May 2023 medical policy updates

Our Medical Affairs Committee (MAC), comprised of network practitioners contracted with Priority Health, meets quarterly to review a set of our medical policies. The policy changes outlined below were approved by MAC at the May 10 meeting and – unless otherwise noted – are effective May 2023.

New prior authorization requirements

In tandem with the policy changes, the following prior authorization requirements will go into effect on July 24, 2023:

Medical policy Details
Panniculectomy / Abdominoplasty (#91605)
 Abdominoplasty (CPT 15847) will require prior authorization.

Unless abdominal wall laxity interferes with activities of daily living and causes a functional impairment, abdominoplasty is considered cosmetic and not medically necessary.

Procedure was previously allowed if prior authorization was approved for the primary procedure, Panniculectomy.
Thyroid-Related Procedures (#91621)
 Thyroid molecular diagnostic tests (CPT codes 81546, 0026U, 0245U, 0204U, 0018U, 0287U and 81210) will require prior authorization.

New medical policies

Medical policy Details
Computerized Dynamic Posturography (#91637)
 New medical policy created to support reduction of coverage for Computerized Dynamic Posturography (CPD).

CDP for the diagnosis of vestibular disorders is experimental and investigational due to insufficient evidence of efficacy. While CDP has been available for many years, no trials evaluated the accuracy of its diagnostic performance or impact on diagnostic decision-making or health outcomes for its use in the diagnosis of vestibular disorders.

CPT codes 92548 and 92549 will no longer be covered effective July 24, 2023.
Category III/T Current Procedural Terminology (CPT®) Codes (#91636)
 New policy to establish Priority Health’s default position: Category III "T" codes are not medically necessary unless addressed in another policy.

This policy is effective May 23, 2023.

Expansion of coverage

Medical policy Details
Breast Related Procedures (#91545)
 The use of bioimpedance spectroscopy is medically necessary for secondary, subclinical (Stage 0 or 1) breast cancer related lymphedema. This change in position is based on the 2023 NCCN Survivorship guidelines. Medical necessity is limited to diagnosis of cancer, other indications remain not medically necessary; also remains as no prior authorization.
Gender Affirming Surgery (#91612)
 Specific procedures that may now be considered medically necessary, but only when performed as part of a component of a comprehensive facial feminization or facial masculinization service performed as an adjunct to gender affirming surgery (items I.A - C) following a diagnosis of gender dysphoria.

An isolated blepharoplasty, brow lift or rhinoplasty, not completed as a component of a comprehensive feminization or masculinization service, is subject to the terms, conditions, limitations and medical necessity criteria specified in Priority Health Medical Policy #91535 – Cosmetic and Reconstructive Surgery Procedures.
Markers for Digestive Disorders (#91583)
 Updated position on anti-drug antibodies to infliximab, adalimumab, vedolizumab or ustekinumab from experimental and investigation to medically necessary if criteria are met. Measurement of anti-drug antibodies are medically necessary for dose escalation. However, routine, or serial testing are not medically necessary.

Medical necessity criteria changes

The following updates are effective July 10, 2023:

Medical policy Details
Percutaneous Left Atrial Appendage Closure (#91605)
 Medical necessity criteria for Percutaneous Left Atrial Appendage Closure have changed from Priority Health criteria to InterQual® criteria.
Implantable Loop Recorder (#91618)
 Medical necessity criteria for implantable loop recorders have changed from Priority Health criteria to InterQual® criteria.

Additional updates

The following updates are minor and don't impact coverage:

Medical policy Details
Cardiovascular Defibrillators (#91410) Deleted pacemakers and pacemaker from the policy scope.
Cosmetic and Reconstructive Surgery Procedures (#91535) Added abdominoplasty to the list of cosmetic procedures.
Enteral Nutrition Therapy (#91278) Clarification: Formulas, food products and supplements that do not require a physician’s order are a covered benefit (e.g., grocery products for a low-protein diet) only when said formula, food product or supplement is designed and intended solely for the dietary management of an inborn error of metabolism (IEM).
Experimental / Investigational / Unproven Care / Benefit Exceptions (#91117)

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
Hemophilia Management (#91569)
 Updated language with pharmacy terminology to reduce ambiguity and misinterpretation.
Infusion Services & Equipment (#91414)
  • Removed outdated name of InterQual criteria set
  • Separated and more clearly described the medical necessity requirements by line of business
Medications with site of service requirements can be found in Priority Health’s Medical Benefit Drug List (MBDL).
Irreversible Electroporation (IRE)-Nanoknife (#91599)
 Added clause, “due to insufficient evidence in the peer-reviewed literature” to explain why NanoKnife is considered experimentational and investigational.
Obstructive Sleep Apnea (#91333)
 Changed values of CPAP Titration Studies: OSA with severe desaturation (oxygen desaturations either a) continuous minutes with SaO2 ≤ 88% [formerly < 87%] or b) 5 total minutes with SaO2 ≤ 90% [formerly < 80%]). These new values align with current standard cutoffs.
Peripheral Nerve Stimulation (#91634)
 Addition: eTNS (external trigeminal nerve stimulation, e.g., Monarch eTNS System) is unproven for treatment of ADHDF and there considered not medically necessary.
Prosthetics / External Policy (#91306) Addition: An osseointegrated / osseoanchored lower limb prosthetic device (e.g., OPRA Implant System) is considered experimental, investigational or unproven.
Recurrent Pregnancy Loss (#91156)
 Changed policy’s name from “Recurrent Spontaneous Abortion” to “Recurrent Pregnancy Loss” to reflect current terminology. No criteria changes were made.
Septoplasty / Rhinoplasty (#91506)
 Addition: Repair of nasal valve collapse with low energy, temperature-controlled (e.g., radiofrequency) subcutaneous / submucosal remodeling (e.g., VivAer) is considered experimentational, investigational and unproven.
Telemedicine / Virtual Services (#91604)
Transcatheter Heart Valve Procedures (#91597)
 Medical necessity criteria and prior authorization requirement for transcatheter pulmonary valve implantation (CPT code 33477) have been removed.