ND Committee Review
Internal Medical Policy Committee 11-14-2019 Annual Review
Internal Medical Policy Committee 11-19-2020 Multiple revisions;
- Broke criteria up into smaller sections, more defined.
Internal Medical Policy Committee 7-22-2021 Revision
- Added
statement regarding
NovoTAL Treatment Planning Software
and
- Added
Procedure code 77299
Internal Medical Policy Committee 9-21-2021 Revision of clarifying language.
Internal Medical Policy Committee 9-28-2022 Revision
Internal Medical Policy Committee 3-23-2023 Annual Review- no changes in criteria
Internal Medical Policy Committee 1-16-2024 Revision- Effective March 04, 2024
Internal Medical Policy Committee 1-14-2025 Annual Review - no changes in criteria