Medicare Advantage

Medical Policy

	MPDocType	Title	MPPolicyNumber	MPNotificationIssuedDate	MPEffectiveDate	MPReissuedDate	MPArchiveNotifEffDate	MPSALogCreatedOn	MPPolicyChangeTypeslt	MPRevisionDate	MPPolicyTitle	MPSiteActivityRemovedDate
	News & Announcements	Coverage of the COVID-19 Vaccination for Medicare Advantage Members (Updated on June 19, 2023)						6/19/2023			Coverage of the COVID-19 Vaccination for Medicare Advantage Members (Updated on June 19, 2023)
	News & Announcements	7/01/2023 CPT & HCPCS Quarterly Code Update Coverage Determinations for Medicare Advantage Products						6/30/2023			7/01/2023 CPT & HCPCS Quarterly Code Update Coverage Determinations for Medicare Advantage Products
	Notifications	eviCore Lab Management	MA06.034j	6/1/2023 10:00 AM	7/1/2023			6/1/2023	Coverage and/or Reimbursement Position;Medical Necessity Criteria;Medical Coding;General Description, Guidelines, or Informational Update		eviCore Lab Management	6/1/2023
	Notifications	eviCore Lab Management	MA06.034j	6/1/2023 10:00 AM	7/1/2023			6/1/2023	Coverage and/or Reimbursement Position;Medical Necessity Criteria;Medical Coding;General Description, Guidelines, or Informational Update		eviCore Lab Management
	Notifications	Intravitreal Injection of Vascular Endothelial Growth Factor (VEGF) Antagonists, VEGF Biosimilars, and combination VEGF/Angiopoietin-2 (Ang-2) inhibitors	MA08.073l	6/20/2023 9:00 AM	9/18/2023			6/20/2023	Medical Necessity Criteria		Intravitreal Injection of Vascular Endothelial Growth Factor (VEGF) Antagonists, VEGF Biosimilars, and combination VEGF/Angiopoietin-2 (Ang-2) inhibitors
	New Policies	Retifanlimab-dlwr (Zynyz TM)	MA08.161		6/5/2023			6/5/2023	This is a New Policy.		Retifanlimab-dlwr (Zynyz TM)
	Updated Policies	Telehealth Services	MA00.036h		6/1/2023			6/1/2023	Medical Necessity Criteria;Medical Coding		Telehealth Services
	Updated Policies	Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer's Disease	MA08.151a		6/5/2023			6/5/2023	Coverage and/or Reimbursement Position;Medical Necessity Criteria;Medical Coding;General Description, Guidelines, or Informational Update		Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer's Disease
	Updated Policies	Removal of Breast Implants	MA11.076g		6/5/2023			6/5/2023	Medical Coding;General Description, Guidelines, or Informational Update		Removal of Breast Implants
	Updated Policies	patisiran (Onpattro®) and vutrisiran (Amvuttra™)	MA08.100c	3/14/2023 10:00 AM	6/12/2023			6/12/2023	Coverage and/or Reimbursement Position;Medical Necessity Criteria;Medical Coding;General Description, Guidelines, or Informational Update		patisiran (Onpattro®) and vutrisiran (Amvuttra™)
	Updated Policies	Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service	MA03.003l	3/10/2023 2:00 PM	6/12/2023			6/12/2023	Coverage and/or Reimbursement Position;Medical Coding		Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service
	Updated Policies	Asparaginase erwinia chrysanthemi (Erwinaze®), asparaginase erwinia chrysanthemi (recombinant)-rywn (Rylaze®)	MA08.085g		6/19/2023			6/19/2023	Medical Necessity Criteria;Medical Coding		Asparaginase erwinia chrysanthemi (Erwinaze®), asparaginase erwinia chrysanthemi (recombinant)-rywn (Rylaze®)
	Updated Policies	Margetuximab-cmkb (Margenza)	MA08.132c		6/19/2023			6/19/2023	Medical Necessity Criteria		Margetuximab-cmkb (Margenza)
