Pending/retired/updated medical policy list
From time to time, we make changes to our medical policies. Priority Health makes them available here for your review before they go into effect.
Effective July 16, 2012
- New: Knee Arthroscopy - 91587 (58KB PDF)
New policy developed and approved through the Medical Affairs Committee and support evidence based guidelines. Beginning July 16, 2012 this procedure must meet criteria and will require prior authorization.
- New: Lumbar Fusion - 91590 (51KB PDF)
New policy developed and approved through the Medical Affairs Committee and support evidence based guidelines. Beginning July 16, 2012 this procedure must meet criteria and will require prior authorization.
- New: Lumbar Laminectomy - 91591 (50KB PDF)
New policy developed and approved through the Medical Affairs Committee and support evidence based guidelines. Beginning July 16, 2012 this procedure must meet criteria and will require prior authorization.
- Retiring: Knee Arthroscopy for Osteoarthritis
Use the new Knee Arthroscopy - 91587 policy effective 07/16/12.
Effective May 28, 2012
- New: Transcatheter Heart Valves - 91597 (99KB PDF)
New policy addressing the criteria for coverage of transcatheter aortic valve implantation (TAVI) and transcatheter pulmonary valve implantation (TPVI).
- Vision Care/Eye Exam - 91538 (86KB PDF)
Summary of change: Criteria added to reflect office-based vision therapy/orthoptics covered only as a treatment for convergence insufficiency (CI) in children. Use of this treatment/therapy for any other indication/diagnosis is considered to be experimental and investigational and is not a covered benefit.
Effective April 25, 2012
- Catheter Ablation for Cardiac Arrhythmias - 91314 (53KB PDF)
Summary of change: Language previously addressed the coverage of catheter ablations as primary or secondary therapy. This language was removed. Language updated to reflect all covered therapies and specific criteria for coverage.
- Enteral Nutritional Therapy - 91278 (55KB PDF)
Summary of change: Coverage clarified, and language also added to reflect that oral 100% hydrolyzed amino acids infant formulas are covered up to 24 months of age when specific criteria are met.
- New: Irreversible Electroporation (IRE) or Nanoknife - 91599 (35KB PDF)
New policy addressing the non-coverage of Irreversible Electroporation (IRE) or Nanoknife for the ablation of cancer as it is considered experimental and investigational.
- Sexual Dysfunction & Impotence - 91160 (57K PDF)
Summary of change: Stem cell therapy for erectile dysfunction was added to the list of non-covered services as it is experimental and investigational.
- Skin Conditions - 91456 (122KB PDF)
Summary of change: Criteria added to reflect additional consideration for home therapy (for those who are able to travel) for the treatment of psoriasis may be made if the treatment has been continuous and long term, > 1 year in duration, has shown to be effective for the member, and is expected to continue long term.
Effective April 02, 2012
- Stimulation Therapy and Devices - 91468 (180KB PDF)
Summary of change: Criteria updated to reflect that vagal nerve stimulation for the treatment of depression is not a covered benefit. Only covered for the treatment of seizures when criteria is met. The Vagal Nerve Stimulation for Depression medical policy will be retired effective 04/02/2012.
- Retiring: Vagal Nerve Stimulation as a Treatment of Depression 91524
Use the updated Stimulation Therapy and Devices medical policy.
Effective April 01, 2012
- Obesity - 91435 (137KB PDF)
Summary of change: Effective 04/01/12, this policy will only apply to requests for prior authorization to contracted Priority Health Weight Loss Centers of Excellence through 05/31/12. It will be retired effective 06/01/12.
- Medical Management of Obesity - 91594 (104KB PDF)
Summary of change: Criteria has significantly changed. New policy requirements are Age ≥ 16 years, BMI ≥ 30, and an intake assessment that shows a patient is in the contemplation or action phase of readiness for change. The new policy allows for the medical weight management program to be provided by a credentialed physician with a declared interest in the medical management of obesity, the member's primary care physician (PCP) or other managing physician. Medical management is no longer required to be prior authorized or provided by a Weight Loss Center of Excellence.
