August 2025 medical policy updates

Our Medical Affairs Committee (MAC), comprised of Priority Health network physicians, met in August and approved the following medical policy updates. Unless otherwise noted, the changes will go into effect on Sept. 1, 2025.

Behavioral Health Residential Treatment (#91625)

This policy will be retired. Providers should instead reference appropriate InterQual® criteria where applicable. Additional information currently provided in the medical policy is being moved to the Priority Health Provider Manual.

Breast Related Procedures (#91545)

Deletion: Moved coverage information for prophylactic mastectomy to medical policy # 91508- Prophylactic Cancer Surgery.

Additions:

  • Neurotization and nerve coaptation in conjunction with breast reconstruction procedures using autologous tissue are considered experimental and investigational.
  • En bloc capsulectomy is only medically necessary for an established or suspected breast implant associated cancer.
  • Breast implant removal is medically necessary according to InterQual criteria.
  • Breast reconstruction procedures are medically necessary according to InterQual criteria.
  • New sections - Related medical policies, Government Regulations, and Medical/Professional Society Guidelines/Position Statement sections.

Clarifications:

  • Formatting changes
  • Removed notations such as asterisks and added them into criteria or moved to applicable sections
  • Reduction mammaplasty for unilateral gynecomastia is medically necessary according to InterQual criteria
  • Replaced covered benefits language with “medically necessary” where applicable

Cranial Helmets (#91504)

A second cranial molding helmet may be medically necessary when criteria are met.

Fetal Surgery (#91120)

Fetal endoscopic tracheal occlusion (FETO) to treat severe congenital diaphragmatic hernia (CDH) is medically necessary when criteria are met.

Home Care (#91023)

Prior authorization will no longer be required for services provided by in network home health agencies.

Home Prothrombin Time or INR Monitoring (#91507)

Removed Medicaid plan language. Consult plan documents or the MDHHS Provider Manual for benefit information.

Hospice Care (#91520)

This policy will be retired and its language will be moved to Priority Health’s Hospice Care billing policy.

Hyperbaric Oxygen Therapy (#91151)

Addition: Home HBOT chambers are experimental and investigational.

Infertility Diagnosis and Treatment / Assisted Reproduction (#91163)

Removed examples of diagnostic and treatment services

Medical Necessity Determination (#91447)

  • Addition:
    • To be considered medically/clinically necessary, services and supplies must not be primarily for the convenience of the member or the health care provider.
    • Medical devices and products, biologics, and drugs must have regulatory approval or clearance, when applicable.
    • New sections: Government Regulations, and FDA/Regulatory.
    • Exclusions: Cosmetic, experimental and/or investigational, or benefit excluded procedures.
  • Deletion: Medicare coverage criteria will be used in the absence of medical policy, plan documents or technology review.

Menorrhagia Treatment (#91575)

  • Addition: Hysterectomy is medically necessary for the treatment of menorrhagia.
  • Clarification:
    • Deleted coverage specific information for IUD for contraception because it is outside the scope of this policy.
    • Deleted exclusion for ELITT.

Non-acute Inpatient Services (#91332)

This policy will be retired and its language added to the Priority Health Skilled Nursing Facility billing policy.

Parenteral Nutrition Therapy (#91517)

Addition: Section I. C. Exclusions

Peripheral Nerve Stimulation (#91634)

Effective Nov. 1, 2025

  • Addition:
    • For Medicare: Added reference to new policy: Tonic Motor Activation (TOMAC) peroneal nerve stimulation for restless leg syndrome (i.e., nidra™) – Medicare Advantage (#91648)
    • Medical necessity criteria for IB-Stim (NeurAxis) auricular stimulation device

Prophylactic Cancer Risk Reduction Surgery (#91508)

  • Prophylactic simple mastectomy is medically necessary for members who have a history of chest radiation before 30 years of age, and members with confirmed pathogenic variants of breast cancer susceptibility genes.
  • Added language from medical policy #91545 - Breast Related Procedures: Additional coverage for an initial procedure (reduction, augmentation or mastopexy) on the contralateral breast to produce symmetry between the affected and unaffected breasts for prophylactic simple mastectomy is medically necessary.
  • Removed age limitations:
    • Prophylactic mastectomy: Requirement of having a first, second-degree and/or third-degree relative who was diagnosed with breast cancer at age 50 or younger.
    • Prophylactic total gastrectomy: Requirement of a positive family history of gastric cancer under the age of 50.

Sexual Dysfunction and Impotence (#91160)

Penile Implant Insertion is medically necessary when InterQual (rather than Priority Health) criteria are met.

Skin Conditions (#91456)

  • Exclusion: Total Body Photography, cryotherapy for the treatment of acne, and salabrasion, are not medically necessary.
  • Clarification:
    • At home phototherapy (UVB) treatments for indications other than psoriasis including vitiligo is experimental and investigational and/or not medically necessary.
    • At home UVB treatments may be medically necessary for members who are unable to travel for office-based treatment due to serious medical or physical conditions (e.g. confined to the home, severity and frequency of flares) or have a history of frequent psoriasis flares which require immediate treatment to control.

Stimulation Therapy and Devices (#91468)

Effective Nov. 1, 2025

Deleted: IB-Stim (NeurAxis) auricular stimulation device as an exclusion (medical necessity criteria for IB-Stim (NeurAxis) auricular stimulation device can now be found in medical policy 91634 – Peripheral Nerve Stimulation).

Surgical Treatments for Lipedema and Lymphedema (#91631)

  • Deletion:
    • Section I. A. 1. Deleted the following inclusion criterion for liposuction for lipedema: Body Mass Index (BMI) ≤ 32 at time of surgery
    • Section I A. 2. Deleted the following exclusion for liposuction for lipedema: Body Mass Index (BMI) > 32
  • Change: Microsurgical procedures for lymphedema are considered medically necessary following a confirmed diagnosis of lymphedema. These procedures are still considered experimental, investigational or unproven when performed prophylactically.
  • Clarification: Restructured section I. A. Lipedema

Tonic Motor Activation (TOMAC) Peroneal Nerve Stimulation for Restless Leg Syndrome (i.e., nidra™) – Medicare Advantage (#91648)

Effective Nov. 1, 2025

This new medical policy applies to Medicare plans only and establishes medical necessity criteria. Prior authorization will be required for the applicable code: E0743 – External lower extremity nerve stimulator for restless leg syndrome, each

Uterine Fibroid Treatment (#91573)

New exclusion for Sonata: a member with an unusually short endometrial cavity (< 4.5 cm fundus-to-external opening of cervix)