Select Health does NOT cover compounded bio-identical hormone replacement therapy (BHRT). The policy states that compounded BHRT safety and efficacy have not been documented in clinical studies and that BHRT prescriptions are uniquely formulated; therefore coverage for these compounds is not provided under the Commercial Plan criteria.

As noted in the policy, compounded prescriptions are only covered when they meet all specified requirements (e.g., include at least one FDA-approved legend medication, contain therapeutic amounts, and have safety/effectiveness supported by literature); BHRT products do not meet these criteria and are explicitly excluded.

Drug compounding that is performed solely for convenience or nonmedical reasons is considered not medically necessary. The policy explains that compounding may be appropriate when a commercially available product does not meet a patient’s clinical needs (for example, unavailable strength, dosage form, or excipient allergy), but routine convenience-based compounding is not covered.

When a compound is similar to a commercially available product but differs only in dosage, form, or absence of nontherapeutic ingredients (e.g., dye, sweetener, preservative), the prescriber must provide clinical documentation justifying the medical need for the compound; absent such justification, coverage may be denied.

Select Health does not cover diagnostic tests for evaluation of chronic fatigue syndrome (CFS) that the policy lists as investigational. Examples include ELISA/ACT testing, evaluation of enteric dysbiosis, evaluation of mitochondrial disorders, functional elevation of NK cells, gene expression profiling, radionuclide scans (SPECT, PET), RNase L assays, serologic tests for Candida, viral serologies (except HIV), and several other specialized immune or molecular tests.

Requests for these listed investigational tests submitted for routine evaluation of CFS will be denied because the policy considers them to lack sufficient evidence of diagnostic utility for confirming or excluding CFS.

Revision history documents that on 2/21/23 the Commercial Plan Policy explicitly added four diagnostic tests to the list of exclusions for CFS: RNase L enzymatic activity assay or RNase L protein quantification; gene expression profiling; evaluation of mitochondrial disorders; and evaluation of enteric dysbiosis.

Use of these newly listed tests as part of routine evaluation for CFS may therefore trigger denial under the Commercial Plan policy effective from that revision.

Select Health limits acceptable intravenous (IV) antibiotic agents for Lyme disease coverage to specified drugs: ceftriaxone, cefotaxime, or penicillin G, with azithromycin as an option for patients with beta-lactam allergy. Use of other IV agents (for example carbapenems, first‑generation cephalosporins, fluoroquinolones, or fluconazole) is considered investigational and is not covered.

The policy also clarifies that IV antibiotic therapy is appropriate only in defined clinical situations (e.g., Lyme arthritis, carditis, objective neurologic complications) and that use of nonlisted IV agents or indications outside the coverage criteria will not be authorized.

Home healthcare services related to the administration of IV therapy that is not covered (for example nursing visits to administer noncovered antibiotics, maintenance of central venous catheters, or home care supplies) are themselves not covered. If the IV antibiotic therapy is not authorized, associated home infusion services and supplies will also be denied.

Viscosupplementation is covered only for the knee. The policy states that viscosupplementation for any joint other than the knee (including TMJ, shoulder, elbow, wrist, hip, and ankle) is considered investigational/experimental and therefore not covered.

Knee viscosupplementation coverage requires meeting the policy’s knee-specific eligibility and diagnostic criteria and does not extend to other joints.

Available comparative evidence does not establish clear superiority of high‑molecular‑weight (HMW) versus low‑molecular‑weight (LMW) hyaluronan products. Systematic reviews and meta-analyses report a modest overall benefit of HA injections versus placebo, but heterogeneity among studies limits definitive conclusions about class-wide superiority.

Individual randomized trials have produced mixed results, and the policy summarizes that relative effectiveness within the HA class cannot be conclusively determined; product selection should therefore follow the policy’s per-product evidence, dosing limits, and documented clinical response rather than an assumption of HMW superiority.

The revision history records multiple material changes over time, including removal of some prior requirements and exclusions (for example, removal of the specialist-only administration requirement and of certain prior chart-note requirements) and addition of new requirements such as failure of a preferred viscosupplement prior to coverage of non‑preferred agents.

