Medical Policy Updates

Table Of Contents

Notification of Policy Revisions Effective May 28, 2013 (Posted May 28, 2013)

Medical Policy Revision
Biofeedback Reference added. No change to policy coverage criteria.
Bone Mineral Density Studies Reference added. No change to Policy Statement.
Botulinum Toxin Injection Removed "urgency and frequency" from #10 under the When Covered section. Added #11. "Overactive bladder (OAB) with symptoms of urge urinary incontinence, urgency, and frequency, in adults who have an inadequate response to or are intolerant of an anticholinergic medication". Reference added. Senior Medical Director review 5/18/2013.
Chromoendoscopy as an Adjunct to Colonoscopy Related policy added. Reference added. No change to policy statement.
Confocal Laser Endomicroscopy New policy issued. Use of confocal laser endomicroscopy is considered investigational. Medical Director review 1/2013. Notification given 2/26/13. Policy effective 5/28/13.
Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate, or Dermatologic Tumors Specialty Matched Consultant Advisory Panel review 5/15/13. No change to policy statement.
Cryosurgical Ablation of Primary or Metastatic Liver Tumors Specialty Matched Consultant Advisory Panel review 5/15/13. No change to policy.
Genetic Testing for Alpha-1 Antitrypsin Deficiency References updated. No changes to Policy Statements.
Genetic Testing for Hereditary Hemochromatosis References updated. Policy Guidelines updated. No changes to Policy Statements.
Hematopoietic Stem-Cell Transplantation for Solid Tumors of Childhood Reference added.
Light Therapy for Dermatologic Conditions References updated. No changes to Policy Statements.
Liver Transplant Specialty Matched Consultant Advisory Panel 5/15/13.
Molecular Markers in Fine Needle Aspirates of the Thyroid Name changed from Mutation Analysis in Fine Needle Aspirates of the Thyroid to Molecular Markers in Fine Needle Aspirates of the Thyroid. Description section updated. Reference to Mutation Analysis changed to Molecular Markers throughout policy as necessary. The When Not covered statement changed from "Mutation analysis in fine-needle aspirates of the thyroid that are cytologically considered to be indeterminate, atypical or suspicious for malignancy is considered to be investigational." to "Mutation analysis in fine-needle aspirates of the thyroid is considered to be investigational. The use of a gene expression classifier in fine-needle aspirates of the thyroid that are cytologically considered to be indeterminate, atypical or suspicious for malignancy, is considered to be investigational." Policy Guidelines updated. Added "Diagnoses that are subject to medical necessity review: 241, 241.0, 241.1, 241.9 to the Billing/Coding section. No change to policy intent. Senior Medical Director review 5/18/13. References added.
Neurostimulation, Electrical Updated the Description and Policy Guidelines in the Peripheral Subcutaneous Field Stimulation section. No change to policy intent, Reference added. Senior Medical Director review 5/18/2013.
Orthotics Added CPT codes 97760 and 97762 to Billing/Coding section.
Pelvic Floor Stimulation as a Treatment of Urinary Incontinence References updated. No changes to Policy Statements.
Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers Specialty Matched Consultant Advisory Panel review 5/15/13. HCPCS code E0670 added to Billing/Coding/Physician Documentation Information Section. No change to policy intent.
Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors Specialty Matched Consultant Advisory Panel review 5/15/13. No change to policy statement.
Semi-Implantable and Fully Implantable Middle Ear Hearing Aid Reference added. Policy guidelines updated. Medical Director review. No change to policy statement.
Surgical Interruption of Pelvic Nerve Pathways for Dysmenorrhea Reference added. No change to policy statement.
Temporomandibular Joint Dysfunction (TMJD) Under "When Not Covered" added hyaluronic acid, and low level laser therapy as non surgical investigational indications. Under "When Covered" C.2.a. added arthrocentesis to covered surgical treatments. Reference added. Notification given 2/26/13 for effective date 5/28/13.
Tocilizumab (Actemra) Under "When Covered" section: added medically necessary indication for polyarticular juvenile idiopathic arthritis (pJIA) since now FDA approved. Under Policy Guidelines, added dosing interval of every 4 weeks. Reference added. Medical director review.
Evidence Based Guidelines
Endoscopic Radiofrequency Ablation or Cryoablation for Barrett's Esophagus Reference added. Related Policy added. No change to the Evidence Based Guideline.
Homocysteine Testing in Cardiac Disease Risk Assessment Specialty Matched Consultant Advisory Panel review. References updated. Medical Director review 5/2013.
Implantable Infusion Pumps Specialty Matched Consultant Advisory Panel review 5/15/2013. No change to guideline statement.
Laboratory Testing for HIV Tropism Reference added. Medical Director review. Rationale updated with the following statement: "Finally, based on initial data, V3 deep sequencing (i.e. next generation sequencing) compared to ESTA or standard third variable (V3)-genotyping may identify additional patients who are unlikely to benefit from CCR5 inhibitor treatment. However, various aspects of the method are not yet standardized for this application and V3 deep sequencing for tropism determination is therefore not recommended." No change to Guideline statement.
Radiofrequency Ablation of Primary or Metastatic Liver Tumors Related Policies list revised. Reference added. Specialty Matched Consultant Advisory Panel meeting 5/15/13. No change to guideline statement.