August 2026 medical policy updates

Deletions:

• Deleted I.B.21 - posterior nasal nerve ablation. This procedure is now considered medically necessary and addressed in new medical policy, 91653 – Posterior Nasal Nerve Ablation

Deletions:

• Removed benefit language for facial scar revision from medical necessity criteria section.
• Removed Blepharoptosis and Brow Ptosis Repair criteria, as applicable criteria are managed through InterQual.
• Removed the pediatric port wine stain (PWS) criterion for superficial PWS on head or neck for psychological or clinical prophylaxis.

Changes:

• Updated section title from Port Wine “Stains”  to "Port Wine “Birthmarks”  to reflect current terminology.
• Updated and clarified the clinical functional impairment documentation requirements require photographic documentation of the affected area.

Deletions:

• Removed the requirement for members to demonstrate compliance with equipment use, as applicable criteria are managed through InterQual.
• Removed preauthorization dollar-threshold language.

Additions:  

• Added exclusion: Intermittent Pneumatic Compression devices (IPC)

Deletions:

• Deleted items 1-4 under I. A.

Additions:  

• Updated table in section V. Regulatory (US Food and Drug Administration)

Deletions:

• Removed general exclusion for maternal complications in I.A, I.B, I.C and I.D
• Removed E.6.g exclusion for contraindications to surgery

Changes:

• Title changed to “Fetal Surgery”; types of procedures are now included in the policy scope

Deletions:

• Removed prior authorization language in the medical necessity criteria section for home physician services.

Additions:  

• Added examples of intermittent skilled nursing services, section to clarify services that may support medical necessity for home skilled nursing care.

Changes:

• Relocated non-covered service language to the applicable policy sections to improve clarity.

Deletions:

• A.: Deleted names of botulinum toxin preferred agents
• I. B.: Deleted benefit details

Additions:  

• Added a definition of infertility.
• Added examples of medically necessary diagnostic testing and procedures for both female and male infertility evaluation.
• Added examples of medically necessary treatments for underlying causes of infertility in both females and males.
• Added examples of medically necessary assisted reproductive technology (ART) services when an applicable infertility rider or fertility benefit is present.

Changes:

• Reorganized infertility diagnostic services into separate female-factor and male-factor evaluation sections.
• Reorganized infertility treatment services into separate female-factor and male-factor treatment sections.
• Expanded and reorganized Assisted Reproductive Technology (ART) benefit requirements, inclusions, exclusions and limitations.

Clarifications:

• Clarified that coverage for infertility diagnostic, treatment, ART and fertility preservation services remains subject to member-specific benefits, riders and plan provisions.

Additions:

• Added a requirement that services meet generally accepted standards of safety and effectiveness to be considered medically necessary.
• Added Evidence-Based Standards section that describes the types of evidence utilized in medical necessity determinations.
• Added exclusions for the following: services lacking credible scientific evidence, convenience services, and non-medical services.

Clarifications:

• Clarified that medical necessity and coverage are separate determinations.
• Clarified that a provider's recommendation alone does not establish medical necessity.

Additions:  

• Added annual quantity limits for therapeutic shoes and inserts for individuals with diabetes.
• Added criteria for replacement of pediatric orthopedic shoes, inserts, lifts, and related modifications when medically necessary due to growth, development, or changes in medical condition.

Changes:

• Relocated criteria for shoes, inserts, shoe lifts and modifications for leg length discrepancy and deformities in pediatrics.
• Updated leg length discrepancy criteria for members less than 18 years of age with no other congenital or neurologic abnormalities from ≥1 inch (2.54 cm) to 2-6cm.

Clarifications:

• Panniculectomy is considered medically necessary when applicable InterQual criteria are met.
• Abdominoplasty is considered medically necessary when applicable Priority Health criteria are met.

Deletions:

• Removed the limitation regarding concurrent use of botulinum toxin (Botox) and total parenteral nutrition (TPN) for gastroparesis.

Additions:  

• Added exclusions for cannabinoid hyperemesis syndrome (CHS) and intravenous wellness, hydration, vitamin and nutrient infusion therapies.
• Added medical necessity criteria for intradialytic parenteral nutrition (IDPN), including end stage renal disease (ERSD)-related malnutrition,  failure of appropriate nutritional interventions, and meeting applicable home parenteral nutrition criteria.
• Added exclusions for IDPN in members with acute kidney injury without end-stage renal disease (ESRD); and for concurrent IDPN and TPN therapy.

Changes:

• Updated home parenteral nutrition criteria by replacing the serum albumin requirement ( <3.4 g/dL) with provider-documented clinical evidence of malnutrition or nutritional risk.
• Increased the IDPN serum albumin threshold from <3.4 g/dL to <3.5 g/dL.

Clarifications:

• Clarified qualifying gastrointestinal condition criteria by separating malabsorptive disorders from gastrointestinal motility/anatomic disorders.
• Clarified requirements regarding failure of oral intake, enteral nutrition, and medical management prior to PN initiation.

