Medical Policy Update

Medical Policy Revisions

Medical Policy: I.211 new title: Electrophysiology (ep) testing and cardiac catheter ablation
Previous title: Cardiac catheter ablation as a treatment for atrial fibrillation

Effective Date: 4/1/2026
Preauthorization Required: Yes

InterQual (IQ) criteria will be utilized for these services (codes noted below):
Electrophysiology (EP) Testing +/- Catheter Ablation, Cardiac 

Codes:
93600 - Bundle of His recording

93602 - Intra-atrial recording

93603 - Right ventricular recording

93609 - Intraventricular and/or intra-atrial mapping of tachycardia site(s) with catheter manipulation to record from multiple sites to identify origin of tachycardia (List separately in addition to code for primary procedure)

93610 - Intra-atrial pacing

93612 - Intraventricular pacing

93613 - Intracardiac electrophysiologic 3-dimensional mapping (List separately in addition to code for primary procedure)

93618 - Induction of arrhythmia by electrical pacing

93619 - Comprehensive electrophysiologic evaluation with right atrial pacing and recording, right ventricular pacing and recording, His bundle recording, including insertion and repositioning of multiple electrode catheters, without induction or attempted induction of arrhythmia

93620 - Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia; with right atrial pacing and recording, right ventricular pacing and recording, His bundle recording

93624 - Electrophysiologic follow-up study with pacing and recording to test effectiveness of therapy, including induction or attempted induction of arrhythmia

93650 - Intracardiac catheter ablation of atrioventricular node function, atrioventricular conduction for creation of complete heart block, with or without temporary pacemaker placement

93653 - Comprehensive electrophysiologic evaluation with insertion and repositioning of multiple electrode catheters, induction or attempted induction of an arrhythmia with right atrial pacing and recording and catheter ablation of arrhythmogenic focus, including intracardiac electrophysiologic 3-dimensional mapping, right ventricular pacing and recording, left atrial pacing and recording from coronary sinus or left atrium, and His bundle recording, when performed; with treatment of supraventricular tachycardia by ablation of fast or slow atrioventricular pathway, accessory atrioventricular connection, cavo-tricuspid isthmus or other single atrial focus or source of atrial re-entry 

93654 - Comprehensive electrophysiologic evaluation with insertion and repositioning of multiple electrode catheters, induction or attempted induction of an arrhythmia with right atrial pacing and recording and catheter ablation of arrhythmogenic focus, including intracardiac electrophysiologic 3-dimensional mapping, right ventricular pacing and recording, left atrial pacing and recording from coronary sinus or left atrium, and His bundle recording, when performed; with treatment of ventricular tachycardia or focus of ventricular ectopy including left ventricular pacing and recording, when performed

93656 - Comprehensive electrophysiologic evaluation with transseptal catheterizations, insertion and repositioning of multiple electrode catheters, induction or attempted induction of an arrhythmia including left or right atrial pacing/recording, and intracardiac catheter ablation of atrial fibrillation by pulmonary vein isolation, including intracardiac electrophysiologic 3-dimensional mapping, intracardiac echocardiography with imaging supervision and interpretation, right ventricular pacing/recording, and His bundle recording, when performed

Medical Policy: III.219 New title: Pacemakers and defibrillators
Previous title: Biventricular pacemaker with and without ICD

Effective Date: 4/1/2026
Preauthorization Required: Yes
Policy Statement:

1. The Single Chamber and Dual Chamber Permanent Cardiac Pacemakers may be considered scientifically validated for either indication:
   1. Documented non-reversible symptomatic bradycardia due to sinus node dysfunction OR
   2. Documented non-reversible symptomatic bradycardia due to second degree and/or third degree atrioventricular block Services are investigational when the above criteria are not met.
2. The following indications are considered investigational for implanted permanent single chamber or dual chamber cardiac pacemakers:
   • Reversible causes of bradycardia such as electrolyte abnormalities, medications or drugs, and hypothermia,
   • Asymptomatic first-degree atrioventricular block,
   • Asymptomatic sinus bradycardia,
   • Asymptomatic sino-atrial block or asymptomatic sinus arrest,
   • Ineffective atrial contractions (e.g., chronic atrial fibrillation or flutter, or giant left atrium) without symptomatic bradycardia,
   • Asymptomatic second-degree atrioventricular block of Mobitz Type I unless the QRS complexes are prolonged or electrophysiological studies have demonstrated that the block is at or beyond the level of the His Bundle (a component of the electrical conduction system of the heart),
   • Syncope of undetermined cause,
   • Bradycardia during sleep,
   • Right bundle branch block with left axis deviation (and other forms of fascicular or bundle branch block) without syncope or other symptoms of intermittent atrioventricular block,
   • Asymptomatic bradycardia in post-myocardial infarction patients about to initiate long-term beta-blocker drug therapy,
   • Frequent or persistent supraventricular tachycardias, except where the pacemaker is specifically for the control of tachycardia, and
   • A clinical condition in which pacing takes place only intermittently and briefly, and which is not associated with a reasonable likelihood that pacing needs will become prolonged.

