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Medical Policy Updates

Table Of Contents

Notification of Policy Revisions Effective August 30, 2016 (Posted August 30, 2016)

Medical Policy Revision
Ablation procedures for peripheral neuromas and peripheral nerves Reference added. Description section updated. Policy Guidelines updated. Radiofrequency ablation of peripheral nerves to treat pain associated with plantar fasciitis or knee osteoarthritis is considered investigational. Policy noticed 5/31/2016 for effective date 8/30/2016.
Adaptive behavioral treatment Specialty Matched Consultant Advisory Panel Review 7/27/2016. No change to policy.
Artificial Pancreas Device Systems Specialty Matched Consultant Panel Review meeting 7/27/2016. No change to policy statement.
Atezolizumab (Tecentriq) for Intravenous Use Deleted HCPCS code C9399 and added C9483 to Billing/Coding section for 10/1/16 effective date.
Brachytherapy Treatment of Breast Cancer Corrected format in "When Covered" section. No change to policy statement.
Carrier Testing for Genetic Disease Specialty Matched Consultant Advisory Panel review 7/2016. Medical Director review 7/2016.
Cochlear Implant Reference added. Policy Guidelines updated. Policy statement changed to indicate that cochlear implantation with a hybrid cochlear implant/hearing aid system is considered medically necessary for patients meeting criteria.
Continuous Passive Motion in the Home Setting References added.
Cord Blood as a Source of Stem Cells Under "Billing/Coding" section, deleted ICD-10 code O34.21 and added the following ICD-10 codes for effective date 10/1/16: O34.211, O34.212, O34.219
Drug Testing in Pain Management and Substance Abuse Treatment Statement regarding specific situations for quantitative drug testing moved from the "when covered" section to "policy guidelines" section. Specialty Matched Consultant Advisory Panel review 7/27/2016.
Electronic Brachytherapy for Nonmelanoma Skin Cancer Updated Policy Guidelines section. Reference added. No change to policy statement.
Eyelid Thermal Pulsation for the Treatment of Dry Eye Syndrome Specialty Matched Consultant Advisory Panel review 6/29/2016. No change to policy statement.
Genetic Testing for Alpha Thalassemia Description section updated. Regulatory Status and Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 7/2016. Medical Director review 7/2016.
Genetic Testing for CHEK2 Mutations for Breast Cancer Updated Policy Guidelines section. Reference added. No change to policy statement.
Genetic Testing for Duchenne and Becker Muscular Dystrophy Regulatory Status updated. Specialty Matched Consultant Advisory Panel review 7/2016. Medical Director review 7/2016.
Genetic Testing for Hereditary Hearing Loss Minor edit to When Covered section; added word "suspected" as recommended by External Physician Consultant. Specialty Matched Consultant Advisory Panel review 7/2016. Medical Director review 7/2016.
Genetic Testing for Hereditary Pancreatitis Specialty Matched Consultant Advisory Panel review 7/2016. Medical Director review 7/2016.
Genetic Testing for Heterozygous Familial Hypercholesterolemia Specialty Matched Consultant Advisory Panel review 7/2016. Medical Director review 7/2016.
Genetic Testing for Lactase Insufficiency References updated. Specialty Matched Consultant Advisory Panel review 7/2016. Medical Director review 7/2016.
Genetic Testing for Mental Health Conditions Policy Guidelines section extensively revised. Specialty Matched Consultant Advisory Panel review 7/27/2016. Policy statement unchanged.
Genetic Testing for Neurofibromatosis Specialty Matched Consultant Advisory Panel review 7/2016. Medical Director review 7/2016.
Genetic Testing for PTEN Hamartoma Tumor Syndrome Specialty Matched Consultant Advisory Panel review 7/2016. Medical Director review 7/2016.
Genetic Testing for Statin-induced Myopathy References updated. Specialty Matched Consultant Advisory Panel review 7/2016. Medical Director review 7/2016.
Genetic Testing for the Diagnosis of Inherited Peripheral Neuropathy Specialty Matched Consultant Advisory Panel review 7/2016. Medical Director review 7/2016.
Implantable Bone Conduction Hearing Aids Reference added. Policy Guidelines updated. Policy statements changed to remove investigational statement for partially implantable devices.
In Vitro Chemoresistance and Chemosensitivity Assays Updated Description and Policy Guidelines sections. Reference added. No change to policy statement.
Intensity-Modulated Radiation Therapy (IMRT) of the Prostate Reference added. No change to policy statement.
Islet Cell Transplantation Specialty Matched Consultant Advisory Panel review meeting 7/27/2016. No change to policy.
Meniscal Allografts and Other Meniscal Implants Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 6/29/2016.
Multigene Expression Assay for Predicting Recurrence in Colon Cancer Updated Description, Policy Guidelines and Regulatory sections. Reference added. No change to policy statement.
PathFinderTG® Molecular Testing Updated Description and Policy Guidelines sections. Removed reference to PathFinder TG Glioma test which is not commercially available. Reference added. No change to policy statement.
Pharmacogenetic Testing for Drug Metabolism Specialty Matched Consultant Advisory Panel review 7/2016. Medical Director review.
Quantitative Electroencephalography as a Diagnostic Aid for Attention Deficit/Hyperactivity Disorder Specialty Matched Consultant Advisory Panel review 7/27/2016. Policy statement unchanged.
Residential Treatment Criteria for admission and continued stay in residential treatment for chemical dependency extensively revised for clarity. Specialty Matched Consultant Advisory Panel review 7/27/2016. Policy intent unchanged.
Romiplostim (NPlate) New policy developed. Romiplostim (NPlate) may be considered medically necessary for the following clinical conditions: 1.Diagnosis of chronic idiopathic thrombocytopenia (ITP); and 2. platelet count ≤30 x 109/L), or upon start of therapy; and 3.history of trial and failure of; or a documented intolerance, FDA labeled contraindication, or hypersensitivity to corticosteroids or immunoglobulins (IVIg or anti-D); or 4. insufficient response to or is not a candidate for splenectomy. Medical director review 6/2016. Policy noticed 7/1/16 for effective date 8/30/16.
Saturation Biopsy for Diagnosis, Staging, and Management of Prostate Cancer Reference added. Policy Guidelines updated. Policy title changed from Saturation Biopsy for Diagnosis and Staging of Prostate Cancer to Saturation Biopsy for Diagnosis, Staging, and Management of Prostate Cancer.
Sensory Integration Therapy and Auditory Integration Therapy Minor revisions to Description section and Policy Guidelines section. Specialty Matched Consultant Advisory Panel review 7/27/16. Policy statement unchanged.
Serum Biomarker Tests for Multiple Sclerosis Specialty Matched Consultant Advisory Panel review 7/2016. Medical Director review 7/2016. Policy archived.
Temporomandibular Joint Dysfunction (TMJD) When Covered and Not Covered sections reformatted. Added the following to the When TMJD is Covered section, item B: non-surgical treatments "Short term physical therapy [is covered] when administered by a licensed physical therapist."
Treatment for Severe Primary IGF-1 Deficiency Specialty Matched Consultant Advisory Panel review meeting 7/27/2016. No change to policy.