Medical Policy Updates

Table Of Contents

Notification of Policy Revisions Effective June 11, 2013 (Posted June 11, 2013)

Medical Policy Revision
Allergy Immunotherapy (Desensitization) References updated. No changes to Policy Statements.
Brachytherapy, Intracavitary Balloon Catheter for Brain Cancer Specialty Matched Consultant Advisory Panel review 5/15/2013. Reference added. No change to policy statement.
Hematopoietic Stem-Cell Transplantation in the Treatment of Germ Cell Tumors Added the following statements to the Description section; "Therapy for germ-cell tumors is generally dictated by several factors, including disease stage, tumor histology, site of tumor primary and response to chemotherapy. Patients with unfavorable prognostic factors may be candidates for hematopoietic stem-cell transplantation." Removed the following statements from the Policy Guidelines section; "Refractory is defined as less than 50% reduction in tumor burden measured by serial computed tomography (CT) scans or levels of circulating tumor markers, such as alpha fetoprotein. Partial response is defined as least a 50% reduction in tumor burden." Reference added. No change to policy intent. Senior Medical Director review 5/18/2013.
Idiopathic Environmental Intolerance (i.e. Multiple Chemical Sensitivities) "When not Covered" statement revised to state: "Treatments for idiopathic environmental illness including but not limited to IVIg, neutralizing therapy of chemical and food extracts, avoidance therapy, elimination diets, and oral nystatin (to treat Candida) are considered investigational." No changes to policy intent. References updated.
Immune Globulin Reference added. "Refractory dermatomyositis, as monotherapy", "dermatomyositis in patients responsive to immunosuppressive therapy", and "post-infectious sequelae" removed from Not Covered section. "Neonatal sepsis" and "Crohn's Disease" added to Not Covered section. Specialty Matched Consultant Advisory Panel review 2/20/13. Notification given 3/12/2013 for effective date 6/11/2013.
Implantable Bone Conduction Hearing Aids Reference added. Added investigational policy statement for partially implantable hearing systems. Added information on partially implantable hearing system, OBC, and Ponto Pro to Description section. Updated Policy Guidelines to include information on partially implantable hearing systems. Specialty Matched Consultant Advisory Panel review 2/20/13. Notification given 3/12/13. Policy effective 6/11/13.
Intensity Modulated Radiation Therapy for Tumors of the Central Nervous System Specialty Matched Consultant Advisory Panel review meeting 5/15/2013. No changes to policy statement. Reference added.
Intensity Modulated Radiation Therapy (IMRT) of Breast and Lung Specialty Matched Consultant Advisory Panel review 5/15/2013. No change to policy statement. Reference added.
Intensity Modulated Radiation Therapy (IMRT) of Head and Neck Specialty Matched Consultant Advisory Panel 5/15/2013. No change to policy statement.
Intensity-Modulated Radiation Therapy (IMRT) of the Prostate Specialty Matched Consultant Advisory Panel review meeting 5/15/2013. No change to policy statement. Reference added.
Orthopedic Applications of Stem Cell Therapy Description section updated. References updated. Policy Guidelines updated. New Policy Statement added: "Allograft bone products containing viable stem cells, including but not limited to demineralized bone matrix (DBM) with stem cells, is considered investigational for all orthopedic applications." The following statement added to Policy Guidelines: "Note: This policy does not address unprocessed allograft bone." Medical Director review 5/2013.
Sacral Nerve Neuromodulation/Stimulation for Pelvic Floor Dysfunction "When Covered" section revised. The length of successful percutaneous test stimulation in medically necessary statements changed from at least 2 weeks to at least 1 week. Fecal incontinence information separated into 2 statements; 1 on trial stimulation and 1 on permanent implantation. Added the following criterion to the "When Covered" statements: "3. The patient is an appropriate surgical candidate." References updated. Medical Director review 5/2013.
Stem-cell Therapy for Peripheral Arterial Disease Description section updated and Related Policies added. Policy Guidelines updated. References updated. No changes to Policy Statements.
Topical Negative Pressure Therapy for Wounds Specialty Matched Consultant Advisory Panel review 5/15/13. No change to policy statements.
Whole Body Computed Tomography Scan as a Screening Test Medical Director review. Archive policy.
Evidence Based Guidelines
Ado-Trastuzumab Emtansine (Trastuzumab-DM1) for Treatment of HER-2 Positive Malignancies New Evidence Based Guideline developed. "The use of ado-trastuzumab emtansine may be appropriate when all of the following conditions have been met: •Patient has HER2-positive, metastatic breast cancer. •Patient has received prior treatment for metastatic disease, or has developed recurrent disease within 6 months of completing adjuvant therapy. •Patient has received prior treatment with trastuzumab and a taxane." "The use of ado-trastuzumab emtansine is not recommended in all other situations, including but not limited to earlier stages of breast cancer, combination treatment with different agents, and treatment of gastric cancer." Senior Medical Director review 5/18/2013.
Cryoablation of Prostate Cancer References updated.
Dynamic Spinal Visualization Medical Director review. Archive policy.
Endobronchial Brachytherapy Specialty Matched Consultant Advisory Panel review 5/15/2013. No change to policy statement. Reference added.
Fecal Analysis in the Diagnosis of Intestinal Dysbiosis Corporate Medical Policy converted to Evidence Based Guideline. Reference added. Related guideline added. Specialty Matched Consultant Advisory Panel review 4/17/13. Added "Fecal Analysis for Intestinal Dysbiosis is not recommended".
Fecal Calprotectin Test Changed Related Policy to Related Guideline.
Interventions for Progressive Scoliosis Description section updated. References updated.
Intraoperative Radiation Therapy Specialty Matched Consultant Advisory Panel review 5/15/2013. No change to guideline statement.
Therapeutic Apheresis References updated.
Vertical Expandable Prosthetic Titanium Rib Description section updated. References updated.