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Medical Policy Updates
Notification of Policy Revisions Effective December 17, 2007
(Posted October 8, 2007)
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Infertility, Diagnosis and Treatment
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Under Benefits Application section, changed "Some plans may provide some coverage, but exclude coverage for in vitro fertilization and similar services." to read "Some plans may provide some coverage, but exclude coverage for artificial means of conception, including, but not limited to artificial insemination, in vitro fertilization and associated services such as drugs, labs, pathology, etc. similar services" Under When Covered section: A. Diagnostic Tests, introductory paragraph: deleted "to diagnose infertility" and added at the end "when performed solely to establish the underlying etiology of infertility"; A.2.a. Semen analysis-added (two specimens at least one month appart), Volume-added (amount), pH-added (acidity), Motility-added (movement) and > 50% at one hour, added "Morphology (size and shape of the sperm): According to World Health Organization criteria at least 30% of the cells should be of normal shape. According to Kruger (strict) morphology criteria which examines the shape and size of the sperm head, 14% or more of the sperm should have normal shaped heads." and "Note: Semen analysis values may vary according to the reference lab used." A.2.b,c & d are now A.2. h,i & j; Inserted the following: A.2.b. "Endocrine evaluation if clinically indicated. (Minimum initial hormonal evaluation should consist of measurement of serum follicle-stimulating-hormone)." A.2.c. "Antisperm antibodies" A.2.d. "Post-ejaculatory urinalysis" A.2.e. "Urine and semen culture" A.2.f. "Vasography" A.2.g. "Scrotal ultrasonography" A.2.i. (now Sperm Penetration Assay), added "NOTE: Covered if used as a diagnostic technique for male infertility; if used as part of IVF, this assay would be covered only if member has benefits for artificial means of conception." B. Basic Treatments reformatted into 1. Infertility Drugs 2.Therapeutic Operative Procedures for the Female and 3.Therapeutic Operative Procedures for the Male: B.1.Infertility Drugs: a. Dopamine agonists (bromocriptine and cabergoline) b. Clomiphene citrate c. Gonadotroins: i. Human chorionic gonadotropin (hCG); ii. Choriogonadotropin alfa (a biosynthetic [recombinant DNA-derived] chorionic gonadotropin; iii. Human menopausal gonadotropins (hMG) (menotropins). Failiure of clomiphene citrate and other techniques of inducing ovulation should be documented. iv. Urofollitropin (human follicle stimulating hormone-FSH; v. Recombinant (biosynthetic) FSH (follitropin alpha, follitropin beta); vi. Recombinant (biosynthetic) luteinizing hormone (lutropin alfa). B.2. Therapeutic Operative Procedures for the female (Note: Benefits for reversal of sterilization are not covered unless otherwise stated by the member certificate.): a. Therapeutic operative laparoscoy (e.g., treatment of endometriosis or periadnexal adhesions); b. Open surgical treatment in women with moderate or severe endometriosis; c. Salpingo-ovariolysis; d. Terminal salpingostomy; e. Fibrioplasty; f. Uterotubal implantation; g. Tubocornual anastomosis; h. Balloon tuboplasty; i. Ovarian wedge resection. B.3. Therapeutic Operative Procedures for the Male (Note: Benefits for reversal of sterilization are not covered unless otherwise stated by the member certificate.): a. Varicocelectomy; b. Transurethral resection of ejaculatory duct; c. Orchiopexy; d. Surgical correction of epididymal blockage for men with obstructive azoospermia: i. Epidymectomy; ii. Epididymovasostomy; iii. excision of epididymal tumors and cysts; iv. Epididymostomy. C. Assisted Reproductive Technology: 3.d. added the following "percutaneous epididymal sperm aspiration (PESA), testicular sperm aspiration (TESA) or testicular sperm extraction (TESE) may be used in conjunction with IVF." deleted C.3.e. "Human Growth Hormone administration in connection with assisted reproductive technologies". Under When not Covered section: A. clarified voluntary sterilization (vasectomy or tubal ligation/occlusion); B. Diagnostic tests, added B.f. "Tests of sperm DNA integrity, including, but not limited to, sperm chromatin assays and sperm DNA fragmentation assays; added B.g. Hemizona assay; added B.h. Hypo-osmotic swelling test. C. Basic Treatments, added C.2.d. Administration of growth hormone, C.2.e. Administration of letrozole C.2.f. Administration of anastrozole. Medical Term Definitions and Reference sources added. Notification given 10/8/07. Effective date 12/17/07.
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Lymphedema Pumps-Sequential Pneumatic Compression Device
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Additional information re: types of pneumatic compression devices added to "Description" section. Under "When Covered" section-added medical necessity criteria for segmented pneumatic compression devices with manual control in each chamber- "A segmented pneumatic compression device with manual control of the pressure in each chamber (HCPCS code E0652) is considered medically necessary only when the patient has unique characteristics that prevent them from receiving satisfactory pneumatic compression treatment using a nonsegmented device with a segmented appliance/sleeve or a segmented compression device without manual control of pressure in each chamber. Such conditions include significant scarring, sensitive skin or the presence of contracture with documentation of the need for a specified pressure to a localized area." The other criteria in the current policy must be met also. Under "When not Covered" section, deleted statement re: two phase lymph preparation and drainage therapy devices (e.g., Flexitouch? Lymphedema System) being not covered/investigational. Under "Policy Guidelines", deleted the paragraph currently in the policy and added information re: the various types of lymphedema pumps and examples of each; also added the following "Lymphedema systems, such as the Flexitouch? Lymphedema System, are comparable to Type III pneumatic compression devices. There are no published peer reviewed controlled clinical trials that demonstrate the superiority of the Flexitouch? Lymphedema System over other comparable units (e.g., those listed under Type III above [HCPCS code E0652]). For medically necessary services, the Plan may compare the cost-effectiveness of alternative services or supplies when determining which of the services or supplies will be covered; therefore this device will not be covered. (Refer to policy number ADM9066 Medical Necessity.) Added Key Words, Medical Term Definitions and Reference Sources. Notification given 10/8/07. Effective date 12/17/07.
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