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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: May 1, 2025

Policy name

Summary of policy or change

Effective date

Section and policy number

Coding or implementation change

Pre-authorization change

  • Changed policy title; policy was previously titled Power Wheelchairs: Group 3
  • Adding group 2 criteria and codes to the policy with this update

August 1, 2025

Durable Medical Equipment #37

Adding HCPCS codes K0820, K0821, K0822, K0823, K0824, K0825, K0826, K0827, K0828, K0829, K0830, K0831, K0835, K0836, K0837, K0838, K0839, K0840, K0841, K0842, K0843 with preauth requirement for this policy for Individual Line of Business only.

Adding codes K0820, K0821, K0822, K0823, K0824, K0825, K0826, K0827, K0828, K0829, K0830, K0831, K0835, K0836, K0837, K0838, K0839, K0840, K0841, K0842, K0843 to the preauth website for Individual Line of Business only.

New medical policy with medical necessity criteria will apply only to Individual members.

August 1, 2025

Durable Medical Equipment #52

  • Adding HCPCS codes E2500, E2502, E2504, E2506, E2508, E2510, E2511, E2512 with preauth requirement for this policy for Individual Line of Business only.
  • Continue unlisted review on code E2599.

Adding codes E2500, E2502, E2504, E2506, E2508, E2510, E2511, E2512 to the preauth website for Individual Line of Business only.

New medical policy with medical necessity criteria will apply only to Individual members.

August 1, 2025

Durable Medical Equipment #97

Adding HCPCS codes L0452, L0454, L0456, L0460, L0466, L0468, L0480, L0482, L0484, L0486, L0626, L0627, L0629, L0630, L0631, L0632, L0633, L0634, L0636, L0637, L0638, L0639, L0640 with preauth requirement for this policy for Individual Line of Business only.

Adding codes L0452, L0454, L0456, L0460, L0466, L0468, L0480, L0482, L0484, L0486, L0626, L0627, L0629, L0630, L0631, L0632, L0633, L0634, L0636, L0637, L0638, L0639, L0640 to the preauth website for Individual Line of Business only.

New lab policy for testosterone testing.

August 1, 2025

Laboratory #81

  • Adding CPT codes 84402, 84410 as not medically necessary when frequency values are exceeded over a rolling 365 days.
  • Adding CPT code 84403 with no clinical edit.

N/A

  • Adding indications for coverage,
  • Clarifying criteria addressing nutritional status, and
  • Adding criteria and required documentation for evaluation of arterial status for neuropathic ulcers.

July 1, 2025

Durable Medical Equipment #42

N/A

N/A

New policy created to address electromagnetic navigation bronchoscopy.

July 1, 2025

Surgery #179

  • Adding CPT codes 31626, 31627 and HCPCS codes C7509, C7510, C7511, C9751 with preauth for this medical policy.
  • Adding HCPCS code A4648 and continue no clinical edit on this code.

Adding CPT codes 31626, 31627 and HCPCS codes C7509, C7510, C7511, C9751 to the preauth website for this medical policy.

Expanding post-service review of rotary air ambulance.

July 1, 2025

Utilization Management #13

N/A

N/A

Added criterion for revision of sleeve gastrectomy due to medication resistant gastroesophageal reflux disease.

June 1, 2025

Surgery #58

N/A

N/A

Combined investigational criteria in the policy.

May 1, 2025

Genetic Testing #44

N/A

N/A

New policy for mechanical residual limb volume management systems (e.g., RevoFit) for upper extremity prostheses.

April 1, 2025

Durable Medical Equipment #98

Added new Q2 HCPCS code L7406 as always not medically necessary for this policy.

N/A

  • Added 13 investigational panel tests
  • Removed 101 tests from the policy.

April 1, 2025

Genetic Testing #64

Added new Q2 CPT 0533U with investigational denial for this policy.

N/A

  • Added the myOLARIS™-KTdx to the policy
  • Changed the DetermaRx test to the new name, RiskReveal.

April 1, 2025

Laboratory #77

Added new Q2 CPT 0542U with investigational denial for this policy.

N/A

Clarified criteria regarding pancreatic cancer and prostate cancer.

April 1, 2025

Medicine #165

N/A

N/A

Clarified policy criteria for functional impairments and documentation of orthodontic treatment.

April 1, 2025

Surgery #137

N/A

N/A

Added NRG1 fusion testing to policy.

March 1, 2025

Genetic Testing #56

N/A

N/A

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

Updated policy to address continuation of ECMO.

March 1, 2025

Medicine #152

N/A

N/A

Updated policy to address the GERDX-System for transoral incisionless fundoplication for treatment of GERD.

