Medical Policy Updates

Notification of Policy Revisions Effective February 15, 2011 (Posted November 09, 2010)

Medical Policy	Revision
Bronchial Thermoplasty	New medical policy issued. Bronchial thermoplasty for the treatment of asthma is considered investigational. Notification given 11/9/10. Effective date 2/15/11. Reviewed with Medical Director 10/2010.
Charged Particle Radiotherapy (proton or helium ion)	Evidenced Based Guideline changed to Medical Policy. Under When Covered section: removed B "Charged particle radiotherapy may be appropriate for treatment of arteriovenous malformations (AVM) or acoustic neuromas that meet the following criteria-lesion is unresectable and lesion is too large (>3cm) and irregularly shaped to be treated with standard radiotherapy; also removed C. Charged particle radiotherapy may be appropriate for treatment of recurrent pituitary adenomas and nasopharyngeal carcinoma following standard radiation therapy. Under When Not Covered section: removed A. For indications other than those listed above, B. For melanoma outside the eye, chondrosarcoma, or chordoma at sites other than the skull base or spine." Under When Not Covered" section: added including but not limited to use of proton beam therapy for non-small-cell lung cancer (NSCLC) at any stage or for recurrence. Rationale updated in "Policy Guidelines" section. References added. "Notification given 11/9/10. Effective date 2/15/11. Reviewed with Senior Medical Director.

Medical Policy

Revision

New medical policy issued. Bronchial thermoplasty for the treatment of asthma is considered investigational. Notification given 11/9/10. Effective date 2/15/11. Reviewed with Medical Director 10/2010.

Charged Particle Radiotherapy (proton or helium ion)

Evidenced Based Guideline changed to Medical Policy. Under When Covered section: removed B "Charged particle radiotherapy may be appropriate for treatment of arteriovenous malformations (AVM) or acoustic neuromas that meet the following criteria-lesion is unresectable and lesion is too large (>3cm) and irregularly shaped to be treated with standard radiotherapy; also removed C. Charged particle radiotherapy may be appropriate for treatment of recurrent pituitary adenomas and nasopharyngeal carcinoma following standard radiation therapy. Under When Not Covered section: removed A. For indications other than those listed above, B. For melanoma outside the eye, chondrosarcoma, or chordoma at sites other than the skull base or spine." Under When Not Covered" section: added including but not limited to use of proton beam therapy for non-small-cell lung cancer (NSCLC) at any stage or for recurrence. Rationale updated in "Policy Guidelines" section. References added. "Notification given 11/9/10. Effective date 2/15/11. Reviewed with Senior Medical Director.