December 2023 Form

WPS Medical Policy Updates The Medical Affairs Medical Policy Committee recently approved medical policies that will become effective on the specified dates. Disclaimer: Medical Policies are for informational purposes only and do not constitute medical advice, plan authorization, an explanation of benefits, or a guarantee of payment. Benefit plans vary in coverage and some plans may not provide coverage for all services listed in a policy. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and federal law. Some benefit plans administered by the organization may not utilize Medical Affairs medical policy in all their coverage determinations. Contact Customer Service as listed on the customer ID card for specific plan, benefit, and network status information. Medical policies are based on constantly changing medical science and are reviewed annually and subject to change. The organization uses tools developed by third parties, such as the evidence-based clinical guidelines developed by MCG to assist in administering health benefits. Medical Policies and MCG guidelines are intended to be used in conjunction with the independent professional medical judgment of a qualified health care provider.

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To obtain a referenced MCG guideline specific to your patient’s review, contact Medical Affairs toll-free at 800-333-5003. •
For general medical policy or MCG requests, email medical.policies@wpsic.com. •
If you have specific questions or comments regarding development of policy content, contact the Medical Policy Editor at medical.policies@wpsic.com or 800-333-5003, ext. 06984. •
For questions regarding medical coding related to Medical Policy Committee policies, contact the Code Governance Committee at codegovernance@wpsic.com.

Medical Policy Highlights Autologous Chondrocyte Implantation (ACI) and Matrix-induced Autologous Chondrocyte Implantation (MACI) Effective Jan 1, 2024 No changes made to this policy. Cartilage Transfer Procedures: Osteoarticular Transfer System (OATS) and Mosaicplasty Effective Jan 1, 2024 No changes made to policy. Gender Dysphoria Treatment Effective Jan 1, 2024 Indications of Coverage: A. Requirements for mastectomy for female-to-male (FtM) individuals or breast augmentation (augmentation mammoplasty and breast implants) in male-to-female (MtF) individuals: 4. Age 18 years or older; OR less than 18 years old with the consent of both parents, Added (or legal guardians). If one parent/guardian cannot provide

consent (due to death or documented extenuating circumstances), then the consent of the remaining parent/ guardian will be acceptable. B. Requirements for gonadectomy (hysterectomy and oophorectomy in female-to-male individuals and orchiectomy in male-to-female individuals: 4. Age 18 years or older; OR less than 18 years old with the consent of both parents, Added (or legal guardians). If one parent/guardian cannot provide consent (due to death or documented extenuating circumstances), then the consent of the remaining parent/guardian will be acceptable. C. Requirements for genital reconstructive surgery: 4. Age 18 years or older; OR less than 18 years old with the consent of both parents, Added (or legal guardians). If one parent/guardian cannot provide consent (due to death or documented extenuating circumstances), then the consent of the remaining parent/guardian will be acceptable. Limitations of Coverage: E. Added 14. Alteration of the skeletal structures of the face, forehead or chin (for facial reconstruction). Added 15. Genioplasty (chin surgery). Added 31. Speech therapy for the purpose of voice modification when there is no speech functional deficit present.
Hip Replacement Surgery Effective Jan. 1, 2024 No changes made to this policy. Knee Replacement Surgery Effective Jan. 1, 2024 Limitations of Coverage: 5. C. Bi-unicompartmental, Added-bicompartmental, or staged bicompartmental knee arthroplasty. Added-6. Intraoperative surgical navigation (e.g., MAKOplasty/MAKO® Tactile Guidance System, KneeAlign® System, iASssit® Knee System, Velys Digital Surgery ([DePuy Synthes], or other surgical navigational system) or robotic assistance for knee arthroplasty (Mako Robotic assisted surgery) are deemed integral to the surgical procedure and are not separately reimbursable. Spinal Cord Stimulator and Peripheral Nerve Stimulation Effective July. 1, 2024 Indications of Coverage: B Permanent Placement of One lumbar Added-or thoracic spinal cord stimulator-is considered medically necessary when all of the following are met: C. Replacement of a lumbar or thoracic Removed-dorsal column electrical spinal stimulator is considered medically necessary when the individual has had previous pain relief response to the spinal cord stimulator, but One of the following are met:

