Provider Press

ICD-10 CODING UPDATE AND FINAL REMINDERS Note The information below was also published on August 5 2015 in Provider Bulletin P30-15 The ICD-10 federal compliance date of October 1 2015 is almost here The help you with your final preparations for the impacts of ICD-10 Blue Cross and Blue Shield of Minnesota and Blue Plus (Blue Cross) is publishing some new information and final reminders New Information bull BeginningOctober12015whensubmittingproceduresforpriorauthorization(PA)

requestsyoumustsubmittheICD-10diagnosiscodePArequestssubmittedbeforeOctober12015mustbesubmittedwiththeICD-9diagnosiscode

bull ProviderPolicyandProcedureManualreferencestoICD-9codeswillbeupdatedtoreflect the appropriate ICD-10 codes We anticipate completing the updates no later thanSeptember12015Toaccessthemanualgotoprovidersbluecrossmncom and select ldquoForms amp Publicationsrdquo then ldquomanualsrdquo

bull ReimbursementpolicyreferencestoICD-9codeswillbeupdatedtoalsoreflecttheappropriateICD-10codesTheupdateswillbecompletedpriortoOctober12015ToaccessreimbursementpolicydocumentsgototheldquoToolsandResourcesrdquosectionofprovidersbluecrossmncom

bull ProvidershavingdifficultywithclaimsubmissionsoftwareafterthecompliancedatemayusethefreeofchargeclaimsubmissionentryontheAvailityproviderportaltosubmittheir claims This process does require registration but is easy to use and is fully tested for ICD-10 functionality For more information visit availitycom

Coding RemindersCode all diagnosis and procedures to the greatest level of specificity possible Medical record documentation must support the code selection on the claim transactions

General Billing RemindersDue to the impacts to our members Blue Cross will not extend the timely filing deadlines or advance payments to any providers who fail to comply with the ICD-10 mandate Claims mustbesubmittedtimelytoBlueCrossAnyclaimsreceivedafterthetimelyfilingperiodspecifiedinyourParticipatingProviderServiceAgreementwillbedeniedasproviderliabilityPlease work with your software vendor and clearinghouse to make sure you are ready to submit ICD-10 coded claims by the compliance date

Onlyoneversionofthecodeset(ICD-9orICD-10)isallowedpersubmittedclaimICD-9onlymustbeusedonclaimswithservicedatesandinpatientdischargedatespriortoOctober12015ICD-10onlymustbeusedonclaimswithservicedatesandinpatientdischargedatesOctober12015andafter

ClaimswithservicedatesspanningOctober12015mustbesubmittedastwoseparateclaims transactions with the exception of inpatient services Please refer to CMS MLN Matters publication for more information

Provider Press

Provider Press is a quarterly newsletter available online at providersbluecrossmncom Issues are published in March June September and December

Inside preview

Front cover article 1 4 FYI2-3 Coding Corner 4 HealthLiteracy5 QualityImprovement6-9Medical and Behavioral HealthPolicyUpdate10-22

Sept 2015 Vol 19 No 3

Provider information

continued on page 4

September 2015 2

Provider Demographic Change Form

The Provider Demographic Change form needs to be completed when your address phone number hospital affiliation or office hours change Go to providersbluecrossmncom and enter ldquoprovider demographic change formrdquo in the search window to obtain the form Completed forms can be

Emailed to ProviderDatabluecrossmncom

Faxed to (651) 662-6684

Mailed to Blue Cross and Blue Shield of Minnesota PDOR316 POBox64560 StPaulMN55164-0560

FYI

PUbLICATIONS AvAILAbLE ONLINE

ThefollowingisalistofQuickPointsandBulletinspublishedfromJune2015toAugust2015thatareavailableonlineatprovidersbluecrossmncom AsareminderBulletinsaremailedtoallparticipatingprovidersaffectedbytheinformation Quick Points are available only on our website unless noted otherwise in the bottom left corner of the publication

QUICk POINTS TITLEQP13-15 Provider Cost Data Update

QP14-15 Update to Buprenorphine and BuprenorphineNaloxone (BunavailtradeSuboxoneregZubsolvreg)PriorAuthorizationandQuantityLimitCriteria

QP15-15 Update to NuvigilregArmodafinilProvigilregModafinilPriorAuthorizationandQuantity Limit Criteria

QP16-15 ICD-10 Provider Partner Testing Summary

QP17-15 WhoisBlueLinkTPA

bULLETINS TITLEP21-15 NewClaimsFilingRulesforAirAmbulanceProviders

P22-15 July2015HCPCSCodeUpdates

P23-15 MedicalNecessityReviewCriteriaUpdateforMHCPSubscribers

P24-15 MentalHealthServicesRequirementforMinnesotaHealthCarePrograms(MHCP) Subscribers

P25-15 NewDrug-relatedPriorAuthorizationCriteriaProproteinConvertaseSubtilisinKexinType9(PCSK9)InhibitorsforFamilialHypercholesterolemiaPAwithQuantityLimit

P26-15 UpdateonKneeArthroplastyCriteriaforMHCPSubscribers

P27-15 Non-CoveredMedicareServicesandOrganizationDeterminationUpdateforPlatinumBlue Subscribers

P28-15 Facility Place of Service Changes

P29-15 MedicareTrainingandEducationRequirements

P30-15 ICD-10CodingUpdateandFinalReminders

P31-15 Common Carrier and Special Transportation Providers Billing Code Updates

FYIHELPFUL PHONE NUMbERSBLUELINE (voice response unit) (651) 662-5200 or 1-800-262-0820

BlueCardreg member benefits or eligibility 1-800-676-BLUE (2583)

FEPreg (voice response unit) (651) 662-5044 or 1-800-859-2128

Availity 1-800-282-4548

Provider services (651) 662-5200 or 1-800-262-0820

Please verify these numbers are correctly programmed into your office phones

September 2015 3

FYI

PROvIDER MANUAL UPDATES The following is a list of Blue Cross and Blue Shield of Minnesota provider manuals thathavebeenupdatedfromJune2015toAugust2015Asareminderprovidermanuals are available online at providersbluecrossmncom To view the manuals select ldquoForms amp publicationsrdquo then ldquomanualsrdquo Updates to the manuals are documented in the ldquoSummary of changesrdquo section of the online manuals

MANUAL NAME

CHAPTER NUMbER AND TITLE

CHANGE

Provider Policy and Procedure Manual

Chapter 11 Coding Policies and Guidelines Medical Services section

Topic of ldquoNon-covered Tobacco Treatmentsrdquo was deleted

Provider Policy and Procedure Manual

Chapter 11 Coding Policies and Guidelines Public Programs section

Content change to Transportation Services (Formerly titled Special Transportation)

Provider Policy and Procedure Manual

Allchapters ReferencestoICD-9codeswillbeupdatedtoreflect the appropriate ICD-10 codes Note We anticipate completing all the updates nolaterthanSeptember12015

REALLy SIMPLE SyNDICATION Not all provider publications are mailed out to providers The majority of our informational Quick Points and the quarterly Provider Press are posted to our website for providers to view Providers frequently ask us how they can be advised when new publications are added to the website at providersbluecrossmncom

ProviderscansignuptogetRSS(reallysimplesyndication)feedsofourlatestnewsreleasesandupdatestoprovider-relatedformsandpublicationsAsampleofthefeeds that can be requested includes

bull Bulletinsbull Forms admin updates and contractingbull Forms credentialingbull Formspre-certificationandpre-authorizationbull Manualsbull Provider Press

bull Quick Points

Go to providersbluecrossmncomandenterldquoRSSrdquointhesearchwindowtolearnmoreaboutRSSQuestionsaboutRSSfeedsspecifictoyourinternalsystemsshould be directed to your IT support area

2015 HOLIDAy SCHEDULEProvider services will be closed on the following days

in2015

Monday September 7

ThursdayNovember26

FridayNovember27

ThursdayDecember24

FridayDecember25

With the exception of the dates stated above representatives answering the provider services numbers are available to assistyou8amto5pmMonday through Thursday and9amto5pmonFriday

September 2015 4

CodINg CorNer

REPLACEMENT CLAIM REMINDERWhendoIneedareplacementclaimWellareyoumakingchangestoaclaimthatwaspreviouslyprocessedIfyesyouwillneedtosendinareplacementclaimThisincludes

bull changing a date of service

bull adding or changing a procedure

bull adding or changing a diagnosis

bull removing a modifier

bull adding a modifier

Note that when adding modifiers -24 -25 -57 -59 -78 andor 79 medical notes supporting the modifier also need to be sent with the replacement claim

SeeProviderBulletinP28-14datedOctober12014formoreinformation

26 OR TC USENot every code in particular radiology codes has a professional component (reported witha-26modifier)andtechnicalcomponent(reportedwithandashTCmodifier)ForexampleCPTcode77387isldquoGuidanceforlocalizationoftargetvolumefordeliveryof radiation treatment delivery includes intrafraction tracking when performedrdquo This code does not have a professional or technical component Thus if it is submitted with acomponentmodifier(-26or-TC)itwillbedeniedbecauseaninvalidmodifierwasappended to the service

ICD-10 CODING UPDATE AND FINAL REMINDERS continued from page 1

httpwwwcmsgovOutreach-and-EducationMedicare-Learning-Network-MLNMLNMattersArticlesDownloadsSE1325pdf

UsethecorrectcodequalifierindicatingwhetherthecodeisICD-9orICD-10forthecode setbeingreportedintheHIPAAtransaction

Reviewyourclaimacknowledgementreportstimelytoensureclaimshavebeencorrectlysubmitted and accepted by Blue Cross Claims rejected on these reports must be corrected and submitted again Claims rejected on acknowledgment reports are not considered submitted for timely filing purposes

AdditionalinformationisavailableundertheICD-10compliancelinkonourwebsiteatprovidersbluecrossmncom

Questions

If you have questions please contact provider services at (651) 662-5200 or 1-800-262-0820

THE HCPCS ARE COMING THE HCPCS ARE COMING Itrsquos not just the ICD codes that will be the coding stars onOctober12015HCPCScodes are updated as well on that fall date Blue Cross will publish a Provider Bulletin closer to the October12015effectivedate that provides more details

September 2015 5

HeALTH LITerACY

Try both aleve 2pills bid with flexeril at hs

Asahealthcareprofessionalyouprobablyunderstandexactlywhatthedoctorwhosentthismessage was saying Take 2 Aleve pills 2 times a day and take 1 Flexeril pill at bedtime But the patient who received it had no idea what the doctor was saying Most people donrsquot Clear communication increases patient safety and adherence to treatment plans

OctoberishealthliteracymonthHerearesomeactivitiesthatyourpracticecliniccanincorporate to help make a healthy difference in your patientrsquos lives

Use the Teach Back method also known as the ldquoshow-merdquo technique to ensure that patients (or care takers) understand their treatment plan and what they need to do Think aboutdoingasimpleteachbacktrainingatyourpracticeduringthemonthofOctoberClickhere for a program ready to use from the Minnesota Health Literacy Partnership

Promote the Ask Me 3 program from the National Patient Safety Foundation which focuses onpatientunderstandingof3simplequestions

1)Whatismymainproblem

2)WhatdoIneedtodo

3)Whyisitimportantformetodothis

You can use these questions to help guide the information you provide during visits with your patients Make sure they know the answer to these questions before they leave your office ConsiderdisplayingpostersandbrochuresthroughoutyourofficeduringOctobertoremindstaffaboutthe3questionsFormoreinformationonAskMe3clickhere

Review your own patient education materials Select a few of the patient education materials that you commonly use in your practice and review them using one of the health literacytoolsfromtheOfficeofDiseasePreventionandHealthPromotionPerhapsformateam to review the pieces together Click hereforresourcesOrcontactusifyouwantacopy of the tool used at Blue Cross

To learn more about building a culture of health literacy and using plain language at your practice please send an email to AlishaOdhiambobluecrossmncomAdditionalinformationcan also be found online at httphealthliteracymnorg

September 2015 6

QuALITY ImproVemeNT

PCC QUALITy OF CARE COMPLAINT REPORTProviders are required to complete the Blue Plus Quality of Care Complaint report forallwrittenandverbalcomplaintsfromBluePlusPrepaidMedicalAssistanceProgram and MinnesotaCare subscribers on a quarterly basis per Minnesota Department of Health regulations Complaints logged at the provider offices are to be investigated and resolved by the providerrsquos office whenever possible

ThesecomplaintsarereportedtoBluePlusinJanuaryAprilJulyandOctoberfor the preceding three months The Primary Care Clinic (PCC) must submit a quarterly report even if the facility does not receive any complaints for the quarter YourcontractoutlinestheproceduresrequiredforyourQualityofCare(QOC)PCCcomplaint reporting adherence agreement

Complaints should no longer be directed to the attention of a single designated personSendingyourPCCQOCcomplaintreportformtoanysourcenotlistedbelowmaydelaytheprocessingofyourPCCQOCcomplaintreport

ToaccessthePCCBluePlusQualityofCareComplaintReportFormgoto providersbluecrossmncom and select ldquoForms amp publicationsrdquo then ldquoforms - clinical operationsrdquo

Submit quarterly PCC QOC reports using one of these methods

Email pcccomplaintbluecrossmncom

Secure fax line (651) 662-4004

Mail Blue Plus AttnQualityHealthManagementDept R472 POBox64179 StPaulMN55164-0179

UTILIzATION MANAGEMENT STATEMENTUtilizationManagement(UM)decisionmakingisbasedonlyonappropriatenessofcareand service and on existing coverage provisions Blue Cross does not compensate providers practitioners or other individuals making UM decisions for denial of coverage or services We do not offer incentives to decision makers to encourage denial of coverage or services that would result in less than appropriate care

September 2015 7

QuALITY ImproVemeNT

CLINICAL PRACTICE GUIDELINES Blue Cross believes that the use of clinical practice guidelines is a key component of Quality Improvement Each year Blue Crossrsquo Clinical Practice Quality Committee (a designee of the Quality Council) approves the adoption of select guidelines that are used to support various programs and initiatives The guidelines do not substitute for sound clinical judgment however they are intended to assist clinicians in understanding key processes for improvement efforts

Clinical Practice Guidelines with hyperlinks are available in Chapter Three of the Blue Cross Provider Policy and Procedure Manual To access the manual go to providersbluecrossmncom and select ldquoForms and Publicationsrdquo then ldquoManualsrdquo

