Pending/retired/updated medical policy list

Retired

This policy didn’t include Priority Health medical criteria, instead referring to EviCore for management / medical necessity determination through EviCore’s relevant guidelines. Refer to EviCore’s guidelines.

Effective Feb. 1, 2025

Changes:

• The following services will change from not medically necessary to medically necessary when InterQual criteria are met: S1034, S1035, S1036, S1037. Applicable InterQual criteria are available in CP: Durable Medical Equipment under Continuous Glucose Monitors, Insulin Pumps, and Automated Insulin Delivery Technology.
• Policy title changed to reflect scope.

Clarification: Clarified section on Medicaid criteria to reflect updates to Michigan Department of Health and Human Services (MDHHS) Medicaid Provider Manual.

New policy

This policy addresses a new area of technology, digital therapeutics (DTx), that’s becoming more prevalent and puts current Priority Health policy and system configuration into writing for transparency.

DTx are health software intended to treat or alleviate a disease, disorder, condition or injury by generating and delivering a therapeutic medical intervention. DTx, including the DTx software and any associated ancillary components, aren't medically necessary for any indication or use, and are experimental, investigational or unproven due to insufficient evidence in current published peer-reviewed literature to support clinical utility and efficacy.

This policy addresses only digital therapeutics. The criteria are not applicable to the medical, behavioral health or pharmacological therapies/treatments or medical devices used in conjunction with digital therapeutics.

• Change: I. B. 4. Annual reporting of specified outcome measures is no longer required. Rather, requirement is that the data collected from the CardioMEMS device is monitored regularly.
• Clarification: I. B. 3. The treating provider and the member have access to a reliable internet connection that allows remote heart failure monitoring.

• Deletion: Removed definitive distance of "30 miles" from the nearest approved site of service that administers oncology drugs as an exception to criteria.
• Addition: Gene and cell therapy are subject to their own site of service considerations.

Additions: Scope was broadened to include:

• Transcutaneous Electrical Acustimulation (TEAS) for Hyperemesis. The corresponding medical policy by that name, No. 91576, is being retired. All contents from that policy have been transcribed to this policy.
• Tonic Motor Activation (TOMAC) peroneal nerve stimulation therapy for restless leg syndrome (RLS) (e.g., Nidra) is not medically necessary.
• Sparrow Ascent (Spark Biomedical, Inc.) and other devices/stimulators/systems that target nerves in the auricular region and are indicated to reduce symptoms associated with opioid withdrawal was added to the section Percutaneous electrical nerve stimulation (PENS) and percutaneous neuromodulation therapy (PNT)

• Deletion: Replaced criteria specific to Medicare members with hyperlink to CMS’ NCD 270.3. This reduces the need to repeat verbatim criteria accessible through CMS' webpage.
• Clarification: Direct readers to indications referenced in other medical policies or prior authorized by TurningPoint.

New policy

Effective Feb. 1, 2025

This policy provides medical necessity criteria for the ablation of the renal sympathetic nerves using radiofrequency or ultrasound for the treatment of resistant hypertension. Within the scope of this policy, CPT codes 0338T and 0339T are covered for:

• Medicare effective Oct. 1, 2024
• Commercial effective Feb. 1, 2024, with prior authorization

Retired

This policy had a narrow scope that didn’t require it to be a standalone policy. The language it contained has been added to the Peripheral Nerve Stimulation policy (#91634).

New policy, effective Nov. 1, 2024

This new policy consolidates Priority Health’s position on the range of BPH procedures, including procedures previously in two separate policies, to be retired:

• Prostatic Artery Embolization for Benign Prostatic Hyperplasia (#91620)
• Prostatic Urethral Lift & Transurethral Water Vapor Therapy for BPH (#91626)

When the policy goes into effect, the following procedures will no longer be covered:

• Transurethral microwave thermotherapy (CPT 53850)
• Transurethral needle ablation of the prostate (CPT 53852)
• Permanent urethral stent (CPT 52282)

New policy, effective Sept. 1, 2024

This new policy was developed to address the growing number of large molecular panels for respiratory and genitourinary infectious diseases. The policy provides medical necessity criteria to outline appropriate use, without changes in coverage or prior authorization requirements.

