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UnitedHealthcare Commercial Medical & Drug Policies

The Medical Policies, Medical Benefit Drug Policies, and corresponding update bulletins for UnitedHealthcare Commercial plans are listed below.

For California members, note that the materials provided to you are guidelines used by this plan to authorize, modify, or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract.

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A monthly notice of recently approved and/or revised Medical Policies and Medical Benefit Drug Policies is provided below for your review. We publish a new announcement on the first calendar day of every month.

The appearance of a health service (e.g., test, drug, device, or procedure) in the Medical Policy Update Bulletin does not imply that UnitedHealthcare provides coverage for the health service. In the event of an inconsistency or conflict between the information provided in the Medical Policy Update Bulletin and the posted policy, the provisions of the posted policy will prevail.

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09/01/2024 – UnitedHealthcare Commercial Medical Policy Update Bulletin: September 2024

Last Published 09.01.2024

This bulletin provides complete details on recently approved, revised, and/or retired UnitedHealthcare Commercial Medical Policies and/or Medical Benefit Drug Policies.

10/01/2024 – UnitedHealthcare Commercial Medical Policy Update Bulletin: October 2024

Last Published 10.01.2024

This bulletin provides complete details on recently approved, revised, and/or retired UnitedHealthcare Commercial Medical Policies and/or Medical Benefit Drug Policies.

11/01/2024 – UnitedHealthcare Commercial Medical Policy Update Bulletin: November 2024

Last Published 11.01.2024

This bulletin provides complete details on recently approved, revised, and/or retired UnitedHealthcare Commercial Medical Policies and/or Medical Benefit Drug Policies.

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UnitedHealthcare Commercial Medical Policy Update Bulletin Archive

Last Published 11.01.2024

A listing of the Medical Policy Update Bulletins for the past two rolling years.

Medical Records Documentation Used for Reviews
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Commercial Medical & Drug Policies Terms and Conditions

Please read the terms and conditions below carefully.

UnitedHealthcare has developed Medical Policies and Medical Benefit Drug Policies to assist us in administering health benefits. These policies are provided for informational purposes, and do not constitute medical advice. Treating physicians and health care providers are solely responsible for determining what care to provide to their patients. Members should always consult their physician before making any decisions about medical care.

Our Medical Policies and Medical Benefit Drug Policies express our determination of whether a health service (e.g., test, drug, device, or procedure) is proven to be effective based on the published clinical evidence. They are also used to decide whether a given health service is medically necessary. Services determined to be experimental, investigational, unproven, or not medically necessary by the clinical evidence are typically not covered

Benefit coverage for health services is determined by the member specific benefit plan document, such as a Certificate of Coverage, Schedule of Benefits, or Summary Plan Description, and applicable laws that may require coverage for a specific service. The member specific benefit plan document identifies which services are covered, which are excluded, and which are subject to limitations. In the event of a conflict, the member specific benefit plan document supersedes these policies and guidelines.

For California members, note that the materials provided to you are guidelines used by this plan to authorize, modify, or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract.

Medical Policies and Medical Benefit Drug Policies are developed as needed, regularly reviewed and updated, and subject to change. They represent a portion of the resources used to support UnitedHealthcare coverage decision making. The information presented in these policies and guidelines is believed to be accurate and current as of the date of publication and is provided on an "AS IS" basis. Additionally, UnitedHealthcare may use tools developed by third parties, such as the InterQual® criteria, to assist us in administering health benefits. The InterQual® criteria are intended to be used in connection with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice. Providers may review the InterQual® criteria here.

UnitedHealthcare's Medical Policies and Medical Benefit Drug Policies do not include notations regarding prior authorization requirements. View the services that are subject to notification/prior authorization requirements.

Medical Policies and Medical Benefit Drug Policies are the property of UnitedHealthcare. Unauthorized copying, use, and distribution of this information are strictly prohibited. The InterQual® criteria are proprietary to Change Healthcare and are not published on this website.

By clicking "I Agree," you agree to the terms and conditions expressed herein, in addition to our Site Use Agreement.

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Ablative Treatment for Spinal Pain – Commercial and Individual Exchange Medical Policy

Last Published 09.01.2024

Effective Date: 01.01.2024 – This policy addresses Intraosseous radiofrequency ablation, ablation for treating sacroiliac pain, and other facet joint nerve ablation procedures for spinal pain. Applicable Procedure Codes: 22899, 27299, 64625, 64628, 64629,

Abnormal Uterine Bleeding and Uterine Fibroids – Commercial and Individual Exchange Medical Policy

Last Published 09.01.2024

Effective Date: 11.01.2023 – This policy addresses endometrial ablation, the use of levonorgestrel-releasing intrauterine devices (LNG-IUD), uterine artery embolization (UAE), magnetic resonance-guided focused ultrasound ablation (MRgFUS), and ultrasound-guided radiofrequency ablation. Applicable Procedure Codes: 0071T, 0072T, 37243, 58563, J7296, J7297, J7298, J7301, J7306, S4981.

Actemra® (Tocilizumab) Injection for Intravenous Infusion – Commercial Medical Benefit Drug Policy

Last Published 07.01.2024

Effective Date: 07.01.2024 – This policy addresses the use of Actemra® (tocilizumab) injection for intravenous infusion for the treatment of polyarticular juvenile idiopathic arthritis, rheumatoid arthritis, systemic juvenile idiopathic arthritis, cytokine release syndrome, acute graft-versus-host disease, and immune checkpoint inhibitor-related toxicities. Applicable Procedure Code: J3262.

Adakveo® (Crizanlizumab-Tmca) – Commercial Medical Benefit Drug Policy

Last Published 05.01.2024

Effective Date: 05.01.2024 – This policy addresses the use of Adakveo® (crizanlizumab-tmca) to reduce the frequency of vasoocclusive crises in patients with sickle cell disease. Applicable Procedure Code: J0791.

Aduhelm® (Aducanumab-Avwa) – Commercial Medical Benefit Drug Policy

Last Published 05.01.2024

Effective Date: 05.01.2024 – This policy addresses the use of Aduhelm® (aducanumab-avwa) for the treatment of Alzheimer’s disease. Applicable Procedure Code: J0172.

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Adzynma (ADAMTS13, Recombinant-Krhn) – Commercial Medical Benefit Drug Policy

Last Published 07.01.2024

Effective Date: 07.01.2024 – This policy addresses the use of Adzynma (ADAMTS13, recombinant-krhn) for the treatment of congenital thrombotic thrombocytopenic purpura (cTTP). Applicable Procedure Code: J7171.

Airway Clearance Devices – Commercial and Individual Exchange Medical Policy

Last Published 03.01.2024

Effective Date: 03.01.2024 – This policy addresses airway clearance devices, such as high-frequency chest wall oscillation systems, and intrapulmonary percussive ventilation (IPV) devices. Applicable Procedure Codes: A7025, A7026, E0481, E0483.

Alpha1-Proteinase Inhibitors – Commercial Medical Benefit Drug Policy

Last Published 11.01.2024

Effective Date: 11.01.2024 – This policy addresses alpha1-proteinase inhibitors (Aralast NP™, Glassia™, Prolastin®-C, and Zemaira®) for chronic augmentation and maintenance therapy of emphysema due to congenital deficiency of alpha1-proteinase inhibitor (A1-PI)/alpha1-antitrypsin (AAT) deficiency. Applicable Procedure Codes: J0256, J0257.

Ambulance Services – Commercial and Individual Exchange Medical Policy

Last Published 11.01.2024

Effective Date: 07.01.2024 – This policy addresses emergency ambulance (ground, water, or air) and non-emergency ambulance (ground or air) services.

"A0225, A0380, A0382, A0384, A0390, A0392, A0394, A0396, A0398, A0420, A0422, A0424, A0425, A0426, A0427, A0428, A0429, A0430, A0431, A0432, A0433, A0434, A0435, A0436, A0998, A0999, S0207, S0208, S9960, S9961, T2007."

Amondys 45® (Casimersen) – Commercial Medical Benefit Drug Policy

Last Published 05.01.2024

Effective Date: 05.01.2024 – This policy addresses the use of Amondys 45® (casimersen) for the treatment of Duchenne muscular dystrophy (DMD). Applicable Procedures Code: J1426.

Antiemetics for Oncology – Commercial Medical Benefit Drug Policy

Last Published 07.01.2024

Effective Date: 07.01.2024 – This policy addresses the use of antiemetics for prevention of chemotherapy-induced nausea and vomiting associated with anticancer agents. Applicable Procedures Codes: J0185, J1434, J1453, J1454, J1456, J1626, J1627, J2405, J2469, J8501, J8655, J8670, Q0162, Q0166.

Apheresis – Commercial and Individual Exchange Medical Policy

Last Published 03.01.2024

Effective Date: 03.01.2024 – This policy addresses apheresis/therapeutic apheresis. Applicable Procedure Codes: 0342T, 36511, 36512, 36513, 36514, 36516, 36522, S2120.

Assisted Administration of Clotting Factors, Coagulant Blood Products & Other Hemostatics (for Oxford Only) – Commercial Medical Benefit Drug Policy

Last Published 11.01.2024

Effective Date: 11.01.2024 – This policy addresses assisted administration of clotting factors and coagulant blood products, including home health care services.

Athletic Pubalgia Surgery – Commercial and Individual Exchange Medical Policy

Last Published 04.02.2024

Effective Date: 04.01.2024 – This policy addresses surgical repair for treating athletic pubalgia. Applicable Procedure Codes: 27299, 49659, 49999.

Autologous Cellular Therapy – Commercial and Individual Exchange Medical Policy

Last Published 10.01.2024

Effective Date: 10.01.2024 – This policy addresses autologous cellular therapy. Applicable Procedures Codes: 0263T, 0264T, 0265T, 0489T, 0490T, 0565T, 0566T, 0717T, 0718T, 27599.

Bariatric Surgery – Commercial and Individual Exchange Medical Policy

Last Published 07.01.2024

Effective Date: 03.01.2024 – This policy addresses bariatric surgical procedures. Applicable Procedure Codes: 43290, 43291, 43644, 43645, 43647, 43648, 43659, 43770, 43771, 43772, 43773, 43774, 43775, 43843, 43845, 43846, 43847, 43848, 43860, 43865, 43881, 43882, 43886, 43887, 43888, 64590, 64595, 64999.

Beds and Mattresses – Commercial and Individual Exchange Medical Policy

Last Published 06.01.2024

Effective Date: 06.01.2024 – This policy addresses hospital beds, mattresses, and accessories. Applicable Procedure Codes: E0193, E0194, E0250, E0251, E0255, E0256, E0260, E0261, E0265, E0266, E0277, E0280, E0290, E0291, E0292, E0293, E0294, E0295, E0296, E0297, E0300, E0301, E0302, E0303, E0304, E0305, E0310, E0316, E0328, E0329, E0910, E0911, E1399.

Benlysta® (Belimumab) – Commercial Medical Benefit Drug Policy

Last Published 11.01.2024

Effective Date: 11.01.2024 – This policy addresses the use of Benlysta® (belimumab) injection for intravenous infusion for the treatment of systemic lupus erythematosus (SLE) and active lupus nephritis (LN). Applicable Procedure Code: J0490.

Botulinum Toxins A and B – Commercial Medical Benefit Drug Policy

Last Published 04.02.2024

Effective Date: 04.01.2024 – This policy addresses the use of botulinum toxin types A and B, including Dysport® (abobotulinumtoxinA), Daxxify® (daxibotulinumtoxinA-lanm), Xeomin® (incobotulinumtoxinA), Botox® (onabotulinumtoxinA), and Myobloc® (rimabotulinumtoxinB). Applicable Procedure Codes: J0585, J0586, J0587, J0588, J0589.

Breast Imaging for Screening and Diagnosing Cancer – Commercial and Individual Exchange Medical Policy

Last Published 11.01.2024

Effective Date: 11.01.2024 – This policy addresses breast imaging, including digital mammography, magnetic resonance imaging (MRI), ultrasound, automated breast ultrasound system, computer-aided detection (CAD), computer-aided tactile breast imaging, electrical impedance scanning (EIS), magnetic resonance elastography (MRE), and molecular breast imaging. Applicable Procedure Codes: 0422T, 0633T, 0634T, 0635T, 0636T, 0637T, 0638T, 76376, 76377, 76391, 76498, 76499, 76641, 76642, 77046, 77047, 77048, 77049, S8080.

Breast Reconstruction – Commercial and Individual Exchange Medical Policy

Last Published 09.01.2024

Effective Date: 09.01.2024 – This policy addresses breast reconstruction post-mastectomy and for the treatment of Poland syndrome, removal of breast implants, and breast repair and reconstruction not post mastectomy. Applicable Procedure Codes: 11920, 11921, 11922, 11970, 11971, 15271, 15272, 15771, 15772, 15777, 19316, 19325, 19328, 19330, 19340, 19342, 19350, 19355, 19357, 19361, 19364, 19367, 19368, 19369, 19370, 19371, 19396, 19499, L8600, S2066, S2067, S2068, S8950.

