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BridgeSpan Health
Medical Policy Update, April 1, 2024
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Changes to BridgeSpan Health Medical
Policies Announced |
| The Plan uses medical policies
as guidelines for coverage decisions within
the member’s written benefits. Below are
summaries of recent changes to The Plan’s
medical policies. The detailed policies and
complete Medical Policy Manual are available
online at www.policy.bridgespanhealth.com/intro.html.
We have included the section and policy number
for your convenience. |
Policy Name |
Summary
of Policy or Change |
|
Coding / Implementation Change
|
|
| Folate Testing |
New policy will address folate testing.
Effective Date: June 1, 2024 |
Laboratory, Policy No. 79 |
Adding CPT codes 82746, 82747 to this medical policy.
Code 82746 will deny as always not medically necessary unless billed with specific diagnosis codes.
Code 82747 will deny as always not medically necessary. |
N/A |
| Biomarkers for Cardiovascular Disease |
New policy addresses measurement or quantitation of lipoprotein subclasses for cardiovascular disease.
Effective Date: May 1, 2024 |
Laboratory, Policy No. 78 |
Adding CPT codes 0052U, 83700, 83701, 83704, 83722 to this policy with investigational denial |
N/A |
| Definitive Lower Limb Prostheses |
Policy updated to include new HCPCS codes for a pneumatic prosthetic knee (L5841) and the RevoFit System for socket volume adjustment (L5783).
Effective Date: April 1, 2024 |
Durable Medical Equipement, Policy No. 18 |
Adding HCPCS: L5783 with always not medically necessary denial, and L5841 with potentially investigational edit. |
N/A |
| Powered Exoskeleton for Ambulation and Rehabilitation |
Policy title changed from: Powered Exoskeleton for Ambulation.
Expanded policy scope to include powered exoskeleton devices for robot-assisted physical therapy.
Effective Date: April 1, 2024 |
Durable Medical Equipement, Policy No. 89 |
Adding HCPCS: E0739
with always investigational edit |
N/A |
| Upper Extremity Rehabilitation System with Brain-Computer Interface |
New Policy with investigational criteria.
Effective Date: April 1, 2024 |
Durable Medical Equipement, Policy No. 94 |
Adding HCPCS: E0738 with always investigational edit |
N/A |
| Evaluating the Utility of Genetic Panels |
Added 16 new investigational tests and removed 41 tests from the policy.
Effective Date: April 1, 2024 |
Genetic Testing, Policy No. 64 |
Deleting CPT: 0170U |
N/A |
| Investigational Gene Expression, Biomarker, and Multianalyte Testing |
Added six investigational tests to the policy.
Effective Date: April 1, 2024 |
Laboratory, Policy No. 77 |
Adding CPT: 0170U, 0441U, 0442U, 0443U, 0446U, 0447U
Continue investigational denial on code 0170U
New codes 0441U 0442U 0443U 0446U 0447U have an investigational denial. |
N/A |
| Gender Affirming Interventions for Gender Dysphoria |
Updating criteria with additional documentation requirements.
Effective Date: April 1, 2024 |
Medicine, Policy No. 153 |
N/A |
N/A |
| Intensity Modulated Radiotherapy (IMRT) of the Central Nervous System (CNS), Head, Neck, and Thyroid |
Updating criteria to require clinical documentation of expected survival.
Effective Date: April 1, 2024 |
Medicine, Policy No. 164 |
N/A |
N/A |
| Intensity Modulated Radiotherapy (IMRT) of the Thorax, Abdomen, Pelvis, and Extremities |
Updating criteria related to pulmonary function.
Effective Date: April 1, 2024 |
Medicine, Policy No. 165 |
N/A |
N/A |
| Bioengineered Skin and Soft Tissue Substitutes and Amniotic Products |
Added three products that may have medical necessity to criteria for non-healing diabetic lower-extremity ulcers.
Effective Date: April 1, 2024 |
Medicine, Policy No. 170 |
Add Q2 HCPCS: A2026, Q4305, Q4306, Q4307, Q4308, Q4309, Q4310
Delete Q2 HCPCS: Q4244
Also removed 2023 deleted HCPCS code: C1849 and
remove Revised and New notes from codes
Code Q4121, remove investigational denial and add preauth.
New 4/1/2024 codes, A2026 Q4305 Q4306 Q4307 Q4308 Q4309 Q4310, adding investigational denial via the Annual Code Set Update PIRF on the 4/11/2024 RPG agenda.