	Updated Policies	Tafasitamab-cxix (Monjuvi®)	MA08.138b		6/19/2023			6/19/2023	Medical Necessity Criteria;Medical Coding		Tafasitamab-cxix (Monjuvi®)
	Updated Policies	Medicare Part B vs. Part D Crossover Drugs	MA08.007af		6/25/2023			6/25/2023	Medical Coding		Medicare Part B vs. Part D Crossover Drugs
	Updated Policies	Ostomy Supplies	MA05.014e		6/30/2023			6/30/2023	General Description, Guidelines, or Informational Update		Ostomy Supplies
	Updated Policies	Injectable Dermal Fillers for Cosmetic Procedures	MA05.021b	3/31/2023 1:00 PM	7/1/2023			6/30/2023	Coverage and/or Reimbursement Position		Injectable Dermal Fillers for Cosmetic Procedures
	Updated Policies	Preventive Care Services	MA00.003v		7/1/2023			6/30/2023	Medical Necessity Criteria;Medical Coding		Preventive Care Services
	Updated Policies	Reimbursement for the Administration of Drugs, Substances, and/or Biologic Agents	MA00.051d		7/1/2023			6/30/2023	Medical Coding		Reimbursement for the Administration of Drugs, Substances, and/or Biologic Agents
	Reissue Policies	Surgical Treatments of Athletic Pubalgia	MA11.093a		6/3/2015	5/31/2023		6/1/2023			Surgical Treatments of Athletic Pubalgia
	Reissue Policies	Percutaneous Image-Guided Lumbar Decompression (PILD) for Spinal Stenosis	MA11.097e		8/29/2022	5/31/2023		6/1/2023			Percutaneous Image-Guided Lumbar Decompression (PILD) for Spinal Stenosis
	Reissue Policies	Anifrolumab-fnia (Saphnelo®)	MA08.140b		4/1/2022	6/2/2023		6/2/2023			Anifrolumab-fnia (Saphnelo®)
	Reissue Policies	Dofetilide (Tikosyn®) Use in the Inpatient Setting	MA08.021b		9/22/2019	6/2/2023		6/2/2023			Dofetilide (Tikosyn®) Use in the Inpatient Setting
	Reissue Policies	Home Based Sleep Studies	MA07.028		7/16/2020	6/14/2023		6/14/2023			Home Based Sleep Studies
	Reissue Policies	Air Ambulance Services	MA12.007b		11/21/2022	6/14/2023		6/14/2023			Air Ambulance Services
	Reissue Policies	Personalized Vaccines (e.g., Provenge®)	MA08.053b		12/20/2021	6/14/2023		6/14/2023			Personalized Vaccines (e.g., Provenge®)
	Reissue Policies	Spesolimab--sbzo (Spevigo®)	MA08.155a		4/1/2023	6/14/2023		6/15/2023			Spesolimab--sbzo (Spevigo®)
	Reissue Policies	Photodynamic Therapy Using Verteporfin (Visudyne®)	MA07.003d		5/7/2018	6/14/2023		6/15/2023			Photodynamic Therapy Using Verteporfin (Visudyne®)
	Reissue Policies	Intravenous (IV) Administration of Fluids as a Treatment of a Medical Condition or for the Preparation of Pharmaceuticals, Biologics, and other Substances	MA00.022		1/1/2015	6/14/2023		6/15/2023			Intravenous (IV) Administration of Fluids as a Treatment of a Medical Condition or for the Preparation of Pharmaceuticals, Biologics, and other Substances
	Reissue Policies	Inebilizumab-cdon (Uplizna)	MA08.126b		8/9/2021	6/14/2023		6/15/2023			Inebilizumab-cdon (Uplizna)
	Reissue Policies	Skilled Nursing Facility (SNF): Skilled and Subacute Levels of Care	MA02.004		11/1/2020	6/14/2023		6/15/2023			Skilled Nursing Facility (SNF): Skilled and Subacute Levels of Care
	Reissue Policies	Automatic External Cardioverter Defibrillators (Wearable and Nonwearable)	MA05.005f		11/21/2022	6/14/2023		6/15/2023			Automatic External Cardioverter Defibrillators (Wearable and Nonwearable)
	Reissue Policies	Photodynamic Therapy (PDT) Using Levulan® Kerastick® or Ameluz® (Aminolevulinic Acid HCl [ALA])	MA07.056d		7/1/2019	6/14/2023		6/15/2023			Photodynamic Therapy (PDT) Using Levulan® Kerastick® or Ameluz® (Aminolevulinic Acid HCl [ALA])