4. The device required removal (explantation) due to suspected infection, Added-which has been resolved. Added-E. Functional Electrical Stimulation (FES) and Neuromuscular Electrical Stimulation (NMES) is considered medically necessary for EITHER of the following: 1. After stroke, patient has hemiplegia or hemiparesis with foot drop, when ALL of the following are met: Stroke onset greater than 3 months prior;

Cognitively able to understand and comply with the rehabilitation protocol; AND Ankle range of motion within limits required for normal gait. 2. New York Heart Association grade III or IV heart failure. Limitations of Coverage: Added-F. Cranial electrical stimulation for treatment of posttraumatic stress disorder is considered experimental, investigational, and unproven. L. Removed-NMES (neuromuscular electrical stimulation). Added-P. Functional Electrical Stimulation (FES) and Neuromuscular Electrical Stimulation (NMES) for any indication other that those noted under Indications of Coverage E. above, including but not limited to anterior cruciate ligament repair or reconstruction, cerebral palsy, chronic obstructive pulmonary disease, dysphagia after stroke, multiple sclerosis, osteoarthritis, spinal cord injury, stroke and lower extremity dysfunction, stroke and upper extremity dysfunction, tetraplegia (quadriplegia), total hip arthroplasty, total knee arthroplasty, unilateral recurrent laryngeal nerve paresis is considered experimental, investigational, and unproven. Added-Q. Electroanalgesia/inferential current therapy (neoGEN) is considered experimental, investigational, and unproven. Added-R. Alpha-Stim (Electromedical Products International, Inc.) for Treatment of Chronic Pain is considered experimental, investigational, and unproven. Added-S. Sacral Neurostimulator for treatment of incontinence and/or constipation is considered experimental, investigational, and unproven. Physical and Occupational Therapy (PT/OT) Effective Feb. 19, 2023 PA required after the 25th visit for combined PT/OT/ST for groups that do not specify a benefit limit on number of visits allowed. Indications of Coverage: General provisions: There must be an expectation that the patient’s condition will improve significantly in a reasonable and generally predictable period of time (restorative therapy), or the services must be necessary for the establishment of a safe and effective maintenance program required in connection with a specific disease state. If at any point in time during treatment it is determined that no further improvement in the patient’s condition will be achieved, the services will no longer be considered medically necessary. Additional physical or occupational therapy will be considered medically necessary with documentation of Any of the following (a., b., or c.): a. Effective, but incomplete therapy as demonstrated by All of the following: i. Significant improvement in function or pain relief as demonstrated by Any of the following: 1. A reduction in pain of at least 20% on a validated pain scale (see below). 2. An improvement in range of motion of at least 10 degrees. 3. An improvement in strength of at least 10%. 4. An improvement in functional status of at least one level on a validated functional scale (see below). ii. At least one goal of therapy that has not been completed. iii. Continued potential for improvement with continued therapy as attested to and documented by the therapist. iv. Documentation of adherence to the plan of care, including home exercises, and other recommendations and at least 70% scheduled visit attendance. b. Need for continued therapy to prepare for or recover from surgery. c. Onset of a new specific condition requiring physical or occupational therapy, or a significant flare or setback of an existing condition. Validated Pain Scales may include the following. Other pain scales may be acceptable. Providers may be asked to provide the clinical validation for scales not listed: Numerical Rating Scale (NRS), Visual Analog Scale (VAS), Defense and Veterans Pain Rating Scale (DVPRS), Adult Non-Verbal Pain Scale (NVPS), Pain Assessment in Advanced Dementia Scale (PAINAD), Behavioral Pain

