Priority Health has provided an update:
Our Medical Advisory Committee (MAC), comprised of network practitioners contracted with Priority Health, recently approved a series of medical policy updates, including:
- Expansion of coverage in three policies
- Two new medical policies
- Medical necessity criteria changes in two policies
Additionally, two new prior authorization requirements will go into effect in tandem with these policy updates. Details on these updates are outlined below. MAC also approved several minor policy updates which don’t impact coverage; these are detailed in our recent news item.
New prior authorization requirements
Effective July 24, 2023, prior authorization will be required for the following procedures:
Medical policyDetailsPanniculectomy / Abdominoplasty (#91605)
Abdominoplasty (CPT 15847) will require prior authorization.
Unless abdominal wall laxity interferes with activities of daily living and causes a functional impairment, abdominoplasty is considered cosmetic and not medically necessary.
Procedure was previously allowed if prior authorization was approved for the primary procedure, Panniculectomy.
Thyroid-Related Procedures (#91621)Thyroid molecular diagnostic tests (CPT codes 81546, 0026U, 0245U, 0204U, 0018U, 0287U and 81210) will require prior authorization.
Expansion of coverage
The following updates are effective May 24, 2023:
Medical policyDetailsBreast Related Procedures (#91544)The use of bioimpedance spectroscopy is medically necessary for secondary, subclinical (Stage 0 or 1) breast cancer related lymphedema. This change in position is based on the 2023 NCCN Survivorship guidelines. Medical necessity is limited to diagnosis of cancer, other indications remain not medically necessary; also remains as no prior authorization.Gender Affirming Surgery (#91612)
Specific procedures that may now be considered medically necessary, but only when performed as part of a component of a comprehensive facial feminization or facial masculinization service performed as an adjunct to gender affirming surgery (items I.A - C) following a diagnosis of gender dysphoria.
An isolated blepharoplasty, brow lift or rhinoplasty, not completed as a component of a comprehensive feminization or masculinization service, is subject to the terms, conditions, limitations and medical necessity criteria specified in Priority Health Medical Policy #91535 – Cosmetic and Reconstructive Surgery Procedures.
Markers for Digestive Disorders (#91583)Updated position on anti-drug antibodies to infliximab, adalimumab, vedolizumab or ustekinumab from experimental and investigation to medically necessary if criteria are met. Measurement of anti-drug antibodies are medically necessary for dose escalation. However, routine, or serial testing are not medically necessary.
New medical policies
Medical policyDetailsComputerized Dynamic Posturography (#91637)
New medical policy created to support reduction of coverage for Computerized Dynamic Posturography (CPD).
CDP for the diagnosis of vestibular disorders is experimental and investigational due to insufficient evidence of efficacy. While CDP has been available for many years, no trials evaluated the accuracy of its diagnostic performance or impact on diagnostic decision-making or health outcomes for its use in the diagnosis of vestibular disorders.
CPT codes 92548 and 92549 will no longer be covered effective July 24, 2023.
Category III/T Current Procedural Terminology (CPT®) Codes (#91636)
New policy to establish Priority Health’s default position: Category III "T" codes are not medically necessary unless addressed in another policy.
This policy is effective May 24, 2023.
Medical necessity criteria changes
The following updates are effective July 10, 2023:
Medical policyDetailsPercutaneous Left Atrial Appendage Closure (#91605)Medical necessity criteria for Percutaneous Left Atrial Appendage Closure have changed from Priority Health criteria to InterQual® criteria.Implantable Loop Recorder (#91618)Medical necessity criteria for implantable loop recorders have changed from Priority Health criteria to InterQual® criteria.