Medical Policies – 3rd Quarter 2018

New Policies

Policy Reference Number

Policy Name

Description

CP.MP.161

Monitored Anesthesia Care

Clinical criteria for administering conscious sedation with the additional assistance from an anesthesia team member for gastrointestinal (GI) endoscopic procedures

Updated Policies

Policy Reference Number

Policy Name

Change

CP.MP.26

Articular Cartilage Defect Repairs

In I.A., changed criteria to state ages 18–55, or documented skeletal maturity if <18, instead of ages15–55, or documented skeletal maturity if <18

Policy Reference Number

Policy Name

Change

CP.MP.37

Bariatric Surgery

Replaced cardiac risk qualifiers with that from the reconstructed revised cardiac risk index (RCRI), in addition to significant arrhythmias and valvular heart disease. Reworded hypothyroidism screening criteria to require testing if signs/symptoms of hypothyroidism other than obesity. Removed requirement for screening for Helicobacter pylori (H. pylori) in high prevalence areas and treatment requirement

CP.MP.125

DNA analysis of stool to screen for colorectal cancer

HCPCS code G0464 removed from the policy as the code is deleted in 2018

CP.MP.106

Endometrial Ablation

Added “previous transmyometrial uterine surgery” in I.D

CP.MP.62

Hyperhidrosis Treatments

Separated criteria for endoscopic thoracic sympathectomy (ETS) and removal of axillary sweat glands, and specified that they meet criteria for iontophoresis A-D. For ETS, added criteria that member heart rate is ≥55 beats per minute; symptoms started before age 16, and surgery is on a member less than age 25; that there be no significant comorbidities; that there is no night sweating, and body mass index     (BMI) <28, per 2011 guidelines

See Change column

Injections for Pain Management

Policy CP.MP.118 has been separated into individual policies:

·      Trigger Point Injections (CP.MP.169)

·      Intradiscal Steroid Injections for Pain Management (CP.MP.167)

·      Selective Nerve Root Blocks and Transforaminal Epidural (CP.MP.165)

·      Caudal or Interlaminar Epidural Steroid Injections (CP.MP.164)

CP.MP.212

Microvolt T wave Alternans Testing

Added known or suspected long QT syndrome (LQTS)

CP.MP.170

Nerve Blocks for Pain Management

Policy split from CP.MP.118 Injections for Pain Management.

·      Sympathetic nerve block for CRPS: reworded diagnostic criteria for complex regional pain syndrome (CRPS), retaining clinical meaning; added requirement of positive response to first or second block, if requesting additional

·      Added that blocks should be at least one week apart

·      Expanded criteria for sympathetic nerve block for pancreatic cancer a separate section and includes celiac plexus neurolysis 

CP.MP.51

Reduction Mammoplasty and Gynecomastia Surgery

Added “chiropractic care or osteopathic manipulative treatment” under I.A.4

Policy Reference Number

Policy Name

Change

CP.MP.166

Sacroiliac Joint Interventions

Clarified II. by adding “≥50%” to the statement

CP.MP.542

Testing for Drugs of Abuse

Modified criteria in I.A.1 that a presumptive test must be performed before a definitive test unless no reliable test is available. Added an indication for testing when the presumptive test is assumed to be positive based on patient history, but quantitative levels are required. Modified II.C. to state that screening in asymptomatic patients is medically unnecessary, unless otherwise stated in section I

CP.MP.151

Transcatheter Closure of Patent Foramen Ovale 

Removed the phrase “to reduce the risk of ischemic stroke” from the medical necessity statement in II. Specified that the “stroke prevention” in section II is “primary stroke prevention”