Medical Policy

Policy updates

The Plan uses medical policies as guidelines for coverage decisions within the member’s written benefits. Below are summaries of recent changes to The Plan’s medical policies. The detailed policies and complete Medical Policy Manual are available online at bridgespanhealth.com. We have included the section and policy number for your convenience.

Last updated: July 1, 2025
Policy name	Summary of policy or change	Effective date	Section and policy number	Coding or implementation change	Pre-authorization change
Patient Lifts and Seat Lifts	New policy addressing patient lifts and seat lifts will apply only to Individual members.	September 1, 2025	Durable Medical Equipment #23	Adding HCPCS codes E0625, E0627, E0629, E0630, E0635, E0636, E0639, E0640, E1035, E1036 with preauth requirement for this policy for Individual Line of Business only.	Adding codes E0625, E0627, E0629, E0630, E0635, E0636, E0639, E0640, E1035, E1036 to the preauth website for Individual Line of Business only.
Identification of Microorganisms Using Nucleic Acid Probes	Updating criteria for large respiratory panel tests (>12 targets) to be considered not medically necessary.	September 1, 2025	Genetic Testing #85	Changing edit on CPT codes 0115U, 0202U, 0223U, 0225U 0373U, 87633 from investigational to not medically necessary for this medical policy.	N/A
New and Emerging Medical Technologies and Procedures	Removed two codes that have been moved into new medical policy SUR237 - Travoprost Drug-eluting Ocular Implants for the Treatment of Glaucoma.	September 1, 2025	Medicine #149	Removing CPT codes 0660T, 0661T from this medical policy, effective 9/1/2025 and moving to new policy SUR237.	N/A
Travoprost Drug-eluting Ocular Implants for the Treatment of Glaucoma	New policy addressing Travoprost Drug-eluting Ocular Implants for the Treatment of Glaucoma.	September 1, 2025	Surgery #237	Adding CPT codes 0660T, 0661T to this policy and continue investigational denial. Adding HCPCS code J7355 to this policy and add investigational denial.	N/A
Power Wheelchairs: Group 2 and Group 3	Changed policy title; policy was previously titled Power Wheelchairs: Group 3 Adding group 2 criteria and codes to the policy with this update	August 1, 2025	Durable Medical Equipment #37	Adding HCPCS codes K0820, K0821, K0822, K0823, K0824, K0825, K0826, K0827, K0828, K0829, K0830, K0831, K0835, K0836, K0837, K0838, K0839, K0840, K0841, K0842, K0843 with preauth requirement for this policy for Individual Line of Business only.	Adding codes K0820, K0821, K0822, K0823, K0824, K0825, K0826, K0827, K0828, K0829, K0830, K0831, K0835, K0836, K0837, K0838, K0839, K0840, K0841, K0842, K0843 to the preauth website for Individual Line of Business only.
Augmentative Communication Devices and Systems	New medical policy with medical necessity criteria will apply only to Individual members.	August 1, 2025	Durable Medical Equipment #52	Adding HCPCS codes E2500, E2502, E2504, E2506, E2508, E2510, E2511, E2512 with preauth requirement for this policy for Individual Line of Business only. Continue unlisted review on code E2599.	Adding codes E2500, E2502, E2504, E2506, E2508, E2510, E2511, E2512 to the preauth website for Individual Line of Business only.
Spinal Orthoses: Thoracic-Lumbar-Sacral (TLSO), Lumbar-Sacral (LSO), and Lumbar	New medical policy with medical necessity criteria will apply only to Individual members.	August 1, 2025	Durable Medical Equipment #97	Adding HCPCS codes L0452, L0454, L0456, L0460, L0466, L0468, L0480, L0482, L0484, L0486, L0626, L0627, L0629, L0630, L0631, L0632, L0633, L0634, L0636, L0637, L0638, L0639, L0640 with preauth requirement for this policy for Individual Line of Business only.	Adding codes L0452, L0454, L0456, L0460, L0466, L0468, L0480, L0482, L0484, L0486, L0626, L0627, L0629, L0630, L0631, L0632, L0633, L0634, L0636, L0637, L0638, L0639, L0640 to the preauth website for Individual Line of Business only.
