April 2010
Investigational and medical necessity reviews
Listed below are recent changes to our medical policies. The complete Medical Policy Manual is available at http://blue.regence.com/trgmedpol/index.html or upon request by contacting your provider consultant. This list does not include medications or Medicare medical policy exceptions.
| New or updated investigational or medical necessity policy criteria |
| Surgery |
Percutaneous Angioplasty and Stenting of Veins (#109)
|
Criterion II clarified to include angioplasty and/or endoprostheses as medically necessary for creation of intrahepatic shunt connections between the portal venous system and the hepatic vein. |
Spinal Cord Stimulation for Treatment of Pain (#45) |
Clarification of criterion I.B.4 related to multispecialty consultation. Added vulvodynia, vulvar vestibulitis, chronic pelvic pain, migraine headache and occipital nerve stimulation for headache to list of investigational indications. |
Total Facet Arthroplasty (#171) |
New investigational policy. |
| Transplant |
Allogeneic Hematopoietic Stem Cell Transplant (#43) |
The subtitle for primitive neuroectodermal tumors was changed to central nervous system (CNS) embryonal tumors. New medical necessity criteria for reduced intensity conditioning allogeneic stem cell transplant have been added to the Hodgkin lymphoma section. |
Autologous Hematopoietic Stem Cell Transplant (#42) |
The subtitle for primitive neuroectodermal tumors was changed to CNS embryonal tumors. New medical necessity criteria have been added for previously untreated CNS embryonal tumors. The investigational criteria for Hodgkin lymphoma have been clarified to state that a second autologous stem cell transplant for relapsed lymphoma after a prior autologous stem cell transplant is investigational. |
Tandem Hematopoietic Stem Cell Transplant (#44) |
The subtitle for primitive neuroectodermal tumors (PNETs) was changed to CNS embryonal tumors and criteria language was simplified to state tandem stem cell transplant is investigational for CNS embryonal tumors. New medical necessity criteria have been added for primary refractory and relapsed Hodgkin lymphoma with poor risk features. |
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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