All Lines of Business

• Endoscopic Sleeve Gastrectomy (ESG) criteria added.
• CPT code 43889 is now covered with prior authorization for all lines of business.
• For Medicare, HNE adopted the InterQual criteria:
  • Procedures, Bariatric Surgery for Treatment of Co-Morbid Conditions Related to Morbid Obesity NCD, Bariatric Surgery.

Corneal Remodeling for Refractive Errors and Corneal Grafting and Transplantation

• Added criteria for corneal graft and amniotic membrane transplantation, corneal stromal lenticule transplantation, limbal stem cell transplantation, and sural nerve grafting for ocular indications across all lines of business.
• Updated CPT/HCPCS and ICD-10 coding guidance and references.

Lutetium Therapeutic Radiopharmaceuticals

• Updated Lutathera criterion I(4) to clarify Ki-67 requirements for well-differentiated G1/G2 (<20%) and G3 (<55%) neuroendocrine tumors.
• Definitions were also revised.

Lymphedema – Surgical Treatment

• No changes were made to the criteria.
• CPT 15847 was removed as it is not applicable to this medical policy.

Speech Language Pathology (SLP) Services

• Minor criteria changes

Achalasia and Gastroesophageal Reflux Disease (GERD)

• Procedures, Select Minimally Invasive GERD Procedures Wellpoint, Transoral Incisionless Fundoplication (TIF)

Cochlear Implants/BAHA/ABI/Bone – Conduction Hearing Aid

• Cochlear Implantation: Procedures, Cochlear Implant NCD, Cochlear Implantation
• Cochlear Implantation – Clinical Trial: Procedures, Cochlear Implant NCD, Cochlear Implantation, Clinical Trial
• Cochlear Implantation – IDE: Procedures, Cochlear Implant NCD, Cochlear Implantation IDE

Percutaneous Left Atrial Appendage Closure

• Procedures, Percutaneous Left Atrial Appendage Closure (LAAC) NCD, Left Atrial Appendage Closure (LAAC) (CED)
• Procedures, Percutaneous Left Atrial Appendage Closure (LAAC) NCD, Left Atrial Appendage Closure (LAAC) Clinical Trial

Percutaneous Neuroablation

• Medicare coverage of select pain management procedures, including facet joint interventions, neuroablation, and BVN thermal destruction for Vertebrogenic lower back pain
• Supporting references have also been updated.

Transcatheter Mitral Valve Repair

• Procedures, Transcatheter Edge-to-Edge Repair (TEER) for Mitral Valve Regurgitation NCD, Transcatheter Edge-to-Edge Repair (TEER) CED Study
• Procedures, Transcatheter Edge-to-Edge Repair (TEER) for Mitral Valve Regurgitation NCD, Transcatheter Edge-to-Edge Repair (TEER) Clinical Trial

Transplants

• Updated the Medicare line of business to adopt available Medicare InterQual criteria.
• Revised the Policy Guidelines and Definitions section.

Treatment for Varicose Veins and Venous Insufficiency

• Procedures, Varicose Veins of the Lower Extremity, Treatment of Wellpoint, Compression Sclerotherapy or Microphlebectomy
• Procedures, Varicose Veins of the Lower Extremity, Treatment of Wellpoint, Ligation +/- Stripping
• Procedures, Varicose Veins of the Lower Extremity, Treatment of Wellpoint, Non-thermal non-tumescent (NTNT) Polidocanol Microfoam (PEM)

Ventricular Assist Devices

• Procedures, Ventricular Assist Devices NCD, Ventricular Assist Device

Commercial and Medicare LOB Only

The following criteria were added:

• Documentation must include the Home Health Certification and Plan of Care (CMS-485), including the treatment plan and documentation of homebound status, as members must be homebound to qualify for home health services.
• For Medicare, Global Criteria for covered home health services are available at: Home Health Services | CMS.