June 2010
Investigational and medical necessity reviews
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 |
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Laboratory |
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Genetic and Molecular Diagnostic Testing (#20) Effective Date: September 1 for general criteria change, genetic counseling requirement and Adenomatous Polyposis Coli (APC) testing in the index patient. |
General criteria added to address molecular diagnostic testing for indications other than testing for inherited diseases. Added criterion for genetic counseling when testing is performed for genetically inherited diseases. Added new investigational test: OncoVue Breast Cancer Risk Test. Criteria related to Familial Adenomatous Polyposis (FAP), MYH-Associated Polyposis (MAP), and Lynch Syndrome clarified. Criteria changed to indicate that testing the index patient with clinically diagnosed APC is considered not medically necessary. |
Medicine |
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Charged Particle (Proton or Helium Ion) Radiation Therapy (#49) Effective Date: September 1 |
Primary treatment of localized prostate cancer is considered not medically necessary because the clinical outcomes with this treatment have not been shown to be superior to other approaches including intensity modulated radiation therapy or conformal radiation therapy. Charged-particle irradiation with proton beams is more costly than other alternatives for treatment. |
Ingestible pH and Pressure Capsule (#117) |
New investigational policy. |
Outpatient Intravenous Insulin Therapy (OIVIT) (#96) |
New investigational policy for outpatient intravenous insulin therapy as a treatment of diabetes. This service is described by new HCPCS G9147. |
Surgery |
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Bariatric Surgery (#58) |
Criteria modified to include Licensed Clinical Social Worker (LCSW) among professionals qualified to perform psychological evaluation of the potential bariatric surgery patient. Added new criterion to address reoperations. Clarified investigational criteria related to endoscopic procedures. |
Keratoprosthesis (#85) |
Criteria change. Keratoprosthesis may be considered medically necessary when criteria are met. |
Transcatheter Radiofrequency Ablation of Arrhythmogenic Foci in the Pulmonary Veins as a Treatment for Atrial Fibrillation (#138) |
Criterion added allowing up to two repeat procedures for patients with recurrent atrial fibrillation or development of atrial flutter following the initial procedure. |
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