Policy updates effective Nov. 1, 2024

• Moving to InterQual criteria: Current medical necessity criteria have been removed and InterQual criteria adopted. Priority Health may consider VEEG medically necessary when the applicable InterQual criteria are met (CP: Procedures subset Video Electroencephalographic (EEG) Monitoring). Note: Priority Health’s medical necessity criteria mirrored InterQual criteria, so providers shouldn’t experience a change.
• Policy scope is now as follows: This medical policy only addresses video electroencephalographic (VEEG) monitoring with video, conducted at home, at a freestanding center or in a hospital-based facility.

Policy updates effective:

• Commercial plans: Jan. 1, 2025
• Medicaid plans: Jan. 1, 2025
• Medicare plans: 2026

Certain procedures or services will require prior authorization following InterQual criteria. See the medical policy for a list of applicable procedures or services.

Policy updates effective Nov. 1, 2024

Criteria were added for autologous fat transplant (harvesting and grafting) for breast reconstruction. Injection of fat cells is limited to 150 cc per breast per procedure due to necrosis or resorption of injected fat cells from high volume fat grafting. Unit limitation of 2 will be placed on CPT 15772 when billed with a diagnosis code related to breast reconstruction.

The Breast Specific Gamma Imaging (#91568) policy was retired as a standalone policy with language added to this policy.

Policy updates effective Nov. 1, 2024

Expanded non-invasive prenatal testing for fetal aneuploidies trisomy 21, 13 and 18 to twin pregnancies; removed provider specialty for ordering, counseling and education. Updated prior authorization guidance for tests associated with EviCore management or the Fertility rider. Updated formatting to improve readability and updated terminology to reflect current usage.

 Policy updates effective Sept. 1, 2024

These policies were updated to clarify language and experimental and investigational positions, or to align with updated industry standards.

These medical policies will be retired Fall 2024, because the procedures within their scope will be managed by TurningPoint Healthcare Solutions LLC (TurningPoint) through our new cardiac surgical authorizations program.

• Addition: V.C - Fractional ablative laser treatment with a CO2 laser for hypertrophic burns and trauma scars for functional impairment is medically necessary; Fractional laser treatment for keloid scars is not medically necessary.
• Addition: Photographic documentation is required for procedures that can have both reconstructive and cosmetic indications. This doesn’t represent a change to prior authorization.
• Clarification: IV.3 – Changed terminology: “individual <20 years of age” to “pediatric patients”

• Clarification: For esophagus region: Changed lesion size from greater than or equal to 15 mm to greater than 15 mm
• Clarification: For esophagus, gastric region: Changed submucosal mass size greater than or equal to 20 mm to greater than 20 mm
• Clarification: For duodenal & colorectal region: Changed polyps size from greater than or equal to 20 mm to greater than 20 mm

• Update: Criteria for digestive enzyme (lipase) cartridge (e.g., RELiZORB Immobilized Lipase Cartridge, Alcresta Therapeutics).
• Clarification: Restructured much of policy criteria to enhance clarity

• Update: Anti-gliadin antibodies (AGA) and anti-reticulin antibodies (ARA) are no longer considered medically necessary serological tests for Celiac disease.
• Update: Deamidated gliadin antibodies (DGP) are no longer considered experimental and investigational for Celiac disease. DGP testing is medically necessary if IgA deficiency is present

• Addition: I.1.b – Specified high resolution manometry (HRM) as the diagnostic test for achalasia
• Deletion: I.1.c-e – Removed outdated criteria for esophageal manometry

• Addition: I.G.3.e - Radiofrequency ablation for sacral nerve is experimental and/or investigational and not medically necessary
• Addition: I.H.2 - Sacroiliac joint fusion with placement of intra-articular implant without the placement of transfixation device (i.e., CornerLoc, TransFasten, LinQ) is experimental and/or investigational and not medically necessary

• Addition: I. R. 31 - Added IB-Stim to the list of non-covered stimulation therapy devices
• Addition: III. Background - Added background/description section for IB-Stim

• One code (97157) not previously covered will be covered.
• 97157 will require prior authorization according to InterQual criteria.