Code Q4244 being deleted via the Annual Code Set Update PIRF on the 4/11/2024 RPG agenda. |
|
| Pectus Excavatum and Carinatum Treatment |
Policy title changed from: Pectus Excavatum and Carinatum Treatment.
Added non-coverage criteria for the use of orthotics in the treatment of pectus carinatum.
Effective Date: April 1, 2024 |
Surgery, Policy No. 12.02 |
Adding:
HCPCS: L1320 with always not medically necessary denial, and
Unlisted HCPCS: L1499 with no change to unlised code review |
N/A |
| Gastroesophageal Reflux Surgery |
Clarified criteria.
Effective Date: April 1, 2024 |
Surgery, Policy No. 186 |
N/A |
N/A |
| Transurethral Water Vapor Thermal Therapy and Transurethral Waterjet Ablation (Aquablation) of the Prostate |
Liberalized to consider Aquablation medically necessary when criteria are met.
Effective Date: April 1, 2024 |
Surgery, Policy No. 210 |
CPT: 0421T, and HCPCS: C2596 changing from investigational denial to require PreAuth. |
Adding CPT: 0421T, and HCPCS: C2596 to the PreAuth website for this policy. |
| Small Bowel, Small Bowel/Liver, and Multivisceral Transplant |
Changed policy title from:
Isolated Small Bowel Transplant.
Added criteria regarding multivisceral transplant previously addressed in TRA18.
Effective Date: April 1, 2024 |
Transplant, Policy No. 09 |
Adding CPT: 43999, 44799, 47133, 47135, 47140, 47141, 47142, 47143, 47144, 47145, 47146, 47147, 47399, 48550, 48551, 48552, 48554, 48999 and
Adding HCPCS: S2053, S2054, S2055, S2152 with no change to edits. |
Adding CPT: 43999, 44135, 44136, 44799, 47135, 47399, 48554, 48999 to the PreAuth webiste for this policy. |
| Administrative Guidelines to Determine Dental vs Medical Services |
Clarified criteria with no change to intent.
Effective Date: March 1, 2024 |
Allied Health, Policy No. 35 |
N/A |
N/A |
| Whole Exome and Whole Genome Sequencing |
Removed references to testing for cancer treatment selection, which will now be addressed in Expanded Molecular Testing of Cancers to Select Targeted Therapies Genetic Testing, Policy No. 83.
Effective Date: March 1, 2024 |
Genetic Testing, Policy No. 76 |
Delete CPT codes 0036U, 0297U, 0298U, 0300U, 0329U from this medical policy |
N/A |
| Expanded Molecular Testing of Cancers to Select Targeted Therapies |
Added whole genome, whole exome, and whole transcriptome testing of cancer tissue to this policy.
Effective Date: March 1, 2024 |
Genetic Testing, Policy No. 83 |
Adding CPT codes 0036U, 0297U, 0298U, 0300U, 0329U to this medical policy and continue investigational denial |
N/A |
| Functional Neuromuscular Electrical Stimulation |
Clarified Criteria with no change to intent.
Effective Date: February 1, 2024 |
Durable Medical Equipment, Policy No. 83.04 |
N/A |
N/A |
| Digital Therapeutic Products for Post-traumatic Stress Disorder and Panic Disorder |
New policy addresses digital therapeutic products for post-traumatic stress disorder and panic disorder.
Effective Date: February 1, 2024 |
Medicine, Policy No. 175.05 |
Added HCPCS code A9291 to this new policy with preauth edit. |
Added HCPCS code A9291 to the preauth website for this policy. |
| Bariatric Surgery |
Clarified definitions and reorganized criteria with no change to intent.
Effective Date: February 1, 2024 |
Surgery, Policy No. 58 |
Added CPT code 0813T to this policy with investigational denial. |
N/A |
| Identification of Microorganisms Using Nucleic Acid Probes |
Added oral HPV testing to policy as investigational.
Effective Date: January 1, 2024 |
Genetic Testing, Policy No. 85 |
Added new Q1 CPT codes 0429U, 87523 to this policy with investigational denial. |
N/A |
| Investigational Gene Expression, Biomarker, and Multianalyte Testing |
Added one new investigational test to the policy.
Effective Date: January 1, 2024 |
Laboratory, Policy No. 77 |
Added new Q1 CPT code 0437U to this policy with investigational denial |
N/A |
| Extracorporeal Shock Wave Therapy (ESWT) |
Changed policy title
from: Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions
Expanded scope of the policy to include Extracorporeal Shock Wave Treatment for all indications.
Effective Date: January 1, 2024 |
Medicine, Policy No. 90 |
Added new Q1 CPT code 0864T and CPT codes 0512T, 0513T to this policy with investigational denial.