Breast Reduction Surgery – Commercial and Individual Exchange Medical Policy

Last Published 06.01.2024

Effective Date: 06.01.2024 – This policy addresses breast reduction surgeries. Applicable Procedure Code: 19318.

Brineura® (Cerliponase Alfa) – Commercial Medical Benefit Drug Policy

Last Published 11.01.2024

Effective Date: 11.01.2024 – This policy addresses the use of Brineura® (cerliponase alfa) in pediatric patients with late infantile neuronal ceroid lipofuscinosis (LINCL). Applicable Procedure Code: J0567.

Briumvi® (Ublituximab-Xiiy) – Commercial Medical Benefit Drug Policy

Last Published 05.01.2024

Effective Date: 05.01.2024 – This policy addresses the use of Briumvi® (ublituximab-xiiy) for the treatment of relapsing forms of multiple sclerosis (MS). Applicable Procedure Code: J2329.

Bronchial Thermoplasty – Commercial and Individual Exchange Medical Policy

Last Published 10.01.2024

Effective Date: 10.01.2024 – This policy addresses bronchial thermoplasty. Applicable Procedure Codes: 31660, 31661.

Brow Ptosis and Eyelid Repair – Commercial and Individual Exchange Medical Policy

Last Published 10.01.2024

Effective Date: 10.01.2024 – This policy addresses brow ptosis, browpexy or internal browlift, eyelid surgery for correction of lagophthalmos, lid retraction surgery, and canthoplasty/canthopexy. Applicable Procedure Codes: 15820, 15821, 15822, 15823, 21280, 21282, 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909, 67911, 67912, 67914, 67915, 67916, 67917, 67921, 67922, 67923, 67924, 67950, 67961, 67966.

Buprenorphine (Brixadi® & Sublocade®) – Commercial Medical Benefit Drug Policy

Last Published 11.01.2024

Effective Date: 11.01.2024 – This policy addresses the use of buprenorphine (Brixadi® and Sublocade®) for the treatment of opioid dependence/opioid use disorder. Applicable Procedure Codes: J0577, J0578, Q9991, Q9992.

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Cardiac Event Monitoring – Commercial and Individual Exchange Medical Policy

Last Published 11.01.2024

Effective Date: 06.01.2024 – This policy addresses cardiac event monitoring, including ambulatory event monitoring, outpatient cardiac telemetry, and implantable loop recorder. Applicable Procedure Codes: 0650T, 33285, 33286, 93224, 93225, 93226, 93227, 93228, 93229, 93241, 93242, 93243, 93244, 93245, 93246, 93247, 93248, 93268, 93270, 93271, 93272, 93285, 93291, 93297, 93298, 93799, E0616, E1399.

Cardiovascular Disease Risk Tests – Commercial and Individual Exchange Medical Policy

Last Published 05.01.2024

Effective Date: 05.01.2024 – This policy addresses arterial compliance testing using waveform analysis, carotid intima-media thickness (CIMT) measurement, advanced lipoprotein analysis, endothelial function assessment, and tests for lipoprotein-associated phospholipase A2 (Lp-PLA2) enzyme, other human A2 phospholipases, long-chain omega-3 fatty acids, and multi-protein biomarkers. Applicable Procedure Codes: 0052U, 0308U, 0309U, 0377U, 0401U, 82172, 83695, 83698, 83701, 83704, 84999, 93050, 93799, 93895, 93998.

Carrier Testing Panels for Genetic Diseases – Commercial and Individual Exchange Medical Policy

Last Published 11.01.2024

Effective Date: 11.01.2024 – This policy addresses the Ashkenazi Jewish carrier screening and expanded carrier screening panel testing. Applicable Procedure Codes: 0400U, 81412, 81443, 81479.

Category III Codes – Commercial and Individual Exchange Medical Policy

Last Published 07.01.2024

Effective Date: 07.01.2024 – This policy addresses the use of Category III codes.

Catheter Ablation for Atrial Fibrillation – Commercial and Individual Exchange Medical Policy

Last Published 02.01.2024

Effective Date: 02.01.2024 – This policy addresses catheter ablation for atrial fibrillation. Applicable Procedure Codes: 93653, 93655, 93656, 93657.

Cell-Free Fetal DNA Testing – Commercial and Individual Exchange Medical Policy

Last Published 10.01.2024

Effective Date: 10.01.2024 – This policy addresses DNA-based noninvasive prenatal tests. Applicable Procedure Codes: 0060U, 0488U, 0489U, 0494U, 81420, 81422, 81479, 81507.

Chelation Therapy for Non-Overload Conditions – Commercial and Individual Exchange Medical Policy

Last Published 06.01.2024

Effective Date: 06.01.2024 – This policy addresses chelation therapy. Applicable Procedure Codes: J0470, J0600, J0895, J3490, J3520, J8499, M0300, S9355.

Chemotherapy Observation or Inpatient Hospitalization – Commercial and Individual Exchange Medical Policy

Last Published 05.01.2024

Effective Date: 05.01.2024 – This policy addresses chemotherapy observation or overnight (inpatient) stay.

Chromosome Microarray Testing (Non-Oncology Conditions) – Commercial and Individual Exchange Medical Policy

Last Published 11.01.2024

Effective Date: 10.01.2024 – This policy addresses genome-wide comparative genomic hybridization microarray testing or single nucleotide polymorphism (SNP) chromosomal microarray analysis. Applicable Procedure Codes: 0156U, 0209U, 81228, 81229, 81349, 81479, S3870.

Cimzia® (Certolizumab Pegol) – Commercial Medical Benefit Drug Policy

Last Published 10.01.2024

Effective Date: 10.01.2024 – This policy addresses the use of Cimzia® (certolizumab pegol) the treatment of Crohn’s disease, rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, non-radiographic axial spondyloarthritis, and plaque psoriasis. Applicable Procedures Codes: 96372, 96401, J0717.

Clinical Trials – Commercial and Individual Exchange Medical Policy

Last Published 08.01.2024

Effective Date: 08.01.2024 – This policy addresses clinical trials. Applicable Procedure Codes: G0276, G0293, G0294, G2000, S9988, S9990, S9991, S9992, S9994, S9996.

Clotting Factors, Coagulant Blood Products & Other Hemostatics – Commercial Medical Benefit Drug Policy

Last Published 11.01.2024

Effective Date: 11.01.2024 – This policy addresses clotting factors and coagulant blood products. Applicable Procedure Codes: J7170, J7175, J7177, J7178, J7179, J7180, J7181, J7182, J7183, J7185, J7186, J7187, J7188, J7189, J7190, J7192, J7193, J7194, J7195, J7198, J7199, J7200, J7201, J7202, J7203, J7204, J7205, J7207, J7208, J7209, J7210, J7211, J7212, J7213, J7214.

Cochlear Implants – Commercial and Individual Exchange Medical Policy

Last Published 11.01.2024

Effective Date: 09.01.2024 – This policy addresses non-hybrid and hybrid cochlear implantation. Applicable Procedure Codes: 69930, L8614, L8615, L8616, L8617, L8618, L8619, L8627, L8628, V5273.

Cognitive Rehabilitation – Commercial and Individual Exchange Medical Policy

Last Published 10.01.2024

Effective Date: 10.01.2024 – This policy addresses cognitive rehabilitation and coma stimulation. Applicable Procedure Codes: 97129, 97130, S9056.

Collagen Crosslinks and Biochemical Markers of Bone Turnover – Commercial and Individual Exchange Medical Policy

Last Published 02.01.2024

Effective Date: 02.01.2024 – This policy addresses serum or urine collagen crosslinks or biochemical markers. Applicable Procedure Code: 82523.

Complement Inhibitors (Soliris® & Ultomiris®) – Commercial Medical Benefit Drug Policy

Last Published 07.01.2024

Effective Date: 07.01.2024 – This policy addresses the use of Soliris® (eculizumab) and Ultomiris® (ravulizumab-cwvz). Applicable Procedure Codes: J1300, J1303.

Computer-Assisted Surgical Navigation for Musculoskeletal Procedures – Commercial and Individual Exchange Medical Policy

Last Published 11.01.2023

Effective Date: 11.01.2023 – This policy addresses computer-assisted surgical navigation for musculoskeletal procedures and the use of intra-operative kinetic balance sensor for implant stability during knee replacement arthroplasty. Applicable Procedures Codes: 0054T, 0055T, 20985, 27599.

Computerized Dynamic Posturography – Commercial and Individual Exchange Medical Policy

Last Published 03.01.2024

Effective Date: 03.01.2024 – This policy addresses computerized dynamic posturography (CDP) testing. Applicable Procedure Codes: 92548, 92549.

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Continuous Glucose Monitoring and Insulin Delivery for Managing Diabetes – Commercial and Individual Exchange Medical Policy

Last Published 10.01.2024

Effective Date: 09.01.2024 – This policy addresses insulin delivery and continuous glucose monitoring for diabetes management. Applicable Procedure Codes: 0446T, 0447T, 0448T, 95249, 95250, 95251, A4226, A4238, A4239, A9274, A9276, A9277, A9278, E0784, E0787, E2102, E2103, S1030, S1031, S1034, S1035, S1036, S1037.

Core Decompression for Avascular Necrosis – Commercial and Individual Exchange Medical Policy

Last Published 10.01.2024

Effective Date: 11.01.2023 – This policy addresses core decompression for avascular necrosis. Applicable Procedure Codes: 21299, 23929, 27299, 27599, 27899, S2325.

Cosentyx® (Secukinumab) – Commercial Medical Benefit Drug Policy

Last Published 07.01.2024

Effective Date: 07.01.2024 – This policy addresses the use of Cosentyx® (secukinumab) for the treatment of psoriatic arthritis (PsA), ankylosing spondylitis (AS), and non-radiographic axial spondyloarthritis (nr-axSpA). Applicable Procedure Code: J3247.

Cosmetic and Reconstructive Procedures – Commercial and Individual Exchange Medical Policy

Last Published 09.01.2024

Effective Date: 08.01.2024 – This policy addresses cosmetic and reconstructive procedures.

Crysvita® (Burosumab-Twza) – Commercial Medical Benefit Drug Policy

Last Published 06.01.2024

Effective Date: 06.01.2024 – This policy addresses the use of Crysvita® (burosumab-twza) for the treatment of X-linked hypophosphatemia (XLH) and Fibroblast Growth Factor 23 (FGF23)-related hypophosphatemia in tumor-induced osteomalacia (TIO). Applicable Procedure Code: J0584.

Cytological Examination of Breast Fluids for Cancer Screening or Diagnosis – Commercial and Individual Exchange Medical Policy

Last Published 08.01.2024

Effective Date: 08.01.2024 – This policy addresses breast ductal lavage, breast ductal fluid aspiration and cytology, and fiberoptic ductoscopy with or without ductal lavage. Applicable Procedure Code: 19499.

Deep Brain and Cortical Stimulation – Commercial and Individual Exchange Medical Policy

Last Published 02.01.2024

Effective Date: 02.01.2024 – This policy addresses deep brain stimulation and responsive cortical stimulation. Applicable Procedure Codes: 61850, 61860, 61863, 61864, 61867, 61868, 61885, 61889, 61891, 61886, 64999, L8679, L8680, L8682, L8685, L8686, L8687, L8688.

Denosumab (Prolia® & Xgeva®) – Commercial Medical Benefit Drug Policy

Last Published 04.02.2024

Effective Date: 04.01.2024 – This policy addresses the use of denosumab (Prolia® & Xgeva®). Applicable Procedure Code: J0897.

Diagnostic Dynamic Spinal Visualization and Vertebral Motion Analysis – Commercial and Individual Exchange Medical Policy

Last Published 11.01.2024

Effective Date: 11.01.2024 – This policy addresses dynamic spinal visualization techniques and vertebral motion analysis. Applicable Procedure Codes: 0693T, 76120, 76125, 76496, 76499.

Diagnostic Spinal Ultrasonography – Commercial and Individual Exchange Medical Policy

Last Published 10.01.2024

Effective Date: 10.01.2024 – This policy addresses spinal and paraspinal ultrasonography. Applicable Procedure Code: 76800.

Discogenic Pain Treatment – Commercial and Individual Exchange Medical Policy

Last Published 02.01.2024

Effective Date: 02.01.2024 – This policy addresses annular closure devices (ACDs), percutaneous injection of allogeneic cellular/tissue-based products, and thermal intradiscal procedures (TIPs) for treating discogenic pain. Applicable Procedure Codes: 0627T, 0628T, 0629T, 0630T, 22526, 22527, 22899, S2348.

Durable Medical Equipment, Orthotics, Medical Supplies and Repairs/Replacements – Commercial and Individual Exchange Medical Policy

Last Published 11.01.2023

Effective Date: 10.01.2023 – This policy addresses durable medical equipment (DME), orthotics, ostomy supplies, medical supplies and repairs/replacements.

Elective Inpatient Services – Commercial and Individual Exchange Medical Policy

Last Published 02.01.2024

Effective Date: 02.01.2024 – This policy addresses planned elective inpatient admission for certain surgeries or procedures.

