UnitedHealthcare Commercia l Medical Policy Update Bulletin: July 2021 In This Issue Take Note Page InterQual® 2021 Clinical Criteria Release • Abnormal Uterine Bleeding and Uterine Fibroids ............................................................................................................................................................................................................ 4 • Airway Clearance Devices ................................................................................................................................................................................................................................................... 4 • Articular Cartilage Defect Repairs ...................................................................................................................................................................................................................................... 4 • Attended Polysomnography for Evaluation of Sleep Disorders ..................................................................................................................................................................................... 4 • Catheter Ablation for Atrial Fibrillation............................................................................................................................................................................................................................... 4 • Continuous Glucose Monitoring and Insulin Delivery for Managing Diabetes ............................................................................................................................................................ 4 • Cosmetic and Reconstructive Procedures ....................................................................................................................................................................................................................... 4 • Deep Brain and Cortical Stimulation.................................................................................................................................................................................................................................. 4 • Hysterectomy......................................................................................................................................................................................................................................................................... 4 • Implanted Electrical Stimulator for Spinal Cord ............................................................................................................................................................................................................... 4 • Minimally Invasive Procedures for Gastroesophageal Reflux Disease (GERD) and Achalasia................................................................................................................................. 4 • Obstructive Sleep Apnea Treatment.................................................................................................................................................................................................................................. 4 • Orthognathic (Jaw) Surgery................................................................................................................................................................................................................................................. 4 • Plagiocephaly and Craniosynostosis Treatment .............................................................................................................................................................................................................. 4 • Pneumatic Compression Devices ...................................................................................................................................................................................................................................... 4 • Rhinoplasty and Other Nasal Surgeries ............................................................................................................................................................................................................................ 4 • Surgery of the Hip ................................................................................................................................................................................................................................................................. 4 • Surgical and Ablative Procedures for Venous Insufficiency and Varicose Veins ........................................................................................................................................................ 4 • Temporomandibular Joint Disorders ................................................................................................................................................................................................................................. 4 • Total Artificial Disc Replacement for the Spine................................................................................................................................................................................................................ 4 Quarterly CPT® and HCPCS Code Updates • Am ondys 45™ (Casimersen) ................................................................................................................................................................................................................................................ 5 • Cardiac Event Monitoring .................................................................................................................................................................................................................................................... 5 Page 1 of 41 UnitedHealthcare Commercial Medical Policy Update Bulletin: July 2021 In This Issue • Evkeeza™ (Evinacumab-Dgnb) ............................................................................................................................................................................................................................................ 5 • Gonadotropin Releasing Hormone Analogs ..................................................................................................................................................................................................................... 5 • Infertility Diagnosis and Treatment..................................................................................................................................................................................................................................... 5 • Long-Acting Injectable Antiretroviral Agents for HIV ....................................................................................................................................................................................................... 5 • Molecular Oncology Testing for Cancer Diagnosis, Prognosis, and Treatment Decisions ....................................................................................................................................... 5 • Oncology Medication Clinical Coverage ........................................................................................................................................................................................................................... 5 • Oxlumo™ (Lumasiran) ........................................................................................................................................................................................................................................................... 5 • Preimplantation Genetic Testing ........................................................................................................................................................................................................................................ 5 • Provider Administered Drugs – Site of Care ..................................................................................................................................................................................................................... 5 • Rituximab (Riabni™, Rituxan®, Ruxience ®, & Truxima ®) .................................................................................................................................................................................................... 5 • Transcatheter Heart Value Procedures ............................................................................................................................................................................................................................. 5 • Vertebral Body Tethering for Scoliosis .............................................................................................................................................................................................................................. 5 Medical Policy Updates Updated • Cardiac Event Monitoring – Effective Jul. 1, 2021 ........................................................................................................................................................................................................... 6 • Carrier Testing for Genetic Diseases – Effective Jul. 1, 2021 .......................................................................................................................................................................................