Carotid Angioplasty Without Stenting and Embolic Protection

Effective 1 de octubre de 2023, CPT code 37216 will change from not covered for Medicare Advantage plans and not medically necessary for commercial products to requiring prior authorization for both Medicare Advantage plans and commercial products utilizing the medical criteria found in the web-based tool. As a result, this policy will be archived effective 1 de octubre de 2023. For additional information, please refer to the policy here.

Orthopedic Applications of Platelet-Rich Plasma

Effective 1 de octubre de 2023, CPT code 0481T and HCPCS code P9020 will be added to this policy and will be considered not covered for Medicare Advantage plans and not medically necessary for commercial products. CPT code 0481T will also be removed from the New Technology and Miscellaneous Services policy, effective 1 de octubre de 2023, which indicates that prior authorization is required for Medicare Advantage plans and that it is considered not medically necessary for commercial products. In summary, there will be a change in coverage for Medicare Advantage plans and no change in coverage for commercial products. For additional information, please refer to the policy here.

New Technology and Miscellaneous Services

Effective 1 de octubre de 2023, CPT code 0481T will be removed from this policy and will be added to the Orthopedic Applications of Platelet-Rich Plasma policy, for both Medicare Advantage plans and commercial products. For Medicare Advantage plans, CPT code 0481T will be considered not covered and will no longer require prior authorization. This change will not result in a change in coverage for commercial products, as CPT code 0481T will continue to be considered not medically necessary. For additional information, please refer to the policy here.

Percutaneous Left Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation  

Effective 1 de octubre de 2023, this policy will be applicable to commercial products only, with no changes. Coverage for Medicare Advantage plans will follow the applicable Centers for Medicare and Medicaid Services (CMS) National Coverage Determination, 20.34, Percutaneous Left Atrial Appendage Closure (LAAC). For additional information, please refer to the policy here.

Miscellaneous Vascular Embolization Procedures

This is a new policy effective 1 de octubre de 2023 that will provide medical criteria for both Medicare Advantage plans and commercial products when CPT codes 37242 and 37243 are submitted for prior authorization. Both of these CPT codes already require prior authorization. Medical criteria for artery embolization for Benign Prostatic Hypertrophy (BPH) will also be included in this policy. As a result, the medical policy Prostate Artery Embolization for Benign Prostatic Hypertrophy will be archived effective 1 de octubre de 2023 (as noted, below). For additional information, please refer to the policy here.

Prostate Artery Embolization for Benign Prostatic Hypertrophy

Effective 1 de octubre de 2023, this policy will be archived and the medical criteria for this procedure can be found in the new policy, above, Miscellaneous Vascular Embolization Procedures, for both Medicare Advantage plans and commercial products. For additional information, please refer to the policy here.

Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer           

Effective 1 de octubre de 2023, CPT code 0039U (SelectMDx testing) will no longer be considered not covered for Medicare Advantage plans, and will require prior authorization and will be considered covered when the medical criteria in the policy is met. There will be no changes for commercial products. There will be no changes for any other tests addressed in this policy for Medicare Advantage plans or commercial products. For additional information, please refer to the policy here.

Hospital Based Clinics                                                                                 

Effective 1 de octubre de 2023, facility-based outpatient psychotherapy treatment and services, including evaluations and intensive/partial hospitalization services, should not be billed on CMS-1500. These services should be billed on a UB-04. For additional information, please refer to the policy here.

Non-reimbursable health service codes                                         

Effective 1 de julio de 2023, codes C9150 and Q4265-Q4285 have been added to this policy. For additional information, please refer to the policy here.

Prior Authorization of Spinal Procedures

Effective 1 de agosto de 2023, CPT code 0809T will require prior authorization for Medicare Advantage Plans via the Spine Procedures vendor. For additional information, please refer to the policy here.