Medical Policy Update

Revised Medical Policies

Medical Policy:  IV.62 Computed Tomography Angiography (CTA) 

Effective Date: 2/15/2026
Preauthorization Required: Yes

1. Computed tomography angiography of the coronary arteries may be considered medically necessary for ANY of the following indications:
   1. Evaluation of a member with no known CAD, who presents with suspected cardiac chest pain and has a low to intermediate pretest probability of CAD based on Framingham risk scoring or American College of Cardiology (ACC) criteria.
   2. Evaluation of a member with no known CAD, who is asymptomatic and has an intermediate pretest probability of CAD based on Framingham risk scoring or American College of Cardiology (ACC) criteria.
   3. Evaluation of a member with or without CAD in whom exercise stress testing, stress echo or stress nuclear scan (including SPECT) is equivocal or indeterminate.
   4. Evaluation of a member with suspected cardiac chest pain or angina equivalent e.g., dyspnea, who has a history of coronary artery bypass graft surgery (CABG) or coronary artery stent placement.
   5. Evaluation of a member to exclude CAD as the cause of ANY of the following clinical presentations:
      1. Left bundle branch block (LBBB) OR
      2. Congestive heart failure (CHF) OR
      3. Systolic or Diastolic Myocardial Dysfunction.
   6. Evaluation of suspected congenital anomalies of the coronary arteries.
   7. Evaluation of a member with suspected arrhythmogenic Right ventricular dysplasia (ARVD) to assess Right ventricular function and morphology.
   8. Pre-operative evaluation of a member scheduled to undergo surgery for ANY of the following conditions:  
      1. valvular heart disease OR
      2. congenital heart disease OR
      3. pericardial disease.
   9. Pre-operative evaluation of a member scheduled to undergo surgery that is considered to be “high risk” due to ANY of the following:
      1. member is elderly OR
      2. emergency operation OR
      3. major vascular surgery such as aorta or other large vessels OR
      4. major surgery involving the chest or abdomen
   10. Pre-operative evaluation of the aortic valve annulus prior to transcatheter aortic valve replacement (TAVR).
2. Computed tomography angiography (CTA) of the coronary arteries for all other indications not listed above is considered Investigational as its effectiveness for other indications has not been established.
3. The use of noninvasive fractional flow reserve following a positive coronary computed tomography angiography (75580) may be considered medically necessary to guide decisions about the use of invasive coronary angiography in individuals with stable chest pain at intermediate risk of coronary artery disease (i.e., suspected or presumed stable ischemic disease).
4. The use of noninvasive fractional flow reserve (75580) not meeting the criteria outlined above is considered investigational.

Adding code: 75580

Medical Policy:  IV.78 Bone Mineral Density Measurement 

Effective Date: 2/15/2026
Preauthorization Required: Yes

1. Peripheral (lower arm, wrist, finger, or heel) bone mineral density (BMD) (77081) testing may be considered medically necessary when conventional central (hip/spine) DXA screening is not feasible or in the management of hyperparathyroidism where peripheral DXA at the forearm (i.e., radius) is essential for evaluation.
2. Screening for osteoporosis using Quantitative Computed Tomography (QCT) (77078), Ultrasound Densitometry and/or Vertebral Fracture Densitometry (77085, 77086, 76777) are Investigational.
3. Bone density study using single or dual photon absorptiometry (78350, 78351) is Investigational.
4. Trabecular Bone Scores (77089, 77090, 77091, 77092) are considered Investigational.

Medical Policy:  I.200 Amniotic Membrane and Amniotic Fluid

Effective Date: 2/15/2026
Preauthorization Required: No

1. The use of amniotic membrane using the following products (Affinity^®, AmnioBand^® Membrane, Biovance^®, EpiCord^®, EpiFix^®, Grafix™, NuShield^®) is considered scientifically validated for the following indications:
   1. Diabetic lower extremity ulcers OR
   2. Neurotrophic keratitis OR
   3. Corneal ulcers and melts OR
   4. Pterygium repair OR
   5. Stevens-Johnson syndrome of the eye OR
   6. Persistent epithelial defects of the eye OR
   7. Difficult to heal chronic venous partial and full-thickness ulcers of the lower extremity that have failed standard wound therapy greater than 4-weeks duration.
2. The use of human amniotic membrane is considered investigational for all other indications.
3. The use of human amniotic fluid injection is considered investigational for all indications.

