Policy updates include:

• Clarifying language added to Criteria I.A. to specify diagnostic facet joint injections
• Minor rewording in Criteria I.A.1.a. Updated to include ≥ four weeks of physical therapy or prescribed home exercise program and ≥ four weeks activity modification
• Removed Criteria I.A.1.c. regarding ≥ six weeks chiropractic, physical therapy, or prescribed home exercise program
• Removed Criteria I.A.1.d. and added to Criteria I.A.1.b
• Removed Criteria I.A.1.e. regarding ≥ six weeks activity modification
• Criteria I.A.1.c. updated to replace disc herniation, radiculitis, discogenic or sacroiliac pain with fracture, tumor, infection, and extraspinal lesion and updated to include pain not associated with radiculopathy or myelopathy and removed pain worse at night
• Pain relief updated from > 75% to ≥ 80 % in Criteria I.A.1.e.
• Note at end of Criteria I. updated to pain relief of < 80% instead of < 75% and updated to specify a second block at the same level is not medically necessary
• Criteria I.B. updated to specify neck or back pain present for ≥ three months
• Pain relief updated from > 75% to ≥ 80 % in Criteria I.B.1.b. and removed ability to perform prior painful movements without significant pain
• Criteria I.B.2.b. updated from at least four months to at least six months
• Criteria I.D. updated to include medical necessity for therapeutic facet joint injections when meeting criteria I.D.1 through I.D.4
• Removed CPT codes 0214T, 0215T, 0217T, and 0218T from coding table

Policy updates include:

• Under I.A. added “with treatment including”
• Added criteria to I.A.1.-I.A.2.:
  • Correction via a minimally invasive approach
  • SCT resection when meeting all of the following: Fetuses with high-risk SCT and hydrops developing at a gestational age earlier than appropriate for delivery and neonatal care (eg. 28-32 weeks gestation)
  • Does not have the following contraindications: Type III or IV Altman-type tumors; Severe placentomegaly; Maternal cervical shortening
• Removed indication I.F.5. Normal fetal karyotype
• Quantified criteria I.F.5.c. to include (≥30 degrees)
• Added criteria I.G. Fetal endoscopic tracheal occlusion (FETO) for congenital diaphragmatic hernia (CDH) when all of the following criteria are met: Severe left-sided CDH; Severe pulmonary hypoplasia defined as a quotient of the observed-to-expected lung-to-head ratios of less than 25%; Gestational age ≤ 30 weeks
• Removed III.A. Open or endoscopic fetal surgery for congenital diaphragmatic hernia (CDH), including temporary tracheal occlusion

Policy updates include:

• Added note for corresponding Medicare policy
• Updated all policy statements to indicate "non-Medicare" health plans
• In I.A.1 changed "both" to "one" of the following and added "taken while member/enrollee was stable (not in acute respiratory failure)"
• Removed criteria for BiPAP failure and contraindications in sections I and II, and replaced with criteria requiring documentation that "member/enrollee could not be appropriately treated with a RAD" and "non-invasive home ventilator will not be used to provide RAD or CPAP therapy"
• Removed criteria in I.A.1.a. and b. for members/enrollees < 18 years
• In 1.A.1a. updated PaCO2 > to greater than or equal to
• In I.C.1 updated BMI > than 30 to greater than or equal to 30
• In 1.C.2 added "at baseline"
• Added criteria I.C.3. "Hypoventilation has been documented by polysomnography and other conditions are not considered the primary cause of hypoventilation"
• Removed medical necessity criteria I.D. for home ventilators for treatment failure of BiPAP
• In II.B. replaced "medical records document improvement" with II.B.1. and 2. "Documentation supports both of the following: Ongoing benefits from use of the device” and "non-invasive home ventilator will not be used to provide RAD or CPAP therapy"