Medical Policy Updates
Notification of Policy Revisions Effective September 14, 2009 (Posted June 08, 2009)
|H-Wave Electrical Stimulation||
New medical policy adopted from the BCBS Association. Reviewed with Senior Medical Director 5/7/09. "BCBSNC will not provide coverage for H-Wave Electrical Stimulation because it is considered investigational. BCBSNC does not cover investigational services." Notice given 6/8/09. Policy effective 9/14/09.
|Percutaneous Axial Anterior Lumbar Fusion||
New policy adopted from the BCBS Association. Reviewed by Senior Medical Director 5/7/09. "Percutaneous Axial Anterior Lumbar Fusion is considered investigational." Notification given 6/8/09. Policy effective 9/14/09.
|Radiofrequency Facet Joint Denervation||
New policy adopted from the BCBS Association. Reviewed with Senior Medical Director 5/7/09. "BCBSNC may provide coverage for Radiofrequency Facet Joint Denervation when it is determined to be medically necessary because the medical criteria and guidelines shown below are met." Under the "When Covered" section; "Radiofrequency denervation of cervical facet joints (C3-4 and below) and lumbar facet joints may be considered medically necessary when all the criteria listed below are met: 1.) No prior spinal fusion surgery in the vertebral level being treated; 2.)Low back (lumbosacral) or neck (cervical) pain, suggestive of facet joint origin as evidenced by the absence of nerve root compression documented in the medical record on history, physical, and radiographic evaluations; and the pain is not radicular; 3.) Pain has failed to respond to three months of conservative management which may consist of therapies such as nonsteroidal anti-inflammatory medications, acetaminophen, manipulation, physical therapy, and a home exercise program; 4.) A trial of controlled diagnostic medial branch blocks (3 separate positive blocks or placebo controlled series of blocks) under fluoroscopic guidance has resulted in at least a 50% reduction in pain; and 5.) If there has been a prior successful radiofrequency (RF) denervation, a minimum time of six months has elapsed since prior RF treatment (per side, per anatomical level of the spine)." The following indications are noted under the "When Not Covered" section; "1.) Radiofrequency denervation is considered investigational for the treatment of chronic spinal/back pain for all uses that do not meet the criteria listed above, including but not limited to treatment of thoracic facet or sacroiliac (SI) joint pain. 2.) Pulsed radiofrequency denervation is considered investigational for the treatment of chronic spinal/back pain." Notice given 6/8/09. Policy effective 9/14/09.