Recommended sources BlueCrossrecognizesthefollowingsourcesforClinicalPracticeGuidelinesfora variety of areas of clinical practice

bullUSPSTFUSPreventiveServicesTaskForce httpwwwuspreventiveservicestaskforceorgbrowseRecIndex

bullAAPAmericanAcademyofPediatricsincludingBrightFutures httppediatricsaappublicationsorgsearchflag=practice_guidelinesampsubmit=yesampx=18ampy=8ampformat=standardamphits=30ampsortspec=dateampsubmit=Gohttppediatricsaappublicationsorgsearchflag=practice_guidelinesampsubmit=yesampx=18ampy=8ampformat=standardamphits=30ampsortspec=dateampsubmit=Go

httpbrightfuturesaaporg

bullICSIInstituteforClinicalSystemsImprovement httpswwwicsiorgguidelines__moreguidelines_a_to_z

Specific guidelines Specific guidelines recommended by Blue Cross include the following

bullBehavioralHealth-ADHD-DiagnosisEvaluationandTreatmentofAttention-DeficitHyperactivityDisorderinChildrenandAdolescents(AAP)-DepressionScreeninginAdults(USPSTF)

bullNon-PreventiveAcuteorChronicConditions-DiabetesndashDiagnosisandManagementofType2DiabetesMellitusinAdults(ICSI)-AsthmandashDiagnosisandManagementofAsthma(ICSI)

bullPreventiveCareGuidelines-PreventiveServicesforAdults(ICSI)-PreventiveServicesChildrenandAdolescents(ICSIandBrightFutures)-RoutinePrenatalCare(ICSI)

Questions concerning Clinical Practice Guidelines can be directed to Eileen Johnson Director Quality and Health Management at (651) 662-4224Acopyoftheclinicalpractice guidelines with hyperlinks is also available by calling Eileen Johnson

September 2015 8

QuALITY ImproVemeNT

bLUE PLUS MEDICAL RECORD DOCUMENTATION REvIEwAdvance Directives

Anadvancedirectiveprovidesanopportunityforadultsofanyagetomaketheirhealthcare wishes known if or when a potential life-threatening event occurs and they are unabletoverbalizetheirwishesatthetimeoftheevent

ArepresentativesamplereviewofourBluePlusmembersrsquomedicalrecordsfordatesofservicein2014hasbeencompletedandtheresultsarebelowWeencourageprovidersto discuss the benefits of completing an advance directive with all our adult members

TOTAL MEMbERS IN SAMPLE

ADvANCE DIRECTIvE PRESENT OR DISCUSSED

AGE RANGE FOR MEMbERS wITH DISCUSSION

MedicareMedicaid Eligible(MSHO)

300 187(62) Avg83Range67-107

Medicaid 600 61(10) Avg48Range20-64

Body Mass Index (BMI) And Counseling For Obesity

Documentation of a memberrsquos BMI is the first step towards addressing the prevalence of obesity in our society Blue Plus completed a review of a sample of Blue Plus membersrsquomedicalrecordswithdatesofservicein2014toevaluatedocumentationofBMIvalueandcounselingforobesityObesityisdefinedasaBMIover30TheresultsareshownbelowOne-thirdofMedicaidmembersdefinedasobesehad documentation of a discussion with their provider concerning their weight management

TOTAL MEMbERS

bMI DOCUMENTED

bMI gt 30 (IF DOCUMENTED)

IF bMI gt 30 ADvISED ON wEIGHT MANAGEMENT

AvERAGE bMI FOR MEMbERS wITH DISCUSSION

MedicareMedicaid Eligible(MSHO)

300 183(61) 70(38) 6(9) Avg3603 Range3089-501

Medicaid 600 550(92) 237(43) 93(39) Avg3807 Range2676-710

Total 900 733(81) 307(42) 99(32) Avg3795

continued on next page

September 2015 9

bLUE PLUS MEDICAL RECORD DOCUMENTATION REvIEw continuedfrompage8

Tobacco Use Assessment And Counseling

AsampleofmedicalrecordswerereviewedtodeterminetobaccouseamongourBlue Plus members and discussions promoting tobacco cessation during a provider visitin2014Whiletobaccouseappearstoberoutinelyassessedatleastonceduring2014onlyhalfofourmembershavedocumentationofprovidereffortsinaddressingthis health concern

TOTAL MEMbERS

ASSESSED FOR TObACCO USE

TObACCO USE AvERAGE AGE OF TObACCO USERS

DISCUSSION ANDOR Rx ASSISTANCE

MSHO 300 281(93) 24(85) Avg75(67-87)

10(42)

PMAPMNCARE 600 518(86) 164(32) Avg44(20-64)

89(54)

Total 900 799(89) 188(24) Avg49 (20-87)

99(53)

These reviews were completed to encourage providers to open the door to meaningful discussions with their patients on important health issues If you have any questions concerning this article please send an email to the Quality and Health Management department co Sheiladalenbluecrossmncom

Better Care Through Quality Improvement

Every year Blue Cross and Blue Shield of Minnesota (Blue Cross) reviews the care delivered to our subscribers This review determines the goals for the quality program The program currently has many goals to improve health services

Making sure our subscribers receive preventive services and health screenings making sure people with health problems like heart disease receive treatment and improving the customer service experience are just a few of the goals in the program

More detailed information is available about Blue Crossrsquo process and outcomes in meeting quality improvement goals related to subscriber care and service You can see more information about our quality improvement program at bluecrossmncom Enter ldquoquality improvement programrdquo in the search field If you are unable to access the website please contact Eileen Johnson Director | AccreditationampQualityImprovementat(651) 662-4224 to request information about the Quality Improvement Program

QuALITY ImproVemeNT

September 2015 9

bLUE PLUS MEDICAL RECORD DOCUMENTATION REvIEw continuedfrompage8

Tobacco Use Assessment And Counseling

AsampleofmedicalrecordswerereviewedtodeterminetobaccouseamongourBlue Plus members and discussions promoting tobacco cessation during a provider visitin2014Whiletobaccouseappearstoberoutinelyassessedatleastonceduring2014onlyhalfofourmembershavedocumentationofprovidereffortsinaddressingthis health concern

TOTAL MEMbERS

ASSESSED FOR TObACCO USE

TObACCO USE AvERAGE AGE OF TObACCO USERS

DISCUSSION ANDOR Rx ASSISTANCE

MSHO 300 281(93) 24(85) Avg75(67-87)

10(42)

PMAPMNCARE 600 518(86) 164(32) Avg44(20-64)

89(54)

Total 900 799(89) 188(24) Avg49 (20-87)

99(53)

These reviews were completed to encourage providers to open the door to meaningful discussions with their patients on important health issues If you have any questions concerning this article please send an email to the Quality and Health Management department co Sheiladalenbluecrossmncom

Better Care Through Quality Improvement

Every year Blue Cross and Blue Shield of Minnesota (Blue Cross) reviews the care delivered to our subscribers This review determines the goals for the quality program The program currently has many goals to improve health services

Making sure our subscribers receive preventive services and health screenings making sure people with health problems like heart disease receive treatment and improving the customer service experience are just a few of the goals in the program

More detailed information is available about Blue Crossrsquo process and outcomes in meeting quality improvement goals related to subscriber care and service You can see more information about our quality improvement program at bluecrossmncom Enter ldquoquality improvement programrdquo in the search field If you are unable to access the website please contact Eileen Johnson Director | AccreditationampQualityImprovementat(651) 662-4224 to request information about the Quality Improvement Program

QuALITY ImproVemeNT

September 2015 10

medICAL ANd BeHAVIorAL HeALTH poLICY updATe

Medical and behavioral health policies are available for your use and review on the Blue Cross and Blue Shield of Minnesota website at providersbluecrossmncom From this site there are two ways to access medical policy information depending on the patientrsquos Blue Plan membership

For out-of-area Blue Plan patients SelectldquoMedicalPolicyPreCertPreAuthRouterrdquoandclickGoYouwillbetakentothepagewhereyouselecteithermedicalpolicyorpre-certificationpriorauthorizationandenterthepatientrsquosthree-letteralphaprefixasfoundontheirmemberidentificationcardandclickGoOnceyouaccepttherequirementsyouwillberoutedtothepatientrsquoshomeplanwhereyoucanaccessmedicalpolicyorpre-certificationpre-authorizationinformation

For local Blue Cross and Blue Shield of Minnesota plan patients SelectldquoMedicalpolicyrdquo(undertheToolsampResources)readandaccepttheBlueCrossMedicalPolicyStatementandthenselectldquoViewAllActivePoliciesrdquoYouhavenownavigatedtotheBlueCrossandBlueShieldofMinnesotaMedicaland Behavioral Health Policy Manual where there are several selections to assist with your inquiry

The ldquoWhatrsquos Newrdquo section identifies our latest new or revised policies approved by Blue Crossrsquo Medical and Behavioral Health Policy Committee at least 50 days ago These policies are now effective and providers should begin following thesepoliciesimmediatelyThesepoliciesalsoappearintheldquoActivePolicyrdquosectionoftheMedicalandBehavioralHealthPolicy Manual

The ldquoUpcoming Policiesrdquo section lists new or revised policies approved by the Blue Cross Medical and Behavioral Health Policy Committee and are effective 50 days from the date they were posted to the ldquoUpcoming Policiesrdquo section of the Medical and Behavioral Health Policy Manual

TheldquoActivePolicyrdquosectioncontainstheentirelistofpolicieseffectiveatthetimeofyourinquiryPleasenoteDHSPrograms(CoverageGuidelinesforDHSPrograms-MHCPManual)andMedicareContractors(PartAndashNationalGovernmentServices[NGS]PartBndashNationalGovernmentServices[NGS]HomeHealthandHospicendashNationalGovernmentServices[NGS]DurableMedicalEquipmentMedicareAdministrativeContractorndashNationalGovernmentServices[NGS]andTheCentersforMedicareandMedicaidServicesndashCMS)haveseparatesections

TheldquoPre-CertificationPre-Authorizationrdquosectionidentifiesvariousservicesproceduresprescriptiondrugsandmedicaldevicesthatrequirepre-certificationpre-authorizationThefollowingPre-CertificationPre-AuthorizationListsareprovidedforreviewCommercial(includingBlueLinkTPA)MNGovernmentProgramsandMedicarePlansTheselistsarenotexclusive to medical policy services only they encompass other services that are subject to pre-certification pre-authorizationrequirements

If you have additional questions regarding medical or behavioral health policy issues call provider services at (651) 662-5200 or 1-800-262-0820 for assistance

September 2015 11

medICAL ANd BeHAVIorAL HeALTH poLICY updATe

MEDICAL AND bEHAvIORAL HEALTH POLICy ACTIvITy

Policies Effective 072015 Notification Posted 052815

Policies developedNone

Policies revisedPneumatic Compression Devices in the Outpatient or Home Setting

bull The use of segmented or non-segmented pneumatic compression devices without calibrated gradient pressure (non-programmablepumps)maybeconsideredMEDICALLYNECESSARYforthetreatmentoflymphedemaintheoutpatientorhomesettingwhenALLofthefollowingcriteriaaremet 1 The patient has undergone a four-week trial of conservative therapy which includes a Use of an appropriate compression bandage system or compression garment bExerciseAND c Elevation of the limb AND 2 Thetreatingphysiciandeterminesthatnosignificantimprovementhasoccurredorsignificantsymptomsremain

following the four-week trialbull The use of segmented pneumatic compression therapy devices with calibrated gradient pressure (programmable pumps)maybeconsideredMEDICALLYNECESSARYintheoutpatientorhomesettingwhenthepatientmeetscriteria for a device without calibrated gradient pressure (non-programmable pumps) and either of the following criteria are met

1 The patientrsquos medical condition has failed to respond to therapy using segmented or non-segmented pneumatic compression devices without calibrated gradient pressure (non-programmable pumps) OR

2Theindividualhasuniquecharacteristics(egsignificantscarring)thatpreventsatisfactorypneumaticcompressiontreatment using segmented or non-segmented pneumatic compression devices without calibrated gradient pressure (non-programmable pumps)

bull The use of segmented or non-segmented pneumatic compression devices without calibrated gradient pressure (non-programmablepumps)maybeconsideredMEDICALLYNECESSARYforthetreatmentofchronicvenousinsufficiencyofthelowerextremitiesintheoutpatientorhomesettingwhenALLofthefollowingcriteriaaremet

1 The patient has one or more venous stasis ulcers AND 2 ThepatienthasundergoneatrialofconservativetherapyforaminimumofsixmonthswhichincludesALLofthe

following a The use of an appropriate compression bandage system or compression garment bAppropriatedressingsforthewound c Exercise and d Elevation of the limb AND 3 Thetreatingphysiciandeterminesthatthevenousstasisulcerhasfailedtoheal

September 2015 12

medICAL ANd BeHAVIorAL HeALTH poLICY updATe

bull The use of segmented pneumatic compression therapy devices with calibrated gradient pressure (programmable pumps)maybeconsideredMEDICALLYNECESSARYintheoutpatientorhomesettingwhenthepatientmeetscriteria for a device without calibrated gradient pressure (nonprogrammable pumps) and either of the following criteria are met

1 The patientrsquos medical condition has failed to respond to therapy using segmented or non-segmented pneumatic compression devices without calibrated gradient pressure (non-programmable pumps)

OR 2Theindividualhasuniquecharacteristics(egsignificantscarring)thatpreventsatisfactorypneumaticcompression

treatment using segmented or non-segmented pneumatic compression devices without calibrated gradient pressure (non-programmable pumps)

bull TheuseofpneumaticcompressiondevicesintheoutpatientorhomesettingmaybeconsideredMEDICALLYNECESSARYinpatientswhohaveundergoneasurgicalprocedurewhenBOTH1and2aremet

1 Patient meets one or more of the following a Major surgery (eg total hip arthroplasty total knee arthroplasty hip fracture repair open abdominal or open

pelvic procedure OR b Patient is at moderate to severe risk of VTE Examples include i Patient is not able to walk unassisted or is bedridden ii Agegreaterthan60yearsanesthesiaatleast2hoursandbedrestatleast4daysduringcurrentepisodeofcare iii Inpatientstayofmorethan2daysduringcurrentepisodeofcare iv Central venous access during current episode of care v Sepsis during current episode of care viActivecancerorcancertreatment vii Significant comorbidity such as recent myocardial infarction congestive heart failure cerebrovascular disease

moderate to severe chronic obstructive pulmonary disease moderate to severe liver disease moderate to severe chronic kidney disease

viiiPregnancy or post-partum state (lt 1 month) ix Hypercoagulable state (eg Factor V Leiden antithrombin III deficiency protein C or S deficiency

antiphospholipidsyndromedysfibrinolysisprothrombin20210defect) x Prior VTE AND 2Thepatienthasacontraindicationtopharmacologicanticoagulantssuchasbeingathigh-riskforbleedingRisk

factors for bleeding include a Bleeding disorder such as hemophilia bActiveliverdisease c Severe renal failure d Previous major bleed (and previous bleeding risk similar to current risk) e Concomitant antiplatelet agent f History of or difficult-to-control surgical bleeding during the current operative procedure extensive surgical

dissection and revision surgery bull Outpatientorhomeuseofpneumaticcompressiondevicesforpost-surgicalVTEprophylaxisisconsideredNOTMEDICALLYNECESSARYforpatientswhohaveundergoneasurgicalprocedurewithalowriskforVTEandwhohaveno additional risk factors for VTE Examples of lower risk surgical procedures include but are not limited to laparoscopic cholecystectomy appendectomy transurethral prostatectomy and inguinal herniorrhaphy

