Effective Date: 04.01.2020 – This policy addresses transarterial radioembolization (TARE) using yttrium-90 (90Y) microspheres for the treatment of malignant tumors. Effective Date: 01.01.2021 – This policy addresses the use of Vyepti™ (Eptinezumab) for the treatment of chronic and episodic migraine. Applicable Procedure Codes: 0052U, 0111T, 0126T, 0423T, 82172, 83695, 83698, 83701, 83704, 93050, 93799, 93895, 93998. Effective Date: 03.01.2020 – This policy addresses breast reduction surgeries. Sign in and you'll get tools that help you use your plan. Effective Date: 12.01.2020 – This policy addresses alpha1-proteinase inhibitors (Aralast NP™, Glassia™, Prolastin®-C, and Zemaira®) for chronic augmentation and maintenance therapy of emphysema due to congenital deficiency of alpha1-proteinase inhibitor (A1-PI)/alpha1-antitrypsin (AAT) deficiency. Applicable Procedure Codes: 20974, 20975, 20979, E0747, E0748, E0749, E0760. Applicable Procedure Codes: 0012U, 0013U, 0014U, 0036U, 0094U, 81415, 81416, 81417, 81425, 81426, 81427. Applicable Procedure Codes: 31295, 31296, 31297, 31298, 31299. Effective Date: 01.01.2021 – This policy addresses gender dysphoria treatment, including gender reassignment surgery and certain ancillary procedures. Effective Date: 01.01.2021 – This policy addresses chemosensitivity and chemoresistance assays in cancer. Applicable Procedure Codes: J1930, J2353, J2354, J2502. Fibrotest - Hepatitis Screening – Community Plan Medical Policy. Applicable Procedure Codes: B4100, B4102, B4103, B4104, B4149, B4150, B4152, B4153, B4154, B4155, B4157, B4158, B4159, B4160, B4161, B4162, B9002, S9433, S9434, S9435. Effective Date: 12.01.2019 – This policy addresses lysis intranasal synechia, repair of nasal vestibular stenosis or alar collapse, rhinoplasty, rhinophyma, and septal dermatoplasty. Applicable Procedure Code: J9210. Medical Policies, Medical Benefit Drug Policies, Coverage Determination Guidelines, and Utilization Review Guidelines are developed as needed, are regularly reviewed and updated, and are subject to change. Effective Date: 06.01.2020 – This policy addresses transpupillary thermotherapy. Effective Date: 05.01.2020 – This policy addresses breast reduction surgeries. Effective Date: 07.01.2020 – This policy addresses manipulative therapy. Applicable Procedure Codes: 0237U, 81410, 81411, 81413, 81414, 81439, 81479, 81493. UnitedHealthcare Connected™ (Medicare-Medicaid Plan) UnitedHealthcare Connected (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and Texas Medicaid to provide benefits of both programs to enrollees. Applicable Procedure Code: J9210. Applicable Procedure Codes: 59072, 59074, 59076, 59897, S2400, S2401, S2402, S2403, S2404, S2405, S2409, S2411. Effective Date: 11.01.2020 – This policy addresses cervical and lumbar artificial total disc replacement. Effective Date: 02.01.2021 – This policy addresses autologous (sural) and allogenic nerve grafts to restore erectile function during or after radical prostatectomy. Benefit enhancements for Maryland dual special needs plan (DSNP), Fourth Quarter 2020 Preferred Drug List Update, Managing Appointment Times and Member Expectations, Radiology and Cardiology Prior Authorization Requests. Applicable Procedure Codes: J0640, J0641, J0642, J9035, J9198, J9199, J9201, J9310, J9312, J9355, J9356, Q5107, Q5112, Q5113, Q5114, Q5115, Q5116, Q5117, Q5118, Q5119. Effective Date: 11.01.2020 – This policy addresses the use of Tepezza® (teprotumumab-trbw) for the treatment of thyroid eye disease. Applicable Procedure Codes: 49659, 49999. These policies and guidelines are provided for informational purposes and do not constitute medical advice. Applicable Procedure Codes: 76498, 93740. Applicable Procedure Codes: 0345T, 0483T, 0484T, 0543T, 0544T, 0545T, 0569T, 0570T, 33361, 33362, 33363, 33364, 33365, 33366, 33367, 33368, 33369, 33418, 33419, 33477, 33999, 93799. Effective Date: 01.01.2021 – This policy addresses the use of Evenity® (romosozumab-aqqg) for the treatment of osteoporosis in postmenopausal patients at high risk for fracture. Unitedhealthcare Community Plan Policy Number On Card. Applicable Procedure Codes: 0097U, 87505, 87506, 87507. Applicable Procedure Codes: 77301, 77338, 77385, 77386, 77387, 77520, 77522, 77523, 77525, G6015, G6016, G6017. Applicable Procedure Code: J0223. Effective Date: 04.01.2019 – This policy addresses occipital neuralgia and headache treatments, including injection of local anesthetics and/or steroids used as occipital nerve blocks, neurostimulation or electrical stimulation, occipital neurectomy, radiofrequency ablation (thermal or pulsed) or denervation, rhizotomy, and surgical nerve decompression.