ATTENTION: For the safety and well-being of our employees, members and the general public, the Community Service Centers (CSCs) in Yonkers and Brentwood will close until further notice on Friday, Nov 20th at 5:00 p.m. Note that the CSC in Jamaica, Queens is also closed. Check which CSCs are open and which remain closed at this time.
  • Medical Policies

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    Allergy Immunotherapy

    Policy PDF

    Policy Name: Allergy Immunotherapy

    Policy Number: CMO 506

    Effective Date of current policy: 9/01/2018

    Description and Scope

    This policy establishes guidelines for medical necessity and appropriate billing for the supervision of preparation and provision of antigens for allergy immunotherapy given by subcutaneous injection.

    Position Statement

    Allergy immunotherapy by subcutaneous injection is considered medically necessary for patients with significant allergy symptoms (allergic asthma, allergic rhinitis, allergic conjunctivitis, and hypersensitivity to stinging insects) that could not be adequately treated by medications or by avoidance of the allergen.

    Allergy immunotherapy to treat chronic urticaria, angioedema, food allergies, migraines, non-allergic rhinitis, and non-allergic asthma is considered experimental/investigational.

    Allergy immunotherapy is limited to a one year supply. The CPT code 95165 requires prior authorization when more than 120 units are billed in one year. The medical information to document the medical necessity of more than 120 units/year should include:

    1. Number of treatment sets ordered, with the mix of antigens in each set and clear documentation explaining the clinical reason for separate treatment sets, and
    2. Number of doses planned per treatment set with clear documentation of the medical necessity of more than 28 doses per treatment set, and
    3. The planned dosage schedule.

    Background

    Allergen immunotherapy is a treatment program for individuals who have hypersensitivity to one or more allergens. The objective of the therapy is to lesson or diminish symptoms when the individual is exposed to the allergen in the future. Immunotherapy consists of injections that contain progressively larger amounts of allergen until the individual reaches and thenisable to continue on a maintenance dose level.

    Definitions

    Allergy: A reaction by the body to something that does not bother most other people. Allergen:A substance that the immune system of the body reacts to.

    Allergy Immunotherapy:Giving a specific allergen to reduce the immune system’s response to it.

    Angioedema: Swelling of tissues in the body. When it is the skin that is swelling, it is called urticaria. Conjunctivitis: The membrane that lines the eyelid and covers the white portion of the eye becomes inflamed.

    Hypersensitivity: A reaction by the body to an irritant or drug that is more extreme than the reaction of most other people.

    Rhinitis: Runny nose, sneezing, or itching of the nose. Subcutaneous:Under the skin.

    Urticaria:Hives.A rash of red raised areas on the skin that usually itch.

    Coding

    Inclusion of a code in the following list does not imply that the procedure is medically necessary or that the code represents a covered benefit. Codes used to identify services associated with this policy may include (but may not be limited to) the following:

    95165 Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; single or multiple antigens (specify number of doses).

    References

    Allergy Immunotherapy-Provision of Antigens, CPT Assistant, April 2000, pg. 4.

    Practice Parameters for Allergen Immunotherapy, Chapter 12: Immunotherapy Schedules and Doses, American Academy of Allergy, Asthma and Immunology (AAAI), V90 Number 1t, January 2003.

    Medical Policy Committee History and Revisions

    Date

    Action

    November 1, 2018

    Initial Approval by the Medical Policy and Benefits

    June 25, 2019

    Reference to Medicare Advantage removal

    Approved with other changes

    May 26, 2020

    Approved without change

    Cosmetic Services

    Policy PDF

    Policy Name: Cosmetic Services

    Policy Number: CMO 500

    Effective Date of current policy: 9/1/2018

    Description and Scope

    This policy applies to procedures that primarily affect the appearance of the member. Specific policies that should be consulted include:

    • MCG Mastectomy for Gynecomastia
    • MCG Reduction Mammoplasty
    • MCG Abdominoplasty
    • MCG Panniculectomy
    • MCG Rhinoplasty
    • MCG Sclerotherapy, Leg Veins
    • MCG Blepharoplasty, Canthoplasty, and Related Procedures
    • Affinity Medical Policy on Gender Dysphoria

    Position Statement

    Treatments that primarily affect the appearance are considered medically necessary only in the following circumstances:

    • The reason for the treatment is to correct a significant congenital defect or anomaly that is beyond normal human variation. An example of this is laser therapy for a significant port wine stain on the face. Or,
    • The reason for the treatment is reconstructive; that is, correcting an abnormal appearance due to injury, disease, or treatment. An example of this is breast reconstruction following mastectomy. Or,
    • The treatment is part of a medically necessary procedure. An example of this is tattooing to allow for radiation therapy. Or,
    • Genitalia or breast surgery for members with gender dysphoria. Please see Policy: Gender Reassignment Surgery for details and for medical necessity criteria.

    Cosmetic treatments are usually not considered eligible for coverage. This includes, but is not limited to, treatments, drugs, products, hospital/facility charges, anesthesia, pathology/lab fees, radiology fees and professional fees by the surgeon, assistant surgeon, consultants and attending physicians.

    Background

    Therapy to change appearance is commonplace. Unwanted hair is treated with creams, medications, electrolysis, and lasers. Baldness is treated with creams and oral medications. Wrinkles, acne scars, uneven pigmentation, thin lips, and aging skin are treated with creams, dermal fillers, lasers, and botulinum toxin. An unprepossessing jawline is treated with genioplasty. Spider veins (telangiectasia) are treated with lasers or a sclerosing solution. Some people have liposuction, treatment of inverted nipples, or removal of accessary nipples. These treatments are considered cosmetic and not medically necessary, except as noted above.

    Certain treatments may be medically necessary or cosmetic depending upon the circumstances. Chemical peels are medically necessary when used to treat pre-malignant lesions that have not responded to standard topical and oral therapies.