Added unlisted code 55899. |
N/A |
| New and Emerging Medical Technologies and Procedures |
Updated the policy in alignment with the 2024 Q1 annual code update.
Effective Date: January 1, 2024 |
Medicine, Policy No. 149 |
Added new Q1 CPT codes 0811T, 0812T, 0814T, 0859T, 0860T, 0861T, 0862T, 0863T, 0865T, 0866T
Added codes 0571T, 0572T, 0573T, 0574T, 0575T, 0576T, 0577T, 0578T, 0579T, 0580T, 0614T from SUR17 that will be archived 1/1/2024 to this medical policy and continue investigational edit.
Deleted: 0499T, 0533T, 0534T, 0535T, 0536T, 0641T, 0642T, 0715T
Revise: 0517T, 0518T, 0519T, 0520T, 0640T
Non-code update deleted: 0619T, 0656T, 0657T, C1761 |
N/A |
| Gender Affirming Interventions for Gender Dysphoria |
Updated criteria to address the OR HB2002 law, added criteria to address facial gender affirming surgery, and clarified existing criteria.
Effective Date: January 1, 2024 |
Medicine, Policy No. 153 |
Adding CPT codes 11920, 11921, 15774, 21125, 21127, 21141, 21142, 21143, 21145, 21146, 21147, 21188, 21193, 21194, 21195, 21196, 21208 to this policy and continue preauth edit.
Adding unlisted code 21299.
Adding codes 21137, 21139 that will require preauth for gender affirming diagnoses. |
Adding CPT codes 11920, 11921, 15774, 21125, 21127, 21141, 21142, 21143, 21145, 21146, 21147, 21188, 21193, 21194, 21195, 21196, 21208, to the preauth website for this policy.
Adding codes 21137, 21139 to the preauth website for this policy with instruction that these codes will require preauth for gender affirming diagnoses. |
| Subcutaneous Tibial Nerve Stimulation |
New policy addressing implantable subcutaneous tibial nerve stimulation devices.
Effective Date: January 1, 2024 |
Surgery, Policy No. 154 |
Added new Q1 CPT codes 0816T, 0817T, 0818T, 0819T to this policy with investigational denial. |
N/A |
| Hypoglossal Nerve Stimulation |
Updating criteria to align with recent FDA approval for the inspireII.
Clarified CPAP intolerance.
Effective Date: January 1, 2024 |
Surgery, Policy No. 215 |
Age requirement changing from 22 to 18. |
N/A |
| Radiofrequency Ablation and Injection of Sacroiliac Joint Nerves |
New policy with always investigational criteria for radio frequency ablation and injections for the nerves of the sacroiliac joint.
Effective Date: January 1, 2024 |
Surgery, Policy No. 231 |
Adding CPT codes 64451, 64625 with investigational denial. |
N/A |
| Ablation for the Treatment of Chronic Rhinitis |
Changed policy title from: Cryoablation for Chronic Rhinitis
Expanded policy scope to include radiofrequency and laser ablation as always investigational treatments for chronic rhinitis.
Effective Date: January 1, 2024 |
Surgery, Policy No. 224 |
Added new Q1 CPT codes 31242, 31243 to this policy with investigational denial. |
N/A |
| Devices for Treatment of Benign Prostatic Hyperplasia, Urethral Stricture, and Urethral Stenosis |
Changed policy title from: Temporary Implanted Nitinol Device (e.g., iTind) for Benign Prostatic Hyperplasia
Policy updated to include drug-coated balloon catheters for benign prostatic hyperplasia and urethral stricture.
Effective Date: January 1, 2024 |
Surgery, Policy No. 230 |
Added new Q1 CPT codes 52284 to this policy with investigational denial.
Moved CPT 0619T from MED149 to this policy with no change to investigational denial. |
N/A |
| Vertebral Body Tethering and Stapling |
New policy addressing vertebral body tethering and stapling as investigational treatments for scoliosis.
Effective Date: January 1, 2024 |
Surgery, Policy No. 232 |
Added new Q1 CPT codes 0790T, 22836, 22837, 22838 to this policy with investigational denial.
Moved CPT codes 0656T, 0657T to this policy from MED149 with no change to investigational denial.
Added unlisted code 22899 with unlisted code review edit. |
N/A |
| Coronary Intravascular Lithotripsy |
New policy addressing coronary intravascular lithotripsy as investigational for all indications.
Effective Date: January 1, 2024 |
Surgery, Policy No. 233 |
Added new Q1 CPT code 92972.
