Medical Policy Updates

Table Of Contents

Notification of Policy Revisions Effective January 6, 2005 (Posted October 28, 2004)

Medical Policy Revision
Breast Surgeries Specialty Matched Consultant Advisory Panel review - 8/27/04. Under Benefits Application; added "Breast surgeries included in this policy may require prior plan approval." Under Section II - Mastectomy for Gynecomastia; Expanded "Description" section, under "When it is Covered" pulled obesity out of #3 and added as a separate entity with guidelines -"If gynecomastia is caused by obesity (BMI>30), it is documented to have failed to respond to conservative measures which must include participation in a clinically supervised, comprehensive weight loss and exercise program for at least 6 months, AND......." Under Section III - Reduction Mammaplasty; "Policy Guidelines", Table I: Schnur Sliding Scale, added "from each breast" to the end of "Threshold of breast tissue to be removed (in grams). Under Section V - Insertion and Removal of Breast Implants; removed "MRI has not been established as a screening modality for breast cancer even in the presence of breast implants." based on MRI of The Breast policy #RAD5105. Reference sources added. Notification given 10/28/04. Effective date 1/6/05.
Correlated Audioelectric Cardiography New policy issued. Correlated audioelectric cardiography is considered investigational.

Reference added. Notification 10/28/2004. Effective 1/6/2005.
External Defibrillators New policy issued. External defibrillators are considered investigational.

References added. Notification 10/28/2004. Effective 1/6/2005.
Screening for Vertebral Fracture with Dual X-Ray Absorptiometry (DEXA) New policy issued. Screening for vertebral fractures with dual x-ray absorptiometry is considered investigational.

Reference added. Notification 10/28/2004. Effective 01/06/2005.
Vacuum Assisted Closure of Wounds Specialty Matched Consultant Advisory Panelreview. Additional information added and criteria changes made regarding acute and subacute wounds. Removed codes K0538, K0539,and K0540 from the policy. They were deleted 1/1/04. Notification given 10/28/04. Effective date of policy is 1/6/2005.