Testosterone Testing	New lab policy for testosterone testing.	August 1, 2025	Laboratory #81	Adding CPT codes 84402, 84410 as not medically necessary when frequency values are exceeded over a rolling 365 days. Adding CPT code 84403 with no clinical edit.	N/A
Mental Health and Eating Disorders	New policy establishes the intensity of service (IOS) standards.	July 1, 2025	Behavioral Health #36	Policy uses revenue codes only: 0124, 1001, 0905, 0912, 0913 with no edit.	N/A
Negative Pressure Wound Therapy in the Outpatient Setting	Adding indications for coverage, Clarifying criteria addressing nutritional status, and Adding criteria and required documentation for evaluation of arterial status for neuropathic ulcers.	July 1, 2025	Durable Medical Equipment #42	N/A	N/A
Invasive Prenatal Fetal Diagnostic Testing for Chromosomal Abnormalities	Removed fetal tissue testing for ultrasound anomalies, which will be addressed in GT79 - Genetic Testing for the Evaluation of Products of Conception and Pregnancy Loss.	July 1, 2025	Genetic Testing #78	N/A	N/A
Genetic Testing for the Evaluation of Products of Conception and Pregnancy Loss	Added a phrase to criterion I to clarify fetal testing after pregnancy termination is addressed in this policy, not GT78 - Invasive Prenatal Fetal Diagnostic Testing for Chromosomal Abnormalities.	July 1, 2025	Genetic Testing #79	N/A	N/A
Investigational Gene Expression, Biomarker, and Multianalyte Testing	Added the IGoCheck and MammoCheck tests from Milagen, Inc. to the policy.	July 1, 2025	Laboratory #77	Added new Q3 CPT codes 0558U, 0559U to this policy with always investigational edit.	N/A
Cardiac Hemodynamic and Thoracic Fluid Index Monitoring for the Management of Heart Failure in the Outpatient Setting	Added new investigational technology.	July 1, 2025	Medicine #33	Added new Q3 CPT codes 0981T, 0982T, 0983T to this policy with always investigational edit.	N/A
New and Emerging Medical Technologies and Procedures	Updated the policy in alignment with the 2025 Q3 annual code update.	July 1, 2025	Medicine #149	Added new Q3 CPT codes 0948T, 0949T, 0951T, 0952T, 0953T, 0954T, 0955T, 0961T, 0962T, 0963T, 0967T, 0972T, 0978T, 0979T, 0980T, 0984T, 0985T, 0986T, 0987T to this policy with always investigational edit.	N/A
Wireless Capsule Endoscopy for Gastrointestinal (GI) Disorders	Policy updated to address upper gastrointestinal optical sensor capsule.	July 1, 2025	Radiology #38	Added new Q3 CPT code 0977T to this policy with always investigational edit.	N/A
Electromagnetic Navigation Bronchoscopy	New policy created to address electromagnetic navigation bronchoscopy.	July 1, 2025	Surgery #179	Adding CPT codes 31626, 31627 and HCPCS codes C7509, C7510, C7511, C9751 with preauth for this medical policy. Adding HCPCS code A4648 and continue no clinical edit on this code.	Adding CPT codes 31626, 31627 and HCPCS codes C7509, C7510, C7511, C9751 to the preauth website for this medical policy.
Responsive Neurostimulation	Added criterion to address the use of epicranial neurostimulation (e.g., EASEE)	July 1, 2025	Surgery #216	Added new Q3 CPT codes 0968T, 0969T to this policy with always investigational edit.	N/A
Long-Term Sub-Scalp Electroencephalography Monitoring Systems	New policy.	July 1, 2025	Surgery #239	Added new Q3 CPT codes 0956T, 0957T, 0958T, 0959T, 0960T to this policy with always investigational edit.	N/A
Percutaneous Laser Ablation of Benign and Malignant Breast Tumors	New policy.	July 1, 2025	Surgery #240	Added new Q3 CPT codes 0970T, 0971T to this policy with always investigational edit.	N/A
Air Ambulance Transport	Expanding post-service review of rotary air ambulance.	July 1, 2025	Utilization Management #13	N/A	N/A
New and Emerging Medical Technologies and Procedures	Removed two codes that have been moved into new medical policy MED178 - Histotripsy for Hepatic or Renal Tumor Treatment, and Removed one code that is addressed in SUR221 - Transcatheter Heart Valve Procedures for Mitral or Tricuspid Valve Disorders excluding Transcatheter Edge to Edge Repair TEER.	June 1, 2025	Medicine #149	Removed CPT codes 0686T, 0888T from this policy and moved to MED178, with no change to the edit. Removed CPT 0545T from this policy that was left in error when it was moved to SUR221 with Q3 code updates effective 7/1/2024.	N/A
