Medical Policy Updates

New policy issued. CT perfusion imaging is considered investigational. Notification given 2/16/09. Effective date 5/18/09.

New policy implemented.  "Molecular testing using the PathFinderTG® system is considered investigational for all indications including but not limited to the evaluation of pancreatic cyst fluid and of suspected or known gliomas."  Reviewed with the Senior Medical Director 12/10/2008.Notification given 2/16/2009.  Policy effective 5/18/2009.

New policy written.  Reviewed with Senior Medical Director 1/22/2009.  Surgical treatment of chest wall deformites (congenital or acquired) may be medically necessary and reconstructive when the following guidelines are met: A.Surgical treatment for Pectus Excavatum: 1. when there is documented functional impairment (i.e., decreased cardiac output and/or abnormal pulmonary function during exercise; OR 2. when future cardiovascular compromise is anticipated; OR 3.  when there is medical record documentation of signs or symptoms that impair the patient’s ability to participate in usual activities, such as shortness of breath (dyspnea) at rest or on exertion; OR 4. when there are arrythmias or clinical stigmata of decreased cardiac output; AND 5.  the Haller Index is greater than or equal to 3.2. AND  6. the procedure is expected to correct the functional impairment.  B.  Surgical treatment for Pectus Carinatum:  1.when there is documented functional impairment (i.e., decreased cardiac output and/or abnormal pulmonary function during exercise; OR  2.  when future cardiovascular compromise is anticipated; OR  3.  when there is medical record documentation of signs or symptoms that impair the patient’s ability to participate in usual activities, such as shortness of breath (dyspnea) at rest or on exertion; OR  4.  when there are arrythmias or clinical stigmata of decreased cardiac output; AND  5.  the Haller Index is less than or equal to 2.0; AND   6.  the procedure is expected to correct the functional impairment.  C.  Surgical treatment for Poland syndrome: 1.  when there is documented functional impairment (i.e., decreased cardiac output and/or abnormal pulmonary function during exercise; OR  2.  when future cardiovascular compromise is anticipated; OR  3.  when there is medical record documentation of signs or symptoms that impair the patient’s ability to participate in usual activities, such as shortness of breath (dyspnea) at rest or on exertion; OR  4.  when there are arrythmias or clinical stigmata of decreased cardiac output; AND  5.  when rib formation  is absent; AND  6.  the procedure is expected to correct the functional impairment.  "When Not Covered":  A.  When the guidelines above are not met; OR B.  When the surgical treatment is for cosmetic reasons (intended to improve appearance and not primarily to restore bodily function or to correct significant deformity resulting from  accidental injury, trauma, or previous therapeutic process.)"  Notification given 2/16/09.  Policy effective 5/18/09.