These changes indicate that certain previous exclusionary or administrative requirements have been eliminated from the current Commercial Plan criteria; providers should consult the current policy text and revision log for details when preparing authorization requests.

Reiterating policy intent, compounding for convenience is explicitly described as not medically necessary. The policy distinguishes clinically justified compounding (e.g., lack of commercially available strength, excipient allergy) from convenience compounding and will deny coverage for the latter.

When convenience-driven compounding is proposed, documentation demonstrating a medical need is required to support any coverage consideration; absent such documentation, claims are subject to denial.

The policy states that the investigational diagnostic tests listed do not confirm or exclude chronic fatigue syndrome (CFS) and are considered not medically necessary for routine evaluation. The IOM-referenced diagnostic threshold guidance is also cited elsewhere in the policy to support use of only clinically indicated, evidence-based testing.

Because these investigational tests lack validated diagnostic utility for CFS, their use for routine evaluation should not be expected to be covered under the policy.

Implantable estradiol pellets (compounded subcutaneous 17 beta‑estradiol pellets) are considered experimental/investigational and are not covered for commercial members. The policy cites the absence of FDA‑approved formulations, unpredictable serum release rates, concerns about reversibility and dosing, and safety risks such as bleeding and infection as reasons for noncoverage.

Given these unresolved safety and pharmacokinetic concerns, implantation of estradiol pellets for menopausal or hormonal indications is excluded from coverage.

For Lyme disease, the policy considers repeat or prolonged IV antibiotic therapy beyond 4 weeks to be not medically necessary. Systematic evidence and randomized trials have not shown benefit for extended antibiotic courses and have demonstrated increased risk of harm, which informs the policy’s limitation on IV antibiotic duration.

Thus, requests for extended (>4 weeks) or repeated IV antibiotic courses for Lyme disease will generally be denied unless they meet the limited, policy-defined exceptions.

The policy enumerates an expanded list of Lyme disease clinical scenarios considered not medically necessary, including prophylactic treatment after a tick bite without clinical findings, treatment of chronic fatigue/fibromyalgia attributed to Lyme, initial treatment of Lyme arthritis without neurologic symptoms, antibiotic-refractory Lyme arthritis after specified prior courses, use of intramuscular antibiotics for Lyme disease, and use of non‑recommended IV agents or investigational tests to justify continued IV therapy.

Providers must document laboratory-confirmed Lyme disease and qualifying clinical manifestations per the policy to support authorization; many other clinical scenarios are excluded from coverage.

The policy requires radiographic confirmation of knee osteoarthritis with radiologic grade II or III (moderate disease) for eligibility; patients with grade I (mild) or grade IV (severe) disease are listed as not eligible for viscosupplementation coverage.

Functional impairment must also be at least moderate. These radiographic and functional thresholds are enforced when evaluating coverage requests for knee viscosupplementation.

Routine repeat viscosupplementation without prior documented response or outside the per-product recommended course/dosing is not supported. The policy requires documentation of prior symptomatic improvement following an initial course and adherence to per-product injection counts and interval recommendations for repeat treatments.

The revision history further clarifies operational updates (for example, preferred-agent sequencing and product additions), but the core requirement remains that repeat treatments be justified by prior documented benefit and conform to product-specific schedules.

The revision history shows that some prior explicit 'not medically necessary' statements or administrative requirements were removed or revised across updates (for example, removal of the specialist-only administration requirement and elimination of a chart‑notes requirement). The chunks provided here do not contain every previous NMN statement; therefore, absence of a specific NMN phrase in these chunks does not imply that a given scenario is covered.

Providers should consult the full, current policy and revision log for precise current NMN language and for operational details that affect authorization decisions.

Drug compounding is defined in the policy as the preparation, mixing, or alteration of medications by a pharmacist or physician to meet an individual patient’s needs; it may be appropriate when commercial products are unavailable in required strengths or forms or when patients have allergies to excipients.

However, the policy emphasizes that compounding must address a documented medical need to be considered for coverage; routine compounding for convenience is explicitly not covered.