August 2024 medical policy updates

Update 10.16.24 - Updated implementation dates for the Varicose Vein Treatment policy (#91326)

Our Medical Advisory Committee (MAC), comprised of Priority Health network physicians, met in August and approved the medical policy updates described below.

Please note the individual policy effective dates listed below.

New medical policies

Benign Prostatic Hyperplasia (BPH) Treatments (#91642)

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)

Infectious Disease Molecular Panels (#91643)

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.

Moving to InterQual® criteria

Electroencephalography (#91510)

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.

Added prior authorization requirement

Varicose Vein Treatment (#91326)

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.

Updated payable units

Breast Related Procedures (#91545)

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.

Updated prior authorization guidance

Genetics: Counseling, Testing, Screening (#91540)

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.

Additional medical policy updates

Policy updates effective Sept. 1, 2024

The following policies were updated to clarify language and experimental and investigational positions, or to align with updated industry standards:

  • Cranial Helmets (#91504)
  • Detoxification (#91104)
  • Hyperbaric Oxygen Therapy (#91151)
  • Hyperhidrosis (#91451)
  • Infertility Diagnosis and Treatment / Assisted Reproduction / Artificial Conception (#91163)
  • Neuropsychological and Psychological Testing (#91537)
  • Skin Conditions (#91456)