Medical Policy Updates

Notification of Policy Revisions Effective August 7, 2006 (Posted June 5, 2006)

Medical Policy	Revision
Bundling Guidelines	Revised guidelines to be consistent with Medicare for reimbursement to pathologists for interpretation of clinical labs with an effective date of August 18, 2006. Notification given 06/05/2006. Live Date 8/21/2006.
Temporomandibular Joint Dysfunction (TMJD) Treatment	Additional information added to "Description" section. Under "When Covered", added: (C.4.a&b.) C.4.) Arthrotomy with total prosthetic joint replacement using the TMJ Concepts Patient-Fitted TMJ Reconstruction Prosthesis™ - This procedure is indicated for reconstruction of the TMJ for treatment of end-stage TMJ disease, when no other viable therapeutic alternatives are available. a.) Patients should be considered if they have one or more of the following conditions: Inflammatory arthritis involving the TMJ not responsive to other modalities of treatment, recurrent fibrous and/or bony ankylosis not responsive to other modalities of treatment, failed tissue graft, failed alloplastic joint reconstruction, loss of vertical mandibular height and/or occlusal relationship due to bone resorption, trauma, developmental abnormality, or pathologic lesion. b.) Total prosthetic joint replacement should not be used for patients with one or more of the following conditions: Active or suspected infections in or about the implantation site, uncontrollable masticatory muscle hyper function (clenching or grinding) which may lead to overload and loosening of screws, known allergy to any of the component materials. (F. Arthrocentesis) reworded: "For the intent of this policy, arthrocentesis for closed [jaw] lock (disc displacement without reduction) is considered advanced conservative management rather than a surgical procedure, and does not need to meet the criteria above." Under "When not Covered", added total joint replacement with the TMJ Fossa-Eminence/Condylar Prosthesis System™ or partial joint replacement with the TMJ Fossa-Eminence Prosthesis™ are not covered. Both devices are considered investigational and BCBSNC does not cover investigational services. Under "Policy Guidelines", added: "At the present time, there is insufficient evidence in the published medical literature to demonstrate the safety, efficacy and long-term outcomes of the TMJ Fossa-Eminence/Condylar Prosthesis System™ for total joint replacement or the TMJ Fossa-Eminence Prosthesis™ for partial joint replacement. (Refer to separate policy number MED1263, Investigational (Experimental) Services.)". Under Billing/Coding/ Physician Documentation, added: "In addition to medical records, a letter of medical necessity is required for all requests for TMJ surgery and should include a detailed history of the condition, diagnostic imaging results and documentation of prior medical and surgical treatment." Key words, medical term definitions and reference sources added. Notification given 6/5/06. Effective date 8/7/06.

Medical Policy

Revision

Bundling Guidelines

Revised guidelines to be consistent with Medicare for reimbursement to pathologists for interpretation of clinical labs with an effective date of August 18, 2006. Notification given 06/05/2006. Live Date 8/21/2006.

Temporomandibular Joint Dysfunction (TMJD) Treatment

Additional information added to "Description" section. Under "When Covered", added: (C.4.a&b.) C.4.) Arthrotomy with total prosthetic joint replacement using the TMJ Concepts Patient-Fitted TMJ Reconstruction Prosthesis™ - This procedure is indicated for reconstruction of the TMJ for treatment of end-stage TMJ disease, when no other viable therapeutic alternatives are available. a.) Patients should be considered if they have one or more of the following conditions: Inflammatory arthritis involving the TMJ not responsive to other modalities of treatment, recurrent fibrous and/or bony ankylosis not responsive to other modalities of treatment, failed tissue graft, failed alloplastic joint reconstruction, loss of vertical mandibular height and/or occlusal relationship due to bone resorption, trauma, developmental abnormality, or pathologic lesion. b.) Total prosthetic joint replacement should not be used for patients with one or more of the following conditions: Active or suspected infections in or about the implantation site, uncontrollable masticatory muscle hyper function (clenching or grinding) which may lead to overload and loosening of screws, known allergy to any of the component materials. (F. Arthrocentesis) reworded: "For the intent of this policy, arthrocentesis for closed [jaw] lock (disc displacement without reduction) is considered advanced conservative management rather than a surgical procedure, and does not need to meet the criteria above." Under "When not Covered", added total joint replacement with the TMJ Fossa-Eminence/Condylar Prosthesis System™ or partial joint replacement with the TMJ Fossa-Eminence Prosthesis™ are not covered. Both devices are considered investigational and BCBSNC does not cover investigational services. Under "Policy Guidelines", added: "At the present time, there is insufficient evidence in the published medical literature to demonstrate the safety, efficacy and long-term outcomes of the TMJ Fossa-Eminence/Condylar Prosthesis System™ for total joint replacement or the TMJ Fossa-Eminence Prosthesis™ for partial joint replacement. (Refer to separate policy number MED1263, Investigational (Experimental) Services.)". Under Billing/Coding/ Physician Documentation, added: "In addition to medical records, a letter of medical necessity is required for all requests for TMJ surgery and should include a detailed history of the condition, diagnostic imaging results and documentation of prior medical and surgical treatment." Key words, medical term definitions and reference sources added. Notification given 6/5/06. Effective date 8/7/06.