September 2015 13

bull TheuseofpneumaticcompressiondevicesintheoutpatientorhomesettingisconsideredINVESTIGATIVEforallotherindications including but not limited to treatment of arterial insufficiency (e g peripheral arterial disease) and restless legs syndrome due to the lack of clinical evidence demonstrating its impact on improved health outcomes

Angioplasty andor Stenting for Intracranial Aneurysms and Atherosclerosis

bull IntracranialstentplacementmaybeconsideredMEDICALLYNECESSARYaspartoftheendovasculartreatmentofintracranial aneurysms for patients when surgical treatment is not feasible and standard endovascular techniques do not allowforcompleteisolationoftheaneurysmegwide-neckaneurysm(4mmormore)orsack-to-neckratiolessthan21

bull IntracranialflowdivertingstentswithFDAapprovalforthetreatmentofintracranialaneurysmsmaybeconsideredMEDICALLYNECESSARYaspartoftheendovasculartreatmentofintracranialaneurysmsthatarelargeorgiantwide-necked(aneurysmsizeof10mmormoreandaneckdiameterof4mmormore)intheinternalcarotidarteryfrom the petrous to the superior hypophyseal segments and which are not amenable to surgical treatment or standard endovascular therapy

bull IntracranialstentplacementisconsideredINVESTIGATIVEinthetreatmentofintracranialaneurysmsexceptasnotedabove due to the lack of clinical evidence demonstrating its impact on improved health outcomes

bull PercutaneoustransluminalangioplastywithorwithoutstentingisconsideredINVESTIGATIVEforthetreatmentofintracranial atherosclerosis due to the lack of clinical evidence demonstrating its impact on improved health outcomes

Surgical Treatment of Femoroacetabular Impingement

bull OpenorarthroscopictreatmentoffemoroacetabularimpingementmaybeconsideredMEDICALLYNECESSARYwhenALLofthefollowingconditionsaremet

AAge Patientisskeletallymaturewithdocumentedclosureofgrowthplates(eg15yearsorolder) B Symptoms 1 Moderate-to-severe hip pain that is worsened by flexion activities (eg squatting or prolonged sitting) and which

significantlylimitsactivitiesAND 2Painwhichisunresponsiveorrecursafteratrialofconservativetherapylastingatleast3months(including

activitymodificationsrestrictionofathleticpursuitsandavoidanceofsymptomaticmotion)AND 3Positiveimpingementsignispresentonclinicalexamination(painelicitedwith90degreesofflexionandinternal

rotation and adduction of the femur) C Imaging 1Imagingstudies(egx-raysMRI)confirmthediagnosisofacamorpincer-typeFAIExamplesofmorphology

indicativeofFAIinclude a pistol-grip deformity

b femoralhead-neckoffsetwithanalphaanglegreaterthan50degrees c a positive wall sign d acetabular retroversion (overcoverage with crossover sign) e coxa profunda or protrusion f damage of the acetabular rim AND 2Noevidenceofadvancedosteoarthritis(definedasTonnisgradeIIorIIIorjointspaceoflessthan2mm)AND 3Noevidenceofsevere(modifiedOuterbridgegradeIV)chondraldamagebull Surgicaltreatmentoffemoroacetabularimpingement(FAI)isconsideredINVESTIGATIVEinallothersituations

medICAL ANd BeHAVIorAL HeALTH poLICY updATe

September 2015 14

Policies inactivatedTobacco Cessation Treatments

Policies Effective 081715 Notification Posted 062515

Policies developedNone

Policies revisedTreatment of Obstructive Sleep Apnea and Snoring in Adults bull Medical Management

A IntraoralAppliances Intraoral appliances (eg mandibular advancingpositioning devices or tongue-retaining devices) may be considered

MEDICALLYNECESSARYwhenALLofthefollowingcriteriaaremet 1PatienthasbeendiagnosedwithOSAdefinedby a AnAHIorRDIof15orgreatereventsperhour OR bAnAHIorRDIbetween5and14eventsperhourwithanyofthefollowingassociatedsymptoms i Excessive daytime sleepiness ii Documented hypertension iii Ischemic heart disease iv History of stroke AND 2Thereisabsenceoftemporomandibulardysfunctionorperiodontaldisease AND 3ThedeviceisprescribedafteradiagnosisofOSAhasbeenestablishedbyaphysicianwhoiseitheradiplomate

oftheAmericanBoardofSleepMedicinearecognizedsubspecialtyoftheAmericanBoardofMedicalSpecialties(ABMS)oranactivestaffmemberofasleepcenterorlaboratoryaccreditedbytheAmericanAcademyofSleepMedicine(AASM)orTheJointCommission

AND 4 The device is custom-fitted by qualified dental personnel under the direction of a Doctor of Dental Surgery (DDS)

or Doctor of Dental Medicine (DMD) B ContinuousPositiveAirwayPressure(CPAP) Continuouspositiveairwaypressure(CPAP)maybeconsideredMEDICALLYNECESSARYinpatientswith

confirmedOSAwith 1AnAHIorRDIof15eventsperhourorgreater OR 2AnAHIorRDIbetween5and14eventsperhourwithanyofthefollowingassociatedsymptoms a Excessive daytime sleepiness b Documented hypertension c Ischemic heart disease d History of stroke

medICAL ANd BeHAVIorAL HeALTH poLICY updATe

September 2015 15

C Bi-levelPositiveAirwayPressure(BiPAP) BiPAPmaybeconsideredMEDICALLYNECESSARYinpatientswho 1MeetthecriteriaforCPAPAND 2HavefailedapriortrialofCPAPOR 3ForwhomBiPAPisfoundtobemoreeffectivethanCPAPinthesleeplaboratory D Auto-AdjustingPAP(APAP) APAPmaybeconsideredMEDICALLYNECESSARYinpatientswho 1MeetthecriteriaforCPAPaboveAND 2HaveacontraindicationtoCPAPhavefailedapriortrialofCPAPORareundergoingatrialofAPAPtotitrate CPAP AND 3Havenoevidencebyhistoryorphysicalexaminationofthefollowingconditions a Central sleep apnea b Congestive heart failure c Chronic pulmonary disease such as chronic obstructive pulmonary disease d Pulmonary hypertension e Obesityhypoventilationsyndromeorotherconditionwhichmaycausenocturnalarterialoxyhemoglobin desaturationbull Surgical Management A Uvulopalatopharyngoplasty(UPPP) UPPPmaybeconsideredMEDICALLYNECESSARYwhenallthefollowingcriteriaaremet 1PresenceofsignificantunexplainedcorpulmonaleorcardiacarrhythmiaresultingfromdocumentedOSA OR 2AnAHIorRDIof15eventsperhourorgreateroranAHIorRDIbetween5and14withdocumented

hypertension ischemic heart disease or history of stroke AND a BMI less than 40 AND bAtrialoforalappliancetherapyhasfailedorthepatientisnotacandidateforanoralappliance AND c PatienthasnotrespondedtoordoesnottolerateCPAPBiPAPorAPAPfollowingaminimumof4hoursper nightforthree(3)monthsofPAPusage B Maxillofacial Procedures Maxillofacial surgical procedures such as inferior sagittal mandibular osteotomy and genioglossal advancement

withorwithouthyoidmyotomyandsuspensionormandibular-maxillaryadvancement(MMA)maybeconsideredMEDICALLYNECESSARYwhenthefollowingcriteriaaremet

1PresenceofsignificantunexplainedcorpulmonaleorcardiacarrhythmiaresultingfromdocumentedOSA OR 2AnAHIorRDIof15eventsperhourorgreateroranAHIorRDIbetween5and14withdocumented

hypertension ischemic heart disease or history of stroke AND a Objectiveevidenceofhypopharyngealobstructiondocumentedbyeitherfiberopticexaminationor cephalometric radiographs AND

medICAL ANd BeHAVIorAL HeALTH poLICY updATe

September 2015 16

b PatienthasnotrespondedtoordoesnottolerateCPAPBiPAPorAPAPfollowingaminimumof4hourspernightforthree(3)monthsofPAPusage

bull Treatment of Snoring TreatmentofsnoringisconsideredNOTMEDICALLYNECESSARYbecausesimplesnoringintheabsenceof

documented obstructive sleep apnea is not considered a medical condition Therefore all procedures for the sole or adjunctivetreatmentofsnoringareconsideredNOTMEDICALLYNECESSARYincludingbutnotlimitedto

A Uvulopalatopharyngoplasty(UPPP) B Uvulectomy C Laser-assisteduvulopalatoplasty(LAUP) D Radiofrequencyvolumetricreductionofthepalataltissues E Radiofrequencyvolumetrictissuereductionofthetonguewithorwithoutradiofrequencyreductionofthepalatal

tissues F Palatal stiffening procedures including but not limited to cautery-assisted palatal stiffening operation and the

implantation of palatal implants G Tongue base suspensionbull Investigative Indications ThefollowingtreatmentsareconsideredINVESTIGATIVEduetoalackofevidencedemonstratingimprovedhealth outcomes AUPPPforanyconditionotherthanobstructivesleepapneaorsnoring B ExpiratoryPositiveAirwayPressure(EPAP)includingtheProventregdevice C OralpressuretherapydevicesincludingbutnotlimitedtotheWinxTMsystem D Atrialpacing EAllothersurgicalproceduresforthesoleoradjunctivetreatmentofobstructivesleepapneaupperairwayresistance

syndrome including but not limited to 1 Uvulectomy 2Laser-assisteduvulopalatoplasty(LAUP) 3Radiofrequencyvolumetricreductionofthepalataltissues 4Radiofrequencyvolumetrictissuereductionofthetonguewithorwithoutradiofrequencyreductionofthepalatal

tissues 5Palatalstiffeningproceduresincludingbutnotlimitedtocautery-assistedpalatalstiffeningoperationandthe

implantation of palatal implants 6 Tongue base suspension 7 Implantable hypoglossal nerve stimulators Respiratory Syncytial Virus (RSV) Prophylaxis bull INITIALRSVSEASON Theuseofimmuneprophylaxis(egpalivizumab[Synagis])forRSVfortheinitialRSVseasonmaybeconsideredMEDICALLYNECESSARYwhenthefollowingcriteriaaremet

A ChronicLungDisease(CLD)ofPrematurity 1Infantwasbornatlt32weeks0daysgestationAND 2Infantisle12monthsofageattheonsetofRSVseasonAND 3Infantrequiresgt21oxygenforatleastthefirst28daysafterbirth B Congenital Heart Disease (CHD) 1 Infant is le12monthsofageattheonsetofRSVseasonANDmeetsONEofthefollowing

medICAL ANd BeHAVIorAL HeALTH poLICY updATe

September 2015 17

medICAL ANd BeHAVIorAL HeALTH poLICY updATe

a AcyanoticCHDwhentheinfantisreceivingmedicationtocontrolcongestiveheartfailureandwillrequireacardiacsurgicalprocedureOR

b CyanoticCHDwhenpalivizumabisrecommendedafterconsultationwithapediatriccardiologistOR c Diagnosis of moderate to severe pulmonary hypertension OR 2Childislt24monthsofageattheonsetofRSVseasonANDmeetsONEofthefollowing a ChildundergoescardiactransplantationduringtheRSVseasonOR b ChildisreceivingRSVprophylaxisandcontinuestorequireprophylaxisafterasurgicalprocedureinvolving cardiac bypass or at the conclusion of extracorporeal membrane oxygenation C AnatomicPulmonaryAbnormalitiesORNeuromuscularDisorder(egcerebralpalsymusculardystrophy) 1 Infant is le12monthsofageattheonsetofRSVseasonAND 2Infanthasimpairedabilitytoclearsecretionsfromtheupperairway D Cystic Fibrosis 1 Infant is le12monthsofageattheonsetofRSVseasonwithevidenceofCLDandormalnutrition E Immunocompromised Status 1Childislt24monthsofageattheonsetofRSVseasonAND 2Childisprofoundlyimmunocompromised(egduetosolidorgantransplantationhematopoieticstem-cell

transplantation or chemotherapy) F Prematurity without CLD or CHD 1Infantwasbornatlt29weeks0daysgestation(ie28weeks6daysorless)AND 2Infantislt12monthsofageattheonsetofRSVseasonbull SECONDRSVSEASON Theuseofimmuneprophylaxis(egpalivizumab[Synagis])forRSVforthepatientrsquossecondyearoftreatmentmaybeconsideredMEDICALLYNECESSARYwhenthefollowingcriteriaaremet

A CLDofPrematurity 1Childwasbornatlt32weeks0daysgestationAND 2Childis12monthstolt24monthsofageattheonsetofthesecondRSVseasonAND 3ChildcontinuestorequireatleastONEofthefollowingwithinsix(6)monthsofthestartofthesecondRSV season a SupplementaloxygenOR b ChronicsystemiccorticosteroidtherapyOR c DiuretictherapyOR d Bronchodilator therapy B Cystic Fibrosis 1Childis12monthstolt24monthsofageattheonsetofthesecondRSVseasonwithevidenceofCLDandor malnutritionbull AdministrationofRSVProphylaxis A Whentheappropriatecriteriaabovearemetamaximumoffive(5)monthlydosesofpalivizumab(Synagisreg)will

becoveredperRSVseason(definedasNovember1stthroughMarch31st) B Thefirstmonthlydoseofpalivizumab(Synagisreg)willbeapprovedforcoverageofadministrationonorafter

November 1st C Apost-operativedoseofpalivizumab(Synagisreg)willbecoveredforchildrenlt24monthswhoarereceiving

RSVprophylaxisandcontinuetorequireprophylaxisafterasurgicalprocedureinvolvingcardiacbypassorattheconclusion of extracorporeal membrane oxygenation

