Medical policy updates for February 2023

The following policy changes were approved by our Medical Advisory Committee and are effective February 2023:

Added single-anastomosis duodenoileal bypass with sleeve gastrectomy (SADI-S) as a bariatric procedure that is covered when the surgical criteria have been met
Added specificity around GERD as a qualifying criterion for corrective revisional bariatric surgery
Reduced the severities specified for each of the five associated qualifying comorbidities for 35 ≤ BMI < 40
Clarified requirements around supervision of the medical weight management program
Clarified what qualifies as active participation and compliance with medical weight management program
Specified that height and weight measurements, along with calculation of BMI, must be conducted by a provider.
Clarified that the BMI calculated from the height and weight obtained at the initial assessment for bariatric surgery will be used to determine medical necessity, regardless of later weight fluctuation.
Clarified that required criteria are based on BMI, not weight

This is a new stand-alone policy extracted from our existing Stimulation Therapy and Devices policy (#91468). This won’t impact providers as the content is unchanged.

Removed age restriction for manual and automatic blood pressure monitors with uncontrolled blood pressure to reflect changes made in MDHHS Provider Manual version 10/1/22. Affects Medicaid only.

Added clarification that pneumatic compression devices are not medically necessary for lymphedema of the head and neck. Update made to ease administrative review burden and doesn’t represent a coverage change since we defer to InterQual criteria for DME, and head / neck aren’t included in InterQual’s recommendation.

Commercial: Clarified indication for cochlear implants. No change to the criteria since it goes through InterQual for review. Just clarifying the policy.
Medicaid: Updated with MDHHS criteria for cochlear implants as MDHHS expanded coverage.

Clarified in the text that MyoPro isn’t covered. Code for MyoPro was already set to not covered. New language clarifies existing position and doesn’t impact coverage.

Extracted sections related to spinal cord column and dorsal root ganglion stimulations for a standalone policy (referenced above).

Clarified that artificial iris devices for congenital aniridia are considered experimental and investigational and are not a covered benefit.

Clarified that the use of bioimpedance isn’t medically necessary for lymphedema monitoring as conventional measurement methods remain the standard of care.