Medical Policy Updates

Notification of Policy Revisions Effective December 21, 2010 (Posted September 14, 2010)

Medical Policy	Revision
Hyperbaric Oxygen Pressurization	Added the following to the list of non-covered indications in the When HBO is Not Covered section: "early treatment (beginning at completion of radiation therapy) to reduce side effects of radiation therapy and autism spectrum disorders." Notification given 9/14/2010 for effective date of 12/21/2010.
Image-Guided Minimally Invasive Lumbar Decompression (IG-MLD) for Spinal Stenosis	New policy written. Image-guided minimally invasive lumbar decompression is considered investigational. Medical Director review 8/12/2010. Notification given 9/14/2010. Policy effective date 12/21/2010.
Laser Treatment of Port Wine Stains	New policy implemented. Laser treatment of port wine stains in the presence of functional impairment related to the port wine stain may be considered medically necessary. Treatment with lasers in combination with photodynamic therapy or topical angiogenesis inhibitors is considered investigational. References added. Notice given 9/14/10 for Policy effective 12/21/2010.