Codes:
33202 - Insertion of epicardial electrode(s); open incision (e.g., thoracotomy, median sternotomy, subxiphoid approach)

33203 - Insertion of epicardial electrode(s); endoscopic approach (e.g., thoracoscopy, pericardioscopy)

33206 - Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial

33207 - Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); ventricular

33208 - Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial and ventricular

33212 - Insertion of pacemaker pulse generator only; with existing single lead

33213 - Insertion of pacemaker pulse generator only; with existing dual leads

33214 - Upgrade of implanted pacemaker system, conversion of single chamber system to dual chamber system (includes removal of previously placed pulse generator, testing of existing lead, insertion of new lead, insertion of new pulse generator)

33215 - Repositioning of previously implanted transvenous pacemaker or implantable defibrillator (right atrial or right ventricular) electrode

33216 - Insertion of a single transvenous electrode, permanent pacemaker or implantable defibrillator

33217 - Insertion of 2 transvenous electrodes, permanent pacemaker or implantable defibrillator

33218 - Repair of single transvenous electrode, permanent pacemaker or implantable defibrillator

33220 - Repair of 2 transvenous electrodes for permanent pacemaker or implantable defibrillator

33221 - Insertion of pacemaker pulse generator only; with existing multiple leads

33223 - Relocation of skin pocket for implantable defibrillator

33224 - Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, with attachment to previously placed pacemaker or implantable defibrillator pulse generator (including revision of pocket, removal, insertion, and/or replacement of existing generator) 33225 - Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of implantable defibrillator or pacemaker pulse generator (e.g., for upgrade to dual chamber system) (List separately in addition to code for primary procedure)

33228 - Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; dual lead system

33229 - Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; multiple lead system

33230 - Insertion of implantable defibrillator pulse generator only; with existing dual leads

33231 - Insertion of implantable defibrillator pulse generator only; with existing multiple leads

33240 - Insertion of implantable defibrillator pulse generator only; with existing single lead

33241 - Removal of implantable defibrillator pulse generator only

33243 - Removal of single or dual chamber implantable defibrillator electrode(s); by thoracotomy

33244 - Removal of single or dual chamber implantable defibrillator electrode(s); by transvenous extraction

33249 - Insertion or replacement of permanent implantable defibrillator system, with transvenous lead(s), single or dual chamber

33262 - Removal of implantable defibrillator pulse generator with replacement of implantable defibrillator pulse generator; single lead system

33263 - Removal of implantable defibrillator pulse generator with replacement of implantable defibrillator pulse generator; dual lead system

33264 - Removal of implantable defibrillator pulse generator with replacement of implantable defibrillator pulse generator; multiple lead system

33270 - Insertion or replacement of permanent subcutaneous implantable defibrillator system, with subcutaneous electrode, including defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters, when performed

33271 - Insertion of subcutaneous implantable defibrillator electrode

33272 - Removal of subcutaneous implantable defibrillator electrode

33273 - Repositioning of previously implanted subcutaneous implantable defibrillator electrode

C1722 - Cardioverter-defibrillator, single chamber (implantable)

G0448 - Insertion or replacement of a permanent pacing cardioverter-defibrillator system with transvenous lead(s), single or dual chamber with insertion of pacing electrode, cardiac venous system, for left ventricular pacing 

Medical Policy: III.57 Cosmetic and reconstructive surgery

Effective Date: 4/1/2026
Preauthorization Required: No

Adding the following criteria:

2. In the absence of documentation that the service was performed to materially improve body function or to correct deformity resulting from an illness or injury, occurring after the effective date of coverage, or a congenital anomaly in the case of a newborn who is a Covered Person, the following procedures will be
   considered "Cosmetic"
   16. Cryotherapy for acne or chemical exfoliation for acne 

