Medical Policy Update March 2019

New:

MYvantage^® Hereditary Comprehensive Cancer Panel

Doula Services — Medicaid

Revised:

Urine Drug/Alcohol Testing

• Removed guideline applicability solely to HMO
• Clarified test types/technical methodologies
• Updated Parent Drugs and Metabolite Chart in Appendix

Gene Expression Profiling

• Added Clonoseq^® for Medicare members
• Removed MYvantage from Limitations/Exclusions and added link to the MYvantage^®Hereditary Comprehensive Cancer Panel Medical Guideline

Obstructive Sleep Apnea Diagnosis and Treatment

• Added the following indications to the attended PSG section for adults:
  • cognitive/physical impairment
  • suspected/established diagnosis of:
    • central sleep apnea
    • periodic limb movement disorder
    • narcolepsy
    • idiopathic hypersomnia
    • parasomnia or nocturnal seizures
  • chronic opiate use
  • oxygen dependency
• Added positive coverage criteria for hypoglossal nerve stimulation (HGNS)

Acupuncture – Medicare benefit update
Beginning on January 1, 2019 Acupuncture is a covered benefit for the following Medicare plans:

• EmblemHealth VIP Essential (HMO)
• VIP Dual (HMO SNP)
• VIP Premier (HMO)
• VIP Rx Carve Out (HMO) - Group Medicare plans for City of New York retirees
• Affinity Medicare Passport Essentials (HMO)
• Affinity Medicare Passport Essentials NYC (HMO)

To provide acupuncture benefits to these Medicare members, you must be a participating provider of EmblemHealth VIP Prime Network.