Clarifications:

• SPRINT PNS is a unique device in that is intended for temporary (60-day) implantation to provide durable symptom relief. The FDA has uniquely classified this device. Sprint PNS has been moved from I. C. and is now addressed separately in I. E. Temporarily Implanted Peripheral Nerve Stimulators. It is considered not medically necessary.
• Updated Section III. BACKGROUND

Additions:

• Updated and expanded table in Section V. Regulatory (US Food and Drug Administration)

Additions:  

• Expanded non-covered indications (e.g., dementia, lymphedema, and rheumatoid arthritis) and organized exclusions by clinical conditions.

Changes:

• Renamed the policy from Monochromatic Phototherapy (Anodyne/MIRE/LLLT) to Photobiomodulation (PBM) and Low-Level Light Therapy (LLLT).
• Revised coverage determination from investigational for all indications to medically necessary for prevention and treatment of oral mucositis when criteria are met.

Clarifications:

• Clarified that non-coverage for investigational indications applies regardless of terminology used, device type or treatment setting.

Deletions:

• I.B.1 and I.B.2 – Removed the requirement for completion of childbearing for prophylactic hysterectomy

Additions:  

• I.C.1. – Added CHD1, PALB2, PTEN, STK11 and TP53 as genetic variants known to predispose a woman to breast cancer
• I.G – Added criteria for prophylactic proctocolectomy or colectomy

Additions:  

• Scope
• Related Policies
• Guidelines / Position Statements
• Regulatory (US Food and Drug Administration)

Deletions:

• Removed Michigan-specific Medicaid and benefit coverage language.
• Removed the provider referral note allowing therapy services for up to 21 days or 10 treatments without a referral.

Additions:  

• Updated cardiac rehabilitation criteria, defining stable chronic heart failure as left ventricular ejection fraction ≤35% with New York Heart Association (NYHA) Class II-IV symptoms.
• Updated cardiac rehabilitation criteria to specify that acute myocardial infarction must have occurred within the previous 12 months to qualify for cardiac rehabilitation.
• Added Heart-Lung transplantation as a qualifying diagnosis for cardiac rehabilitation.

Deletions:

• Deleted I.A.4.b – posterior nasal nerve ablation. This procedure is now considered medically necessary and addressed in PH Medical Policy 91653 – Posterior Nasal Nerve Ablation

Deletions:

• Removed the requirement for 15 or more lesions for chemical peel coverage.
• Removed the exclusions related to pregnancy/lactation and history of keloid formation.
• Removed specific medications listed for the treatment of rosacea.

Additions:  

• Added medical necessity criteria and exclusions for photodynamic therapy (PDT), including treatment of actinic keratoses, cutaneous squamous cell carcinoma in situ (Bowen disease) and low-risk superficial basal cell carcinoma.
• Added medically necessary criteria for vulvar and labial surgical procedures, including treatment of malignancy and premalignant disease.
• Expanded exclusions for keloid treatment (platelet-rich plasma, regenerative medicine therapies, Botox and laser-assisted drug delivery).

Changes:

• Updated chemical peel criteria by replacing topical therapy failure requirement with broader language, allowing treatment when conventional therapies are not feasible, contraindicated or have failed.
• Renamed “Labial Hypertrophy” section to “Vulvar and Labial Surgical Procedures”.

Clarifications:

• Clarified limitations, exclusions and age-specific requirements for psoriasis phototherapy, office-based phototherapy, and targeted UVB therapy.
• Clarified that pulsed dye laser is medically necessary only for nail psoriasis.

Deletions:

• Removed age limitation for RECELL® treatment of burns to align with current FDA indications.

Changes:

• Reclassified Kerecis® as medically necessary for diabetic foot ulcers when medical necessity criteria are met.
• Reclassified SkinTE® from "Not Separately Payable" to "Not Medically Necessary”.

Clarifications:

• Clarified that covered Grafix® products include Grafix PL Core™ and Grafix PL Prime™ in addition to Grafix Core® and Grafix Prime®.

Deletions:

• Deleted redundant exclusions in Non-Covered Electrical Stimulation Therapies

Additions:  

• Added Policy scope.
• Added section II. Centers for Medicare & Medicaid Services (CMS) Coverage Determination
• Added section IV. Guidelines / Position Statements
• Added section V. Regulatory (US Food and Drug Administration)
• Added formal citations for guidelines and position statements to section IX. References

Changes:

• Updated related policies

Changes:

• I.A.1. – changed the age range from 22-70 years to ≥18 to align with new American Academy of Sleep Medicine guideline recommendation

Deletions:

• I.B.1 and 1.C.1 – Removed the requirement for the fibroid to be palpable in the abdomen
• I.C.6 – Removed the requirement for provider training and certification on Sonata

Additions:  

• Policy scope
• Background: Added discussion of corneal collagen cross linking (CXL)
• Guidelines/Position Statements: Added three guidelines that address corneal collagen cross linking
• Regulatory: Updated table. Added FDA labeling for EPIOXA™ HD and EPIOXA™
• References: Added references for corneal collagen cross-linking

Clarifications:

• Moved refractive keratoplasy from Exclusions to its own section, referencing medical policy 91529 Refractive Keratoplasty

Additions:

• Added Section I. C. Exclusions (comprehensive micronutrient panels, intracellular micronutrient analysis, and similar)

Updated:

• III BACKGROUND: Comprehensive Micronutrient or Intracellular Nutrient Testing