Medical Policy Updates

Notification of Policy Revisions Effective October 1, 2012 (Posted June 29, 2012-Re-posted August 21, 2012)

Medical Policy	Revision
Capsaicin (Qutenza^®) - "Notification"	New policy. "Capsaicin (Qutenza^®) may be considered medically necessary when criteria are met. Medical Director review June 10, 2012. Notification given 6/29/2012. Policy effective 10/1/2012. 8/21/12 Notification updated for clarification. Changed the wording in #3 from "No more than 4 patches are to be applied every 90 days" to "3. No more than 4 patches are to be applied per treatment; AND 4. No more than one treatment session should occur within 90 days." in the When Covered section. No change to policy intent.

Medical Policy

Revision

New policy. "Capsaicin (Qutenza^®) may be considered medically necessary when criteria are met. Medical Director review June 10, 2012. Notification given 6/29/2012. Policy effective 10/1/2012. 8/21/12 Notification updated for clarification. Changed the wording in #3 from "No more than 4 patches are to be applied every 90 days" to "3. No more than 4 patches are to be applied per treatment; AND 4. No more than one treatment session should occur within 90 days." in the When Covered section. No change to policy intent.