Histotripsy for Hepatic or Renal Tumor Treatment	New policy addressing Histotripsy for Hepatic or Renal Tumor Treatment.	June 1, 2025	Medicine #178	Moved CPT codes 0686T, 0888T to this medical policy from MED149 and continue investigational denial.	N/A
Bariatric Surgery	Added criterion for revision of sleeve gastrectomy due to medication resistant gastroesophageal reflux disease.	June 1, 2025	Surgery #58	N/A	N/A
Transcutaneous Bone-Conduction and Bone-Anchored Hearing Aids	Clarified criteria. Updated minimum age for Osia system.	June 1, 2025	Surgery #121	N/A	N/A
Noninvasive Prenatal Testing to Determine Fetal Aneuploidies, Microdeletions, Single-Gene Disorders, and Twin Zygosity	Combined investigational criteria in the policy.	May 1, 2025	Genetic Testing #44	N/A	N/A
Mechanical Residual Limb Volume Management System for Upper Extremity Prostheses	New policy for mechanical residual limb volume management systems (e.g., RevoFit) for upper extremity prostheses.	April 1, 2025	Durable Medical Equipment #98	Added new Q2 HCPCS code L7406 as always not medically necessary for this policy.	N/A
Evaluating the Utility of Genetic Panels	Added 13 investigational panel tests Removed 101 tests from the policy.	April 1, 2025	Genetic Testing #64	Added new Q2 CPT 0533U with investigational denial for this policy.	N/A
Investigational Gene Expression, Biomarker, and Multianalyte Testing	Added the myOLARIS™-KTdx to the policy Changed the DetermaRx test to the new name, RiskReveal.	April 1, 2025	Laboratory #77	Added new Q2 CPT 0542U with investigational denial for this policy.	N/A
Intensity Modulated Radiotherapy (IMRT) of the Thorax, Abdomen, Pelvis, and Extremities	Clarified criteria regarding pancreatic cancer and prostate cancer.	April 1, 2025	Medicine #165	N/A	N/A
Orthognathic Surgery	Clarified policy criteria for functional impairments and documentation of orthodontic treatment.	April 1, 2025	Surgery #137	N/A	N/A
Targeted Genetic Testing for Selection of Therapy for Non-Small Cell Lung Cancer (NSCLC)	Added NRG1 fusion testing to policy.	March 1, 2025	Genetic Testing #56	N/A	N/A
Screening Laboratory Testing	New policy addressing screening laboratory testing in asymptomatic individuals.	March 1, 2025	Laboratory #80	Adding CPT codes: 82310, 82330, 82340, 82670, 82681, 82728, 82977, 83540, 83550, 83735, 83970, 83993, 84100, 84105, 84402, 84403, 84410, 84443, 84466, 85651, 85652, 86038, 86039, 86140, 86225, 86235 to the policy with no edit. This will be implemented as an automatic denial for the CPT codes listed when billed with the diagnosis code Z00.00 as a sole diagnosis code.	N/A
Extracorporeal Membrane Oxygenation (ECMO) for the Treatment of Cardiac and Respiratory Failure in Adults	Updated policy to address continuation of ECMO. NOTE: URL for this policy was removed as the policy was archived effective June 1, 2025.	March 1, 2025	Medicine #152	N/A	N/A
Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease (GERD)	Updated policy to address the GERDX-System for transoral incisionless fundoplication for treatment of GERD.	March 1, 2025	Surgery #110	N/A	N/A
Cryosurgical Ablation of Miscellaneous Solid Tumors Outside of the Liver	Added medical necessity criteria for cryoablation of certain desmoid tumors.	March 1, 2025	Surgery #132	N/A	N/A
Sacral Nerve Neuromodulation (Stimulation) for Pelvic Floor Dysfunction	Clarified criteria without change to policy intent.	March 1, 2025	Surgery #134	Added HCPCS codes C1778, C1883 with no clinical edit.	N/A
