Placental and Umbilical Cord Blood as a Source of Stem Cells
Transplantation of cord blood stem cells from related or unrelated donors in patients with an appropriate indication for allogeneic stem-cell transplant is considered medically necessary.
Transplantation of cord blood stem cells from related or unrelated donors in all situations where there is no appropriate indication for allogeneic stem-cell transplant is considered investigational and not covered.
Small Bowel/Liver and Multivisceral Transplant
The policy has been updated with the following criteria language to assist in appropriate patient selection. Candidates should meet the following criteria:
a) Adequate cardiopulmonary status
b) Absence of significant infection that could be exacerbated by immunosuppressive therapy (e.g., chronic active viral hepatitis B, hepatitis C, and human immunodeficiency virus)
c) No history of malignancy within 5 years of transplantation, excluding nonmelanomatous skin cancers
d) Documentation of patient compliance with medical management
e) Evidence of intolerance of total parenteral nutrition (TPN) including, but not limited to, multiple and prolonged hospitalizations to treat TPN-related complications, or the development of progressive but reversible liver failure. In the setting of progressive liver failure, small bowel transplant may be considered a technique to avoid end-stage liver failure related to chronic TPN, thus avoiding the necessity of a multivisceral transplant.
Cryosurgical Ablation and Radiofrequency Ablation
Radiofrequency Facet Joint Denervation
Radiofrequency Facet Joint Denervation may be medically necessary when specific criteria are met, but all other indications are considered investigational and not covered. Coverage will be provided for radiofrequency denervation of cervical facet joints (C3-4 and below) and lumbar facet joints when medically necessary.
Radiofrequency denervation of cervical facet joints (C3-4 and below) and lumbar facet joints may be considered medically necessary when all of the following criteria are met:
-No prior spinal fusion surgery in the vertebral level being treated;
-Low back (lumbosacral) or neck (cervical) pain, suggestive of facet joint origin as evidenced by absence of nerve root compression as documented in the medical record on history, physical and radiographic evaluations; and the pain is not radicular;
-Pain has failed to respond to three (3) months of conservative management which may consist of therapies such as nonsteroidal anti-inflammatory medications, acetaminophen, manipulation, physical therapy, and a home exercise program;
-A trial of controlled diagnostic medial branch blocks (3 separate positive blocks or placebo controlled series of blocks) under fluoroscopic guidance has resulted in at least a 50% reduction in pain; and
-If there has been a prior successful radiofrequency (RF) denervation, a minimum time of six (6) months has elapsed since prior RF treatment (per side, per anatomical level of the spine).
Radiofrequency denervation is considered investigational and is not covered for the treatment of chronic spinal/back pain for all uses that do not meet the above criteria, including but not limited to treatment of thoracic facet or sacroiliac (SI) joint pain.
Pulsed radiofrequency denervation is considered investigational and is not covered for the treatment of chronic spinal/back pain.
Positron Emission Tomography
Oncologic Applications of PET Scanning
Positron emission tomography (PET) scans are covered when medically necessary.
Durable Medical Equipment
Home Apnea Monitoring
Home cardiorespiratory monitoring (pneumogram) may be considered medically necessary in infants less than 12 months of age in the following situations:
-Those who have experienced an apparent life-threatening event; OR
- Those with tracheostomies or anatomic abnormalities that make them vulnerable to airway compromise; OR
-Those with neurologic or metabolic disorders affecting respiratory control; OR
- Those with chronic lung disease (i.e., bronchopulmonary dysplasia), particularly those requiring supplemental oxygen; continuous positive airway pressure; or mechanical ventilation.
Home cardiorespiratory monitoring (pneumogram) is considered not medically necessary in infants solely based on a family history of sudden infant death syndrome (SIDS), but without at least one of the above indications cited.
Pneumatic Compression Pumps for Treatment of Lymphedema
Coverage is provided for pneumatic compression pumps for the treatment of lymphedema when medically necessary.
-Single compartment or multi-chamber non-programmable lymphedema pumps may be considered medically necessary for the treatment of lymphedema that has failed to respond to conservative measures such as elevation of the limb and use of compression garments.
