June 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 Acupuncture Therapy No changes made to policy. Back and Neck Pain Procedures—Epidural Injections Effective Sept. 1, 2023 Indications of Coverage: Removed: Documentation of an average pain level of 6 or greater on a scale of 0 to 10; or intermittent or continuous pain that is causing a functional disability. Removed: moderate (so reads: MRI or CT findings must confirm severe spinal stenosis at the targeted level) Subsequent Epidural Injections: Added: NOTE: If the member’s most recent epidural steroid injection at the same level and for the same specific condition was greater than three months ago, there must be a six-week trial of physical therapy or chiropractic manipulation directed to the targeted spinal area (i.e., lumbar or cervical) in the six months preceding that earlier injection. Removed NOTE: The requirement for physical therapy or chiropractic manipulation may be waived if the member received relief for at least 3 months from a prior epidural injection that was given within the past 12 months at the same level for the same specific condition.

Injection Limits: A session is defined as one date of service in which there is (Clarified) Added: a single level caudal epidural steroid injection (ESI), OR two (2) levels of interlaminar ESIs, OR up to two (2) level TFESI’s (unilateral or bilateral), performed during the same session. When performing therapeutic epidural steroid injections, up to two (2) level TFESI’s (unilateral or bilateral) or two levels of interlaminar ESI’s may be performed during the same session, and injecting more than two vertebral levels during a single session is deemed not medically necessary. Limitations of Coverage: It is considered not medically necessary to inject more than 2 added: vertebral levels during a single session. Removed: Performing interlaminar epidural steroid injection at two levels in one session, on the same date of service, is considered not medically necessary and will be denied. Added: Stem cells and/or Platelet-rich plasma (PRP) injections. Back and Nerve Pain Procedure—Radiofrequency Ablation, Facet, and Other Injections Effective Sept. 1, 2023 Indications of Coverage: Removed: Documentation of average pain levels of 6 or greater on a scale of 0 to 10, or intermittent or continuous pain causing functional disability. Confirmatory (second) facet joint injection/medial branch block (MBB): Added: The confirmatory (second) diagnostic injection procedures must be performed on the same side and same level as the initial injection. Added: Trigeminal Neuralgia Treatments: Trigeminal Nerve Block and/or Non-Pulsed Radiofrequency Ablation/Neuroablation is deemed medically necessary if the member has failed a six month or more trial of pharmacotherapy, had side effects or was unable to tolerate pharmacotherapy. Limitations of Coverage: Added: or trigeminal nerve to medial branch nerve. Added: cluneal, calcaneal (nerves). Added: During a facet/medial branch block session, treatment of more than 3 levels will be denied as not medically necessary. Added: Hydro dissection for the treatment of neuropathic pain Added: Stem cells and/or Platelet Rich Plasma (PRP) Injections. Back Pain Sacroiliac and Coccydynia Treatments Effective Sept. 1, 2023 Indications of coverage: Removed: Documentation of an average pain level of 6 or greater on a scale of 0 to 10, or intermittent/continuous pain that is causing a functional disability. Percutaneous Minimally Invasive Sacroiliac Joint Fusion (Arthrodesis) procedures using an FDA-approved implant Added: Simmetry Sacroiliac Joint Fusion System [Zyga Technology Inc.], SI-LOK Sacroiliac Joint Fixation System [Globus Medical Inc.], Navigation Instruments, ExcelsiusGPS Instruments [Globus Medical Inc.], Rialto SI Fusion System [Medtronic Sofamor Danek], Integrity-SI Fusion System [OsteoCentric Technologies]) Limitations of Coverage: Added: Stem cells and/or Platelet rich plasma (PRP) injections.

Cranial Orthotic Device No changes made to policy. Deep Brain Neurostimulation and Responsive Cortical Stimulation Effective Sept. 1, 2023 Limitations of Coverage: Added: Obsessive-compulsive disorder (OCD). Hyperbaric Oxygen Therapy Effective Sept. 1, 2023 Limitations of coverage: Added: Arterial ulcers. Added: Post-COVID conditions. Added: Venous ulcers. Skin and Soft Tissue Substitute Effective Sept. 1, 2023 Indications of Coverage: Allograft related skin or soft tissue substitutes including EpiFix or Grafix are deemed medically necessary for diabetic ulcers, venous stasis ulcers, burns, surgical postoperative wounds, other acute or chronic wounds, and Added: traumatic wounds, Added: provided that the following are met:
no wound infection; AND no measurable signs of healing with at least four weeks of conventional therapy (that is, no decrease in size or depth of the targeted wound, or no decrease in the degree of exudate or necrotic tissue). Limitations of Coverage: All other Skin and Soft Tissue Substitutes not addressed in the Indications of Coverage for this policy are considered experimental and investigational because there is inadequate evidence in the peer-reviewed medical literature to support their clinical effectiveness, to include but not limited to: Added: Amniofix, Apis, Bio-ConneKt, Celera dual layer or Celera dual membrane, Complete SL and Complete FT, Cygnus, InnovaMatrix AC, Microlyte Matrix, NeoStim TL and NeoStim Membrane and NeoStim DL, NovoSorb, Restrata, Signature Apatch, Suregraft FT and Suregraft XT, Symphony, Tag, TheraGenesis, Vendaje, Vim, XCelliStem, Zenith. Added: GraftJacket NOW (formerly known as GraftJacket) for Musculoskeletal surgical applications. Added: Platelet-Rich Plasma for any wound treatment. Sleep Disorder Testing Effective Sept. 1, 2023 Indications of Coverage: Home Sleep Study: Documentation of any of the following symptoms suggestive of OSA: a. Witnessed apnea. b. Report of having fallen asleep while driving a motor vehicle. c. Gasping/choking while sleeping. d. Epworth sleep score of 10 or higher. Added: OR, Any Three (3) of the following: Added: aa. Significant snoring to those criteria already present. Note: If a sleep study specialist Added: (or specialist in pulmonary medicine or otorhinolaryngology) ordered or was consulted on a home sleep study, allow the home sleep study. Added: If the request for a home sleep study is made by a provider other than a specialist in sleep medicine or pulmonary medicine or otorhinolaryngology, with no consultation to these specialties, then the above criteria must be met. Added: If a home sleep study is requested due to a diagnosis of atrial fibrillation and the clinic notes indicate a concern for concurrent OSA, able to approve.