Codes:
17340 - Cryotherapy (CO2 slush, liquid N2) for acne
17360 - Chemical exfoliation for acne (e.g., acne paste, acid) 

Adding Interqual Criteria will be utilized for tissue transfer (flap)

Codes:
14000 - Adjacent tissue transfer or rearrangement, trunk; defect 10 sq cm or less
14001 - Adjacent tissue transfer or rearrangement, trunk; defect 10.1 sq cm to 30.0 sq cm
14020 - Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10 sq cm or less
14021 - Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10.1 sq cm to 30.0 sq cm
14040 - Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less
14041 - Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10.1 sq cm to 30.0 sq cm
14060 - Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10 sq cm or less
14061 - Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10.1 sq cm to 30.0 sq cm
14301 - Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm
14302 - Adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq cm, or part thereof (List separately in addition to code for primary procedure)
14350 - Filleted finger or toe flap, including preparation of recipient site
15570 - Formation of direct or tubed pedicle, with or without transfer; trunk
15572 - Formation of direct or tubed pedicle, with or without transfer; scalp, arms, or legs
15574 - Formation of direct or tubed pedicle, with or without transfer; forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands or feet
15576 - Formation of direct or tubed pedicle, with or without transfer; eyelids, nose, ears, lips, or intraoral
15600 - Delay of flap or sectioning of flap (division and inset); at trunk
15610 - Delay of flap or sectioning of flap (division and inset); at scalp, arms, or legs
15620 - Delay of flap or sectioning of flap (division and inset); at forehead, cheeks, chin, neck, axillae, genitalia, hands, or feet
15630 - Delay of flap or sectioning of flap (division and inset); at eyelids, nose, ears, or lips
15650 - Transfer, intermediate, of any pedicle flap (e.g., abdomen to wrist, Walking tube), any location
15730 - Midface flap (i.e., zygomaticofacial flap) with preservation of vascular pedicle(s)
15731 - Forehead flap with preservation of vascular pedicle (e.g., axial pattern flap, paramedian forehead flap)
15733 - Muscle, myocutaneous, or fasciocutaneous flap; head and neck with named vascular pedicle (i.e., buccinators, genioglossus, temporalis, masseter, sternocleidomastoid, levator scapulae)
15734 - Muscle, myocutaneous, or fasciocutaneous flap; trunk
15736 - Muscle, myocutaneous, or fasciocutaneous flap; upper extremity
15738 - Muscle, myocutaneous, or fasciocutaneous flap; lower extremity
15740 - Flap; island pedicle requiring identification and dissection of an anatomically named axial vessel
15750 - Flap; neurovascular pedicle
15922 - Excision, coccygeal pressure ulcer, with coccygectomy; with flap closure
15934 - Excision, sacral pressure ulcer, with skin flap closure
15936 - Excision, sacral pressure ulcer, in preparation for muscle or myocutaneous flap or skin graft closure
15944 - Excision, ischial pressure ulcer, with skin flap closure
15946 - Excision, ischial pressure ulcer, with ostectomy, in preparation for muscle or myocutaneous flap or skin graft closure
15952 - Excision, trochanteric pressure ulcer, with skin flap closure
15956 - Excision, trochanteric pressure ulcer, in preparation for muscle or myocutaneous flap or skin graft closure
49904 - Omental flap, extra-abdominal (e.g., for reconstruction of sternal and chest wall defects)
49905 - Omental flap, intra-abdominal (List separately in addition to code for primary procedure)

Medical Policy: III.241 Intravitreal and punctum corticosteroid implants

Effective Date: 4/1/2026
Preauthorization Required: Yes

Note: No change to the current policy, however, this policy will require preauthorization effective 4/1/2026.

