Glucose Monitoring – Continuous
Effective 1 de janeiro, 2023, this policy will direct requests for Implantable Continuous Glucose Monitors (I-CGM) for Medicare Advantage plans, to refer to the Prior Authorization via Web Based Tool for Procedures policy. I-CGM will remain not medically necessary for commercial products. Please refer to the medical policy for additional details here.
Removal of Implantable Devices
Effective 1 de fevereiro, 2023, prior authorization will be required for CPT codes 61880 and 61888. Please refer to the medical policy for additional details here.
Prior Authorization via Web Based Tool for Procedures
Effective 1 de janeiro, 2023, for Medicare Advantage Plans only, please refer to this policy for criteria for Implantable Continuous Glucose Monitors (I-CGM). Effective 1 de fevereiro, 2023, for both Medicare Advantage plans and commercial products, CPT codes 61880 and 61888 will be reviewed via the web-based tool. Additionally, new subsets have been added for CPT codes 61885 and 61886 for both Medicare Advantage plans and commercial products. Also, effective 1 de fevereiro, 2023, prior authorization will be added to codes 29827 (Shoulder Arthroscopy) and 29881 (Knee Arthroscopy) for both Medicare Advantage plans and commercial products. Lastly, effective 1 de fevereiro, 2023, criteria regarding breast reduction has been modified for commercial products only. Please refer to the medical policy for additional details here.
Recombinant and Autologous Platelet-Derived Growth Factors for Wound Healing and Other Non-Orthopedic Conditions Effective 1 de fevereiro, 2023, the criteria used for Medicare members is moving from covered as part of a clinical trial to covered when filed with a covered ICD-10 code. Please refer to the medical policy for additional details here.
Dynamic Spinal Visualization and Vertebral Motion Analysis
Effective 1 de fevereiro, 2023, CPT code 0693T has been removed from this policy and is being added to the New Technology and Miscellaneous Services policy. Please refer to the medical policy for additional details here.
Molecular Markers in Fine Needle Aspiration of the Thyroid
Effective 1 de fevereiro, 2023, the criteria used for medical necessity review of ThyroSeq testing will be updated for both Medicare Advantage plans and commercial products. Additionally, Afirma Xpression Atlas will be added to the policy as not covered for Medicare Advantage plans and not medically necessary for commercial products. Please refer to the medical policy for additional details here.
Peripheral Artery Disease (PAD) Rehabilitation
Effective 1 de fevereiro, 2023, change in coverage was updated for commercial products to covered when criteria is met. No changes were made for Medicare. Please refer to the medical policy for additional details here.
Early Intervention Services
We updated the coding section to include Modifier FQ (optional modifier used for billing Telephone only services) and POS 10. Please refer to the payment policy for additional details here.
Modifier 22 Guidelines
Language was added to the policy to clarify that the additional time indicated on the form must be >120% of the median intra-service time according to CMS to be eligible for approval. Please refer to the payment policy for additional details here.
TEMPORARY Cost Share Waiver for Treatment of Confirmed Cases of COVID-19 During the COVID-19 Crisis
“Out of Network Providers" were added to be included in the policy as required by OHIC, with an effective date of 19 de outubro, 2022. Please refer to the payment policy for additional details here.
Therapeutic Radiopharmaceuticals for Prostate Cancer
Effective 1 de janeiro, 2023, prior authorization requests for HCPCS code A9607, Pluvicto, will be handled by the BCBSRI drug management vendor (Prime) instead of BCBSRI. As a result, the draft BCBSRI policy Therapeutic Radiopharmaceuticals for Prostate Cancer will be archived effective 1 de janeiro, 2023. Please refer to the Prior Authorization of Drugs policy for details regarding this code by clicking here.
Prior Authorization via Web-Based Tool for Durable Medical Equipment (DME)
Effective 1 de fevereiro, 2023, for commercial products only, criteria regarding Pneumatic and Other Compression Devices has been modified. Additionally, for commercial products only, criteria for prosthetics and lower extremity has been modified as well. Please refer to the medical policy for additional detail here.
Prolonged Services
As a reminder, the prolonged policy was updated in November of 2021 to remove 99417 from individual consideration (IC) review and no longer requires medical records.