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Medical Policy Updates

Table Of Contents

Notification of Policy Revisions Effective July 1, 2014 (Posted April 15, 2014)

Medical Policy Revision
Accelerated Partial Breast Radiotherapy (Breast Brachytherapy) Updated the Description section and Regulatory status. Under "When Covered" section added to statement a.: The patient is 45 years old or older for invasive cancer and age 50 years or older for DCIS." References updated. Medical director review 3/2014. Policy noticed on 4/15/14 for effective date 7/1/14.
Brachytherapy Treatment of Breast Cancer Updated Description , Regulatory status, and Policy Guidelines sections. Under "When Not Covered" section added Accuboost as investigational: "Noninvasive brachytherapy using Accuboost® for patients undergoing initial treatment for stage I or II breast cancer when used as local boost irradiation in patients who are also treated with BCS and whole breast external beam radiotherapy". References added. Medical director review 3/2014. Policy noticed 4/15/14 for effective date 7/1/14.
Endovascular Procedures for Intracranial Arterial Disease Description and Policy Guidelines sections updated. Added the following statements to the When Not Covered section; "Intracranial percutaneous transluminal angioplasty with or without stenting is considered investigational in the treatment of cerebral vasospasm after aneurysmal subarachnoid hemorrhage." "Use of intracranial aneurysm flow diverter systems (i.e., Pipeline® Embolization Device) for the endovascular treatment of adults (22 years of age or older) with large or giant wide-necked intracranial aneurysms is considered investigational." "Endovascular interventions (mechanical embolectomy, angioplasty, stenting) are considered investigational in the treatment of acute stroke." This information was previously located in the medical policy titled, Mechanical Embolectomy for Treatment of Acute Stroke which is being archived. Senior Medical Director review 4/27/2014. Reference added. Notification given 4/15/2014. Policy effective 7/1/2014.
Orthopedic Applications of Stem Cell Therapy Specialty Matched Consultant Advisory Panel review 2/2014. Medical Director review 2/2014. Additional products added to the Description section. The following statement added to the "When not Covered" section: "Allograft bone products that are intended to be mixed with autologous bone marrow aspirate are considered investigational." CPT codes 38232 and 38220 in combination with 22520, 22521, 22522, 22523, 22524, 22525, 22533, 22534, 22548, 22551, 22552, 22554, 22558, 22585, 22586, 22590, 22595, 22600, 22612, 22614, 22630, 22632, 22633, 22634, 22800, 22802, 22804, 22808, 22810, 22812, 22856, 22857, 22861, 22864, 22865, 27280, 27299, 27702, 27703 added to "Billing/Coding" section. References updated. Policy noticed 4/15/14 for effective date 7/1/14.