    Some examples of cosmetic and not medically necessary treatments include (but are not limited to):

    • Acne surgery cpt code 10040
    • Chemical peels, including for treatment of acne, acne scars, or pigmentation, cpt codes 15788-15793 and 17360
    • Dermabrasion for treatment of acne, acne scars, or pigmentation, cpt codes 15780 – 15783
    • Ear piercing and repair of a pierced earlobe or pierced body part
    • Breast augmentation (when not used to treat gender dysphoria)
    • Treatment of diastasis recti

    Definitions

    Cosmetic services are services whose primary function is to change an appearance which is within normal human anatomic variation. Accessory nipples, acne scars, and irregular pigmentation are examples of normal human anatomic variation. Common anticipated side effects of cosmetic surgery (for example, nausea and vomiting that results in a hospital stay) are considered part of the cosmetic surgery procedure. Surgery needed to improve the function of an abnormal body part is not considered cosmetic.

    Reconstructive surgery is surgery intended to restore appearance that is abnormal because of congenital anomalies (for example, cleft lip), trauma, disease, or its treatment. Surgery to correct an unpleasing outcome from cosmetic surgery is not considered reconstructive

    Coding

    Inclusion of a code in the following list does not imply that the procedure is medically necessary or that the code represents a covered benefit. Codes used to identify services associated with this policy may include (but may not be limited to) the following:

    10040

    Acne surgery

    11200

    Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions

    11201

    Removal of skin tags; each additional 10 lesions

    11950

    Subcutaneous injection of filling material (e.g., collagen); 1 cc or less

    11951

    Subcutaneous injection of filling material (e.g., collagen); 1.1 to 5.0 cc

    11952

    Subcutaneous injection of filling material (e.g., collagen); 5.1 to 10.0 cc

    11954

    Subcutaneous injection of filling material (e.g., collagen); over 10.0 cc

    15775

    Punch graft for hair transplant; 1 to 15 punch grafts

    15776

    Punch graft for hair transplant; more than 15 punch grafts

    15780

    Dermabrasion; total face (e.g., for acne scarring, fine wrinkling, rhytids, general keratosis)

    15781

    Dermabrasion, segmental, face

    15782

    Dermabrasion, regional, other than face

    15783

    Dermabrasion, superficial, any site, (e.g., tattoo removal)

    15786

    Abrasion; single lesion (e.g., keratosis, scar)

    15787

    Abrasion; each additional 4 lesions or fewer

    15788

    Chemical peel, facial; epidermal

    15789

    Chemical peel, facial; derma

    15790

    Chemical peel; total face

    15791

    Chemical peel; face, hand or elsewhere

    15792

    Chemical peel, nonfacial; epidermal

    15793

    Chemical peel, nonfacial; dermal

    15810

    Salabrasion; 20 sq cm or less

    15811

    Salabrasion; over 20 sq cm

    15819

    Cervicoplasty

    15820

    Blepharoplasty, lower eyelid;

    15821

    Blepharoplasty, lower eyelid; with extensive herniated fat pad

    15824

    Rhytidectomy; forehead

    15825

    Rhytidectomy; neck with platysmal tightening (platysmal flap, P-flap)

    15826

    Rhytidectomy; glabellar frown lines

    15828

    Rhytidectomy; cheek, chin, and neck

    15829

    Rhytidectomy; superficial musculoaponeurotic system (SMAS) flap

    15832

    Excision, excessive skin and subcutaneous tissue (including lipectomy); thigh

    15833

    Excision, excessive skin and subcutaneous tissue (including lipectomy); leg

    15834

    Excision, excessive skin and subcutaneous tissue (including lipectomy); hip

    15835

    Excision, excessive skin and subcutaneous tissue (including lipectomy); buttock

    15836

    Excision, excessive skin and subcutaneous tissue (including lipectomy); arm

    15837

    Excision, excessive skin and subcutaneous tissue (including lipectomy); forearm or hand

    15838

    Excision, excessive skin and subcutaneous tissue (including lipectomy); submental fat pad

    15839

    Excision, excessive skin and subcutaneous tissue (including lipectomy); other area

    15876

    Suction assisted lipectomy; head and neck

    15877

    Suction assisted lipectomy; trunk

    15878

    Suction assisted lipectomy; upper extremity

    15879

    Suction assisted lipectomy; lower extremity

    17106

    Destruction of cutaneous vascular proliferative lesions (e.g., laser technique); less than 10 sq cm

    17107

    Destruction of cutaneous vascular proliferative lesions (e.g., laser technique); 10.0 to 50.0 sq cm

    17108

    Destruction of cutaneous vascular proliferative lesions (e.g., laser technique); over 50.0 sq cm

    17340

    Cryotherapy (CO2 slush, liquid N2) for acne

    17360

    Chemical exfoliation for acne (e.g., acne paste, acid)

    17380

    Electrolysis epilation, each ½ hour

    19120

    Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion (except 19300), open, male or female, 1 or more lesions

    19316

    Mastopexy

    19355

    Correction of inverted nipples

    21120

    Genioplasty; augmentation (autograft, allograft, prosthetic material)

    21121

    Genioplasty; sliding osteotomy, single piece

    21122

    Genioplasty; sliding osteotomies, 2 or more osteotomies (e.g., wedge excision or bone wedge reversal for asymmetrical chin)

    21123

    Genioplasty; sliding, augmentation with interpositional bone grafts (includes obtaining autografts)

    21125

    Augmentation, mandibular body or angle; prosthetic material

    21127

    Augmentation, mandibular body or angle; with bone graft, onlay or interpositional (includes obtaining autograft)

    30400

    Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip

    30410

    Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip

    30420

    Rhinoplasty, primary; including major septal repair

    30430

    Rhinoplasty, secondary; minor revision (small amount of nasal tip work)

    30435

    Rhinoplasty, secondary; intermediate revision (bony work with osteotomies)

    30450

    Rhinoplasty, secondary; major revision (nasal tip work and osteotomies)

    36468

    Single or multiple injections of sclerosing solutions, spider veins (telangiectasia); limb or trunk

    36469

    Single or multiple injections of sclerosing solutions, spider veins (telangiectasia); face

