Medical Policy Updates

Notification of Policy Revisions Effective October 20, 2005 (Posted August 18, 2005)

Medical Policy	Revision
Capsule Endoscopy, Wireless	Revised "Description of Procedure or Service" section to include additional information related to FDA approval and the wireless capsule endoscopy’s use in the esophagus. Added additional signs of significant GI bleeding under "When covered" section. Added second bullet under "When not covered" section to indicate this test would not be covered; "When the Wireless capsule endoscopy is used to view the esophagus. It is considered investigational" and the third bullet, "When used as a technique to evaluate other gastrointestinal diseases not presenting with gastrointestinal bleeding, including, but not limited to celiac sprue, irritable bowel syndrome, small bowel neoplasm, or intestinal polyposis syndrome." Rationale added to "Policy Guidelines" section. "ESO and Esophageal" added to "Policy Key Words" section. Notification given 8/18/2005. Policy effective 10/20/ 2005.
Lithotripsy, Extracorporeal, for Orthopedic Problems	Coverage criteria section of the policy revised as following: 1. (no change) 2. Changed "There has been a lack of response over at least 6 weeks..." to "There has been a documented lack of response over at least 6 weeks..."; "a. rest" changed to "a. rest (defined as use of a cast boot or cessation of painful activities for plantar fasciitis); "b. physical therapy" changed to "b. a formal physical therapy program, which can include either compliance with a home exercise program taught in the physician’s office (in which case the specifics of the program as well as specific references to compliance must be documented in the record; merely referring to "stretching" is not sufficient) OR supervised physical therapy in a physical therapy facility documented by appropriate records"; "c. anti-inflammatory medication" changed to "c. anti-inflammatory medication (name of medication, dose and frequency must be specified)"; d. (no change) e. (no change) 3. (no change). Additional notation made in this section, "Please note: information supplied in cover letters does not replace the need to provide copies of office records to document compliance with the criteria above." Notification given 8/18/2005. Policy effective date 10/20/2005.
Continuous Local Delivery of Anesthesia to Operative Site	Notification of new policy. Continuous infusion of anesthesia to operative wound sites using a disposable infusion pump may be considered medically necessary as a technique for postoperative pain control for surgeries typically requiring oral or parenteral narcotics for pain relief. Catheter insertion and removal is not eligible for separate reimbursement. Notification given 8/18/05. Effective date 10/20/05.