Repeat Polysomnogram (PSG): Added: For re-evaluation (polysomnogram or re-titration study) when an individual with diagnosed obstructive sleep apnea, consistently using a PAP device, but download documents persistently elevated AHI despite use of PAP and a sleep medicine specialist requests a repeat study. Limitations of Coverage: Actigraphy, Added: (when used strictly for diagnosing OSA [if actigraphy is ordered to evaluate sleep-wake cycle, able to approve as medically necessary; for all other indications consult with medical director]). Sleep Disorder Treatment Effective Feb 1, 2023 Description: Added: **This policy does not address other surgical services used to treat OSA.
For these services, such as Uvulopalatopharyngoplasty (UPPP), refer to MCG. (27th ed. A-0245 Uvulopalatopharyngoplasty (UPPP), A-0246 Uvulopalatopharyngoplasty (UPPP), Alternative Procedures). Definitions: Hypopnea, Added: the degree of oxygen saturation is defined as 3% by some sources and 4% by others. Indications of Coverage: Rental and Purchase of PAP Devices: Added: If download documents non-compliance; purchase of CPAP will be denied as not medically necessary due to non-compliance.
Hypoglossal nerve Stimulation (Inspire) for OSA: Removed: eXcite Hypoglossal Nerve Stimulator. Limitations of Coverage: Removed: eXcite Hypoglossal Nerve Stimulator. The following are considered experimental, investigational, and unproven to affect health outcomes or not covered per the member health plan: 1. Expiratory Positive Airway Pressure [EPAP]. Added: (UltePAP, Bongo Rx). 3. Added: Nonsurgical electric muscular stimulation (e.g., eXciteOSA). 7. The Morning Repositioner Added: (daytime alignment device). Telehealth/Telemedicine (Temporary) No changes to this policy, other than it will be retired as it will be changed to a reimbursement policy called Virtual Care Policy. Whole Exome and Whole Genome Sequencing No changes made to policy. Non-Covered Services and Procedures Policy Durable Medical Equipment Effective Sept. 1, 2023 Apos Therapy System. Indications Added: knee pain, or low back pain. Added: Bongo Rx (AirAvent Medical). Indication: Mild to moderate sleep apnea. E/I/U. Removed: C-Brace.

Genetics Effective Sept. 1, 2023 Added: Autism spectrum disorder multigene panel testing to include but not limited to Autism/ID Xpanded Panel, Syndromic Autism Panel, Fulgent ASD Panel, MitoMed Autism assay. Indication: Autism spectrum disorder. E/I/U. Note: for chromosomal microarray analysis (CMA) see MCG. Carrier Screening-Myriad Foresight Carrier screen, Invitae Comprehensive Carrier Screen, Added: QHerit Expanded Carrier Screen Panel. NMN. Added: Comprehensive Molecular Profiling for Tumor evaluation tests, including but not limited to, CANCERPLEX, Caris MI (MI Profile, MI TumorSeek), Foundation (FoundationOne CDx, FoundationOne Heme, FoundationOne Liquid CDx), GPS Cancer, Guardant 360, Guardant Reveal, Insight, OmniSeq, Oncotype MAP Pan-Cancer, Paradigm Cancer Diagnostic (PCDx) Test, PGDx Elio Tissue Complete, Tempus (Tempus xT, Tempus xF, Tempus xG). Indications: All oncologic indications. NMN. Added: Gene expression tests for cutaneous melanoma-DecisionDX-Melanoma, Merlin Tests (SkylineDX). Indications: Primary Cutaneous Melanoma. E/I/U. NMN. Inflammatory Bowel Disease Genetic Testing, Added: PredictSure (KSL Diagnostics). Kidney (Renal) Transplant Rejection testing to include but not limited to, AlloSure, and TruGraft Kidney (Eurofins Transplant Genomics), Added: kSort Assay (Immuncor). Added: RadTox cfDNA Test (DiaCarta Inc.). Indications: Assessment of radiation toxicity in cancer patients to allow for dose adjustment. E/I/U. Added: Tempus HRD. All Indications. E/I/U. NMN. 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. JO24767
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