Medical Policy:  I.202 Bioengineered Skin and Soft Tissue Substitutes

Effective Date: 2/15/2026
Preauthorization Required: No 
Bioengineered Skin and Soft Tissue Substitutes

1. The use of bioengineered skin and soft tissue substitutes is considered scientifically validated for the following indications:
   1. Breast reconstruction(including each of the following: AlloDerm^®, Cortiva^® [AlloMax™], DermACELL™, DermaMatrix™, FlexHD^®, FlexHD^® Pliable™ ) OR
   2. Diabetic lower extremity ulcers (AlloPatch^®a, Apligraf^®, Dermagraft^®, Integra® Omnigraft™ Dermal Regeneration Matrix (also known as Omnigraft™), and Integra Flowable Wound Matrix, mVASC^®, TheraSkin^®) OR
   3. Venous insufficiency lower extremity ulcers (Apligraf^®, Oasis™ Wound Matrix) OR
   4. Dystrophic epidermolysis bullosa (OrCel™ (for the treatment of mitten-hand deformity when standard wound therapy has failed and when provided in accordance with the humanitarian device exemption [HDE] specifications of the U.S. Food and Drug Administration [FDA]) OR
   5. Second- or third-degree burns (Epicel^® (for the treatment of deep dermal or full-thickness burns comprising a total body surface area ≥30% when provided in accordance with the HDE specifications of the FDA), Integra^® Dermal Regeneration Template.
2. The use of bioengineered skin and soft tissue substitutes is considered investigational for all other indications.

Autologous Cell Harvesting Device

1. Autologous cell harvesting device (e.g., RECELL system) is considered scientifically validated for the treatment of 2nd and 3rd degree burns when the following criteria is met:
   1. ONE of the following:
      1. acute partial thickness (2nd and 3rd degree burns in patients 18 years of age and older OR
      2. in combination with meshed autografting for acute full thickness thermal burn wounds in pediatric or adult patients with 3rd degree burns, AND
   2. The member has NONE of the following contraindications
      1. wounds clinically diagnosed as infected or with necrotic tissue present in the wound bed AND
      2. patients with a known hypersensitivity to trypsin or compound sodium lactate solution (e.g., Hartmann's Solution AND
      3. patients with a known hypersensitivity to anesthetics, adrenaline/epinephrine, povidone-iodine or chlorhexidine solutions AND
2. All other uses of autologous cell harvesting device (RECELL system) is considered investigational.

Medical Policy:  VII.35 Oscillatory devices for the treatment of respiratory

DISORDERS
Effective Date: 2/15/2026
Preauthorization Required: Yes
Policy

Medical Policy:  III.62 Surgeries for obstructive sleep apnea

Effective Date: 2/15/2026
Preauthorization Required: Yes
Updating Criteria:

2. Unilateral Hypoglossal nerve stimulation (e.g., Inspire^® Upper Airway Stimulation Device) may be considered medically necessary for the following:
   1.  Adults age ≥ 21 years, AND all of the following
      1. AHI ≥ 15 with less than 20% central apneas, AND
      2. Trial and failure or intolerance of CPAP, AND
      3. Body mass index ≤ 32 kg/m2, AND
      4. Non-concentric retropalatal obstruction on drug-induced sleep endoscopy; OR
   2. Adolescents with Down syndrome age 10 to 21 years, AND all of the following:
      1. AHI >10 and <50, with less than 25% central apneas after prior adenotonsillectomy, AND
      2. Tracheotomy, or failure or intolerance of CPAP; AND
      3. Body mass index ≤ 95th percentile for age; AND
      4. Non-concentric retropalatal obstruction on drug-induced sleep endoscopy.
3. The use of the bilateral hypoglossal nerve stimulation (e.g., Genio Device) is investigational.