Medical Policy Update

Revised Medical Policies

Medical Policy Hip Labrum Reconstruction Surgery

Adding to the policy statement to include labral augmentation.

Labral reconstruction or labral augmentation of the hip using tissue allograft or autograft is investigational for all indications.

New title: Hip Labrum Reconstruction and Augmentation Surgery

Medical Policy Virtual Reality Assisted Therapies 

Effective Date: 02/02/2024
Preauthorization Required: Yes

Adding to policy statement:

1. The use of prescription digital therapeutics (PDTs) (e.g., ReSET, ReSET-O, AKL-TO1, Somryst, and Leva) are considered experimental and investigational because there is insufficient evidence in the effectiveness to provide net health benefits.

New title: Virtual Reality Assisted and Prescription Digital Therapies