Medical Policy Updates

Notification of Policy Revisions Effective July 1, 2012 (Posted March 30, 2012)

Medical Policy	Revision
Automated Percutaneous and Endoscopic Discectomy "Notification"	Title changed from Percutaneous Discectomy to Automated Percutaneous and Endoscopic Discectomy. Description section revised and information related to endoscopic discectomy added. "Endoscopic discectomy is considered investigational as a technique of intervertebral disc decompression in patients with back pain related to disc herniation in the lumbar, thoracic, or cervical spine." Removed the following codes from the Billing/Coding section; 0274T, 0275T, and S2348 as they are not specific to this policy. Medical Director review 3/30/2012. Notification given. Policy effective 7/1/2012.
Bone Morphogenetic Protein "Notification"	Significant revisions to policy. The "When Covered" section revised to state: "A:Use of recombinant human bone morphogenetic protein (rhBMP-2, InFUSE) may be considered medically necessary for the following indications for lumbar fusion in patients where there is a high risk of fusion failure (See Policy Guidelines): and when there are approved indications for lumbar spine fusion surgery (see medical policy titled, "Lumbar Spine Fusion Surgery"):1. As an adjunct to anterior lumbar interbody spinal fusion at one or more levels in skeletally mature patients with approved indications for lumbar spine fusion surgery. 2. For instrumented posterolateral intertransverse lumbar spinal fusion procedures, in conjunction with an FDA-approved device, at one or more levels in skeletally mature patients with degenerative disc disease. B: Use of recombinant human bone morphogenetic protein (rhBMP-2, InFUSE) may be considered medically necessary for the treatment of acute, open fracture of the tibial shaft. C: Use of recombinant human bone morphogenetic protein-7 (rhBMP-7, OP-1) may be considered medically necessary for noninstrumented revision posterolateral intertransverse lumbar spinal fusion in patients where there is a high risk of fusion failure (See Policy Guidelines) and when there are approved indications for lumbar spine fusion surgery (see medical policy titled, "Lumbar Spine Fusion Surgery"):. D: Use of recombinant human bone morphogenetic protein-7 (rhBMP-7, OP-1) may be considered medically necessary as an alternative to autograft in recalcitrant long bone nonunions where use of autograft is unfeasible and alternative treatments (e.g., electrical bone growth stimulation) have failed." The "When not Covered" section revised to state: "Bone Morphogenetic Proteins is considered not medically necessary when all of the above criteria are not met. The use of recombinant human bone morphogenetic protein-2 or recombinant human bone morphogenetic protein-7 is considered investigational for all other indications, including but not limited to: Cervical spinal fusion; Posterior or transforaminal lumbar interbody spinal fusion; As initial treatment or revision of noninstrumented posterolateral intertransverse spinal fusion that does not meet the criteria listed above; As an alternative or adjunct to bone grafting in other locations, including craniomaxillofacial surgeries." Policy Guidelines updated with the following clinical criteria listed as high risk for fusion failure: "one or more previous failed spinal fusion(s); grade III or worse spondylolisthesis; fusion to be performed at more than one level; current tobacco use; diabetes; renal disease; alcoholism; osteoporous; steroid use; when autologous bone and bone marrow harvest are not feasible or are not expected to promote fusion." The following statement was removed from the "Billing/Coding" section: "There is no specific CPT code for bone morphogenetic proteins. Services should be submitted in the form of an unlisted code (such as 20999, 22899, or 27899). Medical records for the explanation of the service rendered may be necessary." Added the following statement to "Billing/Coding" section: "In 2011, CPT code 20930 was revised to include BMP-type materials used in spine surgery." References updated. Medical Director review 2/2012. Specialty Matched Consultant Advisory panel review 2/2012. Policy noticed 3/30/2012 for effective date 7/1/2012.

Medical Policy

Revision

Automated Percutaneous and Endoscopic Discectomy "Notification"

Title changed from Percutaneous Discectomy to Automated Percutaneous and Endoscopic Discectomy. Description section revised and information related to endoscopic discectomy added. "Endoscopic discectomy is considered investigational as a technique of intervertebral disc decompression in patients with back pain related to disc herniation in the lumbar, thoracic, or cervical spine." Removed the following codes from the Billing/Coding section; 0274T, 0275T, and S2348 as they are not specific to this policy. Medical Director review 3/30/2012. Notification given. Policy effective 7/1/2012.

Bone Morphogenetic Protein "Notification"

Significant revisions to policy. The "When Covered" section revised to state: "A:Use of recombinant human bone morphogenetic protein (rhBMP-2, InFUSE) may be considered medically necessary for the following indications for lumbar fusion in patients where there is a high risk of fusion failure (See Policy Guidelines): and when there are approved indications for lumbar spine fusion surgery (see medical policy titled, "Lumbar Spine Fusion Surgery"):1. As an adjunct to anterior lumbar interbody spinal fusion at one or more levels in skeletally mature patients with approved indications for lumbar spine fusion surgery. 2. For instrumented posterolateral intertransverse lumbar spinal fusion procedures, in conjunction with an FDA-approved device, at one or more levels in skeletally mature patients with degenerative disc disease. B: Use of recombinant human bone morphogenetic protein (rhBMP-2, InFUSE) may be considered medically necessary for the treatment of acute, open fracture of the tibial shaft. C: Use of recombinant human bone morphogenetic protein-7 (rhBMP-7, OP-1) may be considered medically necessary for noninstrumented revision posterolateral intertransverse lumbar spinal fusion in patients where there is a high risk of fusion failure (See Policy Guidelines) and when there are approved indications for lumbar spine fusion surgery (see medical policy titled, "Lumbar Spine Fusion Surgery"):. D: Use of recombinant human bone morphogenetic protein-7 (rhBMP-7, OP-1) may be considered medically necessary as an alternative to autograft in recalcitrant long bone nonunions where use of autograft is unfeasible and alternative treatments (e.g., electrical bone growth stimulation) have failed." The "When not Covered" section revised to state: "Bone Morphogenetic Proteins is considered not medically necessary when all of the above criteria are not met. The use of recombinant human bone morphogenetic protein-2 or recombinant human bone morphogenetic protein-7 is considered investigational for all other indications, including but not limited to: Cervical spinal fusion; Posterior or transforaminal lumbar interbody spinal fusion; As initial treatment or revision of noninstrumented posterolateral intertransverse spinal fusion that does not meet the criteria listed above; As an alternative or adjunct to bone grafting in other locations, including craniomaxillofacial surgeries." Policy Guidelines updated with the following clinical criteria listed as high risk for fusion failure: "one or more previous failed spinal fusion(s); grade III or worse spondylolisthesis; fusion to be performed at more than one level; current tobacco use; diabetes; renal disease; alcoholism; osteoporous; steroid use; when autologous bone and bone marrow harvest are not feasible or are not expected to promote fusion." The following statement was removed from the "Billing/Coding" section: "There is no specific CPT code for bone morphogenetic proteins. Services should be submitted in the form of an unlisted code (such as 20999, 22899, or 27899). Medical records for the explanation of the service rendered may be necessary." Added the following statement to "Billing/Coding" section: "In 2011, CPT code 20930 was revised to include BMP-type materials used in spine surgery." References updated. Medical Director review 2/2012. Specialty Matched Consultant Advisory panel review 2/2012. Policy noticed 3/30/2012 for effective date 7/1/2012.