March 1, 2025

Surgery #110

N/A

N/A

Added medical necessity criteria for cryoablation of certain desmoid tumors.

March 1, 2025

Surgery #132

N/A

N/A

Clarified criteria without change to policy intent.

March 1, 2025

Surgery #134

Added HCPCS codes C1778, C1883 with no clinical edit.

N/A

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.

Clarifying documentation requirements for:

  • Conservative therapy, and
  • Documenting tobacco use status.

February 1, 2024

Surgery #187

N/A

N/A

Updated criteria to remove age limits and provide guidance for use of general anesthesia services.

January 1, 2025

Allied Health #35

N/A

N/A

Updated policy to address concurrent optical and electromagnetic stimulation for wound healing.

January 1, 2025

Durable Medical Equipment #83.13

  • Added two new CPT codes 0906T, 0907T as always investigational.
  • Removed deleted CPT codes 0768T, 0769T

N/A

  • Updated policy to address urinary measurement of CXCL10.
  • Clarified criteria for gene expression tests for organs other than the heart.

January 1, 2025

Laboratory #51

Added two new CPT code 0526U as always investigational.

N/A

Added criteria for continuation of treatment.

January 1, 2025

Medicine #14

N/A

N/A

Updated the policy in alignment with the 2025 Q1 annual code update.

January 1, 2025

Medicine #149

  • Added new CPT codes 0901T, 0902T, 0903T, 0904T, 0905T, 0915T, 0916T, 0917T, 0918T, 0919T, 0920T, 0921T, 0922T, 0923T, 0924T, 0925T, 0926T, 0927T, 0928T, 0929T, 0930T, 0931T, 0932T, 0933T, 0934T, 0936T, 0937T, 0938T, 0939T, 0940T, 0946T as always investigational.
  • Added new HCPCS codes C8001, C8003 as always investigational.
  • Revised CPT code 0615T.

N/A

  • Changed policy title; policy was previously titled Magnetic Resonance (MR) Guided Focused Ultrasound (MRgFUS) and High Intensity Focused Ultrasound (HIFU) Ablation.
  • Added criteria related to transurethral ultrasound ablation (TULSA).

January 1, 2025

Surgery #139

  • Added new CPT codes 0947T, 51721, 55881, 55882 as always investigational.
  • Added new CPT code 61715 with preauth edit.

Added new CPT code 61715 to the preauth website for this policy.

Added criteria to address 3D Ablation confirmation software.

January 1, 2025

Surgery #204

  • Added new CPT code 0944T as always investigational.

N/A

  • Changed policy title; policy was previously titled Leadless Cardiac Pacemakers.
  • Updated policy to remove reference to single chamber leadless pacemakers. Only addresses dual chamber leadless pacemakers as investigational.

January 1, 2025

Surgery #217

  • Removed CPT codes 0823T, 0824T, 0825T, 0826T, 33274, 33275 from this policy.
  • Removed HCPCS codes C1605 from this policy.

Removed codes 0823T, 0825T, 33274 from the preauth website for this policy.

Added criteria to address prostatic urethral scaffold device.

January 1, 2025

Surgery #230

  • Added new CPT codes 0941T, 0942T, 0943T, 53865, 53866 as always investigational.
  • Removed deleted HCPCS code C9769 from this policy.

N/A

  • Changed policy title; policy was previously titled Radiofrequency Ablation of the Renal Sympathetic Nerves as a Treatment for Uncontrolled Hypertension.
  • Updated policy to address ultrasound renal denervation for the treatment of hypertension.

January 1, 2025

Surgery #235

  • Added new HCPCS codes C1735, C1736 as always investigational.

N/A

Clarified criteria and documentation requirements.

December 11, 2024

Medicine #153

  • Added CPT codes 15769, 15772 and continue preauth requirement.
  • Added HCPCS codes C1789 with no edit.

Added CPT codes 15769, 15772 to the preauth website for this policy.

Clarified policy criteria with no change to intent.

December 1, 2024

Behavioral Health #18

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

Updated policy to address the REVEAL Lung Nodule Characterization test.

December 1, 2024

Laboratory #73

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

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

Recently archived policies

Policy name

Archive date

Policy number

Intensive In-Home Family Intervention

04/01/2025

Behavioral Health #34

Radioembolization, Transarterial Embolization (TAE), and Transarterial Chemoembolization (TACE)

05/01/2025

Medicine #140

Ovarian, Internal Iliac, and Gonadal Vein Embolization, Ablation, and Sclerotherapy

05/01/2025

Surgery #147