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: December 1, 2024
Policy name	Summary of policy or change	Effective date	Section and policy number	Coding or implementation change	Pre-authorization change
Screening Laboratory Testing	New policy addressing screening laboratory testing in asymptomatic individuals.	March 1, 2025	Laboratory #80	Adding CPT codes: 82310, 82330, 82340, 82670, 82681, 82728, 82977, 83540, 83550, 83735, 83970, 83993, 84100, 84105, 84402, 84403, 84410, 84443, 84466, 85651, 85652, 86038, 86039, 86140, 86225, 86235 to the policy with no edit. This will be implemented as an automatic denial for the CPT codes listed when billed with the diagnosis code Z00.00 as a sole diagnosis code.	N/A
Surgical Site of Care - Hospital Outpatient	Added joint procedure codes that were formerly reviewed by eviCore.	March 1, 2025	Utilization Management #19	Adding CPT codes: 20520, 20525, 20670, 20680, 20693, 20694, 23415, 23450, 23460, 23465, 23515, 23550, 23615, 23630, 23655, 23665, 24105, 24305, 24340, 24341, 24342, 24343, 24345, 24346, 24357, 24358, 24359, 24505, 24516, 24530, 24538, 24545, 24546, 24575, 24579, 24586, 24605, 24620, 24635, 24655, 24665, 24666, 24685, 25000, 25107, 25111, 25112, 25118, 25210, 25215, 25240, 25260, 25270, 25280, 25290, 25295, 25310, 25320, 25360, 25390, 25447, 25505, 25515, 25545, 25565, 25574, 25575, 25600, 25605, 25606, 25607, 25608, 25609, 25628, 25645, 25652, 25825, 26011, 26020, 26055, 26080, 26121, 26123, 26145, 26160, 26236, 26320, 26340, 26350, 26356, 26370, 26410, 26418, 26426, 26440, 26445, 26480, 26516, 26520, 26525, 26540, 26541, 26608, 26615, 26650, 26665, 26676, 26725, 26727, 26735, 26746, 26756, 26765, 26785, 26850, 26860, 26951, 26952, 27335, 27424, 27605, 27606, 27612, 27620, 27625, 27626, 27650, 27652, 27654, 27659, 27675, 27676, 27680, 27685, 27687, 27690, 27691, 27695, 27696, 27698, 27705, 27752, 27762, 27766, 27769, 27781, 27784, 27786, 27788, 27792, 27810, 27814, 27818, 27822, 27823, 27840, 28002, 28005, 28008, 28010, 28022, 28035, 28060, 28062, 28080, 28086, 28090, 28092, 28110, 28112, 28113, 28116, 28118, 28119, 28120, 28122, 28124, 28160, 28190, 28192, 28200, 28208, 28230, 28232, 28234, 28238, 28250, 28270, 28272, 28285, 28288, 28289, 28291, 28292, 28295, 28296, 28297, 28298, 28299, 28300, 28304, 28306, 28308, 28310, 28313, 28315, 28322, 28415, 28445, 28465, 28475, 28476, 28485, 28505, 28515, 28525, 28555, 28585, 28615, 28645, 28715, 28725, 28740, 28750, 28755, 28810, 28820, 28825, 29834, 29837, 29838, 29844, 29846, 29848 which are moving from eviCore joint Site of Care to this policy, (UM19) with preauth edit	Adding CPT codes: 20520, 20525, 20670, 20680, 20693, 20694, 23415, 23450, 23460, 23465, 23515, 23550, 23615, 23630, 23655, 23665, 24105, 24305, 24340, 24341, 24342, 24343, 24345, 24346, 24357, 24358, 24359, 24505, 24516, 24530, 24538, 24545, 24546, 24575, 24579, 24586, 24605, 24620, 24635, 24655, 24665, 24666, 24685, 25000, 25107, 25111, 25112, 25118, 25210, 25215, 25240, 25260, 25270, 25280, 25290, 25295, 25310, 25320, 25360, 25390, 25447, 25505, 25515, 25545, 25565, 25574, 25575, 25600, 25605, 25606, 25607, 25608, 25609, 25628, 25645, 25652, 25825, 26011, 26020, 26055, 26080, 26121, 26123, 26145, 26160, 26236, 26320, 26340, 26350, 26356, 26370, 26410, 26418, 26426, 26440, 26445, 26480, 26516, 26520, 26525, 26540, 26541, 26608, 26615, 26650, 26665, 26676, 26725, 26727, 26735, 26746, 26756, 26765, 26785, 26850, 26860, 26951, 26952, 27335, 27424, 27605, 27606, 27612, 27620, 27625, 27626, 27650, 27652, 27654, 27659, 27675, 27676, 27680, 27685, 27687, 27690, 27691, 27695, 27696, 27698, 27705, 27752, 27762, 27766, 27769, 27781, 27784, 27786, 27788, 27792, 27810, 27814, 27818, 27822, 27823, 27840, 28002, 28005, 28008, 28010, 28022, 28035, 28060, 28062, 28080, 28086, 28090, 28092, 28110, 28112, 28113, 28116, 28118, 28119, 28120, 28122, 28124, 28160, 28190, 28192, 28200, 28208, 28230, 28232, 28234, 28238, 28250, 28270, 28272, 28285, 28288, 28289, 28291, 28292, 28295, 28296, 28297, 28298, 28299, 28300, 28304, 28306, 28308, 28310, 28313, 28315, 28322, 28415, 28445, 28465, 28475, 28476, 28485, 28505, 28515, 28525, 28555, 28585, 28615, 28645, 28715, 28725, 28740, 28750, 28755, 28810, 28820, 28825, 29834, 29837, 29838, 29844, 29846, 29848 to the preauth website for this policy.
