September 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 3D Rendering of MRI/CT/US Effective July 1, 2023 Indications of Coverage: D. Echocardiography (transthoracic or trans-esophageal) when used for Added—one of the following: 1. Evaluation of at least a moderate degree of valvular stenosis or regurgitation. 2. Guidance of transcatheter valve replacement, such as TAVR (transcatheter aortic valve replacement), mitral valve clipping or replacement, or fistula coiling. 3. To assess LV (left ventricular) volume and EF (ejection fraction) prior to ICD (implantable cardioverter defibrillator) implantation, or prior to chemotherapy which is potentially cardiotoxic. E. Ultrasound of Pelvic Conditions: Added—or when the 3D ultrasound/sonohysterogram is being performed instead of hysteroscopy for 1. Uterine intra-cavity lesion when initial US is equivocal. 2. Hydrosalpinxes or peritoneal cysts when initial US is indeterminate. And 5. Infertility evaluation and initial US is indeterminant or equivocal. Capsule Endoscopy Effective Aug. 1, 2023 Indications of Coverage: I.A. 3. Added—elevated to C-reactive protein level, Added-elevated calprotectin, Removed—low albumin level.

Cell-Free Fetal DNA Testing No changes made to policy. Cochlear Implants, Bone Anchored Hearing Aids (BAHA), Auditory Brainstem Implants, and Other Hearing Assistive Devices Effective Aug. 1, 2023 Indications of Coverage: A. 1. Severe post-lingual bilateral sensorineural hearing loss may be considered medically necessary when the individual meets Removed—ALL of the following criteria: impairment (pure tone average of 70 decibels or higher at 500, 1,000, and 2,000 hertz); AND less than 50% score on standardized open set sentence recognition test in ear to be implanted and less than 60% in contralateral ear when using appropriately fitted hearing aids. Added—Impairment of greater than 40 dB (decibels) with limited (e.g., best aided word or open-set sentence cognition test at 60% or less, presented at 60 dB) speech perception benefit from hearing aids.

2. Unilateral or asymmetrical hearing loss (2nd bullet point) profound sensorineural hearing loss in one ear and mild to moderately severe sensorineural hearing loss in the other with less than 30 dB of hearing loss for unilateral, OR 31 to 55 dB hearing loss for asymmetric in contralateral ear, with a difference of at least 15 dB in pure-tone averages between ears (i.e., asymmetric hearing loss [AHL]); AND Removed— one month or more experience with contralateral routing of signal (CROS) hearing aid or other relative non implantable device (e.g., bone anchored hearing aid [BAHA]) without benefit. Added OR, Unilateral sensorineural hearing loss and risk for progression (e.g., due to bacterial meningitis). AND ALL of the following are met for 1. OR 2. Above: Added—No lesions of acoustic nerve or central auditory pathway causing deafness. Removed—Limited speech perception benefit from a trial of hearing aids. Limitations of Coverage: Added—D. Cochlear implants are considered not medically necessary for treatment of tinnitus or any other medical diagnosis other than sensorineural hearing loss. Glaucoma Surgical Treatments Effective July 1, 2023 Limitations of Coverage: Removed: iStent Infinite under F. and N. Infertility and Recurrent Pregnancy Loss Testing and Treatment Effective Dec. 1, 2023 Indications of Coverage: II. Recurrent Pregnancy Loss. Changed—consecutive to two or more pregnancy losses. Removed—7. Karyotypic analysis (chromosome analysis) of products of conception. Added—8. Chromosomal microarray analysis on products of conception (POC) may be considered medically necessary when ONE of the following is met: 1. The member has a pregnancy loss at 20 weeks of gestation or earlier and has a history of recurrent miscarriage (defined as having two or more failed clinical pregnancies including the current loss); OR 2. The member has a pregnancy loss after 20 weeks of gestation, such as intrauterine fetal demise (IUFD) or still birth.