September 2015 18

Chromosomal Microarray Analysis and Next Generation Sequencing to Evaluate Patients with Developmental DelayIntellectual Disability or Autism Spectrum Disorders bullChromosomalmicroarrayanalysismaybeconsideredMEDICALLYNECESSARYfordiagnosingageneticabnormalityin

children with apparent nonsyndromic cognitive developmental delayintellectual disability (DDID) or autism spectrum disorder(ASD)accordingtoacceptedDiagnosticandStatisticalManualofMentalDisorders(DSM)criteriawhenALLof the following conditions are met

AAnyindicatedbiochemicaltestsformetabolicdiseasehavebeenperformedandresultsarenon-diagnosticAND BFMR1geneanalysis(forFragileX)whenclinicallyindicatedisnegativeAND CASDorapparentnon-syndromicDDIDinachildwithmultipleanomaliesnotspecifictoawell-delineatedgenetic

syndromeasdefinedaboveAND DTheresultsofthegenetictestinghavethepotentialtoimpacttheclinicalmanagementofthepatientAND E Testing is requested after the parent(s) andor legal guardian(s) have been engaged in face-to-face genetic

counseling with a healthcare professional who has the appropriate genetics training and experience and is independent of the laboratory performing the test

bullChromosomalmicroarrayanalysisisconsideredINVESTIGATIVEforthefollowingduetoalackofclinicalevidencedemonstrating its impact on improved health outcomes

A Allothercasesofsuspectedgeneticabnormalityinchildrenwithdevelopmentaldelayintellectualdisabilityorautism spectrum disorder

B To confirm the diagnosis of a disorder or syndrome that is routinely diagnosed based on clinical evaluation alone Theseincludebutarenotlimitedtoattentiondeficithyperactivitydisorder(ADHD)learningdisabilitygrowthretardation or speech delay

C Population screeningbullPaneltestingusingnext-generationsequencingisconsideredINVESTIGATIVEinallcasesofsuspectedgeneticabnormalityinchildrenwithDDIDorASD

Spinal Fusion Lumbar bullLumbarspinalfusionmaybeconsideredMEDICALLYNECESSARYforanyofthefollowingindicationswhenacorrelativeabnormalityisconfirmedbyimagingstudies(egx-rayCTMRI)

A Epiduralcompressionorvertebraldestructionfromatumor B Neural compression after spinal fracture C Instability after debridement for infection D Spinal infections (eg osteomyelitis spinal tuberculosis) E Severe or rapidly progressive neurological deficit (eg motor loss sensory loss neurogenic claudication or cauda

equina syndrome) F IdiopathicscoliosiswhenEITHERofthefollowingcriteriaaremet 1ScolioticcurvewithaCobbanglegt45degreesinchildrenwhoareskeletallyimmatureOR 2ScolioticcurvewithaCobbanglegt50degreesresultinginfunctionalimpairmentinskeletallymatureindividuals G Symptomatic pseudarthrosisbullLumbarspinalfusionaloneorinconjunctionwithaprimarydecompressionsurgerymaybeconsideredMEDICALLYNECESSARYfortreatmentofdegenerativeconditionswithspinalinstabilitywhenALLthefollowingcriteriaaremet

A ONEofthefollowingconditionsarepresent 1Post-laminectomyinstabilityOR 2DegenerativescoliosisorkyphosisOR 3SpondylolisthesisOR

medICAL ANd BeHAVIorAL HeALTH poLICY updATe

September 2015 19

4 Spinal stenosis with spondylolisthesis AND B Documentedunremittingpainanddisabilityrefractorytointensiveconservativetherapyfor3monthsIntensive

conservativetherapymusthaveoccurredwithintheprevious12monthsANDmustincludeALLofthefollowing 1Anactiveorganizedandprogressivestrengthandflexibilityprogram NOTEIfapatientisunabletocompletephysicaltherapy(PT)duetoprogressivelyworseningpainanddisability the case will be reviewed on an individual basis by an internal physician reviewer (See Documentation Submission section)AND 2Aminimumoftwosessionsperweekoverthe3-monthperiodAND 3FunctionalassessmentasmeasuredbytheOswestryDisabilityIndex(ODI)demonstratingONEofthe following a Lessthan30improvementintheODIscorebetweenthefirstandlastphysicaltherapysessionOR b ContinuedODIscoreofgreaterthanorequalto40attheconclusionofphysicaltherapy AND 4Aneducationalcomponentthatdealswithpatientexpectationsandperceptionsaswellastheanatomicsources of back pain AND C Diagnosticimaging(egx-rayCTMRI)obtainedwithintheprevious12monthsdemonstratesspinalinstability(gt

3mmoftranslationandor10degreesormoreofangulationofonevertebracomparedtotheadjacentvertebrainaspinal motion segment)

bullLumbarspinalfusioninconjunctionwithadecompressionsurgerymaybeconsideredMEDICALLYNECESSARYinthetreatmentofcertaindegenerativeconditionswithoutexistinginstabilitywhenALLthefollowingcriteriaaremet

A ONEofthefollowingconditionsarepresent 1SpinalstenosisOR 2RecurrentspinalstenosisatthesamesegmentOR 3Recurrentdischerniationwithfailedlaminectomy AND B Documentedunremittingpainanddisabilityrefractorytointensiveconservativetherapyfor3monthsIntensive

conservativetherapymusthaveoccurredwithintheprevious12monthsANDmustincludeALLofthefollowing 1Anactiveorganizedandprogressivestrengthandflexibilityprogram NOTEIfapatientisunabletocompletephysicaltherapy(PT)duetoprogressivelyworseningpainanddisability the case will be reviewed on an individual basis by an internal physician reviewer (See Documentation Submission section) AND 2Aminimumoftwosessionsperweekoverthe3-monthperiodAND 3FunctionalassessmentasmeasuredbytheOswestryDisabilityIndex(ODI)demonstratingONEofthe

following a Lessthan30improvementintheODIscorebetweenthefirstandlastphysicaltherapysessionOR b ContinuedODIscoreofgreaterthanorequalto40attheconclusionofphysicaltherapy AND 4Aneducationalcomponentthatdealswithpatientexpectationsandperceptionsaswellastheanatomicsources of back pain AND C Diagnosticimaging(egCTMRI)obtainedwithintheprevious12monthsdemonstratesspinalcordornerveroot

compression

medICAL ANd BeHAVIorAL HeALTH poLICY updATe

September 2015 20

bullLumbarspinalfusionmaybeconsideredMEDICALLYNECESSARYforchronic(presentforatleast6ndash12months)discogenicbackpainwithoutinstabilitywhenALLthefollowingcriteriaaremet

A Documentedunremittingpainanddisabilityrefractorytointensiveconservativetherapyforatleast3months Intensiveconservativetherapymusthaveoccurredwithintheprevious12monthsANDmustincludeALLofthefollowing

1Anti-inflammatorymedicationandanalgesicsunlesscontraindicatedAND 2TherapeuticinjectionsAND 3Anactiveorganizedandprogressivestrengthandflexibilityprogram NOTEIfapatientisunabletocompletephysicaltherapy(PT)duetoprogressivelyworseningpainanddisability

the case will be reviewed on an individual basis by an internal physician reviewer (See Documentation Submission section)

AND 4Aminimumoftwosessionsperweekoverthe3-monthperiodAND 5FunctionalassessmentasmeasuredbytheOswestryDisabilityIndex(ODI)demonstratingONEofthe

following a Lessthan30improvementintheODIscorebetweenthefirstandlastphysicaltherapysessionOR b ContinuedODIscoreofgreaterthanorequalto40attheconclusionofphysicaltherapy 6Aneducationalcomponentthatdealswithpatientexpectationsandperceptionsaswellastheanatomicsources

of back pain AND B Absenceofuntreatedunderlyingcontributorymentalhealthconditionsorpsychosocialissuesincludingbutnot

limited to depression or drug or alcohol abuse AND C Diagnosticimaging(egMRICT)obtainedwithintheprevious12monthsdemonstratesdegenerativediscdisease

limitedto1ndash2disclevelsbull Documentation supporting the medical necessity criteria described in the policy must be included in the prior authorizationInadditionthefollowingdocumentationmustalsobesubmitted

1 Written report from a radiologist describing findings from spinal diagnostic imaging studies 2 Intensiveconservativetherapy bull DocumentationfromthephysicaltherapistmustincludeOswestryDisabilityIndex(ODI)scores bull Ifapatientisunabletocompletephysicaltherapy(PT)duetoprogressivelyworseningsymptomsofpainand

disability the case will be reviewed on an individual basis by an internal physician reviewer Documentation must be submitted from the physical therapist describing the patientrsquos inability to complete PT

3 Forpatientswithchronicdiscogenicbackpainwithoutinstability(policysectionIV)documentationregardingthe absence of untreated underlying contributory mental health conditions or psychosocial issues including but not limited to depression or drug or alcohol abuse must be submitted by the patientrsquos primary care physician or a Mental Health Professional The Mental Health Professional must meet the Minnesota Department of Human ServicesqualificationsassetforthinMinnStatsect245462subd18(2013)andMinnStatsect2454871subd27(2013)

medICAL ANd BeHAVIorAL HeALTH poLICY updATe

September 2015 21

Policies inactivatedNone There was no Medical and behavioral Health Policy Activity for July 2015

Policies reviewed with no changes in May 2015 and June 2015

Acupuncture

Artificial Intervertebral Disc Cervical Spine

Belimumab

Cardiovascular Disease Risk Assessment and Management Laboratory Evaluation of Non-Traditional Lipid and

Nonlipid Biomarkers

Cellular Immunotherapy for Prostate Cancer

Chelation Therapy

Computerized Dynamic Posturography

Continuous and Intermittent Glucose Monitoring of Interstitial Fluid

Cytochrome P450 Genotyping

Digital Breast Tomosynthesis

Electrocardiographic (ECG) Body Surface Mapping

Endoscopic Radiofrequency Ablation or Cryoablation for Barrettrsquos Esophagus

Epidermal Growth-Factor Receptor (EGFR) Analysis for Non-small Cell Lung Cancer

HP Acthar Gel (Repository Corticotropin)

Hematopoietic Stem-Cell Transplantation for Non-Hodgkin Lymphomas

Hematopoietic Stem-Cell Transplantation for Primary Amyloidosis

Hematopoietic Stem-Cell Transplantation for Waldenstrom Macroglobulinemia

Image-Guided Minimally Invasive Lumbar Decompression for Spinal Stenosis

Liposuction

Lung Cancer Screening Using Computed Tomography (CT)

Mastopexy

Microprocessor-Controlled Prosthesis for the Lower Limb

Myoelectric Prosthesis for the Upper Limb

Organ Transplantation

Percutaneous and Endoscopic Techniques for Disc Decompression

September 2015 22

Medical and Behavioral Health Policy Update

NetworkManagementR317 POBox64560 StPaulMN55164-0560

Provider Press is posted on our website quarterly for business office staff of multi-specialty clinics physicians public health agencies DME providers chiropractors podiatrists physical therapists occupational therapists optometrists and behavioral health professionalsproviders Direct inquiries to

NetworkManagementR317Editor Holly BatchelderPOBox64560StPaulMN55164-0560(651)662-2014tollfree1-800-382-2000ext22014

AdvisorsFaithBauerCPCCPC-HCPC-PJeannieHarpCPCJanineUtechtCPCCPC-HCPC-PCPMAandKarenKiemeleMPH

Information in Provider Press is a general outline Provider and member contracts determine benefits

CPT-4codesnotedareAMAcopyrighted

0915

Peripheral Nerve Stimulation of the Trunk or Limbs for Treatment of Pain

Rhinomanometry and AcousticOptical Rhinometry

Sleep Studies Polysomnograms in Children and Adolescents

Spinal Unloading Devices Patient-Operated

Stem-Cell Therapy for Peripheral Arterial Disease

Subcutaneous Hormone Pellets

Surgical Interruption of Pelvic Nerve Pathways for Primary and Secondary Dysmenorrhea

Systems Pathology Testing for Predicting Risk of Recurrence in Prostate Cancer

Urine Drug Testing for Substance Abuse Treatment and Chronic Pain Management

Wireless Gastric Motility Monitoring

September 2015 12

medICAL ANd BeHAVIorAL HeALTH poLICY updATe

bull The use of segmented pneumatic compression therapy devices with calibrated gradient pressure (programmable pumps)maybeconsideredMEDICALLYNECESSARYintheoutpatientorhomesettingwhenthepatientmeetscriteria for a device without calibrated gradient pressure (nonprogrammable pumps) and either of the following criteria are met

1 The patientrsquos medical condition has failed to respond to therapy using segmented or non-segmented pneumatic compression devices without calibrated gradient pressure (non-programmable pumps)

OR 2Theindividualhasuniquecharacteristics(egsignificantscarring)thatpreventsatisfactorypneumaticcompression

treatment using segmented or non-segmented pneumatic compression devices without calibrated gradient pressure (non-programmable pumps)

bull TheuseofpneumaticcompressiondevicesintheoutpatientorhomesettingmaybeconsideredMEDICALLYNECESSARYinpatientswhohaveundergoneasurgicalprocedurewhenBOTH1and2aremet

1 Patient meets one or more of the following a Major surgery (eg total hip arthroplasty total knee arthroplasty hip fracture repair open abdominal or open

pelvic procedure OR b Patient is at moderate to severe risk of VTE Examples include i Patient is not able to walk unassisted or is bedridden ii Agegreaterthan60yearsanesthesiaatleast2hoursandbedrestatleast4daysduringcurrentepisodeofcare iii Inpatientstayofmorethan2daysduringcurrentepisodeofcare iv Central venous access during current episode of care v Sepsis during current episode of care viActivecancerorcancertreatment vii Significant comorbidity such as recent myocardial infarction congestive heart failure cerebrovascular disease

moderate to severe chronic obstructive pulmonary disease moderate to severe liver disease moderate to severe chronic kidney disease

viiiPregnancy or post-partum state (lt 1 month) ix Hypercoagulable state (eg Factor V Leiden antithrombin III deficiency protein C or S deficiency

antiphospholipidsyndromedysfibrinolysisprothrombin20210defect) x Prior VTE AND 2Thepatienthasacontraindicationtopharmacologicanticoagulantssuchasbeingathigh-riskforbleedingRisk

factors for bleeding include a Bleeding disorder such as hemophilia bActiveliverdisease c Severe renal failure d Previous major bleed (and previous bleeding risk similar to current risk) e Concomitant antiplatelet agent f History of or difficult-to-control surgical bleeding during the current operative procedure extensive surgical

dissection and revision surgery bull Outpatientorhomeuseofpneumaticcompressiondevicesforpost-surgicalVTEprophylaxisisconsideredNOTMEDICALLYNECESSARYforpatientswhohaveundergoneasurgicalprocedurewithalowriskforVTEandwhohaveno additional risk factors for VTE Examples of lower risk surgical procedures include but are not limited to laparoscopic cholecystectomy appendectomy transurethral prostatectomy and inguinal herniorrhaphy