Moved HCPCS code C1761 with no change to investigational denial. |
N/A |
| Surgical Site of Service – Hospital Outpatient |
Updated and clarified policy criteria.
Effective Date: January 1, 2024 |
Utilization Management, Policy No. 19 |
N/A |
N/A |
| Negative Pressure Wound Therapy in the Outpatient Setting |
Clarified criteria for associated clinical care and supplies for effective use of a negative pressure wound therapy (NPWT) system (e.g., wound care services).
Effective Date: December 1, 2023 |
Durable Medical Equipment, Policy No. 42 |
N/A |
N/A |
| Extracorporeal Membrane Oxygenation (ECMO) for the Treatment of Cardiac and Respiratory Failure in Adults |
Simplified the criteria for end stage lung failure. Added language for patients unable to wean from Extracorporeal Membrane Oxygenation (ECMO).
Effective Date: December 1, 2023 |
Medicine, Policy No. 152 |
N/A |
N/A |
| Cochlear Implants |
Added Criteria for Single Sided Deafness.
Effective Date: December 1, 2023 |
Surgery, Policy No. 08 |
Removing CPT codes 92630, 92633 (associated with auditory rehabilitation) from this policy. |
N/A for this policy, but continue the eviCore preauth for CPT codes 92630, 92633. |
| Ventral (including incisional) Hernia Repair |
Updating medical policy criteria notes to reflect new coding rules.
Clarified documentation in the list of information needed for review.
Effective Date: December 1, 2023 |
Surgery, Policy No. 12.03 |
N/A |
N/A |
| Leadless Cardiac Pacemakers |
Expanded criteria to include U.S. Food and Drug Administration (FDA) approved devices.
Effective Date: December 1, 2023 |
Surgery, Policy No. 217 |
N/A |
N/A |
| Heart Transplant |
Clarified criteria related to VAD prior to heart transplant.
Effective Date: December 1, 2023 |
Transplant, Policy No. 02 |
N/A |
N/A |
| Hematopoietic Cell Transplantation for Multiple Myeloma and POEMS Syndrome |
Clarified criteria without change to intent.
Effective Date: December 1, 2023 |
Transplant, Policy No. 45.22 |
N/A |
N/A |
| Hematopoietic Cell Transplantation for Central Nervous System Embryonal Tumors and Ependymoma |
Updated criteria in order to enable stem cell collection.
Effective Date: December 1, 2023 |
Transplant, Policy No. 45.33 |
N/A |
N/A |
| Air Ambulance Transport |
Clarified not medically necessary criteria.
Effective Date: December 1, 2023 |
Utilization Management, Policy No. 13 |
N/A |
N/A |
| Enteral and Oral Nutrition in the Home Setting |
New commercial medical policy applies only to select individual members
Effective Date: November 1, 2023 |
Allied Health, Policy No. 05 |
Adding Not Medically Necessary edit for this policy to the following codes: A9152 A9153 B4100 B4102 B4103 B4104 B4149 B4154 S9432 S9434.
Add preauth requirement for this policy to the following codes: B4034 B4035 B4036 B4081 B4082 B4083 B4087 B4088 B4105 B4150 B4152 B4153 B4155 B4157 B4158 B4159 B4160 B4161 B4162 B9002 B9998 S9433 S9435. |
Add the following codes with preauth requirement to the preauth website: B4034 B4035 B4036 B4081 B4082 B4083 B4087 B4088 B4105 B4150 B4152 B4153 B4155 B4157 B4158 B4159 B4160 B4161 B4162 B9002 B9998 S9433 S9435. |
| Power Wheelchairs: Group 3 |
Updated the criteria for clarity with no change to the intent of the policy.
Effective Date: November 1, 2023 |
Durable Medical Equipment, Policy No. 37 |
N/A |
N/A |
| Identification of Microorganisms Using Nucleic Acid Probes |
Updating policy to consider respiratory pathogen panel testing with 12 or more targets to be investigational
Effective Date: November 1, 2023 |
Genetic Testing, Policy No. 85 |
Add CPT codes: 0115U, 0202U, 0223U, 0225U, 0373U, 87492, 87633 with investigational denial. |
N/A |
| Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy of Intracranial, Skull Base, and Orbital Sites |
Update the criteria for clarity with no change to the intent of the policy.