Electric Tumor Treatment Field Therapy – Commercial and Individual Exchange Medical Policy

Last Published 11.01.2024

Effective Date: 11.01.2024 – This policy addresses the use of devices to generate electric tumor treatment fields (TTF). Applicable Procedure Codes: 77299, A4555, E0766.

Electrical and Ultrasound Bone Growth Stimulators – Commercial and Individual Exchange Medical Policy

Last Published 06.01.2024

Effective Date: 01.01.2024 – This policy addresses electrical and ultrasonic bone growth stimulators. Applicable Procedure Codes: 20974, 20975, 20979, E0747, E0748, E0749, E0760.

Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation – Commercial and Individual Exchange Medical Policy

Last Published 10.01.2024

Effective Date: 10.01.2024 – This policy addresses electrical stimulation for the treatment of pain and muscle rehabilitation, including transcutaneous electrical nerve stimulator (TENS), functional electrical stimulation (FES), and neuromuscular electrical stimulation (NMES). Applicable Procedure Codes: 0278T, 0720T, 63650, 63655, 63663, 63664, 63685, 64555, 64596, 64597, 64598, 64999, A4438, A4556, A4557, A4558, A4593, A4594, A4595, A4630, E0720, E0730, E0731, E0744, E0745, E0762, E0764, E0770, E1399, L8679, L8680, L8682, L8685, L8686, L8687, L8688, S8130, S8131.

Electromagnetic Therapy for Wounds – Commercial and Individual Exchange Medical Policy

Last Published 09.01.2024

Effective Date: 02.01.2024 – This policy addresses electromagnetic therapy for wounds. Applicable Procedure Codes: E0769, G0295, G0329.

Electroretinography – Commercial and Individual Exchange Medical Policy

Last Published 01.01.2024

Effective Date: 01.01.2024 – This policy addresses multifocal electroretinogram (mfERG), pattern electroretinogram (PERG), and pattern electroretinogram optimized for glaucoma screening (PERGLA). Applicable Procedure Codes: 0509T, 92274.

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Elevidys™ (Delandistrogene Moxparvovec-Rokl) – Commercial Medical Benefit Drug Policy

Last Published 01.01.2024

Effective Date: 01.01.2024 – This policy addresses the use of Elevidys™ (delandistrogene moxparvovec-rokl) for the treatment of Duchenne muscular dystrophy (DMD). Applicable Procedure Code: J1413.

Eloctate® [Antihemophilic Factor (Recombinant), FC Fusion Protein] for Connecticut Lines of Business (for Oxford Only) – Commercial Medical Benefit Drug Policy

Last Published 11.01.2024

Effective Date: 11.01.2024 – This policy addresses the use of Eloctate® [antihemophilic factor (recombinant), FC fusion protein] for the treatment of Hemophilia A. Applicable Procedure Codes: J7199, J7205.

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Embolization of the Ovarian and Iliac Veins for Pelvic Congestion Syndrome – Commercial and Individual Exchange Medical Policy

Last Published 02.01.2024

Effective Date: 02.01.2024 – This policy addresses embolization of the ovarian or internal iliac veins. Applicable Procedure Code: 37241.

Enjaymo® (Sutimlimab-Jome) – Commercial Medical Benefit Drug Policy

Last Published 05.01.2024

Effective Date: 05.01.2024 – This policy addresses the use of Enjaymo® (sutimlimab-jome) for the treatment of cold agglutinin disease (CAD). Applicable Procedure Code: J1302.

Enteral Nutrition (Oral and Tube Feeding) (for Commercial Only) – Commercial Medical Policy

Last Published 05.01.2024

Effective Date: 05.01.2024 – This policy addresses enteral nutrition, including enteral formulas and low protein modified food products. Applicable Procedure Codes: B4150, B4152, B4153, B4154, B4155, B4157, B4158, B4159, B4160, B4161, B4162, S9432, S9433, S9435.

Entyvio® (Vedolizumab) – Commercial Medical Benefit Drug Policy

Last Published 06.01.2024

Effective Date: 06.01.2024 – This policy addresses the use of Entyvio® (vedolizumab) for the treatment of Crohn's disease, ulcerative colitis, and immune checkpoint inhibitor-related toxicities. Applicable Procedure Code: J3380.

Epidural Steroid Injections for Spinal Pain – Commercial and Individual Exchange Medical Policy

Last Published 09.01.2024

Effective Date: 07.01.2024 – This policy addresses epidural steroid injections for spinal pain. Applicable Procedure Codes: 62320, 62321, 62322, 62323, 64479, 64480, 64483, 64484.

Epiduroscopy, Epidural Lysis of Adhesions, and Discography – Commercial and Individual Exchange Medical Policy

Last Published 11.01.2024

Effective Date: 11.01.2024 – This policy addresses functional anesthetic discography (FAD), provocative discography, epiduroscopy (including spinal myeloscopy), and percutaneous and endoscopic epidural lysis of adhesions for the diagnosis or treatment of any type of neck, back, or spinal disorder. Applicable Procedure Codes: 62263, 62264, 62290, 62291, 62292, 64999, 72285, 72295.

Erythropoiesis-Stimulating Agents – Commercial Medical Benefit Drug Policy

Last Published 05.01.2024

Effective Date: 05.01.2024 – This policy addresses the use of erythropoiesis-stimulating agents (ESAs), including Aranesp® (darbepoetin alfa), Epogen® (epoetin alfa), Mircera® (methoxy polyethylene glycol-epoetin beta [MPG-epoetin beta]), Procrit® (epoetin alfa), and Retacrit™ (epoetin alfa). Applicable Procedure Codes: J0881, J0882, J0885, J0887, J0888, Q4081, Q5105, Q5106.

Evenity® (Romosozumab-Aqqg) – Commercial Medical Benefit Drug Policy

Last Published 11.01.2024

Effective Date: 11.01.2024 – This policy addresses the use of Evenity® (romosozumab- aqqg) for the treatment of osteoporosis in postmenopausal patients at high risk for fracture. Applicable Procedures Code: J3111.

Evkeeza® (Evinacumab-Dgnb) – Commercial Medical Benefit Drug Policy

Last Published 04.02.2024

Effective Date: 04.01.2024 – This policy addresses the use of Evkeeza® (evinacumab-dgnb) for the treatment of homozygous familial hypercholesterolemia (HoFH). Applicable Procedure Code: J1305.

Exondys 51® (Eteplirsen) – Commercial Medical Benefit Drug Policy

Last Published 05.01.2024

Effective Date: 05.01.2024 – This policy addresses the use of Exondys 51® (eteplirsen) for the treatment of Duchenne muscular dystrophy (DMD). Applicable Procedure Code: J1428.

Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions and Soft Tissue Wounds – Commercial and Individual Exchange Medical Policy

Last Published 10.01.2024

Effective Date: 10.01.2024 – This policy addresses extracorporeal shock wave therapy (ESWT) for musculoskeletal and soft tissue conditions. Applicable Procedure Codes: 0101T, 0102T, 0512T, 0513T, 0864T, 28890.

Facet Joint and Medial Branch Block Injections for Spinal Pain – Commercial and Individual Exchange Medical Policy

Last Published 09.01.2024

Effective Date: 05.01.2024 – This policy addresses facet joint injections/medial branch blocks for spinal pain. Applicable Procedure Codes: 0213T, 0214T, 0215T, 0216T, 0217T, 0218T, 64490, 64491, 64492, 64493, 64494, 64495.

Fecal Microbiota Transplantation – Commercial and Individual Exchange Medical Policy

Last Published 04.02.2024

Effective Date: 04.01.2024 – This policy addresses fecal microbiota transplantation (FMT) via enema for prevention of the recurrence of clostridioides difficile infection (CDI). Applicable Procedure Codes: 0780T, 44705, G0455.

Gamifant® (Emapalumab-Lzsg) – Commercial Medical Benefit Drug Policy

Last Published 12.01.2023

Effective Date: 12.01.2023 – This policy addresses the use of Gamifant® (emapalumab-lzsg) for the treatment of primary and secondary hemophagocytic lymphohistiocytosis (HLH). Applicable Procedure Code: J9210.

Gastrointestinal Motility Disorders, Diagnosis and Treatment – Commercial and Individual Exchange Medical Policy

Last Published 10.01.2024

Effective Date: 07.01.2024 – This policy addresses gastric electrical stimulation therapy; manometry, sensation, tone, and compliance testing; defecography; and electrogastrography/electroenterography. Applicable Procedure Codes: 0779T, 0868T, 43647, 43648, 43881, 43882, 64590, 64595, 72195, 72196, 72197, 74270, 76496, 91117, 91120, 91122, 91132, 91133, A9286, A9900, A9999, E1399.

Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing for Infectious Diarrhea – Commercial and Individual Exchange Medical Policy

Last Published 03.01.2024

Effective Date: 03.01.2024 – This policy addresses multiplex polymerase chain reaction (PCR) panel testing of gastrointestinal pathogens. Applicable Procedure Codes: 87505, 87506, 87507.

Gender Dysphoria Treatment – Commercial and Individual Exchange Medical Policy

Last Published 03.01.2024

Effective Date: 03.01.2024 – This policy addresses gender dysphoria treatment, including surgical treatment and certain ancillary procedures.

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Gene Therapies for Hemophilia B – Commercial Medical Benefit Drug Policy

Last Published 10.01.2024

Effective Date: 10.01.2024 – This policy addresses the use of Beqvez™ (fidanacogene elaparvovec-dzkt) and Hemgenix® (etranacogene dezaparvovec-drlb) for the treatment of hemophilia B. Applicable Procedure Codes: C9172, J1411, J3490, J3590.

Genetic Testing for Cardiac Disease – Commercial and Individual Exchange Medical Policy

Last Published 11.01.2024

Effective Date: 09.01.2024 – This policy addresses genetic testing for cardiac disease. Applicable Procedure Codes: 0237U, 0401U, 0439U, 0440U, 0466U, 81410, 81411, 81413, 81414, 81439, 81479, 81493.

Genetic Testing for Hereditary Cancer – Commercial and Individual Exchange Medical Policy

Last Published 11.01.2024

Effective Date: 07.01.2024 – This policy addresses hereditary breast and ovarian cancer (BRCA1, BRCA2) testing and multi-gene hereditary cancer panel testing. Applicable Procedure Codes: 0101U, 0102U, 0103U, 0129U, 0130U, 0131U, 0132U, 0133U, 0134U, 0135U, 0138U, 0162U, 0238U, 0474U, 0475U, 81162, 81163, 81164, 81165, 81166, 81167, 81216, 81432, 81433, 81435, 81436, 81437, 81438, 81441, 81479.

Genetic Testing for Neuromuscular Disorders – Commercial and Individual Exchange Medical Policy

Last Published 11.01.2024

Effective Date: 10.01.2024 – This policy addresses multi-gene panel testing for the diagnosis of neuromuscular disorders. Applicable Procedure Codes: 0216U, 0217U, 81440, 81460, 81465, 81479.

Givlaari® (Givosiran) – Commercial Medical Benefit Drug Policy

Last Published 05.01.2024

Effective Date: 05.01.2024 – This policy addresses the use of Givlaari® (givosiran) for the treatment of acute hepatic porphyrias. Applicable Procedure Code: J0223.

Glaucoma Surgical Treatments – Commercial and Individual Exchange Medical Policy

Last Published 08.01.2024

Effective Date: 08.01.2024 – This policy addresses glaucoma drainage devices/stents, canaloplasty, and gonioscopy-assisted transluminal trabeculotomy. Applicable Procedure Codes: 0253T, 0449T, 0450T, 0474T, 0671T, 65820, 66174, 66175, 66179, 66180, 66183.

Gonadotropin Releasing Hormone Analogs – Commercial Medical Benefit Drug Policy

Last Published 11.01.2024

Effective Date: 11.01.2024 – This policy addresses gonadotropin releasing hormone analog (GnRH analog) drug products. Applicable Procedure Codes: J1950, J1951, J1952, J1954, J3315, J3316, J9155, J9202, J9217, J9226.

Gynecomastia Surgery – Commercial and Individual Exchange Medical Policy

Last Published 07.01.2024

Effective Date: 07.01.2024 – This policy addresses mastectomy or suction lipectomy for the treatment of benign gynecomastia. Applicable Procedure Code: 19300.

Habilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) – Commercial and Individual Exchange Medical Policy

Last Published 07.01.2024

Effective Date: 07.01.2024 – This policy addresses outpatient habilitation, rehabilitation and maintenance therapy.

Hearing Aids and Devices Including Wearable, Bone-Anchored, and Semi-Implantable – Commercial and Individual Exchange Medical Policy

Last Published 02.01.2024

Effective Date: 02.01.2024 – This policy addresses wearable air conduction, bone-anchored, semi-implantable hearing aids (SEHA), intraoral bone conduction, and laser or light based hearing aids, and totally implanted middle ear hearing systems.

