February 2026 medical policy updates

Additions:

• Updated the policy name to include urethral stricture treatment 
• Urethral Stricture: cystourethroscopy with mechanical urethral dilation and urethral therapeutic drug delivery by drug-coated balloon (Optilume) catheter for recurrent bulbar strictures is considered medically necessary when specified criteria are met

Added non-covered services:

• Electrical stimulation therapy (e.g., TENS, PTNS)
• Acupuncture (e.g., Laser acupuncture (LAT)
• Tuina (Massage) therapy 
• Artificial Intelligence (AI) wearable devices
• Hypnotherapy
• Psychotherapy
• Chiropractic treatment

• Added Extracorporeal Shock Wave Lithotripsy as medically necessary for the treatment of urolithiasis 
• Clarification: Policy was restructured to specify the addition of extracorporeal shock therapy (lithotripsy) may be considered medically necessary, and to indicate extracorporeal shock wave therapy conditions that are considered not medically necessary
• Added non-covered services:
  • Coronary Artery Disease 
  • Peripheral Artery Disease 
  • Lymphedema
  • Multiple Sclerosis
  • Spasticity
  • Stress Urinary Incontinence

• Deletion: Removed “History of Barrett’s Esophagus” as an exclusion for the Magnetic sphincter augmentation (MSA) with the LINX procedure
• Clarification: Added non-covered treatments for GERD Including the following: acupuncture, non-Invasive post -prandial anti-reflux devices, lower esophageal sphincter (LES) electrical stimulation, antireflux mucosal intervention (ARMI) procedures (i.e., antireflux mucosectomy (ARMS) and antireflux mucosal ablation (ARMA))

• Removed exclusion of gastric peroral endoscopic pyloromyotomy or myotomy (G-POEM). The G-POEM procedure for refractory gastroparesis is considered medically necessary when medical policy criteria are met.
• Added G-POEM to the background section

New policy

• This medical policy addresses histotripsy (i.e., non-thermal ablation via acoustic energy delivery) for the treatment of malignant tumors (including the Edison Histotripsy System (HistoSonics)).
• Histotripsy is considered medically necessary when medical policy criteria are met

• Clarification: Added in conditions for clarification that external infusion pumps may be covered for
• Deletion: Deleted exemptions for site of service review, as they’re being moved to a pharmacy policy 

Clarifications:

• Restructured Medical Necessity Criteria section for clarity
• Genioplasty is considered NOT medically necessary:
  • When NOT associated with obstructive apnea, or
  • When performed for the sole purpose of improving individual appearance and profileException: Genioplasty may be considered medically necessary when performed as a component of a comprehensive facial feminization or facial masculinization service performed as an adjunct to gender affirming surgery following a diagnosis of gender dysphoria: (see Priority Health Medical Policy Gender Affirming Surgery – 91612).

• Clarification: Powered upper extremity range of motion assist devices (includes microprocessor, sensors, all components and accessories), custom fabricated (myoelectric devices), are excluded.
• Change: Medical necessity for the following will be assessed by applying InterQual® CP:Durable Medical Equipment criteria:
  • Orthoses, Lower Extremity, Knee-Ankle-Foot (KAFO) and Ankle-Foot (AFO)
  • Orthoses, Thoracic, Lumbar, and Sacral Spine
  • Orthoses, Upper Extremity
• Clarification: Medical necessity for the following is assessed by applying InterQual® CP:Durable Medical Equipment criteria:
  • Orthoses, Cranial Remodeling
  • Orthoses, Lower Extremity, Knee