    36470

    Injection of sclerosing solution; single vein

    36471

    Injection of sclerosing solution; multiple veins, same leg

    69090

    Ear piercing

    69300

    Otoplasty, protruding ear, with or without size reduction

    S0800

    Laser in situ keratomileusis

    S0810

    Photorefractive keratectomy

    S0812

    Phototherapeutic keratectomy

    65760

    Keratomileusis

    65765

    Keratophakia

    65767

    Epikeratoplasty

    65771

    Radial keratotomy

    67901

    Repair of blepharoptosis; frontalis muscle technique with suture or other material (e.g., banked fascia)

    67902

    Repair of blepharoptosis; frontalis muscle technique with autologous fascial sling (includes obtaining fascia)

    67903

    Repair of blepharoptosis; (tarso) levator resection or advancement, internal approach

    67904

    Repair of blepharoptosis; (tarso) levator resection or advancement, external approach

    67906

    Repair of blepharoptosis; superior rectus technique with fascial sling (includes obtaining fascia)

    67908

    Repair of blepharoptosis; conjunctivo-tarso-Muller's muscle-levator resection (e.g., Fasanella-Servat type)

    References

    • • New York State Insurance Department. Regulation 183 (11 NYCRR 56) Health Insurance Claims and Procedure. 2007. http://www.dfs.ny.gov/insurance/r_finala/2007/rf183txt.pdf
    • Specialty matched clinical peer review.
    • Nast A, Dreno B, Bettoli V et al. European Evidence-based (S3) Guidelines for the Treatment of Acne. Journal of the European Academy of Dermatology and Venereology. V 2012, 26 (Suppl. 1), 1–29.
    • Work Group: Zaenglein AL, Pathy AL, Schlosser BJ et al. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol. 2015.12.037.
    • Eichenfield, LF, Krakowski AC, Piggott C, et al. Evidence-Based Recommendations for the Diagnosis and Treatment of Pediatric Acne. Pediatrics. Vol. 131, Issue Supplement 3. 1 May 2013

    Medical Policy Committee History and Revisions

    Date

    Action

    July 24, 2018

    Initial approval by Medical Policy and Benefits Committee

    June 25, 2019

    Approved with no change

    April 3, 2020

    Approved by the Clinical Affairs Committee. The reference to Medicare Advantage was removed. Acne surgery and references for it were added

    COVID-19 Testing

    Policy PDF

    Policy Name: COVID-19 Testing

    Policy Number: CMO 508

    Effective Date of current policy: 5/18/2020

    Description and Scope

    This policy applies to COVID-19 testing for all lines of business.

    Position Statement

    Medically necessary services are services that are necessary to prevent, diagnose, manage or treat conditions in the person that cause acute suffering, endanger life, result in illness or infirmity, interfere with such person's capacity for normal activity, or threaten some significant handicap. For children and youth, medically necessary means health care and services that are necessary to promote normal growth and development and prevent, diagnose, treat, ameliorate or palliate the effects of a physical, mental, behavioral, genetic, or congenital condition, injury or disability.

    When the result of a diagnostic test does not change a member’s treatment or prognosis, that diagnostic test is not medically necessary.

    Viral testing to diagnose COVID-19, which is done on nasal or nasopharyngeal swabs or on sputum, is medically necessary when all of the following are met:

    • The patient has symptoms suggestive of COVID-19 or exposure to a person with COVID-19, and
    • The patient has not previously tested positive for COVID-19, and
    • The test is ordered by a licensed professional who has clinically assessed the member, and
    • The test is ordered by  a  licensed professional whose license allows for the prescription of anti-viral medication [This requirement is not operational during the state of emergency related to COVID-19], and
    • The test is approved by the FDA or has been issued an Emergency Use Authorization by the FDA, or the test has been developed and authorized by New York State, and
    • The laboratory performing the test is certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA) and applicable state law and regulations.

    Testing that is done for employment is not medically necessary.

    Testing that is done for surveillance, public health statistics, or epidemiologic reasons is not medically necessary.

    Testing on the blood to see if a patient has antibodies to the virus that causes COVID-19 is not medically necessary.

    Background

    Coronaviruses are a group of viruses that can cause illnesses ranging from mild diseases, such as a cold, to more serious illnesses, such as pneumonia. Recently, a new coronavirus was detected that had not been previously seen in humans. The disease, called COVID-19, can be spread from person to person.

    There is widespread community transmission of COVID-19 in the New York City metropolitan area, meaning the sources of new infections are unknown. Everyone in this area should act as if they have been exposed to COVID-19.

    The sensitivity and specificity of tests to diagnose COVID-19 are not known, though they are believed to be high enough to be clinically useful. People have tested positive, recovered from the infection and tested negative, and then tested positive once again. The meaning of the subsequent positive test in that circumstance is not known. It is also uncertain if positive tests in those who have recovered from COVID-19 imply that the person is contagious or whether negative tests in the same circumstances imply that the person is not contagious.

    A positive antibody test suggests that the patient has been infected by SARS-CoV-2 at some point in the past. The test may be useful for epidemiologic studies. The test does not determine if the patient is immune or contagious, so it is not useful on an individual basis to make decisions on treatment or prognosis.

    Background

    Coronaviruses are a group of viruses that can cause illnesses ranging from mild diseases, such as a cold, to more serious illnesses, such as pneumonia. Recently, a new coronavirus was detected that had not been previously seen in humans. The disease, called COVID-19, can be spread from person to person.

    There is widespread community transmission of COVID-19 in the New York City metropolitan area, meaning the sources of new infections are unknown. Everyone in this area should act as if they have been exposed to COVID-19.

    The sensitivity and specificity of tests to diagnose COVID-19 are not known, though they are believed to be high enough to be clinically useful. People have tested positive, recovered from the infection and tested negative, and then tested positive once again. The meaning of the subsequent positive test in that circumstance is not known. It is also uncertain if positive tests in those who have recovered from COVID-19 imply that the person is contagious or whether negative tests in the same circumstances imply that the person is not contagious.

    A positive antibody test suggests that the patient has been infected by SARS-CoV-2 at some point in the past. The test may be useful for epidemiologic studies. The test does not determine if the patient is immune or contagious, so it is not useful on an individual basis to make decisions on treatment or prognosis.

    Definitions

    COVID-19: A respiratory disease, newly discovered in December 2019, that has caused the death of almost 100,000 Americans at the time of this policy.