-Single compartment or multi-chamber programmable lymphedema pumps are considered medically necessary for the treatment of lymphedema when:
-The individual is otherwise eligible for non-programmable pumps; and
-There is documentation that the individual has unique characteristics that prevent satisfactory pneumatic compression with single-compartment or multi-chamber non-programmable lymphedema pumps (e.g., significant scarring).
No coverage is provided for two-phase multi-chamber lymphedema pumps (e.g., Flexitouch) for treatment of lymphedema as they are considered investigational.
Continuous Passive Motion (CPM) in the Home Setting
Coverage is provided for the use of Continuous Passive Motion (CPM) in the home setting as an adjunct to physical therapy. The following situations may be considered medically necessary:
1. Under conditions of low postoperative mobility or inability to comply with rehabilitation exercises following a total knee arthroplasty (TKA) or TKA revision. This may include patients with complex regional pain syndrome (reflex sympathetic dystrophy), extensive arthrofibrosis or tendon fibrosis, or physical, mental, or behavioral inability to participate in active physical therapy.
a) Following total knee arthroplasty (TKA), continuous passive motion (CPM) in the home setting will be allowable for up to 17 days after surgery while patients are immobile or unable to bear weight.
2. During the non-weight bearing rehabilitation period following intra-articular cartilage repair procedures of the knee (e.g., microfracture, osteochondral grafting, autologous chondrocyte implantation, treatment of osteochondritis dissecans, repair of tibial plateau fractures).
a) Following intra-articular cartilage repair procedures of the knee, CPM in the home setting will be allowable for up to 6 weeks during non-weight bearing rehabilitation.
No coverage shall be provided for the use of Continuous Passive Motion (CPM) in the home setting for longer periods of time or for all other applications as this is considered not medically necessary.
Serial Endpoint Testing for the Diagnosis and Treatment of Allergic Disorders
Coverage is provided for serial endpoint testing (SET) for the determination of a safe starting dose for testing or immunotherapy when there is potential for the specific allergen in question to produce a severe systemic allergic reaction or anaphylaxis.
Diabetic Services & Supplies
Insulin pump coverage is updated to cover one pump every two years (previously was one every four years). Additional coverage will be reviewed by Pharmacy Management.
Prior authorization criteria for the MiniMed Continuous Glucose Monitoring System are added. The following criteria must be met for approval of the MiniMed Continuous Glucose Monitoring System:
1. Must be prescribed by an endocrinologist;
2. Must be using an insulin pump;
3. Documented hypo- and hyperglycemia at the same time each day; or
4. Hypoglycemia unawareness.
The MiniLink Transmitter is obtained through the DME (durable medical equipment) benefit; the sensors are obtained through the pharmacy benefit. A quantity limit of 10 sensors per 30 days has been established. Each sensor is used for a 3 day period.
Hyperbaric Oxygen (HBO) Therapy
Hyperbaric Oxygen Pressurization (HBO)
The treatment of acute carbon monoxide poisoning is medically necessary. In addition, recommendations from The Undersea and Hyperbaric Medical Society as to the number of treatment sessions for various indications are added.
Cryosurgical Ablation and Radiofrequency Ablation
Radiofrequency Ablation of Primary or Metastatic Liver Tumors
Coverage is provided for radiofrequency ablation of primary or metastatic liver tumors when medically necessary.
Radiofrequency ablation of primary hepatocellular carcinoma (HCC) may be considered medically necessary as a primary treatment of HCC for patients who are not candidates for curative therapy (resection or transplant) when there are no more than 3 nodules and all tumor foci can be adequately treated.
Radiofrequency ablation of primary hepatocellular carcinoma (HCC) may be considered medically necessary as a bridge to transplant, where the intent is to prevent further tumor growth and to maintain a patient’s candidacy for liver transplant.
Radiofrequency ablation of primary hepatocellular carcinoma (HCC) is considered investigational when there are more than three nodules or when not all sites of tumor foci can be adequately treated.
