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Medical Policy Updates
Notification of Policy Revisions Effective August 13, 2007
(Posted June 4, 2007)
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Hyperbaric Oxygen Pressurization
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Definition of Topical Hyperbaric Oxygen therapy added to Description section. Note: topical hyperbaric oxygen therapy is NOT considered hyperbaric oxygen pressurization. (See separate policy titled "Topical Hyperbaric Oxygen Therapy" MED1431). Indications for use of hyperbaric oxygen pressurization have been revised in the Covered and Noncovered sections. Wagner classification of wounds added to Covered section. The following statements were added to the Policy Guidelines section: "While evidence for the treatment of acute carbon monoxide poisoning with HBO pressurization has failed to demonstrate improved health outcomes, this technology is accepted in medical practice as a standard medical therapy for the treatment of carbon monoxide poisoning." Code A4575 deleted. References updated. Specialty Matched Consultant Advisory Panel review 3/15/07, policy changes accepted as written.
Notification given 6/4/07. Effective date 8/13/07.
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Radiofrequency Tissue Remodeling for Urinary Stress Incontinence
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Notification that Section IV (Transvaginal Radiofrequency Bladder Neck Suspension for Urinary Stress Incontinence) of the policy entitled "Urinary Incontinence, Treatment " will be issued as a separate policy entitled "Radiofrequency Tissue Remodeling for Urinary Stress Incontinence". Policy to be effective 8/13/07. Information regarding Renessa Transurethral Radiofrequency System added to "Description" section. Transvaginal radiofrequency bladder neck suspension as a treatment of urinary stress incontinence is currently considered investigational. Added criteria that transurethral radiofrequency tissue remodeling as a treatment of urinary stress incontinence is considered investigational. Policy Guidelines section updated to include transurethral radiofrequency tissue remodeling.
Notification given 6/4/07. Effective date 8/13/07.
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Vesicoureteral Reflux Treatment with Periureteral Bulking Agents
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Notification of new policy. Periureteral bulking agents may be considered medically necessary as a treatment of vesicoureteral reflux grades II–IV when open surgical intervention is otherwise indicated. The use of bulking agents as a treatment of vesicoureteral reflux in clinical situations other than those listed is considered investigational. The use of bulking agents is contraindicated in patients with non-functioning kidney(s), hutch diverticuli, duplicated ureters, active voiding dysfunction, and ongoing urinary tract infection.
Notification given 6/4/07. Effective date 8/13/07.
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