Ablation of Peripheral Nerves to Treat Pain	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
Lumbar Spinal Fusion	Clarifying documentation requirements for: Conservative therapy, and Documenting tobacco use status.	February 1, 2024	Surgery #187	N/A	N/A
Applied Behavior Analysis for the Treatment of Autism Spectrum Disorder	Clarified policy criteria with no change to intent.	December 1, 2024	Behavioral Health #18	N/A	N/A
ClonoSEQ® Testing for the Assessment of Measurable Residual Disease (MRD)	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
Molecular Testing in the Management of Pulmonary Nodules	Updated policy to address the REVEAL Lung Nodule Characterization test.	December 1, 2024	Laboratory #73	N/A	N/A
Rhinoplasty	Adding not medically necessary criteria. Requiring documenation of prior trauma, such as imaging.	December 1, 2024	Surgery #12.28	N/A	N/A
Hematopoietic Cell Transplantation for Multiple Myeloma and POEMS Syndrome	Added clarifying language to the Policy Guidelines section regarding stem cell collection prior to treatment.	December 1, 2024	Transplant #45.22	N/A	N/A
Applied Behavior Analysis for the Treatment of Autism Spectrum Disorder	Clarifying provider type and added context for continuation treatment.	November 1, 2024	Behavioral Health #18	N/A	N/A
Electrical Bone Growth Stimulators (Osteogenic Stimulation)	Edited policy for clarity	November 1, 2024	Durable Medical Equipment #83.11	N/A	N/A
Noninvasive Ventilators in the Home Setting	Edited policy for clarity	November 1, 2024	Durable Medical Equipment #87	N/A	N/A
Reduction Mammaplasty	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
Lower Extremity Sensory Prostheses	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
Amplitude-Modulated Radiofrequency Electromagnetic Fields (AM RF-EMF) for Cancer Treatment	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
Evaluating the Utility of Genetic Panels	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
Fetal Red Blood Cell Antigen Genotyping Using Maternal Plasma	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
Investigational Gene Expression, Biomarker, and Multianalyte Testing	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
Bioengineered Skin and Soft Tissue Substitutes and Amniotic Products	Added C9354 to policy as investigational.	October 1, 2024	Medicine #170	Adding HCPCS: C9354 with always investigational denial	N/A
Digital Therapeutic Products for Gait Training	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
Anterior Abdominal Wall (Including Incisional) Hernia Repair	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
Hysterectomy	Clarified pelvic inflammatory disease criteria.	October 1, 2024	Surgery #218	N/A	N/A
Serologic Genetic and Molecular Screening for Colorectal Cancer	Clarified that the policy addresses Guardant Shield test and continue investigational determination.	September 1, 2024	Genetic Testing #86	N/A	N/A
Charged Particle (Proton) Radiotherapy	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
Transcranial Magnetic Stimulation as a Treatment of Depression and Other Disorders	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
Screening for Vertebral Fracture or Fracture Risk with Dual X-ray Absorptiometry (DXA)	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
Surgical Site of Care-Hospital Outpatient	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.
Substance Use Disorder	Clarified use of ASAM criteria to determine medical necessity.	August 1, 2024	Behavioral Health #35	N/A	N/A
Panniculectomy	Clarified policy criteria with no change to intent.	August 1, 2024	Surgery #12.01	N/A	N/A
Transcatheter Heart Valve Procedures for Mitral or Tricuspid Valve Disorders excluding Transcatheter Edge-to-Edge Repair (TEER)	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.
Radiofrequency Ablation of the Renal Sympathetic Nerves for the Treatment of Uncontrolled Hypertension	New medical policy.	August 1, 2024	Surgery #235	Add CPT codes 0338T, 0339T with investigational edit for this policy.	N/A
Folate Testing	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	N/A	N/A