November 2023 medical policy updates

Our Medical Advisory Committee (MAC), comprised of network physicians contracted with Priority Health, met in November and approved a series of medical policy updates.

Below is a summary of the updates:

Obstructive Sleep Apnea #91333

Effective Dec. 18, 2023, the following testing and diagnostic services will be considered medically necessary when the applicable InterQual criteria are met (previously, Priority Health-specific medical criteria were applied):

  • Home sleep test or limited channel test
  • Facility-based polysomnogram
  • Facility-based titration study

Autologous Chondrocyte Implant / Meniscal Allograft / Osteochondral Replacement #91443

  • Clarified medically necessary procedures for the knee versus other joints
  • Added autologous cellular implant derived from adipose tissue, autologous adipose derived regenerative cell therapy or autologous micro-fragmented adipose injection (i.e., Lipogems) for any musculoskeletal indication are experimental and investigational.

Biofeedback #91002

Clarification: Medicaid / Health Michigan Plan members directed to current Michigan Department of Health and Human Services (MDHHS) Medicaid. Non-coverage position for Medicaid remains unchanged.

Bone Density Studies #91494

Added distal forearm DXA is medically necessary when criteria are met

Cellular and Gene Therapy #91638

Added guidance for Medicaid members

Cingulotomy #91475

Retired policy , created in 2004, as it has limited scope in current practice and low claims volume.

Colorectal Cancer Screening #91547

  • Deleted items 1 through 6 under I.B. Advanced Screening and Evaluation Guidelines
  • Updated reference provided in I.B. Advanced Screening and Evaluation Guidelines

Computerized Tomographic Angiography Coronary Arteries (CCTA) #91614

Fractional Flow Reserve Computed Tomography (FFR-CT) will be considered medically necessary when the applicable eviCore criteria are met (previously, Priority Health-specific medical criteria were applied).

Fecal Microbiota trans Fecal Bacteriotherapy #91603

Clarified section II. Exclusions: Part C – removed the reference to RBX2660 and added a note directing the reader to the Priority Health Medical Benefit Drug List for coverage details for Rebyota™.

Gender Affirming Surgery #91612

Added the following CPT codes to the table: 21172, 14041, 15769

Osteoarthritis of the Knee #91571

  • Added autologous chondrocyte implantation (i.e., Carticel) for the repair of articular cartilage of the knee is medically necessary
  • Added genicular articular embolization for osteoarthritis of the knee is experimental and investigational.

Peripheral Nerve Stimulation #91634

Added that ReActiv8® Implantable Neurostimulation System (Mainstay Medical Ltd.) is unproven and not medically necessary due to insufficient evidence of efficacy.

Surgical Treatment of Obesity #91595

Clarified language around specifications of BMI ranges