The Connection OnlineSM

February 2010

Investigational and medical necessity reviews


Listed below are recent changes to our medical policies. The Medical Policy Manual provides all detailed policies. This list does not include medications or Medicare medical policy exceptions.

New or updated investigational or medical necessity policy criteria
Durable Medical Equipment

Electrical Bone Growth Stimulators (EBGS) (Osteogenic Stimulation) (#10)

Policy criteria updated. Added systemic steroid use as a risk factor for failed fusion; added semi-invasive EBGS as investigational for all indications.

Multi-Chamber Programmable Pneumatic Compression Pumps (#78)
New policy effective May 1

New policy focusing on multi-chamber programmable pneumatic compression pumps (HCPCS E0652) which finds these pumps not medically necessary compared to either single- or multi-chamber non-programmable compression pumps.

Learn more about this policy.
Laboratory
Genetic Testing (#20) New investigational indication added: Apolipoprotein E (apo E) genotyping and phenotyping for the risk assessment and management of cardiovascular disease.
Radiology
Magnetoencephalography (MEG)/Magnetic Source Imaging (MSI) (#22) Policy changed. MEG/MSI is now considered medically necessary for localization of language function as a substitute for Wada testing in patients undergoing surgery for epilepsy, brain tumor or other indications requiring brain resection. MSI remains investigational for all other indications.

Virtual Colonoscopy/ Computed Tomographic (CT) Colonography (#36)

Policy criteria changed from investigational to not medically necessary for those who are unable to undergo a conventional colonoscopy for medical reasons (e.g., continuous anticoagulation therapy or high anesthesia risk); or for those unable to complete a conventional colonoscopy because of colonic stenosis or obstruction.  Virtual colonoscopy is considered not medically necessary except as noted in the criteria above.
Surgery
Radiofrequency Ablation of Tumors (RFA) (#92)

Policy criteria changed:

  • Now considered medically necessary for renal tumors and colorectal metastases in the liver when criteria are met.
  • Criterion for osteoid osteomas expanded to specify that medically necessary tumors are those that cannot be managed with medical treatment.


Added to investigational indications:

    • Initial treatment of osteoid osteomas
    • Bridge to liver transplant
    • Debulking of liver tumors when treatment goal is less than complete resection/ablation.

Varicose Vein Treatment (#104)
Policy change effective May 1

Policy criteria revised:

  1. Photographs of varicose veins to be treated required;
  2. Procedures done in conjunction with endoluminal ablation in the same operative session, same vein are included in the ablation reimbursement.

Learn more about this policy.
Transanal Endoscopic Microsurgery (TEMS) (#162) Policy criteria changed from investigational to medically necessary for treatment of rectal adenomas and T1 rectal adenocarcinomas when criteria are met.


Join our medical policy discussions
We welcome your input and feedback as we draft our medical policies. It's easy to join our email reviewer list. Simply complete our request form.

While we prefer to receive input as policies are developed, we also have a formal process that allows physicians, other health care professionals and facilities to submit additional information, such as clinical trial results, that may warrant a policy review.

 

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