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Blepharoplasty, Blepharoptosis Repair and Brow Lift
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Utilization
Management
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Re-reviewed |
08/21/2023
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Medically necessary for a select population of patients
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Added to medical necessity criteria:
1) Indications for blepharoplasty (upper)/ blepharoptosis repair/ brow lift:
Under sections IB., IIB., and IIIC. --- added as an example “recent botulinum injections in the past six months”.
2) Indications for brow lift:
a) Under III A. And III D.3. added --- “descent below
the level of the superior orbital rim”.
b) Under III D.1. added --- “and/or blepharoptosis
repair”.
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Uvulopalatopharyngoplasty (UPPP or U3P) for Obstructive Sleep Apnea/Hypopnea Syndrome
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Utilization
Management
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Re-Reviewed
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06/19/2023
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Medically necessary for a select population of patients |
UPPP is considered medically necessary for individuals 18 years of age and older with a confirmed diagnosis of Obstructive Sleep Apnea/Hypopnea Syndrome (OSAHS), when
Sleep study performed within the last 3 years indicates one of the following:
- Mild OSAHS with AHI or RDI between 5-14.9 events per hour of sleep, all of the following are met:
a. Intermittent oxyhemoglobin desaturation less than 90% and CT90 at 3% of sleep time or greater.
b. Presence of one or more of the following sleep associated symptoms and/or conditions:
1) Excessive daytime sleepiness documented using a validated sleepiness scale (e.g., Epworth Sleepiness Scale (ESS) > 10; STOP-BANG questionnaire > 2; or other validated scale), that interferes with daily activity or work (e.g., causes safety issues)
2) Impaired neurocognitive function, mood disorders, or insomnia
3) Cardiovascular disease (e.g., history of hypertension, ischemic heart disease, stroke, congestive heart failure, atrial fibrillation, or type 2 diabetes).
- Moderate to severe OSAHS with AHI or RDI value of 15 or more events per hour of sleep.
Note: The physical examination must demonstrate upper airway narrowing, collapse, or obstruction of the retropalatal region (uvula, distal portion of the soft palate, posterior tonsillar pillars, and redundant lateral pharyngeal wall mucosa), as reasonable cause of obstructive sleep apnea (e.g., determined but not limited to nasopharyngoscopy or cephalometry studies).
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Surgical and Minimally Invasive Treatments for Benign Prostatic Hypertrophy/ Hyperplasia (BPH) |
Coverage |
Re-Reviewed
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06/21/2023 |
Covered for some indications; investigative and therefore not covered for all other indications
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New determinations:
• Waterjet tissue ablation (e.g., AquaBeam® Robotic System), also known as aquablation therapy, is not investigative for the treatment of benign prostatic hypertrophy/hyperplasia (BPH).
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