Surgical Site of Care - Hospital Outpatient	Added joint procedure codes that were formerly reviewed by eviCore.	March 1, 2025	Utilization Management #19	Adding CPT codes: 20520, 20525, 20670, 20680, 20693, 20694, 23415, 23450, 23460, 23465, 23515, 23550, 23615, 23630, 23655, 23665, 24105, 24305, 24340, 24341, 24342, 24343, 24345, 24346, 24357, 24358, 24359, 24505, 24516, 24530, 24538, 24545, 24546, 24575, 24579, 24586, 24605, 24620, 24635, 24655, 24665, 24666, 24685, 25000, 25107, 25111, 25112, 25118, 25210, 25215, 25240, 25260, 25270, 25280, 25290, 25295, 25310, 25320, 25360, 25390, 25447, 25505, 25515, 25545, 25565, 25574, 25575, 25600, 25605, 25606, 25607, 25608, 25609, 25628, 25645, 25652, 25825, 26011, 26020, 26055, 26080, 26121, 26123, 26145, 26160, 26236, 26320, 26340, 26350, 26356, 26370, 26410, 26418, 26426, 26440, 26445, 26480, 26516, 26520, 26525, 26540, 26541, 26608, 26615, 26650, 26665, 26676, 26725, 26727, 26735, 26746, 26756, 26765, 26785, 26850, 26860, 26951, 26952, 27335, 27424, 27605, 27606, 27612, 27620, 27625, 27626, 27650, 27652, 27654, 27659, 27675, 27676, 27680, 27685, 27687, 27690, 27691, 27695, 27696, 27698, 27705, 27752, 27762, 27766, 27769, 27781, 27784, 27786, 27788, 27792, 27810, 27814, 27818, 27822, 27823, 27840, 28002, 28005, 28008, 28010, 28022, 28035, 28060, 28062, 28080, 28086, 28090, 28092, 28110, 28112, 28113, 28116, 28118, 28119, 28120, 28122, 28124, 28160, 28190, 28192, 28200, 28208, 28230, 28232, 28234, 28238, 28250, 28270, 28272, 28285, 28288, 28289, 28291, 28292, 28295, 28296, 28297, 28298, 28299, 28300, 28304, 28306, 28308, 28310, 28313, 28315, 28322, 28415, 28445, 28465, 28475, 28476, 28485, 28505, 28515, 28525, 28555, 28585, 28615, 28645, 28715, 28725, 28740, 28750, 28755, 28810, 28820, 28825, 29834, 29837, 29838, 29844, 29846, 29848 which are moving from eviCore joint Site of Care to this policy, (UM19) with preauth edit	Adding CPT codes: 20520, 20525, 20670, 20680, 20693, 20694, 23415, 23450, 23460, 23465, 23515, 23550, 23615, 23630, 23655, 23665, 24105, 24305, 24340, 24341, 24342, 24343, 24345, 24346, 24357, 24358, 24359, 24505, 24516, 24530, 24538, 24545, 24546, 24575, 24579, 24586, 24605, 24620, 24635, 24655, 24665, 24666, 24685, 25000, 25107, 25111, 25112, 25118, 25210, 25215, 25240, 25260, 25270, 25280, 25290, 25295, 25310, 25320, 25360, 25390, 25447, 25505, 25515, 25545, 25565, 25574, 25575, 25600, 25605, 25606, 25607, 25608, 25609, 25628, 25645, 25652, 25825, 26011, 26020, 26055, 26080, 26121, 26123, 26145, 26160, 26236, 26320, 26340, 26350, 26356, 26370, 26410, 26418, 26426, 26440, 26445, 26480, 26516, 26520, 26525, 26540, 26541, 26608, 26615, 26650, 26665, 26676, 26725, 26727, 26735, 26746, 26756, 26765, 26785, 26850, 26860, 26951, 26952, 27335, 27424, 27605, 27606, 27612, 27620, 27625, 27626, 27650, 27652, 27654, 27659, 27675, 27676, 27680, 27685, 27687, 27690, 27691, 27695, 27696, 27698, 27705, 27752, 27762, 27766, 27769, 27781, 27784, 27786, 27788, 27792, 27810, 27814, 27818, 27822, 27823, 27840, 28002, 28005, 28008, 28010, 28022, 28035, 28060, 28062, 28080, 28086, 28090, 28092, 28110, 28112, 28113, 28116, 28118, 28119, 28120, 28122, 28124, 28160, 28190, 28192, 28200, 28208, 28230, 28232, 28234, 28238, 28250, 28270, 28272, 28285, 28288, 28289, 28291, 28292, 28295, 28296, 28297, 28298, 28299, 28300, 28304, 28306, 28308, 28310, 28313, 28315, 28322, 28415, 28445, 28465, 28475, 28476, 28485, 28505, 28515, 28525, 28555, 28585, 28615, 28645, 28715, 28725, 28740, 28750, 28755, 28810, 28820, 28825, 29834, 29837, 29838, 29844, 29846, 29848 to the preauth website for this policy.
Lumbar Spinal Fusion	Clarifying documentation requirements for: Conservative therapy, and Documenting tobacco use status.	February 1, 2024	Surgery #187	N/A	N/A

Recently archived policies
Policy name	Archive date	Policy number
Treatment of Adult Sepsis	07/01/2025	Medicine #172
Extracorporeal Membrane Oxygenation (ECMO) for the Treatment of Cardiac and Respiratory Failure in Adults	06/01/2025	Medicine #152
Radioembolization, Transarterial Embolization (TAE), and Transarterial Chemoembolization (TACE)	05/01/2025	Medicine #140
Ovarian, Internal Iliac, and Gonadal Vein Embolization, Ablation, and Sclerotherapy	05/01/2025	Surgery #147
Intensive In-Home Family Intervention	04/01/2025	Behavioral Health #34