September 2015 13

bull TheuseofpneumaticcompressiondevicesintheoutpatientorhomesettingisconsideredINVESTIGATIVEforallotherindications including but not limited to treatment of arterial insufficiency (e g peripheral arterial disease) and restless legs syndrome due to the lack of clinical evidence demonstrating its impact on improved health outcomes

Angioplasty andor Stenting for Intracranial Aneurysms and Atherosclerosis

bull IntracranialstentplacementmaybeconsideredMEDICALLYNECESSARYaspartoftheendovasculartreatmentofintracranial aneurysms for patients when surgical treatment is not feasible and standard endovascular techniques do not allowforcompleteisolationoftheaneurysmegwide-neckaneurysm(4mmormore)orsack-to-neckratiolessthan21

bull IntracranialflowdivertingstentswithFDAapprovalforthetreatmentofintracranialaneurysmsmaybeconsideredMEDICALLYNECESSARYaspartoftheendovasculartreatmentofintracranialaneurysmsthatarelargeorgiantwide-necked(aneurysmsizeof10mmormoreandaneckdiameterof4mmormore)intheinternalcarotidarteryfrom the petrous to the superior hypophyseal segments and which are not amenable to surgical treatment or standard endovascular therapy

bull IntracranialstentplacementisconsideredINVESTIGATIVEinthetreatmentofintracranialaneurysmsexceptasnotedabove due to the lack of clinical evidence demonstrating its impact on improved health outcomes

bull PercutaneoustransluminalangioplastywithorwithoutstentingisconsideredINVESTIGATIVEforthetreatmentofintracranial atherosclerosis due to the lack of clinical evidence demonstrating its impact on improved health outcomes

Surgical Treatment of Femoroacetabular Impingement

bull OpenorarthroscopictreatmentoffemoroacetabularimpingementmaybeconsideredMEDICALLYNECESSARYwhenALLofthefollowingconditionsaremet

AAge Patientisskeletallymaturewithdocumentedclosureofgrowthplates(eg15yearsorolder) B Symptoms 1 Moderate-to-severe hip pain that is worsened by flexion activities (eg squatting or prolonged sitting) and which

significantlylimitsactivitiesAND 2Painwhichisunresponsiveorrecursafteratrialofconservativetherapylastingatleast3months(including

activitymodificationsrestrictionofathleticpursuitsandavoidanceofsymptomaticmotion)AND 3Positiveimpingementsignispresentonclinicalexamination(painelicitedwith90degreesofflexionandinternal

rotation and adduction of the femur) C Imaging 1Imagingstudies(egx-raysMRI)confirmthediagnosisofacamorpincer-typeFAIExamplesofmorphology

indicativeofFAIinclude a pistol-grip deformity

b femoralhead-neckoffsetwithanalphaanglegreaterthan50degrees c a positive wall sign d acetabular retroversion (overcoverage with crossover sign) e coxa profunda or protrusion f damage of the acetabular rim AND 2Noevidenceofadvancedosteoarthritis(definedasTonnisgradeIIorIIIorjointspaceoflessthan2mm)AND 3Noevidenceofsevere(modifiedOuterbridgegradeIV)chondraldamagebull Surgicaltreatmentoffemoroacetabularimpingement(FAI)isconsideredINVESTIGATIVEinallothersituations

medICAL ANd BeHAVIorAL HeALTH poLICY updATe

September 2015 14

Policies inactivatedTobacco Cessation Treatments

Policies Effective 081715 Notification Posted 062515

Policies developedNone

Policies revisedTreatment of Obstructive Sleep Apnea and Snoring in Adults bull Medical Management

A IntraoralAppliances Intraoral appliances (eg mandibular advancingpositioning devices or tongue-retaining devices) may be considered

MEDICALLYNECESSARYwhenALLofthefollowingcriteriaaremet 1PatienthasbeendiagnosedwithOSAdefinedby a AnAHIorRDIof15orgreatereventsperhour OR bAnAHIorRDIbetween5and14eventsperhourwithanyofthefollowingassociatedsymptoms i Excessive daytime sleepiness ii Documented hypertension iii Ischemic heart disease iv History of stroke AND 2Thereisabsenceoftemporomandibulardysfunctionorperiodontaldisease AND 3ThedeviceisprescribedafteradiagnosisofOSAhasbeenestablishedbyaphysicianwhoiseitheradiplomate

oftheAmericanBoardofSleepMedicinearecognizedsubspecialtyoftheAmericanBoardofMedicalSpecialties(ABMS)oranactivestaffmemberofasleepcenterorlaboratoryaccreditedbytheAmericanAcademyofSleepMedicine(AASM)orTheJointCommission

AND 4 The device is custom-fitted by qualified dental personnel under the direction of a Doctor of Dental Surgery (DDS)

or Doctor of Dental Medicine (DMD) B ContinuousPositiveAirwayPressure(CPAP) Continuouspositiveairwaypressure(CPAP)maybeconsideredMEDICALLYNECESSARYinpatientswith

confirmedOSAwith 1AnAHIorRDIof15eventsperhourorgreater OR 2AnAHIorRDIbetween5and14eventsperhourwithanyofthefollowingassociatedsymptoms a Excessive daytime sleepiness b Documented hypertension c Ischemic heart disease d History of stroke

medICAL ANd BeHAVIorAL HeALTH poLICY updATe

September 2015 15

C Bi-levelPositiveAirwayPressure(BiPAP) BiPAPmaybeconsideredMEDICALLYNECESSARYinpatientswho 1MeetthecriteriaforCPAPAND 2HavefailedapriortrialofCPAPOR 3ForwhomBiPAPisfoundtobemoreeffectivethanCPAPinthesleeplaboratory D Auto-AdjustingPAP(APAP) APAPmaybeconsideredMEDICALLYNECESSARYinpatientswho 1MeetthecriteriaforCPAPaboveAND 2HaveacontraindicationtoCPAPhavefailedapriortrialofCPAPORareundergoingatrialofAPAPtotitrate CPAP AND 3Havenoevidencebyhistoryorphysicalexaminationofthefollowingconditions a Central sleep apnea b Congestive heart failure c Chronic pulmonary disease such as chronic obstructive pulmonary disease d Pulmonary hypertension e Obesityhypoventilationsyndromeorotherconditionwhichmaycausenocturnalarterialoxyhemoglobin desaturationbull Surgical Management A Uvulopalatopharyngoplasty(UPPP) UPPPmaybeconsideredMEDICALLYNECESSARYwhenallthefollowingcriteriaaremet 1PresenceofsignificantunexplainedcorpulmonaleorcardiacarrhythmiaresultingfromdocumentedOSA OR 2AnAHIorRDIof15eventsperhourorgreateroranAHIorRDIbetween5and14withdocumented

hypertension ischemic heart disease or history of stroke AND a BMI less than 40 AND bAtrialoforalappliancetherapyhasfailedorthepatientisnotacandidateforanoralappliance AND c PatienthasnotrespondedtoordoesnottolerateCPAPBiPAPorAPAPfollowingaminimumof4hoursper nightforthree(3)monthsofPAPusage B Maxillofacial Procedures Maxillofacial surgical procedures such as inferior sagittal mandibular osteotomy and genioglossal advancement

withorwithouthyoidmyotomyandsuspensionormandibular-maxillaryadvancement(MMA)maybeconsideredMEDICALLYNECESSARYwhenthefollowingcriteriaaremet

1PresenceofsignificantunexplainedcorpulmonaleorcardiacarrhythmiaresultingfromdocumentedOSA OR 2AnAHIorRDIof15eventsperhourorgreateroranAHIorRDIbetween5and14withdocumented

hypertension ischemic heart disease or history of stroke AND a Objectiveevidenceofhypopharyngealobstructiondocumentedbyeitherfiberopticexaminationor cephalometric radiographs AND

medICAL ANd BeHAVIorAL HeALTH poLICY updATe

September 2015 16

b PatienthasnotrespondedtoordoesnottolerateCPAPBiPAPorAPAPfollowingaminimumof4hourspernightforthree(3)monthsofPAPusage

bull Treatment of Snoring TreatmentofsnoringisconsideredNOTMEDICALLYNECESSARYbecausesimplesnoringintheabsenceof

documented obstructive sleep apnea is not considered a medical condition Therefore all procedures for the sole or adjunctivetreatmentofsnoringareconsideredNOTMEDICALLYNECESSARYincludingbutnotlimitedto

A Uvulopalatopharyngoplasty(UPPP) B Uvulectomy C Laser-assisteduvulopalatoplasty(LAUP) D Radiofrequencyvolumetricreductionofthepalataltissues E Radiofrequencyvolumetrictissuereductionofthetonguewithorwithoutradiofrequencyreductionofthepalatal

tissues F Palatal stiffening procedures including but not limited to cautery-assisted palatal stiffening operation and the

implantation of palatal implants G Tongue base suspensionbull Investigative Indications ThefollowingtreatmentsareconsideredINVESTIGATIVEduetoalackofevidencedemonstratingimprovedhealth outcomes AUPPPforanyconditionotherthanobstructivesleepapneaorsnoring B ExpiratoryPositiveAirwayPressure(EPAP)includingtheProventregdevice C OralpressuretherapydevicesincludingbutnotlimitedtotheWinxTMsystem D Atrialpacing EAllothersurgicalproceduresforthesoleoradjunctivetreatmentofobstructivesleepapneaupperairwayresistance

syndrome including but not limited to 1 Uvulectomy 2Laser-assisteduvulopalatoplasty(LAUP) 3Radiofrequencyvolumetricreductionofthepalataltissues 4Radiofrequencyvolumetrictissuereductionofthetonguewithorwithoutradiofrequencyreductionofthepalatal

tissues 5Palatalstiffeningproceduresincludingbutnotlimitedtocautery-assistedpalatalstiffeningoperationandthe

implantation of palatal implants 6 Tongue base suspension 7 Implantable hypoglossal nerve stimulators Respiratory Syncytial Virus (RSV) Prophylaxis bull INITIALRSVSEASON Theuseofimmuneprophylaxis(egpalivizumab[Synagis])forRSVfortheinitialRSVseasonmaybeconsideredMEDICALLYNECESSARYwhenthefollowingcriteriaaremet

A ChronicLungDisease(CLD)ofPrematurity 1Infantwasbornatlt32weeks0daysgestationAND 2Infantisle12monthsofageattheonsetofRSVseasonAND 3Infantrequiresgt21oxygenforatleastthefirst28daysafterbirth B Congenital Heart Disease (CHD) 1 Infant is le12monthsofageattheonsetofRSVseasonANDmeetsONEofthefollowing

medICAL ANd BeHAVIorAL HeALTH poLICY updATe

September 2015 17

medICAL ANd BeHAVIorAL HeALTH poLICY updATe

a AcyanoticCHDwhentheinfantisreceivingmedicationtocontrolcongestiveheartfailureandwillrequireacardiacsurgicalprocedureOR

b CyanoticCHDwhenpalivizumabisrecommendedafterconsultationwithapediatriccardiologistOR c Diagnosis of moderate to severe pulmonary hypertension OR 2Childislt24monthsofageattheonsetofRSVseasonANDmeetsONEofthefollowing a ChildundergoescardiactransplantationduringtheRSVseasonOR b ChildisreceivingRSVprophylaxisandcontinuestorequireprophylaxisafterasurgicalprocedureinvolving cardiac bypass or at the conclusion of extracorporeal membrane oxygenation C AnatomicPulmonaryAbnormalitiesORNeuromuscularDisorder(egcerebralpalsymusculardystrophy) 1 Infant is le12monthsofageattheonsetofRSVseasonAND 2Infanthasimpairedabilitytoclearsecretionsfromtheupperairway D Cystic Fibrosis 1 Infant is le12monthsofageattheonsetofRSVseasonwithevidenceofCLDandormalnutrition E Immunocompromised Status 1Childislt24monthsofageattheonsetofRSVseasonAND 2Childisprofoundlyimmunocompromised(egduetosolidorgantransplantationhematopoieticstem-cell

transplantation or chemotherapy) F Prematurity without CLD or CHD 1Infantwasbornatlt29weeks0daysgestation(ie28weeks6daysorless)AND 2Infantislt12monthsofageattheonsetofRSVseasonbull SECONDRSVSEASON Theuseofimmuneprophylaxis(egpalivizumab[Synagis])forRSVforthepatientrsquossecondyearoftreatmentmaybeconsideredMEDICALLYNECESSARYwhenthefollowingcriteriaaremet

A CLDofPrematurity 1Childwasbornatlt32weeks0daysgestationAND 2Childis12monthstolt24monthsofageattheonsetofthesecondRSVseasonAND 3ChildcontinuestorequireatleastONEofthefollowingwithinsix(6)monthsofthestartofthesecondRSV season a SupplementaloxygenOR b ChronicsystemiccorticosteroidtherapyOR c DiuretictherapyOR d Bronchodilator therapy B Cystic Fibrosis 1Childis12monthstolt24monthsofageattheonsetofthesecondRSVseasonwithevidenceofCLDandor malnutritionbull AdministrationofRSVProphylaxis A Whentheappropriatecriteriaabovearemetamaximumoffive(5)monthlydosesofpalivizumab(Synagisreg)will

becoveredperRSVseason(definedasNovember1stthroughMarch31st) B Thefirstmonthlydoseofpalivizumab(Synagisreg)willbeapprovedforcoverageofadministrationonorafter

November 1st C Apost-operativedoseofpalivizumab(Synagisreg)willbecoveredforchildrenlt24monthswhoarereceiving

RSVprophylaxisandcontinuetorequireprophylaxisafterasurgicalprocedureinvolvingcardiacbypassorattheconclusion of extracorporeal membrane oxygenation

September 2015 18

Chromosomal Microarray Analysis and Next Generation Sequencing to Evaluate Patients with Developmental DelayIntellectual Disability or Autism Spectrum Disorders bullChromosomalmicroarrayanalysismaybeconsideredMEDICALLYNECESSARYfordiagnosingageneticabnormalityin

children with apparent nonsyndromic cognitive developmental delayintellectual disability (DDID) or autism spectrum disorder(ASD)accordingtoacceptedDiagnosticandStatisticalManualofMentalDisorders(DSM)criteriawhenALLof the following conditions are met