"92590, 92591, 92592, 92593, 92594, 92595, 69799, 69710, 69714, 69716, 69717, 69719, 69729, 69730, S0618, V5010, V5011, V5014, V5020, V5264, V5265, V5275, S2230, V5095, L8690, L8691, L8693, L8694, L8692, V5030, V5040, V5050, V5060, V5070, V5080, V5100, V5120, V5130, V5140, V5150, V5171, V5172, V5181, V5190, V5211, V5212, V5213, V5214, V5215, V5221, V5230, V5242, V5243, V5244, V5245, V5246,V5247, V5248, V5249, V5250, V5251, V5252, V5253, V5254, V5255, V5256, V5257, V5258, V5259, V5260, V5261, V5262, V5263, V5267, V5298",

Hereditary Angioedema (HAE), Treatment and Prophylaxis – Commercial Medical Benefit Drug Policy

Last Published 11.01.2023

Effective Date: 11.01.2023 – This policy addresses the use of C1 esterace inhibitors (human), C1 esterace inhibitors (recombinant), and plasma kallikrein inhibitors (human) for the treatment and prophlaxis of hereditary angioedema (HAE). Applicable Procedure Codes: J0596, J0597, J0598, J1290.

Home Health, Skilled, and Custodial Care Services (for Commercial Only) – Commercial Medical Policy

Last Published 05.01.2024

Effective Date: 05.01.2024 – This policy addresses home health, skilled, and custodial care services.

Home Hemodialysis – Commercial and Individual Exchange Medical Policy

Last Published 05.01.2024

Effective Date: 05.01.2024 – This policy addresses home hemodialysis (HHD). Applicable Procedure Codes: 90963, 90964, 90965, 90966, 90967, 90968, 90969, 90970, 90989, 90993, 99512, S9335.

Home Traction Therapy – Commercial and Individual Exchange Medical Policy

Last Published 04.02.2024

Effective Date: 04.01.2024 – This policy addresses home traction therapy. Applicable Procedure Codes: E0830, E0840, E0849, E0850, E0855, E0856, E0860, E0941.

Hospital Services: Observation and Inpatient – Commercial and Individual Exchange Medical Policy

Last Published 11.01.2024

Effective Date: 11.01.2024 – This policy addresses hospital services for observation versus inpatient level of care.

Hyperbaric Oxygen Therapy and Topical Oxygen Therapy – Commercial and Individual Exchange Medical Policy

Last Published 07.01.2024

Effective Date: 07.01.2024 – This policy addresses hyperbaric oxygen therapy (HBOT) and topical oxygen therapy (TOT). Applicable Procedure Codes: 99183, A4575, E0446, G0277.

Hysterectomy – Commercial and Individual Exchange Medical Policy

Last Published 03.01.2024

Effective Date: 02.01.2024 – This policy addresses hysterectomy. Applicable Procedure Codes: 58150, 58152, 58180, 58260, 58262, 58263, 58267, 58270, 58290, 58291, 58292, 58294, 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573.

Ilaris® (Canakinumab) – Commercial Medical Benefit Drug Policy

Last Published 12.01.2023

Effective Date: 12.01.2023 – This policy addresses the use of Ilaris® (canakinumab) for the treatment of cryopyrin-associated periodic syndromes (CAPS), tumor necrosis factor (TNF) receptor-associated periodic syndrome (TRAPS), hyperimmunoglobulin D (Hyper-IgD) syndrome (HIDS)/mevalonate kinase deficiency (MKD), familial mediterranean fever (FMF), Still’s disease, systemic juvenile idiopathic arthritis (SJIA) and gout flares. Applicable Procedure Code: J0638.

Ilumya® (Tildrakizumab-Asmn) – Commercial Medical Benefit Drug Policy

Last Published 06.01.2024

Effective Date: 06.01.2024 – This policy addresses the use of provider-administered Ilumya® (tildrakizumab-asmn) for the treatment of moderate to severe plaque psoriasis. Applicable Procedure Code: J3245.

Immune Globulin (IVIG and SCIG) – Commercial Medical Benefit Drug Policy

Last Published 07.01.2024

Effective Date: 07.01.2024 – This policy addresses the use of intravenous (IV) and subcutaneous (SC) immune globulin (IG) products. Applicable Procedure Codes: 90283, 90284, J1459, J1551, J1554 , J1555, J1556, J1557, J1558, J1559, J1561, J1566, J1568, J1569, J1572, J1575, J1599.

Implanted Electrical Stimulator for Spinal Cord – Commercial and Individual Exchange Medical Policy

Last Published 02.01.2024

Effective Date: 02.01.2024 – This policy addresses implanted electrical spinal cord and dorsal root ganglion (DRG) stimulation. Applicable Procedure Codes: 63650, 63655, 63685, 63688, C1767, C1778, C1816, C1820, C1822, C1823, C1883, C1897, L8679, L8680, L8682, L8685, L8686, L8687, L8688, L8695.

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Implanted Spinal Drug Delivery Systems – Commercial and Individual Exchange Medical Policy

Last Published 08.01.2024

Effective Date: 08.01.2024 – This policy addresses implanted spinal drug delivery systems for the treatment of cancer-related pain, severe spasticity, and chronic non-malignant pain. Applicable Procedure Codes: 62320, 62321, 62322, 62323, 62324, 62325, 62326, 62327, 62350, 62351, 62360, 62361, 62362.

Infertility Diagnosis, Treatment, and Fertility Preservation – Commercial and Individual Exchange Medical Policy

Last Published 06.01.2024

Effective Date: 06.01.2024 – This policy addresses services for infertility and fertility preservation.

Infliximab (Avsola®, Inflectra®, Remicade®, & Renflexis®) – Commercial Medical Benefit Drug Policy

Last Published 10.01.2024

Effective Date: 10.01.2024 – This policy addresses the use of infliximab products, including Avsola® (infliximab-axxq), Inflectra® (infliximab-dyyb), Remicade® (infliximab), and Renflexis® (infliximab-abda). Applicable Procedure Codes: J1745, Q5103, Q5104, Q5109, Q5121.

Inhaled Nitric Oxide Therapy – Commercial and Individual Exchange Medical Policy

Last Published 11.01.2024

Effective Date: 11.01.2024 – This policy addresses the use of inhaled nitric oxide (iNO) for treating term or near-term infants with hypoxic respiratory failure or echocardiographic evidence of persistent pulmonary hypertension of the newborn (PPHN). Applicable Procedure Code: 94799.

Injectables for Reconstructive Procedures – Commercial and Individual Exchange Medical Policy

Last Published 04.02.2024

Effective Date: 01.01.2024 – This policy addresses dermal filler injections and injectable bulking agents. Applicable Procedure Codes: G0429, L8607, Q2026, Q2028.

Intensity-Modulated Radiation Therapy – Commercial and Individual Exchange Medical Policy

Last Published 02.01.2024

Effective Date: 02.01.2024 – This policy addresses the use of intensity-modulated radiation therapy (IMRT). Applicable Procedure Codes: 77301, 77338, 77385, 77386, 77387, 77520, 77522, 77523, 77525, G6015, G6016, G6017.

Interspinous Fusion and Decompression Devices – Commercial and Individual Exchange Medical Policy

Last Published 02.01.2024

Effective Date: 02.01.2024 – This policy addresses the use of interspinous bony fusion devices and interspinous decompression systems. Applicable Procedure Codes: 22853, 22854, 22859, 22867, 22868, 22869, 22870, 22899, C1821.

Intracanalicular and Intravitreal Corticosteroid Implants – Commercial Medical Benefit Drug Policy

Last Published 08.01.2024

Effective Date: 08.01.2024 – This policy addresses the use of specialty pharmacy medications administered by the intravitreal route for certain ophthalmologic conditions. Applicable Procedure Codes: J1096, J7311, J7312, J7313, J7314.

Intrauterine Fetal Surgery – Commercial and Individual Exchange Medical Policy

Last Published 07.01.2024

Effective Date: 07.01.2024 – This policy addresses intrauterine fetal surgery (IUFS) and fetoscopic endoluminal tracheal occlusion (FETO). Applicable Procedure Codes: 59072, 59074, 59076, 59897, S2400, S2401, S2402, S2403, S2404, S2405, S2409, S2411.

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Intravenous Enzyme Replacement Therapy (ERT) for Gaucher Disease – Commercial Medical Benefit Drug Policy

Last Published 06.01.2024

Effective Date: 06.01.2024 – This policy addresses the use of intravenous enzyme replacement drug products for the treatment of Gaucher disease, including Cerezyme® (imiglucerase), Elelyso® (taliglucerase), and VPRIV® (velaglucerase). Applicable Procedure Codes: J1786, J3060, J3385.

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Intravenous Iron Replacement Therapy (Feraheme®, Injectafer®, & Monoferric®) – Commercial Medical Benefit Drug Policy

Last Published 06.01.2024

Effective Date: 06.01.2024 – This policy addresses the use of intravenous iron replacement therapy with Feraheme® (ferumoxytol), Injectafer® (ferric carboxymaltose), and Monoferric® (ferric derisomaltose) for the treatment of iron deficiency anemia (IDA) with and without chronic kidney disease (CKD). Applicable Procedure Codes: J1437, J1439, Q0138, Q0139.

Ketalar® (Ketamine) and Spravato® (Esketamine) – Commercial Medical Benefit Drug Policy

Last Published 06.01.2024

Effective Date: 06.01.2024 – This policy addresses the use of Ketalar® (ketamine) for anesthesia purposes and Spravato® (esketamine) for the treatment of treatment-resistant depression (TRD) and major depressive disorder (MDD). Applicable Procedure Codes: J3490, S0013.

Kisunla™ (Donanemab-Azbt) – Commercial Medical Benefit Drug Policy

Last Published 11.01.2024

Effective Date: 11.01.2024 – This policy addresses the use of Kisunla™ (donanemab-azbt) for the treatment of Alzheimer’s disease (AD). Applicable Procedure Code: J0175.

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Korsuva® (Difelikefalin) – Commercial Medical Benefit Drug Policy

Last Published 07.01.2024

Effective Date: 07.01.2024 – This policy addresses the use of Korsuva (difelikefalin) for the treatment of moderate-to-severe pruritus associated with chronic kidney disease in adults undergoing hemodialysis. Applicable Procedure Code: J0879.

Krystexxa® (Pegloticase) – Commercial Medical Benefit Drug Policy

Last Published 11.01.2024

Effective Date: 11.01.2024 – This policy addresses the use of Krystexxa® (pegloticase) for treatment of chronic gout refractory to conventional therapy. Applicable Procedure Code: J2507.

Left Atrial Appendage Closure (Occlusion) – Commercial and Individual Exchange Medical Policy

Last Published 11.01.2024

Effective Date: 11.01.2024 – This policy addresses closure (occlusion) of the left atrial appendage (LAA). Applicable Procedure Codes: 33267, 33268, 33340.

Lemtrada® (Alemtuzumab) – Commercial Medical Benefit Drug Policy

Last Published 05.01.2024

Effective Date: 05.01.2024 – This policy addresses the use of Lemtrada® (alemtuzumab) for treatment of relapsing forms of multiple sclerosis. Applicable Procedure Code: J0202.

Leqembi® (Lecanemab-Irmb) – Commercial Medical Benefit Drug Policy

Last Published 11.01.2024

Effective Date: 11.01.2024 – This policy addresses the use of Leqembi® (lecanemab-irmb) for the treatment of Alzheimer’s disease (AD). Applicable Procedure Code: J0174.

Leqvio® (Inclisiran) – Commercial Medical Benefit Drug Policy

Last Published 04.02.2024

Effective Date: 04.01.2024 – This policy addresses the use of Leqvio® (inclisiran) for the treatment of primary hyperlipidemia, heterozygous familial hypercholesterolemia (HeFH), and clinical atherosclerotic cardiovascular disease (ASCVD). Applicable Procedure Code: J1306.

Light and Laser Therapy – Commercial and Individual Exchange Medical Policy

Last Published 01.01.2024

Effective Date: 01.01.2024 – This policy addresses light and laser therapy, including light phototherapy, photodynamic therapy, intense pulsed light, pulsed dye laser, and laser hair removal. Applicable Procedure Codes: 17106, 17107, 17108, 17380.

Liposuction for Lipedema – Commercial and Individual Exchange Medical Policy

Last Published 03.01.2024

Effective Date: 02.01.2024 – This policy addresses liposuction for lipedema when used to treat functional impairment. Applicable Procedure Codes: 15877, 15878, 15879.

Lithotripsy for Salivary Stones – Commercial and Individual Exchange Medical Policy

Last Published 11.01.2024

Effective Date: 11.01.2024 – This policy addresses extracorporeal shock wave lithotripsy (ESWL) and endoscopic intracorporeal laser lithotripsy for treating salivary stones. Applicable Procedure Code: 42699.

Long-Acting Injectable Antiretroviral Agents for HIV – Commercial Medical Benefit Drug Policy

Last Published 11.01.2024

Effective Date: 11.01.2024 – This policy addresses the use of Apretude (cabotegravir), Cabenuva (cabotegravir/rilpivirine), and Sunlenca (lenacapavir) for the treatment of a human immunodeficiency virus type-1 (HIV-1). Applicable Procedure Codes: J0739, J0741, J1961.