    SARS-CoV-2: The virus that causes COVID-19.

    Coding

    COVID-19: A respiratory disease, newly discovered in December 2019, that has caused the death of almost 100,000 Americans at the time of this policy.

    SARS-CoV-2: The virus that causes COVID-19

    86328 Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative, single-step method (e.g., reagent strip); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]).
    86769 Antibody; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]).
    87635 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique.
    U0001 Used for CDC testing laboratories to test patients for SARSCoV-2.
    U0002 Used for non-CDC laboratory tests for SARS-CoV-2/2019-nCoV (COVID-19).
    U0003 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique, making use of high throughput technologies as described by CMS-2020-01-R.
    U0004 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC, making use of high throughput technologies as described by CMS-2020-01-R.

    References

    NOT APPLICABLE

    Medical Policy Committee History and Revisions

    Date Action
    May 18, 2020Initial approval
    May 26, 2020Removed the requirement, during the state of emergency, for the prescribing provider to have a license that allows prescription of antibiotics
    Cryotherapy

    Policy PDF

    Policy Name: Cryotherapy

    Policy Number: CMO 501

    Effective Date of current policy: 9/1/2018

    Description and Scope

    This policy refers to treatments of medical conditions with cryotherapy (the destruction of tissue by freezing).

    Position Statement

    Affinity Health Plan considers cryotherapy medically necessary in some circumstances where evidence-based medicine has proved benefit. Affinity Health Plan considers cryotherapy experimental and investigational where there is insufficient evidence that cryotherapy is safe and effective for this indication. Cryotherapy can be considered medically necessary for treatment of the following conditions:

    • cervical intraepithelial neoplasia
    • uterine bleeding (exclude cancer, pre-cancer or hyperplasia) for menorrhagia or excessive bleeding (as an alternative to hysterectomy)
    • isolated colorectal cancer liver metastases
    • isolated hepatocellular carcinoma (unresectable)
    • unresectable neuroendocrine tumors metastatic to the liver
    • prostate cancer as a primary therapy alternative to surgery or irradiation in individuals with localized disease (T1 or T2 [organ confined] or T3 [locally advanced]) or as salvage therapy for recurrent cancer following failure of radiation therapy
    • malignant endobronchial obstruction
    • renal cell carcinoma, up to 4-cm in size, when any of the following criteria is met:
      1. Persons who are considered high-risk surgical candidates; or
      2. Persons with renal insufficiency, as defined by a glomerular filtration rate of less than or equal to 60 ml/min/m2; or
      3. Persons with a solitary kidney
    • atrial fibrillation
    • skin lesions if either of the following criteria are met:
    • biopsy suggests or clinically the lesion is indicative of pre-malignancy or malignancy, or
    • the lesion restricts vision or obstructs a body orifice
    • low-risk superficial basal cell carcinoma, and squamous cell carcinoma in situ (Bowen disease), where surgery or radiation is contraindicated or impractical
    • soft tissue sarcoma of the extremities or the trunk in symptomatic persons with disseminated metastases

    Affinity Health Plan considers cryotherapy experimental and investigational for any other indication based on lack of sufficient supportive evidence, including:

    • Plantar fasciitis
    • Plantar fibroma
    • Barrett’s esophagus
    • Benign prostatic hypertrophy neck pain
    • Back pain
    • Varicose veins or venous valvular incompetence
    • Breast cancer
    • Breast fibroadenoma

    Background

    Definitions: Cryotherapy, also called cryosurgery, cryoablation, percutaneous cryotherapy or targeted cryoablation therapy, is a minimally invasive treatment that uses extreme cold to freeze and destroy diseased tissue, including cancer some cells. Several cryogens such as liquid nitrogen, nitrous oxide and carbon dioxide are available, but liquid nitrogen is the most commonly used.

    Definitions

    NOT APPLICABLE

    Coding

    Inclusion of a code in the following list does not imply that the procedure is medically necessary or that the code represents a covered benefit. Codes used to identify services associated with this policy may include (but may not be limited to) the following:

    0441T Ablation, percutaneous, cryoablation, includes imaging guidance, lower extremity distal/peripheral nerve
    20983 Ablation therapy for reduction or eradication of 1 or more bone tumors (e.g., metastasis) including adjacent soft tissue when involved by tumor extension, percutaneous, including imaging guidance when performed; cryoablation
    31641 Bronchoscopy (rigid or flexible); with destruction of tumor or relief of stenosis by any method other than excision (e.g., laser therapy, cryotherapy)
    32994 Ablation therapy for reduction or eradication of 1 or more pulmonary tumor(s) including pleura or chest wall when involved by tumor extension, percutaneous, including imaging guidance when performed, unilateral; cryoablation
    33254 Operative tissue ablation and reconstruction of atria, limited (e.g., modified maze procedure)
    33256 Operative tissue ablation and reconstruction of atria, extensive (e.g., maze procedure); with cardiopulmonary bypass
    + 33257 Operative tissue ablation and reconstruction of atria, performed at the time of other cardiac procedure(s), limited (e.g., modified maze procedure) (List separately in addition to code for primary procedure.)
    + 33259 Operative tissue ablation and reconstruction of atria, performed at the time of other cardiac procedure(s), extensive (e.g., maze procedure), with cardiopulmonary bypass
    (List separately in addition to code for primary procedure.)
    50250 Ablation, open, 1 or more renal mass lesion(s), cryosurgical, including intraoperative ultrasound guidance and monitoring, if performed
    50593 Ablation, renal tumor(s), unilateral, percutaneous, cryotherapy
    55873 Cryosurgical ablation of the prostate (includes ultrasonic guidance for interstitial cryosurgical probe placement)
    57511   Cautery of cervix; cryocautery, initial or repeat
    64600 Destruction by neurolytic agent, trigeminal nerve; supraorbital, infraorbital, mental, or inferior alveolar branch (cryoablation of chronic headaches)
    +93657 Additional linear or focal intracardiac catheter ablation of the left or right atrium for treatment of atrial fibrillation remaining after completion of pulmonary vein isolation
    (List separately in addition to code for primary procedure.)