AAnyindicatedbiochemicaltestsformetabolicdiseasehavebeenperformedandresultsarenon-diagnosticAND BFMR1geneanalysis(forFragileX)whenclinicallyindicatedisnegativeAND CASDorapparentnon-syndromicDDIDinachildwithmultipleanomaliesnotspecifictoawell-delineatedgenetic

syndromeasdefinedaboveAND DTheresultsofthegenetictestinghavethepotentialtoimpacttheclinicalmanagementofthepatientAND E Testing is requested after the parent(s) andor legal guardian(s) have been engaged in face-to-face genetic

counseling with a healthcare professional who has the appropriate genetics training and experience and is independent of the laboratory performing the test

bullChromosomalmicroarrayanalysisisconsideredINVESTIGATIVEforthefollowingduetoalackofclinicalevidencedemonstrating its impact on improved health outcomes

A Allothercasesofsuspectedgeneticabnormalityinchildrenwithdevelopmentaldelayintellectualdisabilityorautism spectrum disorder

B To confirm the diagnosis of a disorder or syndrome that is routinely diagnosed based on clinical evaluation alone Theseincludebutarenotlimitedtoattentiondeficithyperactivitydisorder(ADHD)learningdisabilitygrowthretardation or speech delay

C Population screeningbullPaneltestingusingnext-generationsequencingisconsideredINVESTIGATIVEinallcasesofsuspectedgeneticabnormalityinchildrenwithDDIDorASD

Spinal Fusion Lumbar bullLumbarspinalfusionmaybeconsideredMEDICALLYNECESSARYforanyofthefollowingindicationswhenacorrelativeabnormalityisconfirmedbyimagingstudies(egx-rayCTMRI)

A Epiduralcompressionorvertebraldestructionfromatumor B Neural compression after spinal fracture C Instability after debridement for infection D Spinal infections (eg osteomyelitis spinal tuberculosis) E Severe or rapidly progressive neurological deficit (eg motor loss sensory loss neurogenic claudication or cauda

equina syndrome) F IdiopathicscoliosiswhenEITHERofthefollowingcriteriaaremet 1ScolioticcurvewithaCobbanglegt45degreesinchildrenwhoareskeletallyimmatureOR 2ScolioticcurvewithaCobbanglegt50degreesresultinginfunctionalimpairmentinskeletallymatureindividuals G Symptomatic pseudarthrosisbullLumbarspinalfusionaloneorinconjunctionwithaprimarydecompressionsurgerymaybeconsideredMEDICALLYNECESSARYfortreatmentofdegenerativeconditionswithspinalinstabilitywhenALLthefollowingcriteriaaremet

A ONEofthefollowingconditionsarepresent 1Post-laminectomyinstabilityOR 2DegenerativescoliosisorkyphosisOR 3SpondylolisthesisOR

medICAL ANd BeHAVIorAL HeALTH poLICY updATe

September 2015 19

4 Spinal stenosis with spondylolisthesis AND B Documentedunremittingpainanddisabilityrefractorytointensiveconservativetherapyfor3monthsIntensive

conservativetherapymusthaveoccurredwithintheprevious12monthsANDmustincludeALLofthefollowing 1Anactiveorganizedandprogressivestrengthandflexibilityprogram NOTEIfapatientisunabletocompletephysicaltherapy(PT)duetoprogressivelyworseningpainanddisability the case will be reviewed on an individual basis by an internal physician reviewer (See Documentation Submission section)AND 2Aminimumoftwosessionsperweekoverthe3-monthperiodAND 3FunctionalassessmentasmeasuredbytheOswestryDisabilityIndex(ODI)demonstratingONEofthe following a Lessthan30improvementintheODIscorebetweenthefirstandlastphysicaltherapysessionOR b ContinuedODIscoreofgreaterthanorequalto40attheconclusionofphysicaltherapy AND 4Aneducationalcomponentthatdealswithpatientexpectationsandperceptionsaswellastheanatomicsources of back pain AND C Diagnosticimaging(egx-rayCTMRI)obtainedwithintheprevious12monthsdemonstratesspinalinstability(gt

3mmoftranslationandor10degreesormoreofangulationofonevertebracomparedtotheadjacentvertebrainaspinal motion segment)

bullLumbarspinalfusioninconjunctionwithadecompressionsurgerymaybeconsideredMEDICALLYNECESSARYinthetreatmentofcertaindegenerativeconditionswithoutexistinginstabilitywhenALLthefollowingcriteriaaremet

A ONEofthefollowingconditionsarepresent 1SpinalstenosisOR 2RecurrentspinalstenosisatthesamesegmentOR 3Recurrentdischerniationwithfailedlaminectomy AND B Documentedunremittingpainanddisabilityrefractorytointensiveconservativetherapyfor3monthsIntensive

conservativetherapymusthaveoccurredwithintheprevious12monthsANDmustincludeALLofthefollowing 1Anactiveorganizedandprogressivestrengthandflexibilityprogram NOTEIfapatientisunabletocompletephysicaltherapy(PT)duetoprogressivelyworseningpainanddisability the case will be reviewed on an individual basis by an internal physician reviewer (See Documentation Submission section) AND 2Aminimumoftwosessionsperweekoverthe3-monthperiodAND 3FunctionalassessmentasmeasuredbytheOswestryDisabilityIndex(ODI)demonstratingONEofthe

following a Lessthan30improvementintheODIscorebetweenthefirstandlastphysicaltherapysessionOR b ContinuedODIscoreofgreaterthanorequalto40attheconclusionofphysicaltherapy AND 4Aneducationalcomponentthatdealswithpatientexpectationsandperceptionsaswellastheanatomicsources of back pain AND C Diagnosticimaging(egCTMRI)obtainedwithintheprevious12monthsdemonstratesspinalcordornerveroot

compression

medICAL ANd BeHAVIorAL HeALTH poLICY updATe

September 2015 20

bullLumbarspinalfusionmaybeconsideredMEDICALLYNECESSARYforchronic(presentforatleast6ndash12months)discogenicbackpainwithoutinstabilitywhenALLthefollowingcriteriaaremet

A Documentedunremittingpainanddisabilityrefractorytointensiveconservativetherapyforatleast3months Intensiveconservativetherapymusthaveoccurredwithintheprevious12monthsANDmustincludeALLofthefollowing

1Anti-inflammatorymedicationandanalgesicsunlesscontraindicatedAND 2TherapeuticinjectionsAND 3Anactiveorganizedandprogressivestrengthandflexibilityprogram NOTEIfapatientisunabletocompletephysicaltherapy(PT)duetoprogressivelyworseningpainanddisability

the case will be reviewed on an individual basis by an internal physician reviewer (See Documentation Submission section)

AND 4Aminimumoftwosessionsperweekoverthe3-monthperiodAND 5FunctionalassessmentasmeasuredbytheOswestryDisabilityIndex(ODI)demonstratingONEofthe

following a Lessthan30improvementintheODIscorebetweenthefirstandlastphysicaltherapysessionOR b ContinuedODIscoreofgreaterthanorequalto40attheconclusionofphysicaltherapy 6Aneducationalcomponentthatdealswithpatientexpectationsandperceptionsaswellastheanatomicsources

of back pain AND B Absenceofuntreatedunderlyingcontributorymentalhealthconditionsorpsychosocialissuesincludingbutnot

limited to depression or drug or alcohol abuse AND C Diagnosticimaging(egMRICT)obtainedwithintheprevious12monthsdemonstratesdegenerativediscdisease

limitedto1ndash2disclevelsbull Documentation supporting the medical necessity criteria described in the policy must be included in the prior authorizationInadditionthefollowingdocumentationmustalsobesubmitted

1 Written report from a radiologist describing findings from spinal diagnostic imaging studies 2 Intensiveconservativetherapy bull DocumentationfromthephysicaltherapistmustincludeOswestryDisabilityIndex(ODI)scores bull Ifapatientisunabletocompletephysicaltherapy(PT)duetoprogressivelyworseningsymptomsofpainand

disability the case will be reviewed on an individual basis by an internal physician reviewer Documentation must be submitted from the physical therapist describing the patientrsquos inability to complete PT

3 Forpatientswithchronicdiscogenicbackpainwithoutinstability(policysectionIV)documentationregardingthe absence of untreated underlying contributory mental health conditions or psychosocial issues including but not limited to depression or drug or alcohol abuse must be submitted by the patientrsquos primary care physician or a Mental Health Professional The Mental Health Professional must meet the Minnesota Department of Human ServicesqualificationsassetforthinMinnStatsect245462subd18(2013)andMinnStatsect2454871subd27(2013)

medICAL ANd BeHAVIorAL HeALTH poLICY updATe

September 2015 21

Policies inactivatedNone There was no Medical and behavioral Health Policy Activity for July 2015

Policies reviewed with no changes in May 2015 and June 2015

Acupuncture

Artificial Intervertebral Disc Cervical Spine

Belimumab

Cardiovascular Disease Risk Assessment and Management Laboratory Evaluation of Non-Traditional Lipid and

Nonlipid Biomarkers

Cellular Immunotherapy for Prostate Cancer

Chelation Therapy

Computerized Dynamic Posturography

Continuous and Intermittent Glucose Monitoring of Interstitial Fluid

Cytochrome P450 Genotyping

Digital Breast Tomosynthesis

Electrocardiographic (ECG) Body Surface Mapping

Endoscopic Radiofrequency Ablation or Cryoablation for Barrettrsquos Esophagus

Epidermal Growth-Factor Receptor (EGFR) Analysis for Non-small Cell Lung Cancer

HP Acthar Gel (Repository Corticotropin)

Hematopoietic Stem-Cell Transplantation for Non-Hodgkin Lymphomas

Hematopoietic Stem-Cell Transplantation for Primary Amyloidosis

Hematopoietic Stem-Cell Transplantation for Waldenstrom Macroglobulinemia

Image-Guided Minimally Invasive Lumbar Decompression for Spinal Stenosis

Liposuction

Lung Cancer Screening Using Computed Tomography (CT)

Mastopexy

Microprocessor-Controlled Prosthesis for the Lower Limb

Myoelectric Prosthesis for the Upper Limb

Organ Transplantation

Percutaneous and Endoscopic Techniques for Disc Decompression

September 2015 22

Medical and Behavioral Health Policy Update

NetworkManagementR317 POBox64560 StPaulMN55164-0560

Provider Press is posted on our website quarterly for business office staff of multi-specialty clinics physicians public health agencies DME providers chiropractors podiatrists physical therapists occupational therapists optometrists and behavioral health professionalsproviders Direct inquiries to

NetworkManagementR317Editor Holly BatchelderPOBox64560StPaulMN55164-0560(651)662-2014tollfree1-800-382-2000ext22014

AdvisorsFaithBauerCPCCPC-HCPC-PJeannieHarpCPCJanineUtechtCPCCPC-HCPC-PCPMAandKarenKiemeleMPH

Information in Provider Press is a general outline Provider and member contracts determine benefits

CPT-4codesnotedareAMAcopyrighted

0915

Peripheral Nerve Stimulation of the Trunk or Limbs for Treatment of Pain

Rhinomanometry and AcousticOptical Rhinometry

Sleep Studies Polysomnograms in Children and Adolescents

Spinal Unloading Devices Patient-Operated

Stem-Cell Therapy for Peripheral Arterial Disease

Subcutaneous Hormone Pellets

Surgical Interruption of Pelvic Nerve Pathways for Primary and Secondary Dysmenorrhea

Systems Pathology Testing for Predicting Risk of Recurrence in Prostate Cancer

Urine Drug Testing for Substance Abuse Treatment and Chronic Pain Management

Wireless Gastric Motility Monitoring

September 2015 13

bull TheuseofpneumaticcompressiondevicesintheoutpatientorhomesettingisconsideredINVESTIGATIVEforallotherindications including but not limited to treatment of arterial insufficiency (e g peripheral arterial disease) and restless legs syndrome due to the lack of clinical evidence demonstrating its impact on improved health outcomes

Angioplasty andor Stenting for Intracranial Aneurysms and Atherosclerosis

bull IntracranialstentplacementmaybeconsideredMEDICALLYNECESSARYaspartoftheendovasculartreatmentofintracranial aneurysms for patients when surgical treatment is not feasible and standard endovascular techniques do not allowforcompleteisolationoftheaneurysmegwide-neckaneurysm(4mmormore)orsack-to-neckratiolessthan21

bull IntracranialflowdivertingstentswithFDAapprovalforthetreatmentofintracranialaneurysmsmaybeconsideredMEDICALLYNECESSARYaspartoftheendovasculartreatmentofintracranialaneurysmsthatarelargeorgiantwide-necked(aneurysmsizeof10mmormoreandaneckdiameterof4mmormore)intheinternalcarotidarteryfrom the petrous to the superior hypophyseal segments and which are not amenable to surgical treatment or standard endovascular therapy

bull IntracranialstentplacementisconsideredINVESTIGATIVEinthetreatmentofintracranialaneurysmsexceptasnotedabove due to the lack of clinical evidence demonstrating its impact on improved health outcomes

bull PercutaneoustransluminalangioplastywithorwithoutstentingisconsideredINVESTIGATIVEforthetreatmentofintracranial atherosclerosis due to the lack of clinical evidence demonstrating its impact on improved health outcomes

Surgical Treatment of Femoroacetabular Impingement

bull OpenorarthroscopictreatmentoffemoroacetabularimpingementmaybeconsideredMEDICALLYNECESSARYwhenALLofthefollowingconditionsaremet

