May 2022 medical policy updates

The following policy changes were approved by the Medical Advisory Committee (MAC) and are effective May 2022:

• Prostatic Artery Embolization (#91620)
  Expanded coverage to cover a CTA of the pelvis prior to a prosthetic artery embolization (PAE) after the criteria for PAE have been met. Prior authorization for CTA of the pelvis (CPT code 72191) is required through eviCore.
• Stereotactic Radiosurgery and Stereotactic Body Radiotherapy (#91127)
  Specified documentation requirements for stereotactic body radiation therapy (SBRT). Updated medical necessity criteria for SBRT to include pre-service review of prior authorization requests.
• Arthroscopy and Arthroscopically Assisted Surgery for Knee, Hip, and Shoulder (#91628)
  Added new exclusion – the use of biodegradable subacromial balloon spacer (e.g., InSpace, Stryker) is considered experimental, investigational and unproven.
• Continuous Glucose Monitoring (#91466)
  Added new exclusion – software or hardware for downloading data to a device, such as a personal computer, smart phone or tablet, to aid in the self-management of diabetes mellitus is considered not medically necessary.
• Experimental / Investigational / Unproven Care / Benefit Exceptions (#91117)
  Updated Appendices B & D to remove outdated exemptions. Added exemption for Tether, a vertebral body tethering system for skeletally immature patients with progressive idiopathic scoliosis, which is only covered for Commercial products.
• Hearing Augmentation (#91544)
  Updated language to reflect MDHHS Medicaid Provider Manual guidance allowing for non-implantable BAHA. Updated audiology criteria language to mirror MDHHS Medicare Provider Manual language.
• High-Intensity Focused Ultrasound (#91601)
  Edited language for HIFU for prostate cancer to reflect NCCN language. Added language from medical policy #91314 which states that HIFU is experimental and investigation for a stand-alone ablative procedure for atrial fibrillation.
• Infusion Services and Equipment (#91414)
  The updates below align this medical policy with our Pharmacy department’s processes and will go into effect on July 1, 2022. We’ll post the updated medical policy before this effective date.
  Removed site of service exemption for cancer diagnosis
  Added site of service exemption for pediatric members 17 years old or younger
  Added criteria exemption review for members living 30 miles from the nearest approved site that administers oncology drugs
• Moderate Sedation for Interventional Pain Management (#91632)
  New medical policy. Goes into effect on July 25, 2022.
• Skin Conditions (#91456)
  Simplified language and reformatted.
• Spine Procedures (#91581)
  Added that Tether is medically necessary when used according to its FDA HDE approval.
• Transcatheter Heart Valve Procedures (#91597)
  Updated limitations and exclusions to transcatheter aortic valve replacement.
• Varicose Vein Treatment (#91326)
  Expanded coverage to include endoluminous radiofrequency ablation (ERFA) for accessory veins by removing it from the list of procedures considered unproven and not medically necessary.