Scale (BPS), Critical-Care Pain Observation Tool (CPOT), Neonatal/Infant Pain Scale (NIPS)-Pediatric only; CRIES-Pediatrics only, Faces Legs Activity Cry and Consolability (FLACC)-Pediatrics, Non- Communicating Children’s Pain Checklist (NCCPC-R), Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS), Wong-Baker Faces scale, Colour-Circle Pain Scale (CCPS). Validated Strength Scales may include the following. Other scales/methods may be acceptable. Providers may be asked to provide the clinical validation for scales not listed. A validated scale is not required to demonstrate improvement in strength if such improvement can be objectively documented, such as by recording a change in weight or resistance that can be functionally moved, or assessment of specific tasks in a timed or measured method: Medical Research Council Manual Muscle Testing scale- the ”Oxford Scale”, Medical Research Council (MRC) Scale for Muscle Strength, Crane Scale, Kendall Scale, Dynamometer (direct measurement), Force Palte (direct measurement), No Hang Finger Strength Test, Five Time Sit to Stand Test (FTSST). Validated Functional Scales may include the following. Other scales may be acceptable. Providers may be asked to provide the clinical validation for scales not listed: Patient-Specific Functional Scale (PSFS), World Health Organization Disability Assessment Scale (WHODAS 2.0), Functional Recovery Questionnaire (FRQ), STarT Back, Neck Disability Index (NDI), Oswestry Disability Index (ODI), Roland- Morris Disability Questionnaire (RMDQ), Quick Disabilities of Arm Shoulder and Hand (QuickDASH), Lower Extremity Functional Scale (LEFS), Foot and Ankle Ability Measure (FAAM), Pain-Disability Index (PDI). Limitations of Coverage: Not medically necessary for asymptomatic persons or in persons without an identifiable clinical condition; continued physical or occupational therapy in persons whose condition is neither regressing nor improving; once therapeutic benefit has been achieved, or a home exercise program could be used for further gains; maintenance therapies after the patient has achieved therapeutic goals or for patients who show no further meaningful progress; physical or occupational therapy services that do not require the skills of a qualified providers of physical or occupational therapy services provided by non-certified staff such as aides, techs, etc.; percussion hammer; Spray and stretch technique for myofascial pain, including but not limited to Fluori-Methan and vapor coolant; Fluidotherapy (fluidized therapy) for any indication other than the treatment of acute or subacute traumatic or non-traumatic musculoskeletal disorders of the extremities. Fluidotherapy will only be covered when provided by a Physical or Occupational Therapist; Intermittent motorized traction and intersegmental traction, methods of mechanical massage and spinal mobilization of soft tissue (examples include but are not limited to Anatomotor); Craniosacral therapy; Aquatic therapy will only be covered when provided by a Physical or Occupational Therapist. Experimental, Investigational, Unproven for Diathermy, ultrasound and heat treatments for pulmonary conditions; Electromagnetic therapy (e.g., Diapulse®); Home use of diathermy devices (e.g., Magnatherm®), including but not limited to radiofrequency diathermy, high frequency diathermy, short wave diathermy, ultrasound diathermy, microwave diathermy; Low level laser therapy (LLLT) for any use, including but not limited to treatment for carpal tunnel syndrome and/or treatment for cessation of smoking. LLLT is also known by many other names including but not limited to therapeutic laser, low-power laser, low-energy laser, biotimulating laser, photobiostimulating laser, laser phototherapy, cold laser; Neurostructural integration technique; Dry Needling; Kinesiology (kineso taping); Craniosacral Therapy (CST); Microcurrent Electrical Nerve Stimulation (MENS); H-WAVE electrical stimulators; Spinal manipulation for the treatment of non-musculoskeletal conditions and related disorders including but

not limited to: Asthma, Attention Deficit Hyperactivity Disorder (ADHD), Autism spectrum disorders, Dysmenorrhea, Hypertension, Infantile colic, Nocturnal enuresis, Otitis media; Equestrian therapy (e.g., hippotherapy); Remote body and limb kinematic measurement-based therapy (e.g., interactive rehabilitation exercise devices, MindMotion GO); Vertebral Axial Decompression Therapy and Devices. Reminder All genetic, genomic, pharmacogenetic, pharmacogenomic, molecular genetic, mRNA, DNA, chromosome, telomere, single nucleotide polymorphism (SNP), gene sequencing, gene expression profiles, and gene- related panels, tests, and analyses require prior authorization BEFORE the testing is completed. Determination of genetic panel coverage is based on assessment of the test’s analytical and clinical validity, the clinical utility of the test, and evidence demonstrating a positive impact of the test panel on the care of individuals with, or at risk for, the conditions being tested. The Medical Policy Committee (MPC) considers multi-gene test panels experimental, investigational, and unproven to affect health outcomes unless otherwise determined during prior authorization review. The complete library of our medical policies and the quarterly Medical Policy Update reports can be found online at wpshealth.com. No password required! ©2023 Wisconsin Physicians Service Insurance Corporation and WPS Health Plan, Inc. All rights reserved. JO25359
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