Lower Extremity Endovascular Procedures – Commercial and Individual Exchange Medical Policy

Last Published 11.01.2024

Effective Date: 11.01.2023 – This policy addresses endovascular revascularization procedures. Applicable Procedure Codes: 0238T, 0505T, 37220, 37221, 37222, 37223, 37224, 37225, 37226, 37227, 37228, 37229, 37230, 37231, 37232, 37233, 37234, 37235.

Lower Extremity Prosthetics – Commercial and Individual Exchange Medical Policy

Last Published 10.01.2024

Effective Date: 04.01.2024 – This policy addresses the use of lower extremity prosthetic for amputations, endoskeletal knee-shin system with microprocessor control, and combined microprocessor-controlled ankle foot system with power assist.

Luxturna® (Voretigene Neparvovec-Rzyl) – Commercial Medical Benefit Drug Policy

Last Published 11.01.2024

Effective Date: 11.01.2024 – This policy addresses the use of Luxturna® (voretigene neparvovec-rzyl) for the treatment of inherited retinal dystrophies (IRD) caused by mutations in the retinal pigment epithelium-specific protein 65kDa (RPE65) gene. Applicable Procedure Code: J3398.

Macular Degeneration Treatment Procedures – Commercial and Individual Exchange Medical Policy

Last Published 07.01.2024

Effective Date: 07.01.2024 – This policy addresses implantable miniature telescope (IMT), conjunctival incision with posterior extrascleral placement of a pharmacologic agent, laser photocoagulation, and radiation therapy. Applicable Procedure Codes: 0308T, 0378T, 0379T, 67036, 67299, 92499.

Magnetic Resonance Imaging (MRI) and Computed Tomography (CT) Scan – Site of Service – Commercial and Individual Exchange Medical Policy

Last Published 10.01.2024

Effective Date: 10.01.2024 – This policy addresses advanced radiologic imaging procedures performed in a hospital outpatient department.

Manipulation Under Anesthesia – Commercial and Individual Exchange Medical Policy

Last Published 02.01.2024

Effective Date: 02.01.2024 – This policy addresses manipulation under anesthesia (MUA). Applicable Procedure Codes: 21073, 22505, 23700, 25259, 26340, 27198, 27275, 27570, 27860, D7830.

Manipulative Therapy – Commercial and Individual Exchange Medical Policy

Last Published 07.01.2024

Effective Date: 07.01.2024 – This policy addresses manipulative therapy. Applicable Procedure Codes: 98925, 98926, 98927, 98928, 98929, 98940, 98941, 98942, 98943, S8990.

Maximum Dosage and Frequency – Commercial Medical Benefit Drug Policy

Last Published 08.01.2024

Effective Date: 08.01.2024 – This policy addresses the maximum dosage per administration and dosing frequency for certain medications administered by a medical professional.

Mechanical Stretching Devices – Commercial and Individual Exchange Medical Policy

Last Published 11.01.2024

Effective Date: 11.01.2024 – This policy addresses the use of low-load prolonged-duration stretch devices, static progressive (SP) stretch splint devices, and patient actuated serial stretch (PASS) devices. Applicable Procedure Codes: E1399, E1800, E1801, E1806, E1810, E1811, E1812, E1815, E1816, E1818, E1830, E1831, E1841.

Medical Benefit Therapeutic Equivalent Medications – Excluded Drugs – Commercial Medical Benefit Drug Policy

Last Published 10.01.2024

Effective Date: 10.01.2024 – This policy addresses certain medical benefit medications that are healthcare provider administered and have been deemed therapeutically equivalent.

Medical Therapies for Enzyme Deficiencies – Commercial Medical Benefit Drug Policy

Last Published 07.01.2024

Effective Date: 07.01.2024 – This policy addresses drug products used as medical therapies for enzyme deficiency. Applicable Procedure Codes: C9399, J0180, J0217, J0218, J0219, J0221, J1203, J1322, J1458, J1743, J1931, J2508, J2840, J3397, J3490, J3590.

Minimally Invasive Procedures for Gastric and Esophageal Diseases – Commercial and Individual Exchange Medical Policy

Last Published 10.01.2024

Effective Date: 01.01.2024 – This policy addresses minimally invasive endoscopic procedures and devices for treating gastroesophageal reflux disease (GERD) and the Per Oral Endoscopic Myotomy (POEM) procedure for achalasia or diffuse esophageal spasm. Applicable Procedure Codes: 43210, 43257, 43284, 43289, 43497, 43499, 43999.

Minimally Invasive Spine Surgery Procedures – Commercial and Individual Exchange Medical Policy

Last Published 02.01.2024

Effective Date: 02.01.2024 – This policy addresses minimally invasive spine surgery procedures. Applicable Procedure Codes: 0200T, 0201T, 0275T, 22586, 22630, 22899, 62287, 62380, G0276.

Mobility Devices, Options, and Accessories – Commercial and Individual Exchange Medical Policy

Last Published 07.01.2024

Effective Date: 07.01.2024 – This policy addresses mobility devices, options, and accessories.

Molecular Oncology Companion Diagnostic Testing – Commercial and Individual Exchange Medical Policy

Last Published 11.01.2024

Effective Date: 07.01.2024 – This policy addresses companion diagnostic tests using comprehensive genomic profiling (CGP) for oncology indications. Applicable Procedure Codes: 0022U, 0037U, 0179U, 0239U, 0242U, 0473U, 81445, 81449, 81450, 81451, 81455, 81456, 81479, 81599.

Molecular Oncology Testing for Hematologic Cancer Diagnosis, Prognosis, and Treatment Decisions – Commercial and Individual Exchange Medical Policy

Last Published 11.01.2024

Effective Date: 10.01.2024 – This policy addresses molecular oncology testing for hematologic cancer. Applicable Procedure Codes: 0017M, 0050U, 0120U, 0171U, 0285U, 0296U, 0331U, 0364U, 0485U, 81450, 81451, 81455, 81456, 81479, 81599.

Molecular Oncology Testing for Solid Tumor Cancer Diagnosis, Prognosis, and Treatment Decisions – Commercial and Individual Exchange Medical Policy

Last Published 11.01.2024

Effective Date: 10.01.2024 – This policy addresses molecular oncology testing for cancer indications, including breast cancer, prostate cancer, thyroid cancer, hematological cancer, lung cancer, and solid tumor cancers.

Motorized Spinal Traction – Commercial and Individual Exchange Medical Policy

Last Published 07.01.2024

Effective Date: 07.01.2024 – This policy addresses motorized spinal traction devices. Applicable Procedure Code: S9090.

Negative Pressure Wound Therapy – Commercial and Individual Exchange Medical Policy

Last Published 09.01.2024

Effective Date: 04.01.2024 – This policy addresses negative pressure wound therapy. Applicable Procedure Codes: 97605, 97606, 97607, 97608, A6550, A9272, E2402.

Neonatal Fc Receptor Blockers (Rystiggo®, Vyvgart®, & Vyvgart® Hytrulo) – Commercial Medical Benefit Drug Policy

Last Published 10.01.2024

Effective Date: 10.01.2024 – This policy addresses the use of Vyvgart®, Vyvgart® Hytrulo, & Rystiggo® for the treatment of myasthenia gravis. Applicable Procedure Codes: J9332, J9333, J9334.

Nerve Graft to Restore Erectile Function During Radical Prostatectomy – Commercial and Individual Exchange Medical Policy

Last Published 11.01.2024

Effective Date: 11.01.2024 – This policy addresses autologous (sural) and allogenic nerve grafts to restore erectile function during or after radical prostatectomy. Applicable Procedure Codes: 55899, 64999.

Neurophysiologic Testing and Monitoring – Commercial and Individual Exchange Medical Policy

Last Published 01.01.2024

Effective Date: 01.01.2024 – This policy addresses nerve conduction studies and other neurophysiological testing.

Neuropsychological Testing Under the Medical Benefit – Commercial and Individual Exchange Medical Policy

Last Published 09.01.2024

Effective Date: 09.01.2024 – This policy addresses neuropsychological testing and computerized cognitive testing under the medical benefit. Applicable Procedure Codes: 96116, 96121, 96132, 96133, 96136, 96137, 96138, 96139, 96146.

Noncontact Warming Therapy, Ultrasound Therapy, and Fluorescence Imaging for Wounds – Commercial and Individual Exchange Medical Policy

Last Published 09.01.2024

Effective Date: 08.01.2024 – This policy addresses warming therapy, noncontact normothermic wound therapy, noncontact real-time fluorescence wound imaging, and low frequency ultrasound for treating wounds. Applicable Procedure Codes: 0598T, 0599T, 97610, A6000, E0231, E0232.

Obstructive and Central Sleep Apnea Treatment – Commercial and Individual Exchange Medical Policy

Last Published 10.24.2024

Effective Date: 09.01.2024 – This policy addresses nonsurgical and surgical treatment of obstructive sleep apnea (OSA). Applicable Procedure Codes: 21142, 21199, 21206, 21685, 33276, 33277, 33278, 33279, 33280, 33281, 33287, 33288, 41512, 41530, 41599, 42140, 42145, 42299, 64553, 64568, 64569, 64570, 64582, 64583, 64584, 93150, 93151, 93152, 93153, A7049, E0485, E0486, E0492, E0493, E0530, E1399, K1027, L8679, L8680, L8686, S2080, S2900.

Occipital Nerve Injections and Ablation (Including Occipital Neuralgia and Headache) – Commercial and Individual Exchange Medical Policy

Last Published 08.01.2024

Effective Date: 08.01.2024 – This policy addresses occipital neuralgia and headache treatments, including occipital nerve blocks and occipital nerve ablation. Applicable Procedure Codes: 63185, 63190, 64405, 64553, 64555, 64568, 64570, 64575, 64590, 64596, 64597, 64598, 64633, 64634, 64722, 64744, 64771, 64999, A4540, L8679, L8680, L8685.

Ocrevus® (Ocrelizumab) – Commercial Medical Benefit Drug Policy

Last Published 05.01.2024

Effective Date: 05.01.2024 – This policy addresses the use of Ocrevus® (ocrelizumab) for the treatment of multiple sclerosis. Applicable Procedure Code: J2350.

Off-Label/Unproven Specialty Drug Treatment – Commercial Medical Benefit Drug Policy

Last Published 07.01.2024

Effective Date: 07.01.2024 – This policy addresses off-label and unproven indications of FDA-approved injectable specialty drugs.

Office-Based Procedures – Site of Service – Commercial and Individual Exchange Medical Policy

Last Published 06.01.2024

Effective Date: 06.01.2024 – This policy addresses certain elective procedures that are typically performed in an office setting but may be performed in an ambulatory surgical center in certain circumstances. Applicable Procedure Codes: 11402, 11403, 11404, 11406, 11420, 11421, 11422, 11423, 11424, 11426, 11442, 19000, 20552, 20553, 27096, 31579, 57460, 62270, 62321, 64479, 64490, 64493, 64633, 64635.

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Omnibus Codes – Commercial and Individual Exchange Medical Policy

Last Published 05.01.2024

Effective Date: 05.01.2024 – This policy addresses multiple services/procedures.

Omvoh™ (Mirikizumab-Mrkz) – Commercial Medical Benefit Drug Policy

Last Published 07.01.2024

Effective Date: 07.01.2024 – This policy addresses the use of Omvoh™ (mirikizumab-mrkz) injections for the treatment of ulcerative colitis. Applicable Procedure Code: J2267.

Oncology Medication Clinical Coverage – Commercial Medical Benefit Drug Policy

Last Published 09.01.2024

Effective Date: 09.01.2024 – This policy addresses parameters for coverage of injectable oncology medications. Applicable Procedure Codes: A9513, A9590, A9606, A9607, A9699, J0640, J0641, J0642, J1930, J1932, J1950, J1954, J3263, J9022, J9035, J9119, J9198, J9199, J9201, J9202, J9217, J9228, J9271, J9294, J9296, J9297, J9299, J9304, J9305, J9310, J9311, J9312, J9314, J9316, J9355, J9356, Q5107, Q5112, Q5113, Q5114, Q5115, Q5116, Q5117, Q5118, Q5119, Q5123, Q5126, Q5129.

Ophthalmologic Complement Inhibitors – Commercial Medical Benefit Drug Policy

Last Published 04.02.2024

Effective Date: 04.01.2024 – This policy addresses the use of Izervay™ (avacincaptad pegol) and Syfovre™ (pegcetacoplan injection) for the treatment of geographic atrophy (GA) secondary to age-related macular degeneration (AMD). Applicable Procedure Codes: J2781, J2782.

Ophthalmologic Policy: Vascular Endothelial Growth Factor (VEGF) Inhibitors – Commercial Medical Benefit Drug Policy

Last Published 10.01.2024

Effective Date: 10.01.2024 – This policy addresses the use of vascular endothelial growth factor (VEGF) inhibitors. Applicable Procedure Codes: J0177, J0178, J0179, J2777, J2778, J9035, Q5124, Q5128.