Added—Please note that karyotypic analysis (chromosome analysis) of products of conception is deemed medically necessary for any pregnancy loss. Limitations of Coverage: D. Endometrial Receptivity Analysis (ERA). Added—such as Igenomix testing designed to determine the optimal timing of embryo transfer, is deemed experimental, investigational, and unproven and/or subject to the infertility treatment benefits/exclusions of the health plan and therefore not covered. H. Added—6. Sperm DNA fragmentation studies for infertility evaluation and/or recurrent pregnancy loss. Removed—15. Spectrum Preimplantation Genetic Screening (PGS) (Natera)

16. Microarray testing of products of conception Added—unless the above Indications of Coverage A. 9. Are met. Microprocessor-Controlled and Myoelectric Limb Prosthesis Effective Sept. 1, 2023 Indications of Coverage: A. A microprocessor controlled lower limb prosthesis (e.g., Ottobock, C-leg) is considered medically necessary for an above-the-knee Added (transfemoral) amputee, knee disarticulation amputees, Added or transtibial (below the knee) amputee when ALL of the following criteria are met. Limitations of Coverage: Removed—D. Microprocessor controlled ankle and foot prosthetic devices and braces (including but not limited to Proprio Foot [Ossur], iPED® [Martin Bionics], PowerFoot BiOM® [iWalk], and Elan® [Endolite] are considered experimental, investigational, and unproven to affect health outcomes. Negative Pressure Wound Therapy, Wound VAC Effective Sept. 1, 2023 Limitations of Coverage: F. Added—9. For closed surgical incisions following total joint arthroplasty. Panniculectomy, Abdominoplasty and Repair of Diastasis Recti No changes made to policy. Pectus Excavatum, Pectus Carinatum, and Poland Syndrome Treatment No changes made to policy. Pneumatic Compression Devices Effective Dec. 1, 2023 Definitions: Immobilized Added—(i.e., inability to get out of chair/bed and walk to the toilet without the help of another person). Indications of Coverage: A. Home use of a single compartment (non-segmented) without calibrated gradient pressure or multi-chamber (segmented) without calibrated gradient pressure pneumatic compression devices are considered medically necessary Added—for DVT prophylaxis strictly on the lower extremities ONLY in ANY of the following. Limitations of Coverage: Added—I. Non-pneumatic compression devices, such as Dayspring are considered experimental, investigational, and unproven for lymphedema or any other indication.

Pulmonary Artery Pressure Monitoring (CardioMEMS) No changes made to policy. Reduction Mammoplasty Effective Sept. 1, 2023 Indications of Coverage: Removed: D. The primary physician or referring practitioner (not considered adequate if submitted by surgeon) must provide documentation that: 1. The symptoms (listed in section B. above) are directly caused by excessively large breasts and that other possible causes have been ruled out or treated AND 2. The breast reduction surgery is likely to improve the chronic pain/symptoms. Documentation Required: Office notes from the surgeon performing the procedure that must state the amount of breast tissue that is expected to be removed Added (including height and weight or body surface area [BSA]). Septoplasty and Rhinoplasty Effective Aug. 1, 2023 Indications of Coverage: A. Septoplasty 2. The individual has a deviated septum, septal spurring, or a septal deformity Added—causing at least moderate to severe nasal fossa narrowing seen on physical exam, endoscopy, or imaging despite 4 weeks of appropriate medical treatment (e.g., nasal corticosteroids, antihistamines, antibiotics). b. Recurrent sinusitis Added—and/or recurrent nasal congestion. B. Rhinoplasty 1. b. Added—Medical records should address why a septoplasty and/or turbinectomy will not correct the obstruction. Added—c. Nasal obstruction secondary to nasal valve collapse, as indicated by ALL of the following: Clinical findings of collapsed internal nasal valve at rest or collapsed external nasal valve (lateral walls) with inspiration. Infection, allergy, rhinitis, and polyps eliminated as primary cause of nasal obstruction. Patient has received appropriate medical treatment for symptoms, with intranasal antihistamine and intranasal steroids. Symptoms of nasal obstruction (e.g., snoring, mouth breathing) affect quality of life. Added—NOTE: If rhinoplasty is being performed with a medically necessary septoplasty, medical records must document why both procedures are indicated. Limitations of Coverage: E. Removed—Medtronic ALAR stent. Skin and Soft Tissue Substitutes Effective Sept. 1, 2023 Limitations of Coverage: Added—K. ArthroFLEX for all indications, to include musculoskeletal procedures and anterior cruciate reconstruction. Surgical Removal of Redundant Skin and Face/Neck Lift Procedures No changes made to policy.

Tumor Treating Fields (Optune) Effective July 1, 2023 Indications of Coverage: Indications of Coverage B. All of the following are met: 1. Individual is at least—Changed—22 years to 18 years old. Urine Drug/Alcohol Screening and Testing Effective Sept. 1, 2023 Limitations of Coverage: G. Added (e.g., CareView360 test [Newstar Medical Laboratories]). 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. JO25123
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