Radiofrequency ablation may be considered medically necessary as a primary treatment of hepatic metastases 5 cm or less in diameter from colorectal cancer in the absence of extrahepatic metastatic disease if tumor foci are deemed by the attending surgeon to be technically unresectable or patients are precluded from definitive hepatic resection due to underlying condition(s) and, in either case, when all tumor foci can be adequately treated.
Radiofrequency ablation may be considered medically necessary as treatment of hepatic metastases from neuroendocrine tumors in patients with symptomatic disease when systemic therapy has failed to control symptoms.
Radiofrequency ablation for hepatic metastasis is considered investigational and not covered:
-for hepatic metastases from colorectal cancer or neuroendocrine tumors that do not meet the criteria above; and
-for hepatic metastases from other types of cancer with the exception of colorectal cancer or neuroendocrine tumors.
Preimplantation Genetic Testing
No coverage is provided for preimplantation genetic screening (PGS) as an adjunct to in vitro fertilization (IVF) as it is considered not medically necessary.
The following procedures are considered experimental/investigative and members are responsible for any charges for treatment for:
Cosmetic Procedures vs. Reconstructive Procedures
Laser Treatment of Port Wine Stains
No coverage is provided for treatment of port wine lesions of the face with lasers in combination with photodynamic therapy or topical angiogenesis inhibitors as it is considered investigational.
Experimental/Investigational Services Miscellaneous
Fluocinolone acetonide intravitreal implant (Retisert) for all other conditions except the treatment of chronic noninfectious posterior uveitis, in one or both eyes is considered investigational and not covered.
Experimental/Investigative Services Pathology/Laboratory
Pathfinder TG® Molecular Testing
Molecular testing using the Path Finder TG® system for all indications including the evaluation of pancreatic cyst fluid and of suspected or known gliomas is considered investigational and not covered.
Novel Lipid Risk Factors in Risk Assessment and Management of Cardiovascular Disease Measurement of novel lipid risk factors (i.e., apolipoprotein B, apolipoprotein A-I, apolipoprotein E, LDL subclass, HDL subclass, lipoprotein[a]) as an adjunct to LDL cholesterol in the risk assessment and management of cardiovascular disease is considered investigational and not covered.
Proteomics-based testing for the Evaluation of Ovarian (Adnexal) Masses
Except as an aid to further assess the likelihood that malignancy is present when the physician’s (other than gynecological oncologist) independent clinical and radiological pre-operative evaluations do not indicate malignancy in a patient with an ovarian (adnexal) mass, all other uses of the proteomics-based OVA1TM test are investigational and not covered including but not limited to: post-operative testing and monitoring to assess surgical outcome and/or to detect recurrent malignant disease following treatment.
Experimental/Investigative Services Medicine
Electrostimulation and Electromagnetic Therapy for the Treatment of Chronic Wounds
No coverage is provided for the use of the following as these are considered investigational:
-Electrical stimulation using low-intensity direct current, high-voltage pulsed current (HVPC), alternating current (AC), and transcutaneous electrical nerve stimulation (TENS) for the treatment of wounds;
- Electrical stimulation performed by the patient in the home setting for the treatment of wounds; and/or
- Electromagnetic therapy for the treatment of wounds.
Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting
In the ambulatory care and outpatient setting, cardiac hemodynamic monitoring for the management of heart failure utilizing thoracic bioimpedance, inert gas rebreathing, arterial pressure/Valsalva, and implantable direct pressure monitoring of the pulmonary artery are considered investigational and not covered.
Experimental/Investigative Services Surgery
Bronchial thermoplasty for the treatment of asthma is considered investigational and not covered.
Isolated Limb Perfusion/Infusion for Malignant Melanoma
Isolated limb infusion in the treatment of melanoma for all other indications, except when used with melphalan as a therapeutic treatment of local recurrence of nonresectable melanoma (i.e., satellite lesions or “in transit” melanoma); is considered investigational and not covered.
Experimental/Investigative Services Therapy
Inhaled Nitric Oxide as a Treatment of Hypoxic Respiratory Failure
Inhaled nitric oxide for indications including, but not limited to, its use in adults with respiratory distress (ARDS) or premature neonates born at less than 34 weeks gestation is considered investigational and not covered.