Orencia® (Abatacept) Injection for Intravenous Infusion – Commercial Medical Benefit Drug Policy

Last Published 05.01.2024

Effective Date: 05.01.2024 – This policy addresses the use of Orencia® (abatacept) injection for intravenous infusion for the treatment of polyarticular juvenile idiopathic arthritis, rheumatoid arthritis, psoriatic arthritis, chronic graft-versus-host disease, and immune checkpoint inhibitor-related toxicities. Applicable Procedure Code: J0129.

Orthognathic (Jaw) Surgery – Commercial and Individual Exchange Medical Policy

Last Published 06.01.2024

Effective Date: 06.01.2024 – This policy addresses orthognathic (jaw) surgery.

Outpatient Surgical Procedures – Site of Service – Commercial and Individual Exchange Medical Policy

Last Published 06.06.2024

Effective Date: 06.01.2024 – This policy addresses the medical necessity of certain planned surgical procedures when performed in a hospital outpatient department.

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Oxlumo® (Lumasiran) and Rivfloza™ (Nedosiran) – Commercial Medical Benefit Drug Policy

Last Published 07.01.2024

Effective Date: 07.01.2024 – This policy addresses the use of Oxlumo® (Lumasiran) and Rivfloza™ (Nedosiran) for the treatment of primary hyperoxaluria type 1 (PH1). Applicable Procedures Codes: C9399, J0224, J3490.

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Panniculectomy and Body Contouring Procedures – Commercial and Individual Exchange Medical Policy

Last Published 09.01.2024

Effective Date: 07.01.2024 – This policy addresses panniculectomy, abdominoplasty, lipectomy, repair of diastasis recti, and suction-assisted lipectomy. Applicable Procedure Codes: 15830, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15847, 15876, 15877, 15878, 15879.

Parsabiv® (Etelcalcetide) – Commercial Medical Benefit Drug Policy

Last Published 04.02.2024

Effective Date: 04.01.2024 – This policy addresses the use of Parsabiv® (etelcalcetide) for the treatment of secondary hyperparathyroidism with chronic kidney disease. Applicable Procedure Code: J0606.

Patient Lifts – Commercial and Individual Exchange Medical Policy

Last Published 05.01.2024

Effective Date: 05.01.2024 – This policy addresses patient lifts. Applicable Procedure Codes: E0621, E0630, E0635, E0636, E0639, E0640, E1035, E1036.

Pectus Deformity Repair – Commercial and Individual Exchange Medical Policy

Last Published 06.01.2024

Effective Date: 06.01.2024 – This policy addresses surgical repair of pectus excavatum and pectus carinatum. Applicable Procedure Codes: 21740, 21742, 21743.

Pediatric Gait Trainers and Standing Systems – Commercial and Individual Exchange Medical Policy

Last Published 05.01.2024

Effective Date: 05.01.2024 – This policy addresses pediatric gait trainers and standing systems. Applicable Procedure Codes: E0637, E0638, E0641, E0642, E8000, E8001, E8002.

Percutaneous Neuroablation for Pancreatic Cancer Pain, Severe Cancer Pain, and Trigeminal Neuralgia – Commercial and Individual Exchange Medical Policy

Last Published 10.01.2024

Effective Date: 10.01.2024 – This policy addresses percutaneous neuroablation for the treatment of severe cancer pain and trigeminal neuralgia. Applicable Procedure Codes: 64600, 64605, 64610, 64620, 64640.

Percutaneous Patent Foramen Ovale (PFO) Closure – Commercial and Individual Exchange Medical Policy

Last Published 02.01.2024

Effective Date: 02.01.2024 – This policy addresses percutaneous patent foramen ovale closure for the prevention of recurrent ischemic stroke. Applicable Procedure Code: 93580.

Percutaneous Vertebroplasty and Kyphoplasty – Commercial and Individual Exchange Medical Policy

Last Published 08.01.2024

Effective Date: 11.01.2023 – This policy addresses percutaneous vertebroplasty and kyphoplasty for treating spinal pain. Applicable Procedure Codes: 22510, 22511, 22512, 22513, 22514, 22515.

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Pharmacogenetic Panel Testing – Commercial and Individual Exchange Medical Policy

Last Published 11.01.2024

Effective Date: 10.01.2024 – This policy addresses the use of pharmacogenetic multi-gene panel testing for genetic polymorphisms. Applicable Procedure Codes: 0029U, 0173U, 0175U, 0345U, 0347U, 0348U, 0349U, 0350U, 0380U, 0392U, 0411U, 0419U, 0423U, 0434U, 0438U, 0456U, 0460U, 0461U, 0476U, 0477U, 0516U, 81418, 81479.

Plagiocephaly and Craniosynostosis Treatment – Commercial and Individual Exchange Medical Policy

Last Published 11.01.2023

Effective Date: 11.01.2023 – This policy addresses the use of cranial orthotic devices for treating infants following craniosynostosis surgery or for nonsynostotic (nonfusion) deformational or positional plagiocephaly. Applicable Procedure Codes: D5924, L0112, L0113, S1040.

Pneumatic Compression Devices – Commercial and Individual Exchange Medical Policy

Last Published 04.02.2024

Effective Date: 04.01.2024 – This policy addresses pneumatic, advanced intermittent pneumatic and intermittent limb compression devices. Applicable Procedure Codes: A4600, E0650, E0651, E0652, E0655, E0660, E0665, E0666, E0667, E0668, E0669, E0670, E0671, E0672, E0673, E0675, E0676.

Preimplantation Genetic Testing and Related Services – Commercial and Individual Exchange Medical Policy

Last Published 11.01.2024

Effective Date: 10.01.2024 – This policy addresses preimplantation genetic testing (PGT) and related services. Applicable Procedure Codes: 0254U, 58970, 58974, 76948, 81228, 81229, 81349, 81479, 89250, 89251, 89253, 89254, 89255, 89257,89258, 89260, 89261, 89264, 89268, 89272, 89280, 89281, 89290, 89291, 89342, 89352, S4011, S4015, S4016, S4022, S4037.

Preventive Care Services – Commercial and Individual Exchange Medical Policy

Last Published 10.01.2024

Effective Date: 10.01.2024 – This policy addresses preventive care services.

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Private Duty Nursing Services – Commercial and Individual Exchange Medical Policy

Last Published 09.01.2024

Effective Date: 09.01.2024 – This policy addresses private duty nursing services. Applicable Procedure Code: T1000.

Prolotherapy and Platelet Rich Plasma Therapies – Commercial and Individual Exchange Medical Policy

Last Published 09.01.2024

Effective Date: 11.01.2023 – This policy addresses prolotherapy and platelet rich plasma. Applicable Procedure Codes: 0232T, G0460, G0465, M0076, P9020.

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Prostate Surgeries and Interventions – Commercial and Individual Exchange Medical Policy

Last Published 07.01.2024

Effective Date: 07.01.2024 – This policy addresses prostrate surgeries and interventions, including transurethral ablation, cryoablation, Radical prostatectomy, prostatic urethral lift (PUL), high-energy water vapor thermotherapy, Transurethral water jet ablation, and transperineal placement of biodegradable material. Applicable Procedure Codes: 0421T, 0582T, 0619T, 0655T, 0714T, 0738T, 0739T, 0867T, 37243, 52441, 52442, 53850, 53852, 53854, 53855, 55873, 55874.

Proton Beam Radiation Therapy – Commercial and Individual Exchange Medical Policy

Last Published 02.01.2024

Effective Date: 02.01.2024 – This policy addresses proton beam radiation therapy. Applicable Procedure Codes: 77301, 77338, 77385, 77386, 77387, 77520, 77522, 77523, 77525, G6015, G6016, G6017.

Provider Administered Drugs – Preferred Products – Commercial Medical Benefit Drug Policy

Last Published 07.01.2024

Effective Date: 07.01.2024 – This policy addresses preferred provider administered medications covered under the medical benefit. Applicable Procedure Code: J3285.

Provider Administered Drugs – Site of Care – Commercial Medical Benefit Drug Policy

Last Published 10.01.2024

Effective Date: 10.01.2024 – This policy addresses outpatient hospital facility-based intravenous medication infusion and intravenous immune globulin and subcutaneous immune globulin therapy. Applicable Procedure Codes: 90283, 90284, C9167, C9168, C9399, J0129, J0180, J0217, J0218, J0219, J0221, J0222, J0223, J0224, J0225, J0256, J0257, J0490, J0491, J0517, J0584, J0638, J0717, J0739, J0791, J1203, J1300, J1301, J1302, J1303, J1305, J1322, J1426, J1427, J1428, J1429, J1459, J1551, J1554, J1555, J1458, J1557, J1558, J1559, J1561, J1566, J1568, J1569, J1572, J1575, J1576, J1602, J1743, J1745, J1747, J1786, J1823, J1931, J2182, J2327, J2356, J2508, J2786, J2840, J2998, J3032, J3060, J3241, J3245, J3262, J3357, J3358, J3380, J3385, J3397, J3401, J3490, J3590, J9332, J9333, J9334, J9376, J9381, Q5103, Q5104, Q5121.

Qalsody® (Tofersen) – Commercial Medical Benefit Drug Policy

Last Published 06.01.2024

Effective Date: 06.01.2024 – This policy addresses the use of Qalsody® (tofersen) for the treatment of amyotrophic lateral sclerosis (ALS). Applicable Procedure Code: J1304.

Radiation Therapy: Fractionation, Image-Guidance, and Special Services – Commercial and Individual Exchange Medical Policy

Last Published 02.01.2024

Effective Date: 02.01.2024 – This policy addresses radiation therapy fractionation, image-guided radiation therapy (IGRT), and special radiation therapy services.

Radicava® (Edaravone) – Commercial Medical Benefit Drug Policy

Last Published 05.01.2024

Effective Date: 05.01.2024 – This policy addresses the use of Radicava® (edaravone) for the treatment of amyotrophic lateral sclerosis (ALS). Applicable Procedure Code: J1301.

Reblozyl® (Luspatercept-Aamt) – Commercial Medical Benefit Drug Policy

Last Published 05.01.2024

Effective Date: 05.01.2024 – This policy addresses Reblozyl® (luspatercept-aamt) for the treatment of anemia in adult patients with beta thalassemia and symptomatic anemia in patients with myelodysplastic syndromes or myleodysplastic/myeloproliferative neoplasms. Applicable Procedure Code: J0896.

Rebyota™ (Fecal Microbiota, Live-Jslm) – Commercial Medical Benefit Drug Policy

Last Published 01.01.2024

Effective Date: 01.01.2024 – This policy addresses the use of Rebyota™ (fecal microbiota, live-jslm) for prevention of the recurrence of clostridioides difficile infection (CDI). Applicable Procedure Codes: G0455, J1440.

Repository Corticotropin Injections – Commercial Medical Benefit Drug Policy

Last Published 04.02.2024

Effective Date: 04.01.2024 – This policy addresses the use of repository corticotropin injections for the treatment of infantile spasm, opsoclonus-myoclonus syndrome, and acute exacerbation of multiple sclerosis (MS). Applicable Procedure Codes: J0801, J0802.

Respiratory Interleukins (Cinqair®, Fasenra®, & Nucala®) – Commercial Medical Benefit Drug Policy

Last Published 11.01.2024

Effective Date: 11.01.2024 – This policy addresses the use of interleukin-5 (IL-5) antagonists, including Cinqair® (reslizumab), Fasenra® (benralizumab), and Nucala® (mepolizumab). Applicable Procedure Codes: J0517, J2182, J2786.

Review at Launch for New to Market Medications – Commercial Medical Benefit Drug Policy

Last Published 11.01.2024

Effective Date: 07.01.2024 – This policy addresses review of certain new to market medications that are healthcare provider administered. Applicable Procedure Codes: C9399, J3490, J3590.

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Rhinoplasty and Other Nasal Procedures – Commercial and Individual Exchange Medical Policy

Last Published 09.01.2024

Effective Date: 07.01.2024 – This policy addresses lysis intranasal synechia, repair of nasal vestibular stenosis or alar collapse, rhinoplasty, rhinophyma, septal dermatoplasty, nasal polypectomy, nasal septal swell body reduction, and nasal implants . Applicable Procedure Codes: 30117, 30120, 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, 30465, 30468, 30469, 30999, 31237, 64999, L8699.

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Rituximab (Riabni®, Rituxan®, Ruxience®, & Truxima®) – Commercial Medical Benefit Drug Policy

Last Published 08.01.2024

Effective Date: 08.01.2024 – This policy addresses the use of Riabni® (rituximab-arrx), Rituxan® (rituximab), Ruxience® (rituximab-pvvr), and Truxima® (rituximab-abbs). Applicable Procedure Codes: J3590, J9311, J9312, J9999, Q5115, Q5119, Q5123.

RNA-Targeted Therapies (Amvuttra® and Onpattro®) – Commercial Medical Benefit Drug Policy

Last Published 08.01.2024

Effective Date: 08.01.2024 – This policy addresses the use of Amvuttra® (vutrisiran) and Onpattro® (patisiran) for the treatment of polyneuropathy of hereditary transthyretin-mediated (hATTR) amyloidosis. Applicable Procedures Codes: J0222, J0225.

