01/01/2019
| This version of the policy will become effective 01/01/2019.
The Company’s coverage position has changed from Benefit Contract Exclusion to Medically Necessary for the following conditions:
- Headache (migraine and tension)
- Post-operative nausea and vomiting
- Chemotherapy-induced nausea and vomiting
- Nausea of pregnancy
- Low back pain
- Pain from osteoarthritis of the knee and hip
- Chronic neck pain
The following ICD-10 CM codes have been added to Attachment A of this policy:
G43.001, G43.009, G43.011, G43.019, G43.101, G43.109, G43.111, G43.119, G43.401, G43.409, G43.411, G43.419, G43.501, G43.509, G43.511, G43.519, G43.601, G43.609, G43.009, G43.011, G43.019, G43.101, G43.109, G43.111, G43.119, G43.401, G43.409, G43.411, G43.419, G43.501, G43.509, G43.511, G43.519. G43.601, G43.609, G43.611, G43.619, G43.701, G43.709, G43.711, G43.719, G43.801, G43.809, G43.811, G43.819, G43.821, G43.829, G43.831, G43.839, G43.901, G43.909, G43.911, G43.919, G44.201, G44.209, G44.211, G44.219, G44.221, G44.229, K91.0, M16.0, M16.10, M16.11, M16.12, M16.2, M16.30, M16.31, M16.32, M16.4, M16.50, M16.51, M16.52,M16.6, M16.7, M16.9, M17.0, M17.10, M17.11, M17.12, M17.2, M17.30, M17.31, M17.32, M17.4, M17.5, M17.9, M54.2, M54.5, O21.0, O21.1, O21.2, O21.8, O21.9, R11.2
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