1. A fluocinolone acetonide intravitreal implant 0.59 mg (Retisert^®) (J7311) may be considered Scientifically Validated for:
   1. the treatment of chronic noninfectious intermediate, posterior, or panuveitis
2. A fluocinolone acetonide intravitreal implant 0.19 mg (lluvien^®) (J7313) may be considered Scientifically Validated for:
   1. diabetic macular edema in patients who have been previously treated with a course of corticosteroids and did not have a clinically significant rise in intra-ocular pressure
3. A dexamethasone intravitreal implant 0.7 mg (Ozurdex™) (J7312) may be considered Scientifically Validated for the treatment of:
   1. noninfectious ocular inflammation, or uvetitis, affecting the intermediate or posterior segment of the eye OR
   2. macular edema following branch or central retinal vein occlusion OR
   3. diabetic macular edema
4. A fluocinolone acetonide intravitreal implant 0.59 mg (Retisert^®) (J7311) or 0.19 (lluvien^®) (J7313) or dexamethasone intravitreal implant 0.7mg (Ozurdex™) (J7312) is considered investigational for all other indications including but not limited to the following:
   1. Birdshot retinochoroidopathy
   2. Cystoid macular edema related to retinitis pigmentosa
   3. Idiopathic macular telangiectasia type 1
   4. Postoperative macular edema
   5. Circumscribed choroidal hemangiomas
   6. Proliferative vitreoretinopathy
   7. Radiation retinopathy
   8. Prophylaxis of cystoid macular edema in patients with noninfectious intermediate uveitis or posterior uveitis and cataract undergoing cataract surgery
5. A punctum dexamethasone insert .04mg (Dextenza^®) (J1096) may be considered Scientifically Validated for the treatment of:
   1. ocular inflammation and pain following ophthalmic surgery
6. A punctum dexamethasone insert .04mg (Dextenza^®) (J1096) is considered investigational for all other indications.
7. Fluocinolone acetonide intravitreal implant 0.18 mg (Yutiq^®) (J7314) is considered investigational for all indications including but not limited to chronic noninfectious
   posterior uveitis affecting the posterior segment of the eye.
8. Repeat services are considered investigational when being provided outside of the time frames because it has not been found to be safe and effective according to FDA labeling:
   1. Retisert every 2.5 years
   2. Iluvien every 3 years
   3. Ozurdex every 6 months
   4. Dextenza every 4 weeks.

Codes:
J1096 - Dexametha opth insert 0.1 mg
J7311 - Inj., retisert, 0.01 mg
J7312 - Dexamethasone intra implant
J7313 - Inj., iluvien, 0.01 mg
J7314 - Inj., yutiq, 0.01 mg

Medical Policy: III.190 New title: Evolent joint surgeries
Previous title: total knee and hip replacement

Effective Date: 4/1/2026
Preauthorization Required: Yes

Summary: Joint surgery codes require prior authorization, managed by Evolent, for hip, knee, and shoulder procedures.

Hip Procedures

Procedure	Primary Code	Additional Codes
Revision/Conversion Hip Arthroplasty	27134	27132, 27134, 27137, 27138
Total Hip Arthroplasty / Resurfacing	27130	27130, S2118
Femoroacetabular Impingement (FAI) Hip Surgery	29914	29914, 29915, 29916
Hip Surgery – Other	29863	29860, 29861, 29862, 29863

Knee Procedures

Procedure	Primary Code	Additional Codes
Revision Knee Arthroplasty	27487	27486, 27487
Total Knee Arthroplasty (TKA)	27447	27447
Partial-Unicompartmental Knee Arthroplasty (UKA)	27446	27446, 27438
Knee Manipulation under Anesthesia (MUA)	27570	27570, 29884
Knee Ligament Reconstruction/Repair	29888	27405, 27407, 27409, 27427, 27428, 27429, 29888, 29889
Knee Meniscectomy/Meniscal Repair/Transplant	29880	27332, 27333, 27403, 29868, 29880, 29881, 29882, 29883
Knee Surgery – Other	29879	27412, 27415, 27416, 27418, 27420, 27422, 27424, 27425, 29866, 29867, 29870, 29873, 29874, 29875, 29876, 29877, 29879, 29885, 29886, 29887, G0289

Shoulder Procedures

Procedure	Primary Code	Additional Codes
Revision Shoulder Arthroplasty	23474	23473, 23474
Total/Reverse Shoulder Arthroplasty/Resurfacing	23472	23472
Partial Shoulder Arthroplasty/Hemiarthroplasty	23470	23470
Frozen Shoulder Repair/Adhesive Capsulitis	29825	29825
Shoulder Labral Repair	29806	23450, 23455, 23460, 23462, 23465, 23466, 29806, 29807
Shoulder Rotator Cuff Repair	29827	23410, 23412, 23420, 29827
Shoulder Surgery – Other	23415	23120, 23125, 23130, 23405, 23415, 23430, 23700, 29805, 29819, 29820, 29821, 29822, 29823, 29824, 29825, +29826, 29828