Roctavian™ (Valoctocogene Roxaparvovec-Rvox) – Commercial Medical Benefit Drug Policy

Last Published 01.01.2024

Effective Date: 01.01.2024 – This policy addresses the use of Roctavian™ (valoctocogene roxaparvovec-rvox) for the treatment of Hemophilia A (factor VIII Deficiency). Applicable Procedure Code: J1412.

Ryplazim® (Plasminogen, Human-Tvmh) – Commercial Medical Benefit Drug Policy

Last Published 04.02.2024

Effective Date: 04.01.2024 – This policy addresses Ryplazim® (plasminogen, human-tvmh) for the treatment of plasminogen deficiency type 1 (hypoplasminogenemia). Applicable Procedure Codes: J2998, J3490, J3590.

Sacral Nerve Stimulation for Urinary and Fecal Indications – Commercial and Individual Exchange Medical Policy

Last Published 10.01.2024

Effective Date: 10.01.2024 – This policy addresses sacral nerve stimulation for urinary and fecal indications. Applicable Procedure Codes: 0784T, 0785T, 0786T, 0787T, 64561, 64581, 64585, 64590, 64595, L8679, L8680, L8682, L8685, L8686, L8687, L8688.

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Sacroiliac Joint Interventions – Commercial and Individual Exchange Medical Policy

Last Published 01.01.2024

Effective Date: 01.01.2024 – This policy addresses sacroiliac joint interventions, including sacroiliac joint injections and sacroiliac joint fusion. Applicable Procedure Codes: 27096, 27278, 27279, 27280, 64451, G0260.

Saphnelo® (Anifrolumab-Fnia) – Commercial Medical Benefit Drug Policy

Last Published 07.01.2024

Effective Date: 07.01.2024 – This policy addresses Saphnelo® (anifrolumab-fnia) for the treatment of moderate to severe systemic lupus erythematosus (SLE). Applicable Procedure Code: J0491.

Scenesse® (Afamelanotide) – Commercial Medical Benefit Drug Policy

Last Published 07.01.2024

Effective Date: 07.01.2024 – This policy addresses Scenesse® (afamelanotide) for the treatment of erythropoietic protoporphyria (EPP). Applicable Procedures Code: J7352.

Screening Colonoscopy Procedures – Site of Service – Commercial and Individual Exchange Medical Policy

Last Published 11.01.2024

Effective Date: 11.01.2024 – This policy addresses planned preventive screening colonoscopies performed in a hospital outpatient department. Applicable Procedures Codes: 45378, 45380, 45381, 45384, 45385, G0105, G0121.

Self-Administered Medications – Commercial Medical Benefit Drug Policy

Last Published 08.01.2024

Effective Date: 08.01.2024 – This policy addresses medications that are determined to be self-administered and excluded from medical coverage.

Sensory Integration Therapy and Auditory Integration Training – Commercial and Individual Exchange Medical Policy

Last Published 11.01.2024

Effective Date: 11.01.2024 – This policy addresses sensory integration therapy and auditory integration training. Applicable Procedure Code: 97533.

Simponi Aria® (Golimumab) Injection for Intravenous Infusion – Commercial Medical Benefit Drug Policy

Last Published 03.01.2024

Effective Date: 03.01.2024 – This policy addresses Simponi Aria® (golimumab) injection for intravenous infusion for the treatment of ankylosing spondylitis, psoriatic arthritis, rheumatoid arthritis, and polyarticular juvenile idiopathic arthritis. Applicable Procedure Code: J1602.

Sinus Surgeries and Interventions – Commercial and Individual Exchange Medical Policy

Last Published 11.01.2024

Effective Date: 09.01.2024 – This policy addresses balloon sinus ostial dilation, functional endoscopic sinus surgery (FESS), and self-expanding absorptive sinus ostial dilation. Applicable Procedure Codes: 31240, 31253, 31254, 31255, 31256, 31257, 31259, 31267, 31276, 31287, 31288, 31295, 31296, 31297, 31298, 31299.

Skin and Soft Tissue Substitutes – Commercial and Individual Exchange Medical Policy

Last Published 09.03.2024

Effective Date: 09.01.2024 – This policy addresses skin and soft tissue substitutes.

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Skyrizi® (Risankizumab-Rzaa) – Commercial Medical Benefit Drug Policy

Last Published 10.01.2024

Effective Date: 10.01.2024 – This policy addresses the intravenous use of Skyrizi® (risankizumab-rzaa) injection for the treatment of Crohn’s disease (CD). Applicable Procedures Code: J2327.

Sleep Studies – Commercial and Individual Exchange Medical Policy

Last Published 11.01.2024

Effective Date: 11.01.2024 – This policy addresses home sleep apnea testing, attended full-channel polysomnography performed in a healthcare facility or laboratory setting, daytime sleep studies, attended PAP titration and attended repeat testing. Applicable Procedure Codes: 95782, 95783, 95800, 95801, 95803, 95805, 95806, 95807, 95808, 95810, 95811, G0398, G0399, G0400.

Sodium Hyaluronate – Commercial Medical Benefit Drug Policy

Last Published 06.01.2024

Effective Date: 06.01.2024 – This policy addresses intra-articular injections of sodium hyaluronate. Applicable Procedure Codes: 20605, 20606, 20610, 20611, J3490, J7318, J7320, J7321, J7322, J7323, J7324, J7325, J7326, J7327, J7328, J7329, J7331, J7332.

Somatostatin Analogs – Commercial Medical Benefit Drug Policy

Last Published 10.01.2024

Effective Date: 10.01.2024 – This policy addresses the use of somatostatin analogs, including Sandostatin® (octreotide acetate), Sandostatin® LAR (octreotide acetate LAR), Signifor® (pasireotide diaspartate), Signifor® LAR (pasireotide), and Somatuline® Depot (lanreotide), and Lanreotide Injection. Applicable Procedure Codes: J1930, J1932, J2353, J2354, J2502.

Speech Generating Devices – Commercial and Individual Exchange Medical Policy

Last Published 05.01.2024

Effective Date: 05.01.2024 – This policy addresses speech generating devices. Applicable Procedure Codes: E2500, E2502, E2504, E2506, E2508, E2510, E2511, E2512, E2599.

Spevigo® (Spesolimab-Sbzo) – Commercial Medical Benefit Drug Policy

Last Published 10.01.2024

Effective Date: 10.01.2024 – This policy addresses the use of Spevigo® (spesolimab-sbzo) for the treatment of generalized pustular psoriasis (GPP). Applicable Procedure Code: J1747.

Spinal Fusion and Bone Healing Enhancement Products – Commercial and Individual Exchange Medical Policy

Last Published 10.01.2024

Effective Date: 10.01.2024 – This policy addresses spinal fusion enhancement products. Applicable Procedure Codes: 0814T, 20930, 20931, 20939, 22899.

Spinal Fusion and Decompression – Commercial and Individual Exchange Medical Policy

Last Published 03.01.2024

Effective Date: 03.01.2024 – This policy addresses spinal fusion and decompression procedures, laminectomy, isolated facet fusion, dynamic stabilization systems, and total facet joint arthroplasty.

Spinraza® (Nusinersen) – Commercial Medical Benefit Drug Policy

Last Published 09.01.2024

Effective Date: 09.01.2024 – This policy addresses the use of Spinraza® (nusinersen) for the treatment of spinal muscular atrophy (SMA). Applicable Procedure Code: J2326.

Stelara® (Ustekinumab) – Commercial Medical Benefit Drug Policy

Last Published 03.01.2024

Effective Date: 03.01.2024 – This policy addresses the use of Stelara® (ustekinumab) for the treatment of Crohn’s disease, plaque psoriasis, psoriatic arthritis, and ulcerative colitis. Applicable Procedure Codes: J3357, J3358.

Stereotactic Body Radiation Therapy and Stereotactic Radiosurgery – Commercial and Individual Exchange Medical Policy

Last Published 02.01.2024

Effective Date: 02.01.2024 – This policy addresses stereotactic radiation therapy, including stereotactic radiosurgery (SRS) and stereotactic body radiation therapy (SBRT). Applicable Procedures Codes: 32701, 61796, 61797, 61798, 61799, 61800, 63620, 63621, 77301, 77371, 77372, 77373, 77432, 77435, G0339, G0340.

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Subcutaneous Implantable Naltrexone Pellets – Commercial Medical Benefit Drug Policy

Last Published 01.01.2024

Effective Date: 01.01.2024 – This policy addresses the use of compounded implantable drug pellets. Applicable Procedure Codes: 11981, 11982, 11983, J3490, J7999.

Surgery of the Ankle – Commercial and Individual Exchange Medical Policy

Last Published 09.01.2024

Effective Date: 09.01.2024 – This policy addresses surgery of the ankle. Applicable Procedure Codes: 27685, 27700, 27702, 27703, 27704, 28446, 28899, 29891, 29892, 29894, 29895, 29897, 29898, 29899.

Surgery of the Elbow – Commercial and Individual Exchange Medical Policy

Last Published 10.01.2024

Effective Date: 11.01.2023 – This policy addresses surgery of the elbow. Applicable Procedure Codes: 24360, 24361, 24362, 24363, 24366, 24370, 24371, 29830, 29834, 29835, 29836, 29837, 29838.

Surgery of the Foot – Commercial and Individual Exchange Medical Policy

Last Published 09.01.2024

Effective Date: 09.01.2024 – This policy addresses surgery of the foot. Applicable Procedure Codes: 28285, 28289, 28291, 28292, 28295, 28297, 28298, 28299, 28296, 28299, 28899, 29893.

Surgery of the Hand or Wrist – Commercial and Individual Exchange Medical Policy

Last Published 08.01.2024

Effective Date: 08.01.2024 – This policy addresses surgery of the hand or wrist. Applicable Procedure Codes: 25441, 25442, 25443, 25444, 25445, 25446, 25449, 26530, 26531, 26535, 26536, 29840, 29843, 29844, 29845, 29846, 29847.

Surgery of the Hip – Commercial and Individual Exchange Medical Policy

Last Published 11.01.2024

Effective Date: 11.01.2024 – This policy addresses surgery of the hip and femoroacetabular impingement (FAI) syndrome. Applicable Procedure Codes: 27120, 27125, 27130, 27132, 27134, 27137, 27138, 27299, 29860, 29861, 29862, 29863, 29914, 29915, 29916, 29999, S2118.

Surgery of the Knee – Commercial and Individual Exchange Medical Policy

Last Published 11.01.2024

Effective Date: 11.01.2024 – This policy addresses surgery of the knee. Applicable Procedure Codes: 0737T, 27412, 27415, 27416, 27418, 27437, 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447, 27486, 27487, 27568, 27569, 27664, 27665, 29866, 29867, 29868, 29870, 29871, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889, G0428, J7330, S2112.

Surgery of the Shoulder – Commercial and Individual Exchange Medical Policy

Last Published 11.01.2024

Effective Date: 11.01.2024 – This policy addresses surgery of the shoulder. Applicable Procedure Codes: 23470, 23472, 23473, 23474, 29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827, 29828.

Surgical and Ablative Procedures for Venous Insufficiency and Varicose Veins – Commercial and Individual Exchange Medical Policy

Last Published 09.03.2024

Effective Date: 07.01.2024 – This policy addresses varicose vein ablative and stripping procedures and ligation procedures. Applicable Procedure Codes: 36465, 36466, 36468, 36470, 36471, 36473, 36474, 36475, 36476, 36478, 36479, 36482, 36483, 37500, 37700.

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Surgical Treatment of Lymphedema – Commercial and Individual Exchange Medical Policy

Last Published 11.01.2024

Effective Date: 11.01.2023 – This policy addresses surgical procedures for the treatment or prevention of lymphedema. Applicable Procedure Codes: 15830, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15847, 15876, 15877, 15878, 15879, 38999, 49906.

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Sympathetic Blockade – Commercial and Individual Exchange Medical Policy

Last Published 09.01.2024

Effective Date: 09.01.2024 – This policy addresses the use of a sympathetic blockade using a local anesthetic. Applicable Procedure Codes: 64510, 64517, 64520, 64530.

Synagis® (Palivizumab) – Commercial Medical Benefit Drug Policy

Last Published 10.01.2024

Effective Date: 10.01.2024 – This policy addresses the use of Synagis® (palivizumab) to prevent serious respiratory syncytial virus disease (RSV) in high risk infants and young children. Applicable Procedure Code: 90378.

Tepezza® (Teprotumumab-Trbw) – Commercial Medical Benefit Drug Policy

Last Published 11.01.2024

Effective Date: 11.01.2024 – This policy addresses the use of Tepezza® (teprotumumab-trbw) for the treatment of thyroid eye disease. Applicable Procedure Code: J3241.

