| Medical Policy |
Revision |
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Ankle Replacement, Total
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Specialty Matched Consultant Advisory Panel review on 5/23/2005. No changed made to the policy statement. Reference added. SUR6029 added as key word. CPT code 27703 added to Billing/ Coding section. Notification given 6/2/2005. Effective date 8/4/2005.
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Continuous Passive Motion in the Home Setting
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Specialty Matched Consultant Advisory Panel review on 5/23/2005. DME0030 added to key words. References added. Title changed from "Continuous Passive Motion for Rehabilitation following Joint Surgery" to "Continuous Passive Motion in the Home Setting". Policy statement changed to indicate that CPM is no longer covered outside of the acute hospital setting. Policy Guidelines section updated to include rationale for noncoverage. There is lacking published literature to support the coverage of CPM of the knee in the home setting or coverage of ACL repair or other joints in either the acute hospital or home setting. Coverage and Noncoverage sections changed to reflect changed policy statement. Notification given 6/2/2005. Policy effective date 8/4/2005. Effective date extended to 10/6/2005.
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Cryosurgery Ablation of the Prostate
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Specialty Matched Consultant Advisory Panel review 5/23/05. Description section revised. Under "When Covered" section added salvage cryosurgery of the prostate for recurrent cancer as covered for patients with localized disease who have failed a trial of radiation therapy as their primary treatment and meet one of the following conditions: Stage T2B or below, Gleason score less than 9, PSA less that 8 ng/mL. Under "When not Covered" removed numbers 2 & 3 and incorporated number 1 into the first sentence. Policy status changed to "Active policy, no longer scheduled for routine literature review." Notice give 6/2/05. Effective date 8/4/05.
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Insulin Potentiation Therapy
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New policy written. Insulin Potentiation Therapy is considered investigational. Notice given 6/2/05. Effective date of policy is 8/4/05.
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Minimally Invasive Hip and Knee Arthroplasty
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Specialty Matched Consultant Advisory Panel review on 05/23/2005. Reference added. Title changed to include Knee Arthroplasty as well as Hip. Description of procedure enhanced to describe both hip and knee minimally invasive procedures. CPT 27599 added to Billing/Coding section. Policy statement expanded to include knee indication for noncoverage. Knee inserted into Covered and Noncovered Sections. Policy Guidelines section created to explain rationale for noncoverage. Minimally invasive knee replacement and knee added to key words. Notice given 6/2/2005. Policy effective date 8/4/2005.
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