    References

    Public Health Law, Sections 201 and 206 and Social Services Law, Sections 363-a and 365-a(2) New York Codes, Rules and Regulations Title 18 Section 505.2(l)

    Medical Policy Committee History and Revisions

    Date

    Action

    July 24, 2018

    Initial approval by Medical Policy and Benefits Committee

    June 25, 2019

    Removed 20982 from code list

    May 26, 2020

    Reapproved with no changes

    Experimental or Investigational Determination

    Policy PDF

    Policy Name: Experimental or Investigational Determination

    Policy Number: CMO 509

    Effective Date of current policy: 9/1/2018

    Description and Scope

    This policy establishes guidelines for determining whether a service should be considered experimental or investigational (E/I). The policy applies to all lines of business.

    Position Statement

    "Experimental or Investigational treatment" means a drug, device, service, or treatment for which:

    1. there is insufficient outcome data available from controlled clinical trials published in the peer-reviewed literature to substantiate its safety and effectiveness for the illness or injury involved; or
    2. approval required from the FDA for marketing to the public has not been granted; or
    3. a recognized national medical or dental society or regulatory agency has determined, in writing, that it is experimental or investigational, or for research purposes; or
    4. it is a type of drug, device, or treatment that is the subject of an investigational new drug treatment pursuant to 21 C.F.R. § 312.21, or is the subject of an investigational device treatment pursuant to 21 C.F.R. § 812.36; or
    5. the written protocol or protocols used by the treating facility or by another facility studying the same drug, device, procedure, or treatment, states that it is experimental or investigational; or
    6. services are provided within a clinical trial; or
    7. the provision of a pharmaceutical product for a use other than those uses for which such pharmaceutical product has been approved for marketing by the federal Food and Drug Administration, unless NYS or Federal law or regulations require that the specific use in question should be covered.

    In order to determine whether a treatment is E/I, the above definition will be used.  The above definition may be used itself, or a particular treatment may have an Affinity policy, MCG guideline, or Hayes recommendation.  MCG guidelines for E/I treatments are given the Recommendation Grade (RG) of one of the following:

    • RG B: Evidence is insufficient, conflicting, or poor and demonstrates an incomplete assessment of net benefit vs. harm; additional research is recommended.
    • RG C1: Evidence demonstrates a lack of net benefit; additional research is recommended.
    • RG C2: Evidence demonstrates potential harm that outweighs benefit; additional research is recommended.

    A Hayes rating of C, D1, or D2 may be considered E/I.

    Background

    If a requested service is covered, it may be reviewed for medical necessity. A covered service that is not medically necessary may be denied as “not medically necessary,” “cosmetic and not medically necessary,” or “Experimental or Investigational.” This policy gives the framework for when a service should be considered Experimental or Investigational. This framework may be used to construct other policies or to make decisions on requests where the policy has not yet been adopted.

    Definitions

    E/I: Experimental or Investigational
    MCG: a company, part of Hearst Health, that constructs and licenses evidence-based care guidelines
    Hayes: a company, part of TractManager, that licenses evidence-based assessments of health technologies
    FDA: Food and Drug Administration
    C.F.R.: Code of Federal Regulations

    Coding

    Not applicable

    References

    • New York Codes, Rules and Regulations Title 10 Section 69-10.1
    • Hayes Rating https://evidence.hayesinc.com/static/HRating Downloaded 06/02/2020
    • MCG Content Guide to Ambulatory Care https://careweb.careguidelines.com/ed24/index.html Downloaded 06/02/2020

    Medical Policy Committee History and Revisions

    Date

    Action

    June 2, 2020

    Policy adopted

     

     

     

     

    Interspinous and Interlaminar Stabilization/Distraction Implants

    Policy PDF

    Policy Name: Interspinous and Interlaminar Stabilization/Distraction Implants

    Policy Number: CMO 505

    Effective Date of current policy: 11/1/2018

    Description and Scope

    This policy applies to procedures that are used to relieve symptoms of lumbar spinal stenosis, a narrowing of the passages for the spinal cord and nerves.

    Position Statement

    Implanted devices for treatment of spinal stenosis are considered investigational and not medically necessary.

    Background

    Interspinous and interlaminar implants (spacers) stabilize or distract the adjacent lamina and/or spinous processes and restrict extension in order to reduce pain in patients with lumbar spinal stenosis and neurogenic claudication. Interspinous spacers are small devices implanted between the vertebral spinous processes. After implantation the device is opened or expanded to distract (open) the neural foramen and decompress the nerves. Interlaminar spacers are implanted midline between adjacent lamina and spinous processes to provide dynamic stabilization following decompressive surgery.

    Overall, use of interspinous or interlaminar distraction devices (spacers) used as an alternative to spinal decompression show high failure and complication rates. Greater certainty about the net health benefit of these devices may be obtained when moderately sized RCT on decompression with and without the implants are published. The evidence at this time is insufficient to determine the effects of the technology on health outcome.

    Definitions

    Spinal stenosis occurs when the spine is narrowed in one or more areas. This puts pressure on the spinal cord and nerves and may cause pain.

    Coding

    CPT 22867 Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; single level
    CPT 22868 Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; second level
    CPT 22869 Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level
    CPT 22870 Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; second level
    HCPCS: C1821Interspinous process distraction device (implantable)

    References

    • Care guidelines from MCG ACG: A-0494 (AC)
    • Interlaminar/Interspinous Process Distraction Devices for Neurogenic Claudication or Lumbar Spinal Stenosis. Center for Evidence-based Policy, Oregon Health & Science University.
    • Hayes, Inc. Clinical Research Response Superior Interspinous Spacer System (Vertiflex, Inc.) for Spinal Stenosis, Lansdale, PA; May 17, 2018.
    • Hayes, Inc. Health Technology Brief AxiaLIF (Axial Lumbar Interbody Fusion) System (TranS1 Inc.) for Percutaneous Lumbosacral Surgery. Lansdale, PA: Archived 2015.
    • Hayes, Inc. Health Technology Brief. Coflex Interlaminar Stabilization Device (Paradigm Spine LLC) for Treatment of Lumbar Spinal Stenosis. Lansdale, PA: Updated September 2018.
    • Hayes, Inc. Health Technology Brief. eXtreme Lateral Interbody Fusion (XLIF; NuVasive Inc.) for Treatment of Degenerative Spinal Disorders. Lansdale, PA: June 2018.
    • Hayes, Inc. Health Technology Brief. Minimally Invasive Lumbar Decompression (mild; Vertos Medical Inc.) for Lumbar Spinal Stenosis. Lansdale, PA: October 2014.
    • Hayes, Inc. Health Technology Brief. Percutaneous sacroplasty for treatment of sacral insufficiency fractures. Lansdale, PA: Updated September 2014.

