Providers

Medical Policy Upcoming Updates

Notification Date: June 19, 2024

Utilization Management Policies	Policy Type	Status	Effective Date	Determination	Summary of Changes
Female Breast Reduction Surgery – Reduction Mammoplasty	Utilization Management	Re-Reviewed	08/19/2024	Medically necessary for a select population of patients	*In addition to* the required pre-service negative mammogram for women over 40 years of age, the following criteria have been added: The imaging can be either a mammogram or other appropriate imaging (e.g., MRI), *and* The following age category has been added: Women 30 to 40 years of age who have a first-degree family history of breast cancer at high-risk due to a known or suspected genetic mutations (e.g., BRCA1/2).

Utilization Management Policies

Policy Type

Status

Effective Date

Determination

Summary of Changes

Female Breast Reduction Surgery – Reduction Mammoplasty

Utilization Management

Re-Reviewed

08/19/2024

Medically necessary for a select population of patients

In addition to the required pre-service negative mammogram for women over 40 years of age, the following criteria have been added:

The imaging can be either a mammogram or other appropriate imaging (e.g., MRI), and
The following age category has been added:
- Women 30 to 40 years of age who have a first-degree family history of breast cancer at high-risk due to a known or suspected genetic mutations (e.g., BRCA1/2).

Coverage Policies	Policy Type	Status	Effective Date	Determination	Summary of Changes
Eye-Movement Analysis without Spatial Calibration (e.g., EyeBOX® system)	Coverage	New	08/19/2024	Investigative and therefore not covered	Investigative for the diagnosis of mild traumatic brain injury or concussion. Reliable evidence does not permit conclusions concerning its effectiveness.
Genetic Testing – 27 total policies	Coverage	Re-Review	07/01/2024	Covered for some indications; investigative and therefore not covered for all other indications	Changes reflect updated and validated genetic testing clinical criteria by Concert Genetics, an industry-leader in genetic testing technology assessment and policy development. Changes to coverage determinations are policy dependent. Refer to specific coverage policies for further information.

Coverage Policies

Policy Type

Status

Effective Date

Determination

Summary of Changes

Eye-Movement Analysis without Spatial Calibration (e.g., EyeBOX® system)

Coverage

New

08/19/2024

Investigative and therefore not covered

Investigative for the diagnosis of mild traumatic brain injury or concussion. Reliable evidence does not permit conclusions concerning its effectiveness.

Genetic Testing – 27 total policies

Coverage

Re-Review

07/01/2024

Covered for some indications; investigative and therefore not covered for all other indications

Changes reflect updated and validated genetic testing clinical criteria by Concert Genetics, an industry-leader in genetic testing technology assessment and policy development.

Changes to coverage determinations are policy dependent.

Refer to specific coverage policies for further information.