November 2025 medical policy updates

Added the following exclusions to clarify Priority Health’s current position:

• Use of the RhinAer® radiofrequency device (Aerin medical Inc.) to treat rhinitis as an exclusion (reflects previously established position).
• Rhinophototherapy (intranasal phototherapy) as an exclusion.
• Repository emulsion therapy as an exclusion.

• Addition: Scalp cooling devices for prevention of chemotherapy-induced Alopecia: See Priority Health Medical Policy #91535 Cosmetic and Reconstructive Surgery Procedures
• Clarification: Photographic documentation must be submitted with all prior authorization requests.

Effective Feb. 1, 2026

• An implantable continuous glucose monitor (I-CGM; e.g., Eversense Continuous Glucose Monitoring System; Senseonics, Inc.) – previously not covered – may be considered medically necessary for a commercial member when criteria are met

• Addition: Coverage is not provided for scalp cooling devices for prevention of chemotherapy-induced alopecia. Use of such devices is purely for cosmetic purposes and does not add to cancer treatment or medical care

Additions:

• In situations where there is no corresponding presumptive (qualitative, semi-quantitative) test available, definitive (confirmatory; quantitative) urine drug testing may be considered medically necessary as an initial testing modality.
• There may be additional limitations to drug testing frequency, as detailed in Priority Health Billing Policy No. 008 – Drug Testing.

Effective Jan. 1, 2026

• Deletion: Removed exclusion of assisted communication devices

• Addition: Cardioneural ablation for treatment of vasovagal syncope is considered experimental, investigational or unproven

Effective Feb. 1, 2026

• Addition: Nerve conduction studies: Routine testing for polyneuropathy of diabetes or end stage renal disease (ESRD) is not considered medically necessary and is not covered. Testing for the sole purpose of monitoring disease intensity or treatment efficacy in these two conditions is also not covered

Effective Jan. 1, 2026

Additions:

• Breast augmentation is a medically necessary gender affirming chest surgery when criteria are met.
• Age limit for government sponsored plans

Clarification:

• Removed asterisks and notes when applicable

• Clarification: Gastrointestinal pathogen panel (GIPP) are medically necessary when criteria are met.

Additions:

• Crohn’s Prognostic, IBD sgi Diagnostic and PredictSure IDB are experimental and investigational.
• Medical necessity criteria for Helicobacter pylori testing

• This policy will soon be retired and its contents moved to a billing policy. We’ll share the billing policy when available and retire this medical policy at that time.

Clarifications:

• TurningPoint reviews platelet rich plasma (PRP), autologous blood-derived growth factors, bone marrow aspirate concentrate (BMAC) only when submitted as an adjunct to a primary orthopedic/MSK procedure.
• Formatting changes

Effective Feb. 1, 2026

• Endoscopic Sleeve Gastroplasty (ESG) may be considered medically necessary when specified criteria are met.
• Transoral Outlet Reduction (TORe) may be considered medically necessary when specified criteria are met

Clarifications: Corrective bariatric surgery: Diagnosis of gastroesophageal reflux disease (GERD) must have been confirmed by one or more of the following:

• Abnormal 24-hour pH monitoring
• Endoscopically proven LA grade C or D esophagitis

Policy formerly called Telemedicine / Virtual Services

• Deletion: Moving criteria and codes related to telemedicine to Priority Health Billing Policy
• Clarification: Clarified medical necessity criteria for telemonitoring

Effective Feb. 1, 2026

• Radiofrequency ablation of benign thyroid nodules: If compressive symptoms (e.g. dysphagia, neck fullness/pressure, hoarseness, shortness of breath) are present, one radiofrequency ablation (RFA) treatment per benign nodule per year is considered medically necessary

• Addition: Home intraocular pressure monitoring devices (e.g., The iCare device for measurement of intraocular pressure) are considered not medically necessary and therefore excluded. There is limited evidence to suggest that home intraocular pressure monitoring improves clinical outcomes.
• Clarification: Eyelid thermal pulsation therapy, vectored thermal pulsation or thermal-activated restorative gland expression therapy (e.g., LipiFlow, TearCare) is considered not medically necessary as a treatment for chronic dry eye and meibomian gland dysfunction. There is inconsistent evidence that these therapies may benefit patients more than standard at-home warm compress treatments.