Medical Policy Updates

Notification of Policy Revisions Effective February 21, 2012 (Posted November 22, 2011)

Medical Policy	Revision
External Defibrillators "Notification"	Policy Guidelines for use of AICD updated. New adult primary prevention guidelines are as follows: "ischemic cardiomyopathy with New York Heart Association (NYHA) functional Class II or Class III symptoms, a history of myocardial infarction at least 40 days before ICD treatment, and left ventricular ejection fraction of 35% or less; or ischemic cardiomyopathy with NYHA functional Class I symptoms, a history of myocardial infarction at least 40 days before ICD treatment, and left ventricular ejection fraction of 30% or less; or nonischemic dilated cardiomyopathy and left ventricular ejection fraction of 35% or less, after reversible causes have been excluded, and the response to optimal medical therapy has been adequately determined; or hypertrophic cardiomyopathy (HCM) with 1 or more major risk factors for sudden cardiac death (history of premature HCM-related sudden death in 1 or more first-degree relatives younger than 50 years; left ventricular hypertrophy greater than 30 mm; 1 or more runs of nonsustained ventricular tachycardia at heart rates of 120 beats per minute or greater on 24-hour Holter monitoring; prior unexplained syncope inconsistent with neurocardiogenic origin) and judged to be at high risk for sudden cardiac death by a physician experienced in the care of patients with HCM." New pediatric indications for AICDs are as follows: "The use of the AICD may be considered medically necessary in children who meet any of the following criteria: survivors of cardiac arrest, after reversible causes have been excluded; symptomatic, sustained ventricular tachycardia in association with congenital heart disease in patients who have undergone hemodynamic and electrophysiologic evaluation; or congenital heart disease with recurrent syncope of undetermined origin in the presence of either ventricular dysfunction or inducible ventricular arrhythmias. The use of the AICD is considered investigational for all other indications in pediatric patients." References updated. Medical Director review 11/2011. Notification given 11/22/11 for effective date of 02/21/12.
Viscocanalostomy and Canaloplasty "Notification"	New policy issued. Canaloplasty may be considered medically necessary as a method to reduce intraocular pressure in patients with chronic primary open-angle glaucoma under the following conditions: Medical therapy has failed to adequately control intraocular pressure, AND the patient is not a candidate for any other intraocular pressure lowering procedure (e.g. trabeculectomy or glaucoma drainage implant) due to a high risk for complications. Canaloplasty is considered investigational under all other conditions, including angle-closure glaucoma. Viscocanalostomy is considered investigational. Notification given 11/22/11. Effective date 2/21/12. Reviewed with Medical Director.

Medical Policy

Revision

External Defibrillators "Notification"

Policy Guidelines for use of AICD updated. New adult primary prevention guidelines are as follows: "ischemic cardiomyopathy with New York Heart Association (NYHA) functional Class II or Class III symptoms, a history of myocardial infarction at least 40 days before ICD treatment, and left ventricular ejection fraction of 35% or less; or ischemic cardiomyopathy with NYHA functional Class I symptoms, a history of myocardial infarction at least 40 days before ICD treatment, and left ventricular ejection fraction of 30% or less; or nonischemic dilated cardiomyopathy and left ventricular ejection fraction of 35% or less, after reversible causes have been excluded, and the response to optimal medical therapy has been adequately determined; or hypertrophic cardiomyopathy (HCM) with 1 or more major risk factors for sudden cardiac death (history of premature HCM-related sudden death in 1 or more first-degree relatives younger than 50 years; left ventricular hypertrophy greater than 30 mm; 1 or more runs of nonsustained ventricular tachycardia at heart rates of 120 beats per minute or greater on 24-hour Holter monitoring; prior unexplained syncope inconsistent with neurocardiogenic origin) and judged to be at high risk for sudden cardiac death by a physician experienced in the care of patients with HCM." New pediatric indications for AICDs are as follows: "The use of the AICD may be considered medically necessary in children who meet any of the following criteria: survivors of cardiac arrest, after reversible causes have been excluded; symptomatic, sustained ventricular tachycardia in association with congenital heart disease in patients who have undergone hemodynamic and electrophysiologic evaluation; or congenital heart disease with recurrent syncope of undetermined origin in the presence of either ventricular dysfunction or inducible ventricular arrhythmias. The use of the AICD is considered investigational for all other indications in pediatric patients." References updated. Medical Director review 11/2011. Notification given 11/22/11 for effective date of 02/21/12.

Viscocanalostomy and Canaloplasty "Notification"

New policy issued. Canaloplasty may be considered medically necessary as a method to reduce intraocular pressure in patients with chronic primary open-angle glaucoma under the following conditions: Medical therapy has failed to adequately control intraocular pressure, AND the patient is not a candidate for any other intraocular pressure lowering procedure (e.g. trabeculectomy or glaucoma drainage implant) due to a high risk for complications. Canaloplasty is considered investigational under all other conditions, including angle-closure glaucoma. Viscocanalostomy is considered investigational. Notification given 11/22/11. Effective date 2/21/12. Reviewed with Medical Director.