AAge Patientisskeletallymaturewithdocumentedclosureofgrowthplates(eg15yearsorolder) B Symptoms 1 Moderate-to-severe hip pain that is worsened by flexion activities (eg squatting or prolonged sitting) and which

significantlylimitsactivitiesAND 2Painwhichisunresponsiveorrecursafteratrialofconservativetherapylastingatleast3months(including

activitymodificationsrestrictionofathleticpursuitsandavoidanceofsymptomaticmotion)AND 3Positiveimpingementsignispresentonclinicalexamination(painelicitedwith90degreesofflexionandinternal

rotation and adduction of the femur) C Imaging 1Imagingstudies(egx-raysMRI)confirmthediagnosisofacamorpincer-typeFAIExamplesofmorphology

indicativeofFAIinclude a pistol-grip deformity

b femoralhead-neckoffsetwithanalphaanglegreaterthan50degrees c a positive wall sign d acetabular retroversion (overcoverage with crossover sign) e coxa profunda or protrusion f damage of the acetabular rim AND 2Noevidenceofadvancedosteoarthritis(definedasTonnisgradeIIorIIIorjointspaceoflessthan2mm)AND 3Noevidenceofsevere(modifiedOuterbridgegradeIV)chondraldamagebull Surgicaltreatmentoffemoroacetabularimpingement(FAI)isconsideredINVESTIGATIVEinallothersituations

medICAL ANd BeHAVIorAL HeALTH poLICY updATe

September 2015 14

Policies inactivatedTobacco Cessation Treatments

Policies Effective 081715 Notification Posted 062515

Policies developedNone

Policies revisedTreatment of Obstructive Sleep Apnea and Snoring in Adults bull Medical Management

A IntraoralAppliances Intraoral appliances (eg mandibular advancingpositioning devices or tongue-retaining devices) may be considered

MEDICALLYNECESSARYwhenALLofthefollowingcriteriaaremet 1PatienthasbeendiagnosedwithOSAdefinedby a AnAHIorRDIof15orgreatereventsperhour OR bAnAHIorRDIbetween5and14eventsperhourwithanyofthefollowingassociatedsymptoms i Excessive daytime sleepiness ii Documented hypertension iii Ischemic heart disease iv History of stroke AND 2Thereisabsenceoftemporomandibulardysfunctionorperiodontaldisease AND 3ThedeviceisprescribedafteradiagnosisofOSAhasbeenestablishedbyaphysicianwhoiseitheradiplomate

oftheAmericanBoardofSleepMedicinearecognizedsubspecialtyoftheAmericanBoardofMedicalSpecialties(ABMS)oranactivestaffmemberofasleepcenterorlaboratoryaccreditedbytheAmericanAcademyofSleepMedicine(AASM)orTheJointCommission

AND 4 The device is custom-fitted by qualified dental personnel under the direction of a Doctor of Dental Surgery (DDS)

or Doctor of Dental Medicine (DMD) B ContinuousPositiveAirwayPressure(CPAP) Continuouspositiveairwaypressure(CPAP)maybeconsideredMEDICALLYNECESSARYinpatientswith

confirmedOSAwith 1AnAHIorRDIof15eventsperhourorgreater OR 2AnAHIorRDIbetween5and14eventsperhourwithanyofthefollowingassociatedsymptoms a Excessive daytime sleepiness b Documented hypertension c Ischemic heart disease d History of stroke

medICAL ANd BeHAVIorAL HeALTH poLICY updATe

September 2015 15

C Bi-levelPositiveAirwayPressure(BiPAP) BiPAPmaybeconsideredMEDICALLYNECESSARYinpatientswho 1MeetthecriteriaforCPAPAND 2HavefailedapriortrialofCPAPOR 3ForwhomBiPAPisfoundtobemoreeffectivethanCPAPinthesleeplaboratory D Auto-AdjustingPAP(APAP) APAPmaybeconsideredMEDICALLYNECESSARYinpatientswho 1MeetthecriteriaforCPAPaboveAND 2HaveacontraindicationtoCPAPhavefailedapriortrialofCPAPORareundergoingatrialofAPAPtotitrate CPAP AND 3Havenoevidencebyhistoryorphysicalexaminationofthefollowingconditions a Central sleep apnea b Congestive heart failure c Chronic pulmonary disease such as chronic obstructive pulmonary disease d Pulmonary hypertension e Obesityhypoventilationsyndromeorotherconditionwhichmaycausenocturnalarterialoxyhemoglobin desaturationbull Surgical Management A Uvulopalatopharyngoplasty(UPPP) UPPPmaybeconsideredMEDICALLYNECESSARYwhenallthefollowingcriteriaaremet 1PresenceofsignificantunexplainedcorpulmonaleorcardiacarrhythmiaresultingfromdocumentedOSA OR 2AnAHIorRDIof15eventsperhourorgreateroranAHIorRDIbetween5and14withdocumented

hypertension ischemic heart disease or history of stroke AND a BMI less than 40 AND bAtrialoforalappliancetherapyhasfailedorthepatientisnotacandidateforanoralappliance AND c PatienthasnotrespondedtoordoesnottolerateCPAPBiPAPorAPAPfollowingaminimumof4hoursper nightforthree(3)monthsofPAPusage B Maxillofacial Procedures Maxillofacial surgical procedures such as inferior sagittal mandibular osteotomy and genioglossal advancement

withorwithouthyoidmyotomyandsuspensionormandibular-maxillaryadvancement(MMA)maybeconsideredMEDICALLYNECESSARYwhenthefollowingcriteriaaremet

1PresenceofsignificantunexplainedcorpulmonaleorcardiacarrhythmiaresultingfromdocumentedOSA OR 2AnAHIorRDIof15eventsperhourorgreateroranAHIorRDIbetween5and14withdocumented

hypertension ischemic heart disease or history of stroke AND a Objectiveevidenceofhypopharyngealobstructiondocumentedbyeitherfiberopticexaminationor cephalometric radiographs AND

medICAL ANd BeHAVIorAL HeALTH poLICY updATe

September 2015 16

b PatienthasnotrespondedtoordoesnottolerateCPAPBiPAPorAPAPfollowingaminimumof4hourspernightforthree(3)monthsofPAPusage

bull Treatment of Snoring TreatmentofsnoringisconsideredNOTMEDICALLYNECESSARYbecausesimplesnoringintheabsenceof

documented obstructive sleep apnea is not considered a medical condition Therefore all procedures for the sole or adjunctivetreatmentofsnoringareconsideredNOTMEDICALLYNECESSARYincludingbutnotlimitedto

A Uvulopalatopharyngoplasty(UPPP) B Uvulectomy C Laser-assisteduvulopalatoplasty(LAUP) D Radiofrequencyvolumetricreductionofthepalataltissues E Radiofrequencyvolumetrictissuereductionofthetonguewithorwithoutradiofrequencyreductionofthepalatal

tissues F Palatal stiffening procedures including but not limited to cautery-assisted palatal stiffening operation and the

implantation of palatal implants G Tongue base suspensionbull Investigative Indications ThefollowingtreatmentsareconsideredINVESTIGATIVEduetoalackofevidencedemonstratingimprovedhealth outcomes AUPPPforanyconditionotherthanobstructivesleepapneaorsnoring B ExpiratoryPositiveAirwayPressure(EPAP)includingtheProventregdevice C OralpressuretherapydevicesincludingbutnotlimitedtotheWinxTMsystem D Atrialpacing EAllothersurgicalproceduresforthesoleoradjunctivetreatmentofobstructivesleepapneaupperairwayresistance

syndrome including but not limited to 1 Uvulectomy 2Laser-assisteduvulopalatoplasty(LAUP) 3Radiofrequencyvolumetricreductionofthepalataltissues 4Radiofrequencyvolumetrictissuereductionofthetonguewithorwithoutradiofrequencyreductionofthepalatal

tissues 5Palatalstiffeningproceduresincludingbutnotlimitedtocautery-assistedpalatalstiffeningoperationandthe

implantation of palatal implants 6 Tongue base suspension 7 Implantable hypoglossal nerve stimulators Respiratory Syncytial Virus (RSV) Prophylaxis bull INITIALRSVSEASON Theuseofimmuneprophylaxis(egpalivizumab[Synagis])forRSVfortheinitialRSVseasonmaybeconsideredMEDICALLYNECESSARYwhenthefollowingcriteriaaremet

A ChronicLungDisease(CLD)ofPrematurity 1Infantwasbornatlt32weeks0daysgestationAND 2Infantisle12monthsofageattheonsetofRSVseasonAND 3Infantrequiresgt21oxygenforatleastthefirst28daysafterbirth B Congenital Heart Disease (CHD) 1 Infant is le12monthsofageattheonsetofRSVseasonANDmeetsONEofthefollowing

medICAL ANd BeHAVIorAL HeALTH poLICY updATe

September 2015 17

medICAL ANd BeHAVIorAL HeALTH poLICY updATe

a AcyanoticCHDwhentheinfantisreceivingmedicationtocontrolcongestiveheartfailureandwillrequireacardiacsurgicalprocedureOR

b CyanoticCHDwhenpalivizumabisrecommendedafterconsultationwithapediatriccardiologistOR c Diagnosis of moderate to severe pulmonary hypertension OR 2Childislt24monthsofageattheonsetofRSVseasonANDmeetsONEofthefollowing a ChildundergoescardiactransplantationduringtheRSVseasonOR b ChildisreceivingRSVprophylaxisandcontinuestorequireprophylaxisafterasurgicalprocedureinvolving cardiac bypass or at the conclusion of extracorporeal membrane oxygenation C AnatomicPulmonaryAbnormalitiesORNeuromuscularDisorder(egcerebralpalsymusculardystrophy) 1 Infant is le12monthsofageattheonsetofRSVseasonAND 2Infanthasimpairedabilitytoclearsecretionsfromtheupperairway D Cystic Fibrosis 1 Infant is le12monthsofageattheonsetofRSVseasonwithevidenceofCLDandormalnutrition E Immunocompromised Status 1Childislt24monthsofageattheonsetofRSVseasonAND 2Childisprofoundlyimmunocompromised(egduetosolidorgantransplantationhematopoieticstem-cell

transplantation or chemotherapy) F Prematurity without CLD or CHD 1Infantwasbornatlt29weeks0daysgestation(ie28weeks6daysorless)AND 2Infantislt12monthsofageattheonsetofRSVseasonbull SECONDRSVSEASON Theuseofimmuneprophylaxis(egpalivizumab[Synagis])forRSVforthepatientrsquossecondyearoftreatmentmaybeconsideredMEDICALLYNECESSARYwhenthefollowingcriteriaaremet

A CLDofPrematurity 1Childwasbornatlt32weeks0daysgestationAND 2Childis12monthstolt24monthsofageattheonsetofthesecondRSVseasonAND 3ChildcontinuestorequireatleastONEofthefollowingwithinsix(6)monthsofthestartofthesecondRSV season a SupplementaloxygenOR b ChronicsystemiccorticosteroidtherapyOR c DiuretictherapyOR d Bronchodilator therapy B Cystic Fibrosis 1Childis12monthstolt24monthsofageattheonsetofthesecondRSVseasonwithevidenceofCLDandor malnutritionbull AdministrationofRSVProphylaxis A Whentheappropriatecriteriaabovearemetamaximumoffive(5)monthlydosesofpalivizumab(Synagisreg)will

becoveredperRSVseason(definedasNovember1stthroughMarch31st) B Thefirstmonthlydoseofpalivizumab(Synagisreg)willbeapprovedforcoverageofadministrationonorafter

November 1st C Apost-operativedoseofpalivizumab(Synagisreg)willbecoveredforchildrenlt24monthswhoarereceiving

RSVprophylaxisandcontinuetorequireprophylaxisafterasurgicalprocedureinvolvingcardiacbypassorattheconclusion of extracorporeal membrane oxygenation

September 2015 18

Chromosomal Microarray Analysis and Next Generation Sequencing to Evaluate Patients with Developmental DelayIntellectual Disability or Autism Spectrum Disorders bullChromosomalmicroarrayanalysismaybeconsideredMEDICALLYNECESSARYfordiagnosingageneticabnormalityin

children with apparent nonsyndromic cognitive developmental delayintellectual disability (DDID) or autism spectrum disorder(ASD)accordingtoacceptedDiagnosticandStatisticalManualofMentalDisorders(DSM)criteriawhenALLof the following conditions are met

AAnyindicatedbiochemicaltestsformetabolicdiseasehavebeenperformedandresultsarenon-diagnosticAND BFMR1geneanalysis(forFragileX)whenclinicallyindicatedisnegativeAND CASDorapparentnon-syndromicDDIDinachildwithmultipleanomaliesnotspecifictoawell-delineatedgenetic

syndromeasdefinedaboveAND DTheresultsofthegenetictestinghavethepotentialtoimpacttheclinicalmanagementofthepatientAND E Testing is requested after the parent(s) andor legal guardian(s) have been engaged in face-to-face genetic

counseling with a healthcare professional who has the appropriate genetics training and experience and is independent of the laboratory performing the test

bullChromosomalmicroarrayanalysisisconsideredINVESTIGATIVEforthefollowingduetoalackofclinicalevidencedemonstrating its impact on improved health outcomes

A Allothercasesofsuspectedgeneticabnormalityinchildrenwithdevelopmentaldelayintellectualdisabilityorautism spectrum disorder

B To confirm the diagnosis of a disorder or syndrome that is routinely diagnosed based on clinical evaluation alone Theseincludebutarenotlimitedtoattentiondeficithyperactivitydisorder(ADHD)learningdisabilitygrowthretardation or speech delay

C Population screeningbullPaneltestingusingnext-generationsequencingisconsideredINVESTIGATIVEinallcasesofsuspectedgeneticabnormalityinchildrenwithDDIDorASD

Spinal Fusion Lumbar bullLumbarspinalfusionmaybeconsideredMEDICALLYNECESSARYforanyofthefollowingindicationswhenacorrelativeabnormalityisconfirmedbyimagingstudies(egx-rayCTMRI)

A Epiduralcompressionorvertebraldestructionfromatumor B Neural compression after spinal fracture C Instability after debridement for infection D Spinal infections (eg osteomyelitis spinal tuberculosis) E Severe or rapidly progressive neurological deficit (eg motor loss sensory loss neurogenic claudication or cauda

equina syndrome) F IdiopathicscoliosiswhenEITHERofthefollowingcriteriaaremet 1ScolioticcurvewithaCobbanglegt45degreesinchildrenwhoareskeletallyimmatureOR 2ScolioticcurvewithaCobbanglegt50degreesresultinginfunctionalimpairmentinskeletallymatureindividuals G Symptomatic pseudarthrosisbullLumbarspinalfusionaloneorinconjunctionwithaprimarydecompressionsurgerymaybeconsideredMEDICALLYNECESSARYfortreatmentofdegenerativeconditionswithspinalinstabilitywhenALLthefollowingcriteriaaremet

