN may be covered as part of a clinical trial when the criteria of the Clinical Trials medical policies #91606 or #91448 are met."

Added:  

• Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC)- E/I/U

Changed:  

• Updated name to capture inclusion of pressurized intraperitoneal aerosol chemotherapy
• Updated policy scope to include PIPAC

Deleted:  

• Statement that NanoKnife is not FDA approved for cancer treatment

Updated:  

• Background and references, including information on the PRESERVE study

Changed: 

• Moved Section “C” (Anesthesia and moderate sedation for all other pain management services are not covered unless done with a surgical procedure) and combined with section “B”
• Updated background section for clarity

Removed: 

• Removed the following under medical necessity: “RFA procedures are limited to two per year. RFA procedures beyond two per year require medical review.”

Changed: 

• Moving conventional sacroiliac (SI) Joint Radiofrequency from E/I/U to medically necessary when criteria is met. Prior Authorization required. 
• Updated E/I/U: Cooled radiofrequency ablation (e.g., Coolief) for all indications (except Knee OA. See Priority Health medical policy #91571: Osteoarthritis of the Knee)

Added:

• Medical necessity criteria for repeat RFA for back and neck pain 
• Expanded not medically necessary to include nerve cryoablation (such as intercostal nerve cryoablation) and cryodenervation.

Changed:  

• Genicular nerve RFA moving from not medically necessary to medically necessary when criteria is met. Prior Authorization Required. 

Added:  

• Covered treatments for OA of the knee: Partial or total knee arthroscopy
• Additional non medically necessary treatments for knee OA-Transcutaneous electrical nerve stimulation (TENS), Neuroablative therapies (e.g.,cryoneurolysis), biomechanical shoe‑based devices, implanted shock absorbers (e.g., MISHA®), synthetic cartilage implants, low‑level laser therapy, and prolotherapy.

Deleted:  

• Related policy that was retired (Autologous Chondrocyte Implant/Meniscal Allograft).

Retired policy 

This medical policy will be retired, and its content will be migrated into a billing policy.

Deleted: 

• Outdated references

Added: 

• Expanded policy scope to include POEM for: Zenker’s Diverticulum and select non-achalasia spastic motility disorders, with medical necessity criteria. 

Changed:  

• Revised select exclusions in Section 1.3 (e.g., prior esophageal surgery or irradiation) from absolute exclusions to case‑by‑case clinical considerations

Clarified: 

• Language added/removed/changed to better explain criteria guidelines 
• Updated layout for inclusions, exclusions, limitations sections.

Removed: 

• Removed MI Medicaid-specific language

Clarified: 

• Use of InterQual criteria for medical necessity determination of: Lower extremity prosthetics; Electrically powered, externally powered, and/or microprocessor controlled

Added: 

• Medically necessary tests / studies / indications for evaluation and treatment of recurrent pregnancy loss (RPL)
• Not medically necessary tests / studies for evaluation and treatment of RPL

New policy 

This new policy outlines the medical necessity criteria required to support providing medical procedures in a hospital outpatient department (HOPD) vs an ambulatory surgery center (ASC) or physician office. Note: this policy doesn’t address medical necessity for individual medical procedures, and it doesn’t apply to emergency services or inpatient procedures.

Removed: 

• Cymetra when used for treatment of vocal cord paralysis. This product is discontinued.

Added: 

• Skin substitutes for Burns-Biobrane- glove; Integra® Meshed Bilayer Wound Matrix (MBWM), ReCell
• Skin substitutes for DFU- AlloPatch Pliable, AmnioBand®
• Skin substitutes for VLU- AmnioBand®
• Diagnosis: Dystrophic Epidermolysis Bullosa and medical necessity criteria

Changed: 

• Reorganized the policy to an indication-based structure with medical necessity criteria. Prior Authorization required.
• Moved Integra® Omnigraft Dermal Regeneration Matrix to ulcer indications only, as this product is FDA indicated for ulcers.
• Moved Integra® Bilayer Matrix Wound Dressing (“Integra® Bilayer Wound Matrix”) from severe burn treatment to second degree burn treatment, per FDA guidelines
• Moved Integra Meshed Bilayer Wound Matrix from severe burn treatment to second degree burn treatment, per FDA guidelines
• Reclassified application of skin cell suspension (15011-15018, C8002) from not covered, to medically necessary for burn indications when medical criteria is met.

New policy 

This new policy applies to Medicare Advantage (MA) plans only. It addresses SSBCI – supplemental benefits that aren’t primarily health-related and may be offered to eligible members. The policy: 

• Lists comorbid and medically complex chronic conditions considered to be life threatening or that significantly limit overall health or function
• Specifies when an MA member is at high risk of hospitalization of other adverse health outcomes
• Specifies when an MA member requires intensive care coordination

Added:  

• Not medically necessary (E/I/U) indication: Central Auditory Processing Disorder

Changed:  

• Removed required number threshold for therapy services related to acquired hearing loss to align with society guidelines..

Clarified:  

• Updated layout of policy and language for clarity

Removed: 

• I.A.2.a.: Removed exclusion for persistent or active substance or alcohol abuse
• Stem Cell Transplant for Autoimmune Diseases: removed lower age limit of 18 for autologous hematopoietic stem cell transplantation for the treatment of multiple sclerosis

Added: 

• Stem Cell Transplant for Multiple Myeloma, Amyloidosis or Polyneuropathy, Organomegaly, Endocrinopathy, Monoclonal gammopathy and skin changes (POEMS syndrome): added risk-adapted criteria for tandem therapy for multiple myeloma

New policy 

This policy outlines medical necessity criteria, limitations, and exclusions for surgical dressings and surgical wound care supplies, when a qualifying wound is present.

Removed: 

• Copay specifications

Changed:  

• Percutaneous transcatheter closure of congenital atrial septal defect is considered medically necessary when InterQual® criteria have been met

Clarified:  

• Clarified exclusions to transcatheter closure of septal defects

Deleted:  

• 1.A.5 Removed length of time (3 month) requirement for patients with a history of substance abuse prior to transplant approval

Changed:  

• Updated the policy title to reflect a comprehensive tinnitus management framework.

Added: 

• Inclusions and exclusions
• Exclusions include acupuncture, biofeedback, brain implant, cognitive behavioral therapy, deep brain stimulation (DBS) neuromodulation, psychedelic- assisted therapy, sound therapy, including transmeatal laser irradiation

• Insertion of an extracorporeal left ventricular assist device is considered medically necessary when the applicable InterQual® criteria are met.

• Insertion of an intracorporeal left ventricular assist device is considered medically necessary when the applicable InterQual® criteria are met:
• Criteria for insertion of a percutaneous left ventricular assist device have been modified