November 2024 medical policy updates

Our Medical Advisory Committee (MAC), comprised of Priority Health network physicians, met in November and approved a series of medical policy updates. Below is a summary of the updates made.

New medical policies & policies addressing updated coverage

Continuous Glucose Monitoring and Insulin Pumps (#91466)

Policy update effective Feb. 1, 2025

The following services will change from not medically necessary to medically necessary when InterQual criteria are met:

  • S1034: Artificial pancreas device system (e.g., low glucose suspend [LGS] feature) including continuous glucose monitor, blood glucose device, insulin pump and computer algorithm that communicates with all of the devices
  • S1035: Sensor; invasive (e.g., subcutaneous), disposable, for use with artificial pancreas device system
  • S1036: Transmitter; external, for use with artificial pancreas device system
  • S1037: Receiver (monitor); external, for use with artificial pancreas device system

Applicable InterQual criteria are available in CP: Durable Medical Equipment under Continuous Glucose Monitors, Insulin Pumps, and Automated Insulin Delivery Technology.

Digital Therapeutics (#91645)

Policy effective Dec. 1, 2024

This new 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.

Renal Denervation for Resistant Hypertension (#91644)

Policy effective Feb. 1, 2025

This new 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, 2025, with prior authorization

Retired medical policies

Effective Dec. 1, 2024

  • Computerized Tomographic Angiography - Coronary Arteries (CCTA) (#91614) – This policy didn’t include Priority Health medical criteria, instead referring to EviCore for management / medical necessity determination through EviCore’s relevant guidelines. Providers should refer to EviCore’s guidelines.
  • Transcutaneous Electrical Acustimulation (TEAS) For Hyperemesis Gravidarum (#91576) – 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).

Additional medical policy updates

Effective Dec. 1, 2024

The following policies were updated to clarify language or to align with updated industry standards. See the policy changes list in our Provider Manual for details on each policy update.

  • Electrophysiology Testing & Catheter Ablation for Cardiac Arrhythmias (#91314)
  • Feeding Disorders (#91469)
  • Gender Affirming Surgery (#91612)
  • Gender Dysphoria Non-Surgical Treatment (#91622)
  • Implantable Heart Failure Monitors (#91610)
  • Infusion Services & Equipment (#91414)
  • Orthognathic Surgery (#91273)
  • Peripheral Nerve Stimulation (#91634)
  • Platelet Rich Plasma/Platelet Rich Fibrin Matrix/Autologous Blood-Derived Products/BMAC (#91553)
  • Pulse Oximetry for Home Use (#91452)
  • Septoplasty/Rhinoplasty (#91506)
  • Surgical Treatment of Obesity (#91595)
  • Vision Care (#91538)