Medical Policy Updates

Table Of Contents

Notification of Policy Revisions Effective December 31, 2013 (Posted October 15, 2013)

Medical Policy Revision
Bone Morphogenetic Protein "Notification" Policy extensively revised. Description section updated. "When Covered" section revised to state: "Use of recombinant human bone morphogenetic protein-2 (rhBMP-2, InFUSE) may be considered medically necessary in skeletally mature patients: •For anterior lumbar interbody fusion procedures when use of autograft is unfeasible. •For instrumented posterolateral intertransverse spinal fusion procedures when use of autograft is unfeasible. Use of recombinant human bone morphogenetic protein-7 (rhBMP-7, OP-1) may be considered medically necessary in skeletally mature patients: •For revision posterolateral intertransverse lumbar spinal fusion, when use of autograft is unfeasible. •For recalcitrant long-bone nonunions where use of autograft is unfeasible and alternative conservative treatments have failed." "When not Covered" section revised to state: "Bone morphogenetic protein (rhBMP-2 or rhBMP-7) is considered not medically necessary for all other indications, including but not limited to spinal fusion when use of autograft is feasible." Policy Guidelines updated. References updated. Medical Director review 10/2013. Policy noticed on 10/15/13 for effective date 12/31/13.
Intra Articular Hyaluronan Injections for Treatment of Osteoarthritis of the Knee "Notification" Evidence Based Guideline converted to Corporate Medical Policy. Description section revised. Information regarding preferred medications Euflexxa® and Synvisc/Synvisc One®, added to Policy Statement. "When Covered" section revised as follows: "Euflexxa® and Synvisc/Synvisc One® injections may be considered medically necessary for the treatment of pain in osteoarthritis of the knee when conservative treatment has failed. Non-preferred intra-articular hyaluronan injections may be covered if the patient has previously used at least one of the preferred drugs as indicated above, and such drug has been detrimental to the patient's health or has been ineffective in treating the patient's condition." "When not Covered" section revised to state: "The use of intra-articular hyaluronan injections in the knee is not covered when the above criteria are not met. Intra-articular injections in joints other than the knee are considered investigational." Medical Director review. References updated. Notification given 10/15/13 for effective date 12/31/13.