• I.2 - Deleted Medicaid criteria and replaced with a link to the Michigan Department of Health & Human Services (MDHHS) Medicaid Provider Manual. This section policy repeated criteria already stated in the MDHHS Medicaid Provider Manual.
• Updated Description/Background section

• Replaced reference to the retired Incontinence Supplies for Medicaid Members policy #91502 with a link to the Michigan Department of Health & Human Services (MDHHS) Medicaid Provider Manual.
• Updated description section

• Addition: I.C.2 – Gastric peroral endoscopic pyloromyotomy or myotomy (G-POEM) for the treatment of gastroparesis isn’t medically necessary.
• Updated description section.

• I.G.5 – The use of wide-area transepithelial sampling (WATS3D) for screening or surveillance of Barrett's esophagus (BE) is experimental and investigational.
• I.G. 6 – The use of TissueCypher Barrett’s Esophagus Assay to predict risk of BE to progress to HGD or cancer is considered experimental and investigational.
• The codes associated with these updates are currently not covered.

• I.A & I.B: Replaced Medicaid specific criteria for BAHA and Cochlear implants with a link to the Michigan Department of Health & Human Services (MDHHS) Medicaid Provider Manual.
• Removed exclusion for hybrid cochlear implants.
• I.B.2: Hybrid cochlear implants are medically necessary when InterQual criteria are met. (The associated codes are already set to require prior authorization.)

• Name change: Policy title was changed to broaden the scope to include central sleep apnea.
• Addition: Remede is experimental / investigational / unproven and not medically necessary. Remede is used for the treatment of central sleep apnea and was reviewed at the November 2023 Medical Technology Assessment Committee Meeting.

• I. J. 1. D: Added language on implanted tibial nerve stimulators (including eCoin), Priority Health’s non-medically necessary position and brief rationale.
• I. J. 1. B: InterStim Continence Control Therapy / Sacral Nerve Stimulation: The policy previously broadly stated a “1-2-week trial” was required. Clarified that a patient must have had a successful test stimulation with either (1) trial period of up to 7 days with a temporary lead or (2) up to 14 days with a permanent lead in order to support subsequent implantation.

• 1. A. 3. e.: Deleted tobacco use and lactation from the list of exclusions to bariatric surgery in order to be no more restrictive than the Michigan Association of Health Plans (MAHP) Bariatric Surgery Guidelines for Commercial Coverage (2023).
• Added note: This medical policy doesn’t apply to Priority Health Medicaid members. See the MDHHS Medicaid Provider Manual (Practitioner, Section 3 – General Practice, Section 3.25, Weight Reduction).

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

• 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.

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

• 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.

Clarification: Revised language describing procedures (I. A through F).

Addition: Added Carticel and MACI as examples of Autologous chondrocyte implants

NEW policy

This new policy is applicable only to Commercial and Medicare to address questions around cellular and gene therapies, including CAR T cell class. The policy documents existing processes and criteria. There are no changes to current operations or criteria.

NEW policy

Effective 10/23/2023. Service codes C9764-C9767 (limb perfusion in the proximal lower extremities) are covered for all plan types. Service codes C9772-C9775 (interventions in the distal aspect of the lower extremity) are not medically necessary and will not be separately payable for Commercial and Medicaid.

Addition:

• Therapeutic shoes and inserts for persons without diabetes are requested/billed using “L” codes. (Specific “L” codes may be non-covered for certain products—see product limitations at bottom of section VI. CODING INFORMATION.)
• Added parentheticals: Orthopedic shoes (1 pair per plan year) and inserts (3 pair per plan year) may be covered if any of the following applies.

Additions:

• The drug, device, treatment or procedure is not widely used and generally accepted as standard medical care for the condition, disease, illness or injury being treated as reported in nationally recognized peer-reviewed medical literature published in the English language are experimental, investigational or unproven.
• Definition of peer-reviewed literature.
• Category III code is considered experimental, investigational and unproven unless there is a Priority Health medical policy that specifically addresses coverage or medical necessity.

Deletion:

• Appendix B. Moved the Appendix to Category III Procedural Terminology (CPT®) Codes policy #91636

• Removed outdated name of InterQual criteria set
• Separated and more clearly described the medical necessity requirements by line of business

• Removed store and forward and provider to provider consultation from telemedicine exclusions
• Updated coding section to reflect the end of the Public Health Emergency (PHE) period
• Effective May 12, 2023