November 2022 medical policy updates

The following policy changes were approved by our Medical Advisory Committee and are effective November 2022:

Autism Spectrum Disorders - 91615

Added an exclusion for Artificial intelligence (AI) devices, prescription digital diagnostics or mobile medical applications (MMA) for the diagnosis of ASD (e.g., Canvas Dx, Cognoa)

Biofeedback - 91002

Added prescription digital therapeutic devices (e.g., Freespira) as experimental, investigational, or unproven

Continuous Glucose Monitoring - 91466

Clarified prior authorization requirements by line of business – no change to criteria

Gender Affirming Surgery - 91612

Removed criteria that the procedure be recommended by two qualified professionals
Removed requirement that procedure be completed by surgeon with training and active practice in gender-affirming surgical procedures
Added criteria for gonadectomy for documentation of permanence resultant proposed GAS
Added note regarding reproductive services, referencing other Priority Heath medical policies
Noted that reversal of gender affirming surgery isn’t a covered benefit
Updated policy title from “Gender Reassignment Surgery”
Updated terminology throughout to reflect the latest conventions in the Standards of Care for the Health of Transgender and Gender Diverse People
Reduced documentation of continuous hormonal therapy for gender incongruence from 12 months to 6 months
Clarified qualifying diagnosis of gender incongruence
Removed exclusions for facial reconstruction, trachea shave and reduction thyroid chondroplasty

Gender Dysphoria and/or Incongruence, Non-Surgical Treatment - 91622

Updated terminology throughout to reflect the latest conventions in the Standards of Care for the Health of Transgender and Gender Diverse People
Changed criteria for hormone therapy requiring at least 3 months of mental health therapy
Clarified evidence needed to demonstrate gender diversity / incongruence has been sustained over time
Removed voice therapy exclusion

Genetics: Counseling, Testing and Screening - 91540

Replaced “covered” with “medically necessary” where appropriate
Formatting changes

Intensity Modulated Radiation Therapy - 91633

Removed criteria: "D4. Radiation oncologist review of dose-volume histograms for all targets and critical structures." Change made because completing a histogram required simulation that’s not typically completed until after plan approval is provided.

Markers for Digestive Disorders - 91583

Replaced “covered” with “medically necessary” where appropriate
Formatting changes

Peripheral Nerve Stimulation - 91634

Added criteria from existing “Stimulation Therapy and Devices” policy (91648) on TENS, PENS and permanently implanted peripheral nerve stimulation and devices, and added specific examples of those devices.

Rehabilitative, Habilitative Medicine Services - 91318

Clarified policy to include exclusionary criteria for osteopathic manipulative treatment (OMT) used in the following, as it’s considered experimental and investigational or not medically necessary:

Craniosacral therapy
Non-somatic internal organ disorders
Non-musculoskeletal disorders
Scoliosis
Temporomandibular joint (TMJ) disorder
Prevention of the indications above
Condition has returned to pre-symptom state
Little or no improvement is demonstrated within 30 days of the initial visit despite modification of the treatment plan