Medical Policy Updates

Notification of Policy Revisions Effective October 6, 2005 (Posted August 4, 2005)

Medical Policy	Revision
Herniated Lumbar Disc Treatment, Percutaneous	Specialty Matched Consultant Advisory Panel review 6/24/2005. Reordered Policy Sections. Under "Policy" section changed statement to indicate that Percutaneous Lumbar Discectomy is now considered investigational. In "Section I – Intradiscal Electrothermal Annuloplasty" added statement in description, "The Oratec SpineCath System is the device used in this procedure." Added rationale under "Policy Guidelines" section. Removed HCPCS S2370 and S2371 which were deleted in 2004. In "Section II – Nucleoplasty", revised description. Added rationale to "Policy Guidelines" section. In "Section IV – Percutaneous Lumbar Discectomy" revised description. Removed previous criteria in the "When covered" section and changed to "Not applicable". Under "When Percutaneous Lumbar Discectomy is not covered" removed previous text and added statement, "Percutaneous lumbar discectomy is considered investigational as a technique of intervertebral disc decompression in patients with back pain related to disc herniation in the lumbar, thoracic, or cervical spine." Added rationale under "Policy Guidelines". References added. Notice given 8/4/05. Effective date of policy is 10/6/2005.
Xolair (Omalizumab)	Specialty Matched Consultant Advisory Panel review 6/17/05. "Description" section revised. Under "Benefits Application" section, added information re: Member Health Partnership Program for Asthma. "When Covered" section separated into initial coverage review, continuation of coverage review beyond 6 months and after 12 months. Also #5 re: evidence of reversible disease deleted from this section and incorporated into the "Description" section regarding the initial assessment and diagnosis of asthma. Policy Guidelines expanded to list characteristics exhibited with moderate persistent asthma and severe persistent asthma. Notice given 8/4/05. Effective date 10/6/05.

Medical Policy

Revision

Herniated Lumbar Disc Treatment, Percutaneous

Specialty Matched Consultant Advisory Panel review 6/24/2005. Reordered Policy Sections. Under "Policy" section changed statement to indicate that Percutaneous Lumbar Discectomy is now considered investigational. In "Section I – Intradiscal Electrothermal Annuloplasty" added statement in description, "The Oratec SpineCath System is the device used in this procedure." Added rationale under "Policy Guidelines" section. Removed HCPCS S2370 and S2371 which were deleted in 2004. In "Section II – Nucleoplasty", revised description. Added rationale to "Policy Guidelines" section. In "Section IV – Percutaneous Lumbar Discectomy" revised description. Removed previous criteria in the "When covered" section and changed to "Not applicable". Under "When Percutaneous Lumbar Discectomy is not covered" removed previous text and added statement, "Percutaneous lumbar discectomy is considered investigational as a technique of intervertebral disc decompression in patients with back pain related to disc herniation in the lumbar, thoracic, or cervical spine." Added rationale under "Policy Guidelines". References added. Notice given 8/4/05. Effective date of policy is 10/6/2005.

Xolair (Omalizumab)

Specialty Matched Consultant Advisory Panel review 6/17/05. "Description" section revised. Under "Benefits Application" section, added information re: Member Health Partnership Program for Asthma. "When Covered" section separated into initial coverage review, continuation of coverage review beyond 6 months and after 12 months. Also #5 re: evidence of reversible disease deleted from this section and incorporated into the "Description" section regarding the initial assessment and diagnosis of asthma. Policy Guidelines expanded to list characteristics exhibited with moderate persistent asthma and severe persistent asthma. Notice given 8/4/05. Effective date 10/6/05.