Testosterone Replacement or Supplementation Therapy – Commercial Medical Benefit Drug Policy

Last Published 07.01.2024

Effective Date: 07.01.2024 – This policy addresses the use of injectable testosterone and testosterone pellets for replacement therapy in conditions associated with a deficiency or absence of endogenous testosterone. Applicable Procedure Codes: 11980, J1071, J3121, J3145, S0189.

Tezspire® (Tezepelumab-Ekko) – Commercial Medical Benefit Drug Policy

Last Published 11.01.2024

Effective Date: 11.01.2024 – This policy addresses the use of Tezspire® (tezepelumab) for the treatment of severe asthma. Applicable Procedure Code: J2356.

Total Artificial Disc Replacement for the Spine – Commercial and Individual Exchange Medical Policy

Last Published 02.01.2024

Effective Date: 02.01.2024 – This policy addresses cervical and lumbar artificial total disc replacement. Applicable Procedure Codes: 0098T, 0165T, 22856, 22857, 22858, 22860, 22861, 22862, 22899.

Transanal Minimally Invasive Surgical Procedures – Commercial and Individual Exchange Medical Policy

Last Published 08.01.2024

Effective Date: 05.01.2024 – This policy addresses transanal endoscopic microsurgery (TEMS) and transanal minimally invasive surgery (TAMIS). Applicable Procedure Code: 0184T.

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Transarterial Radioembolization (TARE)/Selective Internal Radiation Therapy (SIRT) for the Treatment of Malignant Cancers of the Liver – Commercial and Individual Exchange Medical Policy

Last Published 10.01.2024

Effective Date: 08.01.2024 – This policy addresses transarterial radioembolization (TARE)/selective internal radiation therapy (SIRT) using yttrium-90 microspheres for the treatment of malignant cancers of the liver. Applicable Procedure Codes: 37243, 75984, 79445, S2095.

Transcatheter Heart Valve Procedures – Commercial and Individual Exchange Medical Policy

Last Published 11.01.2024

Effective Date: 04.01.2024 – This policy addresses transcatheter heart valve (aortic, pulmonary, mitral) procedures. Applicable Procedure Codes: 0345T, 0483T, 0484T, 0543T, 0544T, 0545T, 0569T, 0570T, 0646T, 0805T, 0806T, 33361, 33362, 33363, 33364, 33365, 33366, 33367, 33368, 33369, 33370, 33418, 33419, 33477, 33999, 93799.

Transcranial Magnetic Stimulation – Commercial and Individual Exchange Medical Policy

Last Published 02.01.2024

Effective Date: 02.01.2024 – This policy addresses transcranial magnetic stimulation and navigated transcranial magnetic stimulation (nTMS). Applicable Procedure Codes: 0858T, 64999, 90867, 90868, 90869.

Transpupillary Thermotherapy – Commercial and Individual Exchange Medical Policy

Last Published 04.02.2024

Effective Date: 04.01.2024 – This policy addresses transpupillary thermotherapy. Applicable Procedure Codes: 67299, 92499.

Treatment of Temporomandibular Joint Disorders – Commercial and Individual Exchange Medical Policy

Last Published 03.01.2024

Effective Date: 03.01.2024 – This policy addresses treatment of temporomandibular joint (TMJ) disorders. Applicable Procedure Codes: 20552, 20553, 20605, 20606, 21010, 21050, 21060, 21070, 21085, 21089, 21110, 21240, 21242, 21243, 21247, 21299, 21499, 29800, 29804, 90901, 97039, 97139, E0746, E1399, E1700, E1701, and E1702.

Trogarzo® (Ibalizumab-Uiyk) – Commercial Medical Benefit Drug Policy

Last Published 07.01.2024

Effective Date: 07.01.2024 – This policy addresses the use of Trogarzo® (ibalizumab-uiyk) for the treatment of multi-drug resistant human immunodeficiency virus (HIV). Applicable Procedure Code: J1746.

Tysabri® (Natalizumab) – Commercial Medical Benefit Drug Policy

Last Published 05.01.2024

Effective Date: 05.01.2024 – This policy addresses the use of Tysabri® (natalizumab) for the treatment of relapsing forms of multiple sclerosis and Crohn's disease. Applicable Procedure Code: J2323.

Tzield® (Teplizumab-Mzwv) – Commercial Medical Benefit Drug Policy

Last Published 08.01.2024

Effective Date: 08.01.2024 – This policy addresses the use of Tzield® (teplizumab-mzwv) to delay the onset of stage 3 type 1 diabetes. Applicable Procedure Code: J9381.

Umbilical Cord Blood Harvesting and Storage for Future Use – Commercial and Individual Exchange Medical Policy

Last Published 08.01.2024

Effective Date: 07.01.2024 – This policy addresses collection and storage of umbilical cord blood. Applicable Procedure Codes: 38205, 38206, 38207, 88240, S2140.

Unicondylar Spacer Devices for Treatment of Pain or Disability – Commercial and Individual Exchange Medical Policy

Last Published 01.01.2024

Effective Date: 01.01.2024 – This policy addresses unicondylar spacer devices for treating knee joint pain or disability from any cause. Applicable Procedure Code: 27599.

Uplizna® (Inebilizumab-Cdon) – Commercial Medical Benefit Drug Policy

Last Published 06.01.2024

Effective Date: 06.01.2024 – This policy addresses Uplizna® (inebilizumab-cdon) for the treatment of neuromyelitis optica spectrum disorder (NMOSD). Applicable Procedures Code: J1823.

Upper Extremity Prosthetic Devices – Commercial and Individual Exchange Medical Policy

Last Published 10.01.2024

Effective Date: 04.01.2024 – This policy addresses upper extremity myoelectric prosthetic devices. Applicable Procedure Codes: L6026, L6611, L6621, L6629, L6632, L6677, L6680, L6682, L6686, L6687, L6688, L6694, L6695, L6696, L6697, L6698, L6715, L6880, L6881, L6882, L6883, L6884, L6890, L6925, L6935, L6945, L6955, L6975, L7007, L7008, L7009, L7045, L7180, L7181, L7190, L7191, L7259, L7360, L7364, L7366, L7367, L7368, L7400, L7401, L7403, L7404, L8465.

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Vaccines – Commercial Medical Benefit Drug Policy

Last Published 11.01.2023

Effective Date: 11.01.2023 – This policy addresses vaccines/immunizations.

Vagus and External Trigeminal Nerve Stimulation – Commercial and Individual Exchange Medical Policy

Last Published 01.01.2024

Effective Date: 01.01.2024 – This policy addresses implantable vagus nerve stimulators and transcutaneous (non-implantable) vagus and trigeminal nerve stimulators. Applicable Procedure Codes: 61885, 61886, 64553, 64568, 64570, A4541, E0733, E0735, E0770, E1399, L8679, L8680, L8682, L8683, L8685, L8686, L8687, L8688.

Veopoz™ (Pozelimab-Bbfg) – Commercial Medical Benefit Drug Policy

Last Published 06.01.2024

Effective Date: 06.01.2024 – This policy addresses the use of Veopoz™ (pozelimab-bbfg) for the treatment of CD55-deficient protein-losing enteropathy (PLE) (i.e., CHAPLE disease). Applicable Procedure Code: J9376.

Vertebral Body Tethering for Scoliosis – Commercial and Individual Exchange Medical Policy

Last Published 01.01.2024

Effective Date: 01.01.2024 – This policy addresses vertebral body tethering for the treatment of scoliosis. Applicable Procedure Code: 0656T, 0657T, 22836, 22837, 22899.

Video Electroencephalographic (vEEG) Monitoring and Recording – Commercial and Individual Exchange Medical Policy

Last Published 01.01.2024

Effective Date: 01.01.2024 – This policy addresses video electroencephalographic (EEG) monitoring and recording. Applicable Procedure Codes: 95700, 95711, 95712, 95713, 95714, 95715, 95716, 95718, 95720, 95722, 95724, 95726.

Viltepso® (Viltolarsen) – Commercial Medical Benefit Drug Policy

Last Published 06.01.2024

Effective Date: 06.01.2024 – This policy addresses Viltepso® (viltolarsen) for the treatment of Duchenne muscular dystrophy (DMD). Applicable Procedures Code: J1427.

Virtual Upper Gastrointestinal Endoscopy – Commercial and Individual Exchange Medical Policy

Last Published 11.01.2024

Effective Date: 11.01.2024 – This policy addresses virtual upper gastrointestinal endoscopy. Applicable Procedure Codes: 76497, 76498.

Visual Information Processing Evaluation and Orthoptic and Vision Therapy – Commercial and Individual Exchange Medical Policy

Last Published 01.01.2024

Effective Date: 01.01.2024 – This policy addresses occlusion therapy, pharmacologic penalization therapy, orthoptic or vision therapy, prism adaptation therapy, visual perception therapy, vision restoration therapy, and the use of visual information processing evaluations to diagnose reading or learning disabilities. Applicable Procedure Codes: 0687T, 0688T, 0704T, 0705T, 0706T, 92065, 92066, 92499.

Vyepti® (Eptinezumab-Jjmr) – Commercial Medical Benefit Drug Policy

Last Published 08.01.2024

Effective Date: 08.01.2024 – This policy addresses the use of Vyepti® (Eptinezumab) for the treatment of chronic and episodic migraine. Applicable Procedure Code: J3032.

Vyjuvek® (Beramagene Geperpavec-Svdt) – Commercial Medical Benefit Drug Policy

Last Published 06.01.2024

Effective Date: 06.01.2024 – This policy addresses the use of Vyjuvek™ (beramagene geperpavec-svdt) for the treatment of wounds in patients with dystrophic epidermolysis bullosa (DEB). Applicable Procedure Code: J3401.

Vyondys 53® (Golodirsen) – Commercial Medical Benefit Drug Policy

Last Published 05.01.2024

Effective Date: 05.01.2024 – This policy addresses the use of Vyondys 53® (golodirsen) for the treatment of Duchenne muscular dystrophy (DMD). Applicable Procedures Code: J1429.

Walkers – Commercial and Individual Exchange Medical Policy

Last Published 06.01.2024

Effective Date: 06.01.2024 – This policy addresses the use of walkers. Applicable Procedure Codes: A4636, A4637, E0130, E0135, E0140, E0141, E0143, E0144, E0147, E0148, E0149, E0154, E0155, E0156, E0157, E0158, E0159.

White Blood Cell Colony Stimulating Factors – Commercial Medical Benefit Drug Policy

Last Published 07.01.2024

Effective Date: 07.01.2024 – This policy addresses the use of white blood cell colony stimulating factors (CSFs), including the drug products Fulphila, Fylnetra, Granix, Leukine, Neulasta, Neupogen, Nivestym, Nyvepria, Releuko, Rolvedon, Stimufend, Udenyca, Zarxio, and Ziextenzo. Applicable Procedure Codes: J1442, J1447, J1449, J2506, J2820, JQ5101, Q5108, Q5110, Q5111, Q5120, Q5122, Q5125, Q5127, Q5130.

Whole Exome and Whole Genome Sequencing (Non-Oncology Conditions) – Commercial and Individual Exchange Medical Policy

Last Published 11.01.2024

Effective Date: 07.01.2024 – This policy addresses whole exome and whole genome sequencing. Applicable Procedure Codes: 0094U, 0212U, 0213U, 0214U, 0215U, 0260U, 0264U, 0265U, 0266U, 0267U, 0335U, 0336U, 0425U, 0426U, 0454U, 0469U, 81415, 81416, 81417, 81425, 81426, 81427.

Xiaflex® (Collagenase Clostridium Histolyticum) – Commercial Medical Benefit Drug Policy

Last Published 12.01.2023

Effective Date: 12.01.2023 – This policy addresses the use of Xiaflex® (collagenase clostridium histolyticum) for the treatment of Dupuytren’s contracture and Peyronie’s disease. Applicable Procedure Codes: 20527, 26341, J0775.

Xolair® (Omalizumab) – Commercial Medical Benefit Drug Policy

Last Published 08.01.2024

Effective Date: 08.01.2024 – This policy addresses the use of Xolair® (omalizumab) for subcutaneous use for the treatment of moderate to severe persistent asthma, chronic urticaria, and nasal polyps. Applicable Procedure Code: J2357.

Zolgensma® (Onasemnogene Abeparvovec-Xioi) – Commercial Medical Benefit Drug Policy

Last Published 12.01.2023

Effective Date: 12.01.2023 – This policy addresses the use of Zolgensma® (onasemnogene abeparvovec-xioi) for the treatment of spinal muscular atrophy (SMA). Applicable Procedure Code: J3399.

Zulresso® (Brexanolone) – Commercial Medical Benefit Drug Policy

Last Published 11.01.2024

Effective Date: 11.01.2024 – This policy addresses the use of Zulresso® (brexanolone) for the treatment of postpartum depression (PPD) in adults. Applicable Procedure Code: J1632.

Copies of UnitedHealthcare's Medical Policies and Medical Benefit Drug Policies can also be obtained by sending a written request to:

UnitedHealthcare Policy Requests
4 Research Drive
Shelton, CT 06484

For questions, please contact your local Network Management representative or call the Provider Services number on the back of the member’s ID card.