    Medical Policy Committee History and Revisions

    Date

    Action

    July 24, 2018

    Initial approval by Medical Policy and Benefits Committee

    June 25, 2019

    Reformatted for clarity; Updated references; added a definition of spinal stenosis

    May 26, 2020

    Expanded policy to apply to all reviews

    Manipulation Under Anesthesia (MUA)

    Policy PDF

    Policy Name: Manipulation Under Anesthesia (MUA)

    Policy Number: CMO 507

    Effective Date of current policy: July 24,2018

    Description and Scope

    This policy describes when manipulation under anesthesia (MUA) can be medically necessary.

    Position Statement

    MUA should only be performed on select patients who have failed to respond to conservative therapy. The following indications/conditions are considered medically necessary for MUA:

    • Adhesive capsulitis (i.e., frozen shoulder) when there is failure of conservative medical management including medications with or without articular injections, home exercise programs, and physical therapy; or
    • Elbow joint for arthrofibrosis following elbow surgery or fracture, or
    • Arthrofibrosis of the knee following trauma or knee surgery (e.g., total knee replacement, anterior cruciate ligament repair) with less than 90 degrees range of motion 4 weeks to 6 months following surgery.

    MUA provided for the above indications/conditions consists of a SINGLE treatment session involving an isolated joint.

    Affinity Health Plan considers MUA not medically necessary and/or experimental and investigational for the following joints since there is insufficient evidence to establish its efficacy:

    • Ankle
    • Hip
    • Knee (for any condition other than for arthrofibrosis following total knee arthroplasty, knee surgery, or fracture)
    • Pelvis for diastasis or subluxation
    • Shoulder for any condition other than adhesive capsulitis
    • Spine
    • Temporomandibular
    • Toe
    • Wrist

    There is a lack of peer-reviewed published evidence supporting the need for multiple, repeat sessions of MUA for multiple body joints.

    Background

    Manipulation under anesthesia (MUA) is intended to reduce pain and improve range of motion. It is a treatment modality that consists of manipulation and stretching procedures performed while the patient has received anesthesia (e.g., conscious sedation, general anesthesia). The rationale for this approach is that fibrotic changes in the per articular and intra-articular soft tissues hinder movement, and sometimes it is necessary to anesthetize patients to reduce muscle tone and protective reflex mechanisms so that the joints can be manipulated effectively. Those who advocate this procedure assert that it will break up adhesions within the surrounding joints and stretch the restricting fibrotic tissue to a length compatible with motion, thereby, increasing joint function and reducing pain.

    Definitions

    Manipulation under anesthesia (MUA) is a noninvasive procedure to treat chronic pain unmanageable by other methods. MUA is designed not only to relieve pain, but also to break up excessive scar tissue. Contraindications to MUA include the following conditions:

    • Osteoporosis
    • Bone or other cancer
    • Uncontrolled diabetes
    • Heart disease or uncontrolled hypertension
    • Acute inflammatory arthritis
    • Strep or staph infection
    • Bone fracture

    Coding

    Inclusion of a code in the following list does not imply that the procedure is medically necessary or that the code represents a covered benefit. Codes used to identify services associated with this policy may include (but may not be limited to) the following:

    CPT 23700 MANIPULATION UNDER ANESTHESIA, SHOULDER JOINT, INCLUDING APPLICATION OF FIXATION APPARATUS (DISLOCATION EXCLUDED)

    CPT 24300 MANIPULATION, ELBOW, UNDER ANESTHESIA

    CPT 27570 MANIPULATION OF KNEE JOINT UNDER GENERAL ANESTHESIA (INCLUDES APPLICATION OF TRACTION OR OTHER FIXATION DEVICES)

    CPT 27275 Manipulation, hip joint, requiring general anesthesia CPT 25259 Manipulation, wrist, under anesthesia

    CPT 26340 Manipulation, finger joint, under anesthesia, each joint

    ICD 10 codes that Support Medical Necessity:

    M24.611 - M24.619- Ankylosis, right shoulder - Ankylosis, unspecified shoulder

    M24.621 - M24.629- Ankylosis, right elbow - Ankylosis, unspecified elbow

    M66.211 - M66.219- Spontaneous rupture of extensor tendons, right shoulder - Spontaneous rupture of extensor tendons, unspecified shoulder

    M66.811 - M66.819- Spontaneous rupture of other tendons, right shoulder - Spontaneous rupture of other tendons, unspecified shoulder

    M75.00 - M75.02- Adhesive capsulitis of unspecified shoulder - Adhesive capsulitis of left shoulder

    M75.100 - M75.122- Unspecified rotator cuff tear or rupture of unspecified shoulder, not specified as traumatic - Complete rotator cuff tear or rupture of left shoulder, not specified as traumatic

    M75.30 - M75.32- Calcific tendinitis of unspecified shoulder - Calcific tendinitis of left shoulder

    M75.50 - M75.52- Bursitis of unspecified shoulder - Bursitis of left shoulder

    References

    Centers for Medicare and Medicaid LCD Title Manipulation Under Anesthesia (MUA) L33594

    Medical Policy Committee History and Revisions

    Date

    Action

    July 24, 2018

    Approved by Medical Policy & Benefit Committee

    June 25, 2019

    Removed reference to Medicare Advantage

    May 26, 2020

    Approved without change

    Pediatric Multidisciplinary Feeding Therapy

    Policy PDF

    Policy Name: Pediatric Multidisciplinary Feeding Therapy

    Policy Number: CMO 504

    Effective Date of current policy: 9/1/2018

    Description and Scope

    This policy describes multidisciplinary pediatric feeding therapy and the indications for treatment.

