Pending/retired/updated medical policy list

Note: The changes below were made for clarity and consistency with Priority Health’s current position on FDA-approved SLIT tablets.

Additions:

• I. Notes: Reference to the Priority Health Billing & Coding Policy entitled Allergy Injections / Immunotherapy has been added. Recent changes to this billing & coding policy were made to in vitro testing:
  
  - In vitro testing isn’t payable when a skin test is also performed for the same antigen with the exception of latex sensitivity, Hymenoptera and nut/peanut sensitivity.
  - In vitro testing must be supported within the medical record as a substitute for in vivo testing (skin testing) and, effective Nov. 11, 2024, will be limited to 30 allergens over a 12-month period.

Changes:

• I. B.: In the prior revision (R9), all sublingual immunotherapy (SLIT) was listed as not medically necessary. With this revision (R10), only SLIT tablets that have not been approved by the FDA, as well as all aqueous SLIT formulations, are not medically necessary. Reader is now referred to Priority Health’s current Pharmacy Benefit regarding coverage for FDA-approved SLIT tablets.

Note: The addition below does not represent a change. Language was added to the policy to clarify an existing Priority Health position.

Additions:

• Exclusions: B. 13. Equine-assisted activities therapies (e.g., hippotherapy, therapeutic riding) has been added as an exclusion

Additions:

• The d-Nav® System (Hygieia, Inc.) is considered medically necessary when used by adults with Type 2 diabetes as an aid in optimizing insulin management. Use of the d-Nav® System is limited to Health Care Providers who have been trained by Hygieia or a Hygieia trained person on the use of the d-Nav® System, including setup of the patient’s Phone App. Use of the d-Nav® System requires a prescription.

Clarifications:

• Policy was restructured to first specify any digital therapeutics that may be considered medically necessary (inclusions), and second to indicate that all other digital therapeutics not expressly named as inclusions are considered not medically necessary for any indication or use, and are experimental, investigational, or unproven (exclusions).

Deletions:

• I. A. 2.: Deleted a significantly shortened life expectancy from list of absolute contraindications to renal transplantation as there is no universally accepted life expectancy below which an individual is ineligible for kidney transplantation.

Note: The update below isn’t a change in coverage. ESWT is currently not covered for any indication.

Addition:

• Low intensity ESWT for the treatment of erectile dysfunction is considered experimental and investigational.

Note: The change below isn’t a change in coverage.

Clarification:

• I.A.3.c.iii – Deleted hyaluronic acid as an example of conservative therapy
• I.A.8.c – Deferred to Pharmacy documents for coverage and prior authorization rules for anti-fungal agents.
• I.B.2 – Added cross reference to related medical policy: Extracorporeal Shock Wave Therapy (ESWT) # 91527

Addition:

• I.A.3. a – Directions on how to access third party delegated clinical guidelines
• I.K.2.: Criteria on multi-marker tumors panel from retired Multi-Marker Tumor Panels policy # 91609

Addition:

• D – Added cross reference to the Digital Therapeutics medical policy # 91645
• I. H – The Buffalo Model is experimental and investigational.

Addition:

• I.C.: Site of service exceptions for starting doses with multiple administrations, complexity of infusion, and when receiving immune checkpoint inhibitors in combination with provider-administered chemotherapy on the same day

Deletion:

• I.C.: Deletion: Removed age exemption from site of service review; exceptions are made based on complexity of infusion.

• New medical policy
• Puts information currently available in our Provider Manual into a medical policy. No changes were made.

Change:

• LITT is considered is medically necessary for primary and recurrent brain tumors or relapsed brain metastases when criteria are met.

Policy changes effective May 1, 2025

Addition / clarification:

• I.A 6.e. – Proactive therapeutic drug monitoring to predict therapeutic response in the management of IBD or UC (e.g., PredictrPK IFX) is not medically necessary.
• I.C. – Methane and hydrogen breath tests are medically necessary for the diagnosis of suspected lactose intolerance. At-home breath tests (e.g., TrioSmart) are not medically necessary.

Retiring medical policy. Moving criteria to Genetics: Counseling, Testing and Screening (#91540) policy.

Changes:

• Coverage for drug therapy recommended by next-generation sequencing results shall be determined by pharmacy drug coverage policies and requirements.

• New medical policy
• Consolidated criteria which currently exist across multiple medical policies, e.g. radiofrequency ablation (RFA) for back pain from the Spine Procedures policy # 91581 into one policy.
• Addresses currently non-covered experimental & investigational procedures (e.g., Coolief, iovera, pulsed RFA) which are billed with codes which could be applicable to covered and established procedures

Note: The addition below does not represent a change. Language was added to the policy to clarify an existing Priority Health position.

Addition:

• I.A.6 – Equine therapy (e.g., hippotherapy, therapeutic riding) is considered experimental and investigation or not medically necessary.

Additions:

• Reference to Neuroablation for Pain Management (#91647) medical policy
• Directions for providers to find TurningPoint medical necessity criteria

Deletions:

• I.G. – Moved radiofrequency ablation for back pain criteria to Neuroablation for Pain Management (#91647) medical policy.

Note: The additions below do not represent a change. Language was added to the policy to clarify Priority Health’s current position.

Additions:

• P. ELECTRIC TUMOR TREATMENT FIELDS (ETTF) DEVICES: Added the following text (italics): ETTF devices for all other indications are considered experimental and not covered, including, but not limited to, the following: Intrabuccal devices that deliver systemic amplitude-modulated radiofrequency electromagnetic field stimulation (AM RF EMF) for treatment of cancer (e.g., TheraBionic P1 device (TheraBionic, Inc.)).
• J. INCONTINENCE STIMULATOR: added section e. Transcutaneous Tibial Nerve Stimulation (TTNS) . Transcutaneous tibial nerve stimulation for treatment of overactive bladder and its associated symptoms is considered not medically necessary.

Clarifications:

• Utilization management and medical necessity criteria around transcatheter cardiac valve replacements and repairs have been clarified.
• Any procedures or interventions that are outside the scope of transcatheter heart valve procedures have been removed.