Effective Date: November 1, 2023 |
Surgery, Policy No. 213 |
Add Q4 new HCPCS code C9788 with investigational edit. |
N/A |
| Hysterectomy |
New commercial medical policy applies only to select individual members and will include pre-authorization requirements for select diagnosis codes
Effective Date: November 1, 2023 |
Surgery, Policy No. 218 |
Add preauth requirement for this policy to the following codes: 58150, 58152, 58180, 58260, 58262, 58267, 58270, 58275, 58280, 58290, 58291, 58292, 58294, 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573.
If one of the following diagnosis is not billed in the primary position a Workflow will bypass the preauth: A18.17 A54.24 A54.85 A56.11 A74.81 D06.0 D06.1 D06.7 D06.9 D21.9 D25.0 D25.1 D25.2 D25.9 G89.29 K66.0 N70.01 N70.02 N70.03 N70.11 N70.12 N70.13 N70.91 N70.92 N70.93 N71.01 N71.1 N71.9 N72 N73.0 N73.1 N73.2 N73.3 N73.4 N73.5 N73.6 N73.8 N73.9 N74 N80.0 N80.1 N80.2 N80.3 N80.4 N80.5 N80.8 N80.9 N83.6 N83.7 N87.0 N87.1 N87.9 N92.0 N92.1 N92.3 N92.4 N92.5 N92.6 N93.0 N93.8 N93.9 N94.0 N94.10 N94.11 N94.12 N94.19 N94.4 N94.5 N94.6 N94.89 N94.9 N95.0 N99.4 R10.2 R87.610 R87.611 R87.612 R87.613 R87.619 R87.810 |
Add the following codes with preauth requirement to the preauth website: 58150, 58152, 58180, 58260, 58262, 58267, 58270, 58275, 58280, 58290, 58291, 58292, 58294, 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573.
If one of the following diagnosis is not billed in the primary position a Workflow will bypass the preauth: A18.17 A54.24 A54.85 A56.11 A74.81 D06.0 D06.1 D06.7 D06.9 D21.9 D25.0 D25.1 D25.2 D25.9 G89.29 K66.0 N70.01 N70.02 N70.03 N70.11 N70.12 N70.13 N70.91 N70.92 N70.93 N71.01 N71.1 N71.9 N72 N73.0 N73.1 N73.2 N73.3 N73.4 N73.5 N73.6 N73.8 N73.9 N74 N80.0 N80.1 N80.2 N80.3 N80.4 N80.5 N80.8 N80.9 N83.6 N83.7 N87.0 N87.1 N87.9 N92.0 N92.1 N92.3 N92.4 N92.5 N92.6 N93.0 N93.8 N93.9 N94.0 N94.10 N94.11 N94.12 N94.19 N94.4 N94.5 N94.6 N94.89 N94.9 N95.0 N99.4 R10.2 R87.610 R87.611 R87.612 R87.613 R87.619 R87.810 |
| Air Ambulance Transport |
Updating commercial medical policy to add post-service review for select individual members.
Effective Date: November 1, 2023 |
Utilization Management, Policy No. 13 |
Adding HCPCS code S9961 with post service review. |
N/A |
| The following
is a list of recently archived policies: |
| Small Bowel/Liver and Multivisceral Transplant |
Policy Archived: April 1, 2024 |
Transplant, Policy No. 18 |
| Autologous Hematopoietic Cell Transplantation for Malignant Astrocytomas and Gliomas |
Policy Archived: April 1, 2024 |
Transplant, Policy No. 45.34 |
| Eating Disorder Inpatient Treatment |
Policy Archived: February 1, 2024 |
Behavioral Health, Policy No. 25 |
| Eating Disorder Intensive Outpatient |
Policy Archived: February 1, 2024 |
Behavioral Health, Policy No. 26 |
| Eating Disorder Partial Hospitalization |
Policy Archived: February 1, 2024 |
Behavioral Health, Policy No. 27 |
| Eating Disorder Residential Treatment |
Policy Archived: February 1, 2024 |
Behavioral Health, Policy No. 28 |
| Psychiatric Inpatient Hospitalization |
Policy Archived: February 1, 2024 |
Behavioral Health, Policy No. 29 |
| Psychiatric Intensive Outpatient |
Policy Archived: February 1, 2024 |
Behavioral Health, Policy No. 30 |
| Psychiatric Partial Hospitalization |
Policy Archived: February 1, 2024 |
Behavioral Health, Policy No. 31 |
| Psychiatric Residential Treatment |
Policy Archived: February 1, 2024 |
Behavioral Health, Policy No. 32 |
| Implantable Cardioverter Defibrillator |
Policy Archived: January 1, 2024 |
Surgery, Policy No. 17 |
| Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer |
Policy Archived: December 1, 2023 |
Transplant, Policy No. 45.26 |
