Medical Policy

Policy updates

The Plan uses medical policies as guidelines for coverage decisions within the member’s written benefits. Below are summaries of recent changes to The Plan’s medical policies. The detailed policies and complete Medical Policy Manual are available online at bridgespanhealth.com. We have included the section and policy number for your convenience.

Last updated: November 1, 2024

Policy name

Summary of policy or change

Effective date

Section and policy number

Coding or implementation change

Pre-authorization change

New investigational policy for the use of ablation of peripheral nerves to treat pain.

February 1, 2024

Surgery #236

Adding CPT codes: 0440T, 0441T, 0442T and continue investigational denial. Adding CPT codes 64624, 64640 and add investigational denial for this policy. Adding CPT code 64999 and continue unlisted review.

N/A

Clarifying documentation requirements for:

  • Conservative therapy, and
  • Documenting tobacco use status.

February 1, 2024

Surgery #187

N/A

N/A

Clarifying that the clonoSEQ B-cell test, but not the T-cell test, may be considered medically necessary.

December 1, 2024

Genetic Testing #88

N/A

N/A

  • Adding not medically necessary criteria.
  • Requiring documenation of prior trauma, such as imaging.

December 1, 2024

Surgery #12.28

N/A

N/A

Clarifying provider type and added context for continuation treatment.

November 1, 2024

Behavioral Health #18

N/A

N/A

Edited policy for clarity

November 1, 2024

Durable Medical Equipment #83.11

N/A

N/A

Edited policy for clarity

November 1, 2024

Durable Medical Equipment #87

N/A

N/A

  • Revised policy to consider mammaplasty in individuals between 16-18 years of age to be potentially medically necessary when there is clinical reason for the earlier surgery.
  • Simplified the criteria related to the indications for the surgery.
  • Removed shoulder grooving.

November 1, 2024

Surgery #60

N/A

N/A

New policy to address lower extremity sensory prostheses.

October 1, 2024

Durable Medical Equipment #95

Added new Q4 HCPCS codes L8720, L8721 with investigational denial for this new policy.

N/A

New policy to address amplitude-modulated radiofrequency electromagnetic fields (AM RF-EMF) for cancer treatment.

October 1, 2024

Durable Medical Equipment #96

Added new Q4 HCPCS code E0767 with investigational edit for this new policy

N/A

  • Added nine investigational panel tests
  • Removed eight tests from the policy.

October 1, 2024

Genetic Testing #64

Added new Q4 CPT codes 0476U, 0477U, 0516U with investigational denial.

N/A

  • Changed policy title; policy was previously titled Fetal RHD Genotyping Using Maternal Plasma
  • Policy now addresses all cell-free fetal red blood cell antigen genotyping.

October 1, 2024

Genetic Testing #74

Added new Q4 CPT codes 0488U, 0494U with investigational denial.

N/A

Added four new investigational tests to policy.

October 1, 2024

Laboratory #77

Added new Q4 CPT codes 0506U, 0510U, 0512U, 0513U with investigational denial.

N/A

Added C9354 to policy as investigational.

October 1, 2024

Medicine #170

Adding HCPCS: C9354 with always investigational denial

N/A

New policy to address digital therapeutic products for gait training.

October 1, 2024

Medicine #175.06

Added new Q4 HCPCS code E3200 with investigational edit for this new policy

N/A

  • Changed policy title from: Ventral (Including Incisional) Hernia Repair
  • Deletd Criterion I.B (Bowel obstruction or strangulation) because all ICD-10 codes that require review are for hernias “without obstruction or gangrene.”
  • Updated “ventral” hernia to “anterior abdominal hernia.”

October 1, 2024

Surgery #12.03

N/A

N/A

Clarified pelvic inflammatory disease criteria.

October 1, 2024

Surgery #218

N/A

N/A

Clarified that the policy addresses Guardant Shield test and continue investigational determination.

September 1, 2024

Genetic Testing #86

N/A

N/A

Adding requirement of professional attestation related to cost to list of required documentation with no change to current criteria.

September 1, 2024

Medicine #49

N/A

N/A

  • Added clarifying language for provider type and Transcranial Magnetic Stimulation (TMS) protocols.
  • Added investigational criteria for accelerated protocols.

September 1, 2024

Medicine #148

N/A

N/A

Updated to include trabecular bone score for vertebral fracture risk as investigational.

September 1, 2024

Radiology #48

Add CPT codes 77089, 77090, 77091, 77092 to the policy with always investigational edit.

N/A

  • Changed policy title; policy was previously titled Surgical Site of Service- Hospital Outpatient
  • Updated terminology throughout the policy.

September 1, 2024

Utilization Management #19

N/A

Updated the policy title on the preauth website for this policy.

Clarified use of ASAM criteria to determine medical necessity.

August 1, 2024

Behavioral Health #35

N/A

N/A

Clarified policy criteria with no change to intent.

August 1, 2024

Surgery #12.01

N/A

N/A

New medical policy.

August 1, 2024

Surgery #221

  • Add CPT codes 0483T, 0484T and remove always investigational edit and add PA for this policy.
  • Add CPT codes 0543T, 0544T, 0569T, 0570T, 0646T, 0805T, 0806T and keep always investigational edits for this policy.

Add CPT codes 0483T, 0484T to the preauth website for this policy.

New medical policy.

August 1, 2024

Surgery #235

Add CPT codes 0338T, 0339T with investigational edit for this policy.

N/A

New policy will address folate testing.

June 1, 2024

Laboratory #79

  • Adding CPT codes 82746, 82747 to this medical policy.
  • Code 82746 will deny as always not medically necessary unless billed with specific diagnosis codes.
  • Code 82747 will deny as always not medically necessary.

N/A

Recently archived policies

Policy name

Archive date

Policy number

No policies archived in past six months

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