	Reissue Policies	Percutaneous Coronary Intervention, Coronary Angiography and Arterial Ultrasound	MA11.113g		1/1/2023	6/28/2023		6/28/2023			Percutaneous Coronary Intervention, Coronary Angiography and Arterial Ultrasound
	Reissue Policies	Endovascular Grafts for Abdominal Aortic Aneurysms (AAA), Aorto-Iliac Aneurysms, and Infrarenal Aortic Aneurysms	MA11.012f		1/1/2022	6/28/2023		6/28/2023			Endovascular Grafts for Abdominal Aortic Aneurysms (AAA), Aorto-Iliac Aneurysms, and Infrarenal Aortic Aneurysms
	Reissue Policies	Outpatient Physical Medicine and Rehabilitation Services- Physical Therapy (PT) and Occupational Therapy (OT)	MA10.003i		8/29/2022	6/28/2023		6/29/2023			Outpatient Physical Medicine and Rehabilitation Services- Physical Therapy (PT) and Occupational Therapy (OT)
	Reissue Policies	Uterine Artery Embolization	MA11.045c		5/20/2019	6/28/2023		6/29/2023			Uterine Artery Embolization
	Reissue Policies	Speech Therapy	MA10.007c		1/1/2020	6/28/2023		6/29/2023			Speech Therapy
	Reissue Policies	Sentinel Lymph Node Biopsy and Mapping	MA11.068e		1/1/2023	6/28/2023		6/29/2023			Sentinel Lymph Node Biopsy and Mapping
	Reissue Policies	Hyaluronan Acid Therapies for Osteoarthritis of the Knee	MA11.023k		4/1/2021	6/28/2023		6/29/2023			Hyaluronan Acid Therapies for Osteoarthritis of the Knee
	Reissue Policies	Laparoscopic, Percutaneous, and Transcervical Techniques for Uterine Fibroid Myolysis	MA11.116		6/6/2022	6/28/2023		6/29/2023			Laparoscopic, Percutaneous, and Transcervical Techniques for Uterine Fibroid Myolysis
	Reissue Policies	Prophylactic Mastectomy, Oophorectomy/Salpingo-Oophorectomy, and Hysterectomy	MA11.077f		10/1/2022	6/28/2023		6/29/2023			Prophylactic Mastectomy, Oophorectomy/Salpingo-Oophorectomy, and Hysterectomy
	Reissue Policies	Endometrial Ablation	MA11.065d		5/20/2019	6/28/2023		6/29/2023			Endometrial Ablation
	Reissue Policies	Complete Decongestive Therapy (CDT)	MA07.042		12/30/2014	6/28/2023		6/29/2023			Complete Decongestive Therapy (CDT)
	Coding Update	Presumptive and Definitive Drug Testing in Substance Abuse and Pain Management Treatments	MA06.025q		7/1/2023			6/30/2023			Presumptive and Definitive Drug Testing in Substance Abuse and Pain Management Treatments
	Coding Update	Coagulation Factors	MA08.004u		7/1/2023			6/30/2023			Coagulation Factors
	Coding Update	Immune Globulin Intravenous (IVIG), Subcutaneous (SCIG)	MA08.009r		7/1/2023			6/30/2023			Immune Globulin Intravenous (IVIG), Subcutaneous (SCIG)
	Coding Update	Wound Care: Skin Substitutes for the Treatment of Burns and Chronic, Non-Healing Wounds	MA11.015u		7/1/2023			6/30/2023			Wound Care: Skin Substitutes for the Treatment of Burns and Chronic, Non-Healing Wounds
	Coding Update	Implantable Infusion Pumps	MA05.053m		7/1/2023			6/30/2023			Implantable Infusion Pumps
	Coding Update	Mosunetuzumab-axgb (Lunsumio™)	MA08.158a		7/1/2023			6/30/2023			Mosunetuzumab-axgb (Lunsumio™)
	Coding Update	Ublituximab-xiiy (Briumvi TM) for intravenous use	MA08.160a		7/1/2023			6/30/2023			Ublituximab-xiiy (Briumvi TM) for intravenous use
	Coding Update	Mirvetuximab soravtansine-gynx (Elahere TM)	MA08.159a		7/1/2023			6/30/2023			Mirvetuximab soravtansine-gynx (Elahere TM)
	Archived Policies	Lysis of Epidural Adhesions	MA11.095a	6/30/2023 12:00 PM	7/31/2023			6/30/2023			Lysis of Epidural Adhesions