    Position Statement

    • Outpatient Pediatric Multidisciplinary Intensive Feeding Programs are considered medically necessary when ALL of the following criteria are met:
      • The individual has received a comprehensive history, physical and behavioral evaluation.
      • The individual has had adequate treatment for any contributing underlying medical conditions without resolution of the feeding problem. Documentation of specific interventions attempted by the interdisciplinary team that have not resulted in improvement over the course of at least a two(2) month period.
      • A feeding disorder has been diagnosed in association with a medical, nutritional or behavioral problem.
      • The program will be provided by an interdisciplinary team that includes the following: a behavioral health therapist, speech and language pathologist/therapist, occupational therapist, registered dietitian, clinical coordinator and supervising physician.
      • An individualized treatment plan is provided that defines short term and long term objectives with measurable metrics and which reflect meaningful improvement.
      • The treatment plan must include active participation of the child’s parent or guardian.
      • Suboptimal score on nutritional assessment has been documented as indicated by any of the following:
        • A rate of weight that causes a decrease in 2 or more major percentile lines over time (e.g., from 75th to 25th) or
        • Weight loss or minimal weight gain over 2 months for children whose weight for height or weight for length in below the 5%.  

    **Note: Regular documentation supporting significant progress toward treatment is required to determine the medical necessity of continuation of a pediatric intensive multidisciplinary feeding program.

    • Inpatient Pediatric Multidisciplinary Intensive Feeding Programs are considered medically necessary when ALL of the following criteria are met:
      • Individual meets above criteria for an outpatient pediatric intensive multi-disciplinary feeding program
      • There is documented failure or contraindication for an outpatient intensive multi-disciplinary feeding program
      • Individual is stable medically and is capable of participating in an inpatient multidisciplinary intensive feeding program
    • A pediatric intensive multidisciplinary feeding program is considered not medically necessary for any of the following:
      • When the individual’s condition is such that it would be medically appropriate to receive services in a less intensive setting (e.g., home feeding program can be utilized)
      • Treatment provided is to prevent or slow deterioration in function or prevent reoccurrences
      • Significant therapeutic improvement is not expected within two months
      • Therapy that duplicates services already being provided as part of an authorized therapy program through another therapy discipline
      • Swallowing/feeding therapy for food aversions in members that are meeting normal growth and developmental milestones
      • When coordinated multidisciplinary care is not provided or not required

    Background

    Feeding Disorders - This term refers to a condition in which a child is unable or refuses to eat and/or drink sufficient quantities of food to support normal growth for the individual age. This avoidant or restrictive food intake can result in significant organic, nutritional or emotional ramifications.

    Signs or symptoms of potential organic problems include dysphagia (difficulty swallowing), odynophagia (painful swallowing), choking, coughing or wheezing. Additional issues, although less urgent, may include growth failure, diarrhea and vomiting.

    Behavioral issues, including but not limited to developmental disabilities and autism spectrum disorder, are another major factor in treatment of feeding disorders.

    A comprehensive interdisciplinary team will usually include a behavioral health therapist, speech and language pathologist/therapist, registered dietitian, occupational therapist, clinical coordinator and supervising physician.

    Definitions

    Intensive Feeding Programs – Defined as a multidisciplinary approach to the assessment and management of complex swallowing and feeding disorders. These disorders are generally seen in younger children, unlike anorexia and bulimia which are commonly seen in adolescents and adults. However, some individuals up to the age of eighteen (18) may require the services of an intensive feeding program.

    Outpatient Intensive Feeding Program – This setting is usually the appropriate for most individuals who require multidisciplinary intensive feeding therapy.

    Inpatient Intensive Feeding Program – This setting is usually reserved for infants and children 3 years of age and under with a diagnosis of failure to thrive (FTT), [note: The American Academy of Pediatrics is moving away from the pejorative term, “Failure to Thrive”, recommending the use of “Pediatric Undernutrition”, as noted in its Bright Futures in Practice-Guidelines.], severe developmental or physical disabilities or following a surgical procedure.

    **The individual must have failed an outpatient multidisciplinary intensive feeding program or is unable to participate in an outpatient program because of a medical contraindication.