- Surgical Treatment of Obesity - 91595 (118KB PDF)
Summary of change: Criteria has significantly changed. New policy requirements are: a) BMI ≥ 35, participation in a medical weight management program and at least one obesity-related co-morbidity, or b) BMI ≥ 40, co-morbidity is not required, however, participation in a medical weight management program is, or c) BMI ≥ 50, no co-morbidity or participation in medical weight loss program. See policy for additional requirements.
Effective March 29, 2012
- New: Computed Tomography Scanning for Lung Cancer Screening - 91600 (39KB PDF)
Summary of change: New policy addressing the non-coverage of spiral computed tomography (CT) scanning, also known as helical CT or low-dose CT scanning, for screening for lung cancer for average risk or high risk groups (e.g., smokers) because it is not recommended by the United States Preventive Services Task Force (www.uspstf.gov).
Effective March 02, 2012
- Bronchial Thermoplasty - 91577 (46KB PDF)
Summary of change: Coverage criteria for bronchial thermoplasty added to the policy. Previously it was not covered.
- Markers for Digestive Disorders - 91583 (113KB PDF)
Summary of change: Criteria expanded to clarify testing that is considered experimental and investigational, and to reflect that genetic testing as an initial screening in symptomatic or in asymptomatic individuals is considered to be experimental and investigational (i.e. MyCeliacID, PROMETHEUS® Celiac Genetics).
- Pharmacogenomics Testing - 91570 (63KB PDF)
Summary of change: All non-covered testing moved from the criteria section of the policy to an appendix; several new non-covered tests added.
- Tumor Markers - 91562 (66KB PDF)
Summary of change: A listing of non-covered tumor markers added as Appendix II. The list is not all-inclusive and any tumor marker not listed is still subject to the main policy criteria.
Effective Feb. 15, 2012
Effective Feb. 09, 2012
- Cardiovascular Risk Markers - 91559 (49KB PDF)
Summary of change: Lipoprotein particle size and concentration/density measurement (previously covered) and natriuretic peptides added to the list of tests that are not covered for the screening, management or diagnosis of CVD.
- Colorectal Cancer Screening - 91547 (50KB PDF)
Summary of change: Computer tomography colonography (CTC) added to list of standard tests covered for general colon cancer screening. CTC will still require prior authorization.
Effective Jan. 09, 2012
- New: Balloon Sinus Ostial Dilation - 91596 (40KB PDF)
New policy on the use of balloon sinus ostial dilation, e.g. Balloon Sinuplasty™, as investigational and not medically necessary for the treatment of any sinus condition, including but not limited to sinusitis.
- Home Hemodialysis (Formerly End Stage Renal Disease & Home Hemodialysis) - 91526 (41KB PDF)
Summary of change: ESRD and intradialytic parenteral nutrition (IDPN) criteria and descriptions were removed; IDPN criteria were added to Parenteral Nutritional Therapy Policy 91517.
- Intraoperative Radiotherapy IORT - 91556 (46KB PDF)
Summary of change: Criteria added for the coverage of intraoperative radiation therapy (IORT) as part of clinical care for breast cancer if certain criteria are met. Language updated to reflect that IORT would also be covered as part of a clinical trial for breast cancer if criteria for coverage as part of clinical care is not met.
- Parenteral Nutritional Therapy 91517 (56KB PDF)
Summary of change: Policy title changed from Parenteral Nutritional Therapy in the Home. Intradialytic parenteral nutrition (IDPN) criteria, formerly part of the Home Hemodialysis Medical Policy 91526, has been added. Medical necessity review section updated: Prior authorization is only required for home parenteral nutrition.
Back to the listing of current Medical Policies
You'll need a recent version of Adobe® Reader software to view and print PDF files. Download it free now!
