Artificial Pancreas Device System     

Effective February 1, 2024, we have updated the medically necessary policy statement with criteria added for the artificial pancreas device system with a closed-loop insulin delivery system (bionic pancreas) for individuals with type 1 diabetes. For additional details related to this policy, please click here. 

Cosmetic Services Procedures 

Effective January 1, 2024, we added reference in this policy related to the new policy Gender Affirming Care. For additional details related to this policy, please click here.

Diagnosis and Treatment of Sacroiliac Joint Pain     

Effective February 1, 2024, commercial products criteria for minimally invasive fixation/fusion of the SIJ using transiliac placement of a titanium triangular implant has been updated. CPT codes 0775T and 0809T have been added to this policy and will not be medically necessary for commercial products. (For these services for Medicare Advantage plans, please refer to the Prior Authorization of Spinal Procedures policy). For additional details related to this policy, please click here.

Digital Health Technologies for Attention Deficit/Hyperactivity Disorder (REVISED POLICY TITLE)                                                                                    

This policy was formerly known as Digital Health Therapies for Attention Deficit/Hyperactivity Disorder. The statement within the policy has been revised from “Prescription digital therapy is considered not covered/not medically necessary for the treatment of ADHD” to “The use of EndeavorRx is considered not covered/not medically necessary for all indications including attention-deficit/hyperactivity disorder.” This went into effect December 1, 2023. For additional details related to this policy, please click here.

Drugs and Biologics                                                  

This policy was edited to include the requirement that claims must include a National Drug Code (NDC). For additional details related to this policy, please click here.

E-Consults/Interprofessional Consults/Electronic Consults                                                       

This policy was edited to include that the codes listed in the policy should not be billed with telemedicine place of service codes 02 or 10. For additional details related to this policy, please click here.

Hearing Aid Coverage and Mandate                      

For commercial products, starting January 1, 2023, upon a plan’s renewal, plans have eliminated the distinction in hearing aid benefits by age. Clients with a New England Health Plan (NEHP) product will be covered at $2,000 per hearing aid. All other plans will cover $1,500 per hearing aid. For additional details related to this policy, please click here.

Minimal Residual Disease Testing for Cacer

Effective January 1, 2024, prior authorization will be removed from CPT code 0364U (clonoSEQ) for Medicare advantage plans and commercial products. The service will be considered medically necessary when filed with one of the medically necessary ICD-10-CM codes listed in the policy. For additional details related to this policy, please click here.

Minimally Invasive Procedures for Back Pain (REVISED POLICY TITLE) 

Policy formerly known as Minimally Invasive Procedures for Back Pain Related to Disc Disease. Statements regarding different minimally invasive procedures have been separated to provide clarity. Additionally, intraosseous radiofrequency ablation of the basivertebral nerve (e.g., Intracept® system) using CPT codes 64628 and 64629 will be considered medically necessary for Medicare Advantage Plans when the criteria in the policy has been met. The procedure will remain not medically necessary for commercial products. This will go into effect February 1, 2024. For additional details related to this policy, please click here.

Non-Reimbursable health service codes                             

Effective October 1, 2023, CPT codes Q4285 and Q4286 have been added to this policy for commercial and Medicare Advantage plans for facilities. 

Effective January 1, 2024, code 0006M has been removed from this policy and codes 55970 and 55980 have been added to this policy and identified as Use Alternate Codes for commercial and Medicare Advantage plans for facilities and professional providers. 

For additional details related to this policy, please click here.

Percutaneous and Subcutaneous Tibial Nerve Stimulation (REVISED POLICY TITLE) 

This policy, formerly known as Percutaneous Tibial Nerve Stimulation, will now address subcutaneous tibial nerve stimulation. This service will not be covered for Medicare Advantage plans and not medically necessary for commercial products. This will go into effect February 1, 2024. For additional details related to this policy, please click here.

Percutaneous Electrical Nerve Stimulation, Percutaneous Neuromodulation Therapy, and Restorative Neurostimulation Therapy  (REVISED POLICY TITLE)

This policy, formerly known as Percutaneous Electrical Nerve Stimulation and Percutaneous Neuromodulation Therapy, will have a new indication added regarding restorative neurostimulation therapy (Reactiv8). This will not be covered for Medicare Advantage plans and not medically necessary for commercial products. This will go into effect February 1, 2024. For additional details related to this policy, please click here.