    Coding

    Not applicable

    References

    • Peer Reviewed Publications:
    • Ayoob KT, Barresi I. Feeding disorders in children: taking an interdisciplinary approach. Pediatr Ann. 2007; 36(8):478-483.
    • Babbitt RL, Hoch TA, Coe DA, et al. Behavioral assessment and treatment of pediatric feeding disorders. J Dev Behav Pediatr. 1994; 15(4):278-291.
    • Borowitz KC, Borowitz SM. Feeding problems in infants and children: assessment and etiology. Pediatr Clin North Am. 2018 Feb;65(1):59-72.
    • Benoit D, Wang EE, Zlotkin SH. Discontinuation of enterostomy tube feeding by behavioral treatment in early childhood: a randomized controlled trial. J Pediatr. 2000; 137(4):498-503.
    • Brown J, Kim C, Lim A, et al. Successful gastrostomy tube weaning program using an intensive multidisciplinary team approach. J Pediatr Gastroenterol Nutr. 2014; 58(6):743-749.
    • Cooper-Brown L, Copeland S, Dailey S, et al. Feeding and swallowing dysfunction in genetic syndromes. Dev Disabil Res Rev. 2008; 14(2):147-157.
    • Crosby J, Duerksen DR. A prospective study of tube- and feeding-related complications in patients receiving long-term home enteral nutrition. JPEN J Parenter Enteral Nutr. 2007; 31(4):274-277.
    • Field D, Garland M, Williams K. Correlates of specific childhood feeding problems. J Paediatr Child Health. 2003; 39(4):299-304.
    • Gisel E. Interventions and outcomes for children with dysphagia. Dev Disabil Res Rev. 2008; 14(2):165- 173.
    • Greer AJ, Gulotta CS, Masler EA, Laud RB. Caregiver stress and outcomes of children with pediatric feeding disorders; Field D, Garland M, Williams K. Correlates of specific childhood feeding problems. J Paediatr Child Health. 2003; 39(4):299-304.
    • Gisel E. Interventions and outcomes for children with dysphagia. Dev Disabil Res Rev. 2008; 14(2):165- 173.
    • Greer AJ, Gulotta CS, Masler EA, Laud RB. Caregiver stress and outcomes of children with pediatric feeding disorders treated in an intensive interdisciplinary program. J Pediatr Psychol. 2008; 33(6):612- 620.
    • Kane ML. Pediatric failure to thrive. Clin Fam Pract. 2003; 5(2):293-311.
    • Kodak T, Piazza CC. Assessment and behavioral treatment of feeding and sleeping disorders in children with autism spectrum disorders. Child Adolesc Psychiatr Clin N Am. 2008; 17(4):887-905.
    • Krugman SD, Dubowitz H. Failure to thrive. Am Fam Physician. 2003; 68(5):879-884.
    • Lifschitz CH. Feeding problems in infants and children. Curr Treat Options Gastroenterol. 2001; 4(5):451- 457.
    • Manikin R, Perman JA. Pediatric feeding disorders. J Clin Gastroenterol. 2002; 30(1):34-46.
    • Marshall DD. Primary care follow-up of the neonatal intensive care unit graduate. Clin Fam Pract. 2003; 5(2):243-263.
    • Mathisen B, Worrall L, Masel J, et al. Feeding problems in infants with gastro-oesophageal reflux disease: a controlled study. J Paediatr Child Health. 1999; 35(2):163-169.
    • Piazza CC. Feeding disorders and behavior: what have we learned? Dev Disabil Res Rev. 2008; 14(2):174- 181.
    • Raynor P, Rudolf MC. Anthropometric indices of failure to thrive. Arch Dis Child. 2000; 82(5):364-365.
    • Rogers B. Feeding method and health outcomes of children with cerebral palsy. J Pediatr. 2004; 145(2 Suppl):S28-S32.
    • Rommel N, De Meyer AM, Feenstra L, Veereman-Wauters G. The complexity of feeding problems in 700 infants and young children presenting to a tertiary care institution. J Pediatr Gastroenterol Nutr. 2003; 37(1):75-84.
    • Ross ES, Browne JV. Developmental progression of feeding skills: an approach to supporting feeding in preterm infants. Semin Neonatol. 2002; 7(6):469-475.
    • Rudolph CD, Link DT. Feeding disorders in infants and children. Pediatr Clin North Am. 2002; 49(1):97- 112.
    • Saarilehto S, Lapinleimu H, Keskinen S, et al. Growth, energy intake, and meal pattern in five-year-old children considered as poor eaters. J Pediatr. 2004; 144(3):363-367.
    • Schädler G, Süss-Burghart H, Toschke AM, et al. Feeding disorders in ex-prematures: causes--response to therapy--long term outcome. Eur J Pediatr. 2007; 166(8):803-808.
    • Schreck KA, Williams K, Smith AF. A comparison of eating behaviors between children with and without autism. J Autism Dev Disord. 2004; 34(4):433-438.
    • Sharp WG, Stubbs KH, Adams H, et al. Intensive, manual-based intervention for pediatric feeding disorders: results from a randomized pilot trial. J Pediatr Gastroenterol Nutr. 2016; 62(4):658-663.
    • Sheppard JJ. Using motor learning approaches for treating swallowing and feeding disorders: a review. Lang Speech Hear Serv Sch. 2008; 39(2):227-236.
    • Sigman GS. Eating disorders in children and adolescents. Pediatr Clin North Am. 2003; 50(5):1139-1177.
    • Silverman AH, Kirby M, Clifford LM, et al. Nutritional and psychosocial outcomes of gastrostomy tube- dependent children completing an intensive inpatient behavioral treatment program. J Pediatr Gastroenterol Nutr. 2013; 57(5):668-672.
    • Tack J, Talley NJ, Camilleri M, et al. Functional gastroduodenal disorders. Gastroenterology. 2006; 130(5):1466-1479.
    • Vohr BR, Wright LL, Dusick AM, et al. Neurodevelopmental and functional outcomes of extremely low birth weight infants in the National Institute of Child Health and Human Development Neonatal Research Network, 1993-1994. Pediatrics. 2000; 105(6):1216-1226.
    • Government Agency, Medical Society, and Other Authoritative Publications:
    • American Speech-Language-Hearing Association (ASHA) position statement. Roles of speech-language pathologists in swallowing and feeding disorders. 2005. Available at: http://www.asha.org/policy/ps2005-00112.htm.
    • CDC Growth Charts. Available at: http://www.cdc.gov/growthcharts/.

    Medical Policy Committee History and Revisions

    Date

    Action

    July 24, 2018

    Initial approval by Medical Policy and Benefits Committee

    June 25, 2019

    Reworded sections for clarity; Removed CPT codes

    May 26, 2020

    Reworded sections for clarity.

    Utilization Review with minimal information

    Policy PDF

    Policy Name: Utilization Review with minimal information

    Policy Number: CMO 502

    Effective Date of current policy: 9/1/2018

    Description and Scope

    This policy applies to utilization review where insufficient medical information is obtained.

    Position Statement

    In order to determine the medical necessity of a request, Affinity Health Plan requires sufficient information to use MCG guidelines. Without enough information, the admission will be denied as not medically necessary. In particular, if Affinity Health Plan is given only the diagnosis and no further information is submitted after reasonable attempts by the plan to get further information, the request will be denied as not medically necessary.

    Definitions

    MCG guidelines are nationally recognized, evidence-based criteria that are used to determine medical necessity of a hospital admission as well as other treatments.

    Coding

    NOT APPLICABLE

    References

     

    Medical Policy Committee History and Revisions

    Date Action
    July 24, 2018Initial approval by Medical Policy and Benefits Committee
    June 25, 2019Approved with no change
    May 26, 2020 Expanded policy to apply to all reviews
  • Disclaimer

    Affinity Health Plan has developed medical policies that serve as one set of guidelines for coverage decisions. Benefit plans vary in coverage and some plans may not provide coverage for certain services discussed in medical policies. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and/or federal law. Medical policy does not constitute plan authorization, nor is it an explanation of benefits. The policies are not medical advice. Affinity Health Plan reserves the right to change medical policies.