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February Medical Policy Update

Audience: All Providers

In our constant effort to provide you with information in the fastest, most efficient way possible, Univera Healthcare medical policies are now available by clicking here.

Please find attached your regular monthly update containing the following:

  • A summary of new policies recently approved by the Medical Policy Committee available on the web
  • A summary of current policies recently updated by the Medical Policy Committee that are available on the web
  • A listing of draft medical policies available on our website for participating practitioners’ review and comments

If you are unable to access our medical policies through our website, hard copies are available upon request. Please contact Customer Care at 1-866-265-5983.

Please remember that medical policies are used by Univera Healthcare as a guide. Coverage decisions are made on a case-by-case basis and in accordance with the member’s contract. While a technology or service may be medically necessary, payment of benefits is subject to the member’s eligibility on the date the service is rendered and any exclusion in the member’s contract. Before rendering care, physicians and providers should verify the member’s eligibility for the service by calling Customer Care at the number listed above.

To ensure that the development of corporate medical policies occurs through an open, collaborative process, we encourage our participating practitioners to become actively involved in medical policy development.  Each month, draft policies are posted here for participating practitioners’ review and comment.  Providers now have the capability of attaching supporting documentation related to their comments. To request a copy of any of the following drafts, the new/updated medical policies listed in this memo, or any medical policy or protocol, please contact Customer Care at 1-866-265-5983.  The following policies are tentatively scheduled to be available for comment in February 2021:

  • Focal Therapies for the Treatment of Prostate Cancer (previously: Cryosurgery for Prostate Cancer) 
  • Sacral Nerve Stimulation 

Corporate medical policies are used as a guide. Coverage decisions are made on a case-by-case basis and in accordance with the member's contract.  While a technology or service may be medically necessary, payment of benefits is subject to the member's eligibility on the date the service is rendered and the benefit/exclusion provisions of the member's contract. Before rendering care, providers should verify the member's eligibility for the service by calling Customer Care.

The following new and updated medical policies have been reviewed and approved on January 21, 2021 by the Corporate Medical Policy Committee, including practitioner representatives from Western New York.  Complete detailed policies are available by clicking here. Questions regarding medical policies may be directed to your Customer Care representative.

Medical Policies are also located on the website for Univera Healthcare members at  To access our policies, members need to click on the Members menu option. 

Policies referenced in this newsletter are written for commercial contracts only.  Medical policies only apply to Medicare products when a contract benefit exists and where there are no National or Local Medicare coverage decisions for the specific service.  A link to CMS coverage has been provided for some Univera Healthcare medical policies.  Please refer to the Centers for Medicare and Medicaid Services (CMS) for medical policies pertaining to Senior contracts.  To review CMS policies, go to: and search for national Medicare coverage determinations and New York Medicare policies. 

Please note: 

Although medical policies are effective services may not be reviewed until our systems are updated.  

When policy criteria change, the Health Plan’s requirements related to medical records may also change.  Providers should call Customer Care or check the Univera Healthcare website for the most up-to-date information on medical records requirements.  Medical records requirements can be found on line by clicking on For providers, followed by electronic payment and remittance and lastly by clicking on medical record requirements.  Failure to send in the required records with the claim submission could delay claim processing and payment.

CURRENT POLICIES – significant updates 
(#6.01.30) Brachytherapy After Breast-Conserving Surgery, as Boost With Whole Breast Irradiation or Alone as Accelerated Partial Breast Irradiation), considered accelerated partial breast irradiation, allows for a targeted delivery of radiation inside the breast. Brachytherapy is utilized mostly as an adjunct to whole breast irradiation following breast conserving surgery such as a lumpectomy.  There are several methods of breast brachytherapy.  While interstitial brachytherapy involves the implantation of radioactive agents via numerous cannulas through the breast tissue surrounding the surgical cavity, balloon brachytherapy uses a single radiation source placed in an inflatable catheter inside the surgical cavity.  Electronic brachytherapy devices use a disposable, microminiature radiation source to deliver radiation rather than radioisotopes. It is designed to deliver doses of x-ray radiation directly to the excised tumor bed to deliver intracavitary or interstitial radiation to surgical margins following lumpectomy for breast cancer.  Accelerated partial breast irradiation using either an interstitial or balloon brachytherapy (e.g., MammoSiteTM) is considered a medically appropriate treatment option in women with breast cancer who meet specific criteria as outlined in the medical policy. Electronic brachytherapy is considered  investigational based on the American Brachytherapy Society Guidelines on APBI. Intra-operative breast radiotherapy is considered medically appropriate in women aged 50 years or older who meet criteria for accelerated partial breast irradiation (APBI) per recommendations from The American Society of Radiation Oncology (ASTRO) and include women with low or intermediate nuclear grade, screening-detected DCIS measuring 2.5 cm or less with negative margin widths of three mm or less.

(#7.01.84) Gender Reassignment Surgery for gender dysphoria outlines those surgeries considered medically appropriate and utilizes the World Professional Association for Transgender Health Standards of Care (formerly known as The Harry Benjamin International Gender Dysphoria Association Standards of Care (SOC) for Gender Identity Disorders) for guidance.  This  update includes medically appropriate criteria for voice therapy, voice modification surgery, thyroid cartilage reduction, facial feminization surgery, and other surgeries and procedures for the treatment of gender dysphoria.

CURRENT POLICIES - minor updates
The following policies have been updated by the Health Plan Medical Directors to reflect minor changes, such as applicable references, criteria, or system pend, and are available on our website.

  • (#7.01.88) Bronchial Thermoplasty 
  • (#5.01.15) Collagenase Clostridium Histolyticum (Xiaflex) for Fibroproliferative Disorders 
  • (#6.01.37) CT (Computed Tomography) Perfusion Imaging of the Brain 
  • (#6.01.40) Electromagnetic Navigation Bronchoscopy 
  • (#7.01.64) Gastric Electrical Stimulation 
  • (#2.02.30) Genotyping for Cytochrome P450 for Drug Metabolism 
  • (#2.01.24) Growth Factors for Wound Healing 
  • (#3.01.03) Ketamine Therapy for Psychiatric Disorders 
  • (#8.01.23) Low-level Laser Therapy (LLLT) 
  • (#6.01.02) Nuclear Breast Imaging Techniques 
  • (#3.01.09) Transcranial Magnetic Stimulation (TMS)

 DELETED Medical Policies 
The following policy is scheduled to be deleted as it has been determined that it is no longer being medically managed. 

  • (#2.02.02) Signal Averaged Electrocardiogram (SAECG) 

ARCHIVED Medical Policies
Policies are archived either because the technology has become standard of care or because there has been little utilization or few requests. Archived policies are available on the Internet Web site.

PREVIOUSLY ARCHIVED medical policies

  • (#2.01.13) Computerized Motion Diagnostic Imaging (CMDI)/Gait Analysis 
  • (#2.02.37) Genotyping or Phenotyping for Thiopurine Methyltransferase (TPMT) for Patients Treated with Azathioprine (6-MP) 
  • (#7.02.07) Liver Transplantation
  • (#6.01.19) Low-dose Computed Tomography (LDCT) for Lung Cancer Screening
  • (#2.01.41) Measurement of Exhaled Markers of Airway Inflammation in Patients with Asthma
  • (#2.02.29) Molecular Testing for the Management of Pancreatic Cysts 
  • (#7.01.01) Pancreas Transplant: (Pancreas transplant alone, pancreas transplant after kidney transplant, simultaneous pancreas kidney transplant), Islet Cell Transplant
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