Medical Policy Update

Revised Medical Policies

Medical Policy I.212 Sympathetic Nerve Blocks

Effective Date: 06/01/2024
Preauthorization Required: Yes

Adding policy statement:
The use of the ganglion impar block is considered investigational for all indications.

Medical Policy I.195 Botox

Effective Date: 06/01/2024
Preauthorization Required: Yes

Adding FDA approved age limits for the below indications:

Botox/onabotulinumtoxin A (J0585)
Hemifacial spasm, concomitant strabismus: 12 years and older
Focal and hand dystonia: 16 years and older
Achalasia, chronic anal fissure, Frey’s syndrome, hyperhidrosis, laryngeal spasm, neurogenic bladder (detrusor), neuromyelitis optica, overactive bladder, schilder’s disease, upper extremity tremor: 18 years and older

Removing infantile esotropia as a covered indication.

Xeomin/incobotulinumtoxina (J0588) and Dysport/botulinum toxin type A (J0586)
Upper and lower limb spasticity: 2 years and older
Blepharospasm: 12 years and older
Cervical dystonia: 16 years and older

Medical Policy III.237 Treatment of Lymphedema and Lipedema

Adding criteria:

2. Lipectomy or liposuction is considered not medically necessary for lymphedema when the above criteria are not met and for all other indications.
3. Lymphatic physiologic microsurgery to treat lymphedema (including, but not limited to, lymphaticolymphatic bypass, lymphovenous bypass, lymphaticovenous anastomosis, autologous lymph node transplantation, and vascularized lymph node transfer is considered investigational.

Medical Policy IV.81 Radiology

Adding CPT code 74175 (Computed tomographic angiography, abdomen, with contrast material(s), including noncontrast images, if performed and image postprocessing.

Medical Policy VIII.2 Contact Lens and/or Glasses

This policy is being retired as of 06/01/2024. Contact Lens and Glasses will no longer be covered for the following diagnosis:

• Bullous Keratopathy
• Corneal Ulcers (Recurrent indolent)
• Corneal Erosions and Abrasions (Recurrent
• Stevens-Johnson Syndrome
• Corneal Transplants
• Fuchs' Dystrophy of the Cornea
• Keratoconus

Medical Policy III.170 Lumbar Artificial Intervertebral Discs

Medical Policy III.170 Lumbar Artificial Intervertebral Discs will retire and CPT codes 0164T, 0165T, 22857, 22860, 22862 and 22865 will be reviewed with criteria under Medical Policy III.187 NIA (Interventional Pain Management and Cervical/Lumbar Spine Surgery).

Submission of the pre-service review.

• Call toll free 1-866-972-9642 from 7 a.m. - 7 p.m. (CST) (8 a.m. - 8 p.m. EST).
• Visit the website RadMD.com