Providers

Medical Policy Upcoming Updates

Notification Date: April 20, 2022

Below are the policies that are new or have been reviewed, along with the determination and summary of any changes.

Policy Title	Status	Effective Date	Determination	Summary of Change
Bariatric Surgery (III-SUR.30)	Re-Reviewed	05/16/2022 Enhanced Benefit	Medically necessary for a select population of patients	The following two comorbidities have been added for individuals with a BMI between 35 and 39.9: Non-alcoholic steatohepatitis (NASH) Non-alcoholic fatty liver disease (NAFLD) All other criteria remain as previously determined.

Policy Title

Status

Effective Date

Determination

Summary of Change

Bariatric Surgery (III-SUR.30)

Re-Reviewed

05/16/2022

Enhanced Benefit

Medically necessary for a select population of patients

The following two comorbidities have been added for individuals with a BMI between 35 and 39.9:

Non-alcoholic steatohepatitis (NASH)
Non-alcoholic fatty liver disease (NAFLD)

All other criteria remain as previously determined.

Policy Title	Status	Effective Date	Determination
Office-Based Cryoablation for Chronic Rhinitis (e.g., ClariFix)	New	06/20/2022	Investigative and therefore not covered

Policy Title

Status

Effective Date

Determination

Office-Based Cryoablation

for Chronic Rhinitis (e.g., ClariFix)

New

06/20/2022

Investigative and therefore not covered