A ONEofthefollowingconditionsarepresent 1Post-laminectomyinstabilityOR 2DegenerativescoliosisorkyphosisOR 3SpondylolisthesisOR

medICAL ANd BeHAVIorAL HeALTH poLICY updATe

September 2015 19

4 Spinal stenosis with spondylolisthesis AND B Documentedunremittingpainanddisabilityrefractorytointensiveconservativetherapyfor3monthsIntensive

conservativetherapymusthaveoccurredwithintheprevious12monthsANDmustincludeALLofthefollowing 1Anactiveorganizedandprogressivestrengthandflexibilityprogram NOTEIfapatientisunabletocompletephysicaltherapy(PT)duetoprogressivelyworseningpainanddisability the case will be reviewed on an individual basis by an internal physician reviewer (See Documentation Submission section)AND 2Aminimumoftwosessionsperweekoverthe3-monthperiodAND 3FunctionalassessmentasmeasuredbytheOswestryDisabilityIndex(ODI)demonstratingONEofthe following a Lessthan30improvementintheODIscorebetweenthefirstandlastphysicaltherapysessionOR b ContinuedODIscoreofgreaterthanorequalto40attheconclusionofphysicaltherapy AND 4Aneducationalcomponentthatdealswithpatientexpectationsandperceptionsaswellastheanatomicsources of back pain AND C Diagnosticimaging(egx-rayCTMRI)obtainedwithintheprevious12monthsdemonstratesspinalinstability(gt

3mmoftranslationandor10degreesormoreofangulationofonevertebracomparedtotheadjacentvertebrainaspinal motion segment)

bullLumbarspinalfusioninconjunctionwithadecompressionsurgerymaybeconsideredMEDICALLYNECESSARYinthetreatmentofcertaindegenerativeconditionswithoutexistinginstabilitywhenALLthefollowingcriteriaaremet

A ONEofthefollowingconditionsarepresent 1SpinalstenosisOR 2RecurrentspinalstenosisatthesamesegmentOR 3Recurrentdischerniationwithfailedlaminectomy AND B Documentedunremittingpainanddisabilityrefractorytointensiveconservativetherapyfor3monthsIntensive

conservativetherapymusthaveoccurredwithintheprevious12monthsANDmustincludeALLofthefollowing 1Anactiveorganizedandprogressivestrengthandflexibilityprogram NOTEIfapatientisunabletocompletephysicaltherapy(PT)duetoprogressivelyworseningpainanddisability the case will be reviewed on an individual basis by an internal physician reviewer (See Documentation Submission section) AND 2Aminimumoftwosessionsperweekoverthe3-monthperiodAND 3FunctionalassessmentasmeasuredbytheOswestryDisabilityIndex(ODI)demonstratingONEofthe

following a Lessthan30improvementintheODIscorebetweenthefirstandlastphysicaltherapysessionOR b ContinuedODIscoreofgreaterthanorequalto40attheconclusionofphysicaltherapy AND 4Aneducationalcomponentthatdealswithpatientexpectationsandperceptionsaswellastheanatomicsources of back pain AND C Diagnosticimaging(egCTMRI)obtainedwithintheprevious12monthsdemonstratesspinalcordornerveroot

compression

medICAL ANd BeHAVIorAL HeALTH poLICY updATe

September 2015 20

bullLumbarspinalfusionmaybeconsideredMEDICALLYNECESSARYforchronic(presentforatleast6ndash12months)discogenicbackpainwithoutinstabilitywhenALLthefollowingcriteriaaremet

A Documentedunremittingpainanddisabilityrefractorytointensiveconservativetherapyforatleast3months Intensiveconservativetherapymusthaveoccurredwithintheprevious12monthsANDmustincludeALLofthefollowing

1Anti-inflammatorymedicationandanalgesicsunlesscontraindicatedAND 2TherapeuticinjectionsAND 3Anactiveorganizedandprogressivestrengthandflexibilityprogram NOTEIfapatientisunabletocompletephysicaltherapy(PT)duetoprogressivelyworseningpainanddisability

the case will be reviewed on an individual basis by an internal physician reviewer (See Documentation Submission section)

AND 4Aminimumoftwosessionsperweekoverthe3-monthperiodAND 5FunctionalassessmentasmeasuredbytheOswestryDisabilityIndex(ODI)demonstratingONEofthe

following a Lessthan30improvementintheODIscorebetweenthefirstandlastphysicaltherapysessionOR b ContinuedODIscoreofgreaterthanorequalto40attheconclusionofphysicaltherapy 6Aneducationalcomponentthatdealswithpatientexpectationsandperceptionsaswellastheanatomicsources

of back pain AND B Absenceofuntreatedunderlyingcontributorymentalhealthconditionsorpsychosocialissuesincludingbutnot

limited to depression or drug or alcohol abuse AND C Diagnosticimaging(egMRICT)obtainedwithintheprevious12monthsdemonstratesdegenerativediscdisease

limitedto1ndash2disclevelsbull Documentation supporting the medical necessity criteria described in the policy must be included in the prior authorizationInadditionthefollowingdocumentationmustalsobesubmitted

1 Written report from a radiologist describing findings from spinal diagnostic imaging studies 2 Intensiveconservativetherapy bull DocumentationfromthephysicaltherapistmustincludeOswestryDisabilityIndex(ODI)scores bull Ifapatientisunabletocompletephysicaltherapy(PT)duetoprogressivelyworseningsymptomsofpainand

disability the case will be reviewed on an individual basis by an internal physician reviewer Documentation must be submitted from the physical therapist describing the patientrsquos inability to complete PT

3 Forpatientswithchronicdiscogenicbackpainwithoutinstability(policysectionIV)documentationregardingthe absence of untreated underlying contributory mental health conditions or psychosocial issues including but not limited to depression or drug or alcohol abuse must be submitted by the patientrsquos primary care physician or a Mental Health Professional The Mental Health Professional must meet the Minnesota Department of Human ServicesqualificationsassetforthinMinnStatsect245462subd18(2013)andMinnStatsect2454871subd27(2013)

medICAL ANd BeHAVIorAL HeALTH poLICY updATe

September 2015 21

Policies inactivatedNone There was no Medical and behavioral Health Policy Activity for July 2015

Policies reviewed with no changes in May 2015 and June 2015

Acupuncture

Artificial Intervertebral Disc Cervical Spine

Belimumab

Cardiovascular Disease Risk Assessment and Management Laboratory Evaluation of Non-Traditional Lipid and

Nonlipid Biomarkers

Cellular Immunotherapy for Prostate Cancer

Chelation Therapy

Computerized Dynamic Posturography

Continuous and Intermittent Glucose Monitoring of Interstitial Fluid

Cytochrome P450 Genotyping

Digital Breast Tomosynthesis

Electrocardiographic (ECG) Body Surface Mapping

Endoscopic Radiofrequency Ablation or Cryoablation for Barrettrsquos Esophagus

Epidermal Growth-Factor Receptor (EGFR) Analysis for Non-small Cell Lung Cancer

HP Acthar Gel (Repository Corticotropin)

Hematopoietic Stem-Cell Transplantation for Non-Hodgkin Lymphomas

Hematopoietic Stem-Cell Transplantation for Primary Amyloidosis

Hematopoietic Stem-Cell Transplantation for Waldenstrom Macroglobulinemia

Image-Guided Minimally Invasive Lumbar Decompression for Spinal Stenosis

Liposuction

Lung Cancer Screening Using Computed Tomography (CT)

Mastopexy

Microprocessor-Controlled Prosthesis for the Lower Limb

Myoelectric Prosthesis for the Upper Limb

Organ Transplantation

Percutaneous and Endoscopic Techniques for Disc Decompression

September 2015 22

Medical and Behavioral Health Policy Update

NetworkManagementR317 POBox64560 StPaulMN55164-0560

Provider Press is posted on our website quarterly for business office staff of multi-specialty clinics physicians public health agencies DME providers chiropractors podiatrists physical therapists occupational therapists optometrists and behavioral health professionalsproviders Direct inquiries to

NetworkManagementR317Editor Holly BatchelderPOBox64560StPaulMN55164-0560(651)662-2014tollfree1-800-382-2000ext22014

AdvisorsFaithBauerCPCCPC-HCPC-PJeannieHarpCPCJanineUtechtCPCCPC-HCPC-PCPMAandKarenKiemeleMPH

Information in Provider Press is a general outline Provider and member contracts determine benefits

CPT-4codesnotedareAMAcopyrighted

0915

Peripheral Nerve Stimulation of the Trunk or Limbs for Treatment of Pain

Rhinomanometry and AcousticOptical Rhinometry

Sleep Studies Polysomnograms in Children and Adolescents

Spinal Unloading Devices Patient-Operated

Stem-Cell Therapy for Peripheral Arterial Disease

Subcutaneous Hormone Pellets

Surgical Interruption of Pelvic Nerve Pathways for Primary and Secondary Dysmenorrhea

Systems Pathology Testing for Predicting Risk of Recurrence in Prostate Cancer

Urine Drug Testing for Substance Abuse Treatment and Chronic Pain Management

Wireless Gastric Motility Monitoring

September 2015 14

Policies inactivatedTobacco Cessation Treatments

Policies Effective 081715 Notification Posted 062515

Policies developedNone

Policies revisedTreatment of Obstructive Sleep Apnea and Snoring in Adults bull Medical Management

A IntraoralAppliances Intraoral appliances (eg mandibular advancingpositioning devices or tongue-retaining devices) may be considered

MEDICALLYNECESSARYwhenALLofthefollowingcriteriaaremet 1PatienthasbeendiagnosedwithOSAdefinedby a AnAHIorRDIof15orgreatereventsperhour OR bAnAHIorRDIbetween5and14eventsperhourwithanyofthefollowingassociatedsymptoms i Excessive daytime sleepiness ii Documented hypertension iii Ischemic heart disease iv History of stroke AND 2Thereisabsenceoftemporomandibulardysfunctionorperiodontaldisease AND 3ThedeviceisprescribedafteradiagnosisofOSAhasbeenestablishedbyaphysicianwhoiseitheradiplomate

oftheAmericanBoardofSleepMedicinearecognizedsubspecialtyoftheAmericanBoardofMedicalSpecialties(ABMS)oranactivestaffmemberofasleepcenterorlaboratoryaccreditedbytheAmericanAcademyofSleepMedicine(AASM)orTheJointCommission

AND 4 The device is custom-fitted by qualified dental personnel under the direction of a Doctor of Dental Surgery (DDS)

or Doctor of Dental Medicine (DMD) B ContinuousPositiveAirwayPressure(CPAP) Continuouspositiveairwaypressure(CPAP)maybeconsideredMEDICALLYNECESSARYinpatientswith

confirmedOSAwith 1AnAHIorRDIof15eventsperhourorgreater OR 2AnAHIorRDIbetween5and14eventsperhourwithanyofthefollowingassociatedsymptoms a Excessive daytime sleepiness b Documented hypertension c Ischemic heart disease d History of stroke

medICAL ANd BeHAVIorAL HeALTH poLICY updATe

September 2015 15

C Bi-levelPositiveAirwayPressure(BiPAP) BiPAPmaybeconsideredMEDICALLYNECESSARYinpatientswho 1MeetthecriteriaforCPAPAND 2HavefailedapriortrialofCPAPOR 3ForwhomBiPAPisfoundtobemoreeffectivethanCPAPinthesleeplaboratory D Auto-AdjustingPAP(APAP) APAPmaybeconsideredMEDICALLYNECESSARYinpatientswho 1MeetthecriteriaforCPAPaboveAND 2HaveacontraindicationtoCPAPhavefailedapriortrialofCPAPORareundergoingatrialofAPAPtotitrate CPAP AND 3Havenoevidencebyhistoryorphysicalexaminationofthefollowingconditions a Central sleep apnea b Congestive heart failure c Chronic pulmonary disease such as chronic obstructive pulmonary disease d Pulmonary hypertension e Obesityhypoventilationsyndromeorotherconditionwhichmaycausenocturnalarterialoxyhemoglobin desaturationbull Surgical Management A Uvulopalatopharyngoplasty(UPPP) UPPPmaybeconsideredMEDICALLYNECESSARYwhenallthefollowingcriteriaaremet 1PresenceofsignificantunexplainedcorpulmonaleorcardiacarrhythmiaresultingfromdocumentedOSA OR 2AnAHIorRDIof15eventsperhourorgreateroranAHIorRDIbetween5and14withdocumented

hypertension ischemic heart disease or history of stroke AND a BMI less than 40 AND bAtrialoforalappliancetherapyhasfailedorthepatientisnotacandidateforanoralappliance AND c PatienthasnotrespondedtoordoesnottolerateCPAPBiPAPorAPAPfollowingaminimumof4hoursper nightforthree(3)monthsofPAPusage B Maxillofacial Procedures Maxillofacial surgical procedures such as inferior sagittal mandibular osteotomy and genioglossal advancement

withorwithouthyoidmyotomyandsuspensionormandibular-maxillaryadvancement(MMA)maybeconsideredMEDICALLYNECESSARYwhenthefollowingcriteriaaremet

1PresenceofsignificantunexplainedcorpulmonaleorcardiacarrhythmiaresultingfromdocumentedOSA OR 2AnAHIorRDIof15eventsperhourorgreateroranAHIorRDIbetween5and14withdocumented

hypertension ischemic heart disease or history of stroke AND a Objectiveevidenceofhypopharyngealobstructiondocumentedbyeitherfiberopticexaminationor cephalometric radiographs AND

medICAL ANd BeHAVIorAL HeALTH poLICY updATe

September 2015 16

b PatienthasnotrespondedtoordoesnottolerateCPAPBiPAPorAPAPfollowingaminimumof4hourspernightforthree(3)monthsofPAPusage

bull Treatment of Snoring TreatmentofsnoringisconsideredNOTMEDICALLYNECESSARYbecausesimplesnoringintheabsenceof

documented obstructive sleep apnea is not considered a medical condition Therefore all procedures for the sole or adjunctivetreatmentofsnoringareconsideredNOTMEDICALLYNECESSARYincludingbutnotlimitedto

A Uvulopalatopharyngoplasty(UPPP) B Uvulectomy C Laser-assisteduvulopalatoplasty(LAUP) D Radiofrequencyvolumetricreductionofthepalataltissues E Radiofrequencyvolumetrictissuereductionofthetonguewithorwithoutradiofrequencyreductionofthepalatal

tissues F Palatal stiffening procedures including but not limited to cautery-assisted palatal stiffening operation and the

implantation of palatal implants G Tongue base suspensionbull Investigative Indications ThefollowingtreatmentsareconsideredINVESTIGATIVEduetoalackofevidencedemonstratingimprovedhealth outcomes AUPPPforanyconditionotherthanobstructivesleepapneaorsnoring B ExpiratoryPositiveAirwayPressure(EPAP)includingtheProventregdevice C OralpressuretherapydevicesincludingbutnotlimitedtotheWinxTMsystem D Atrialpacing EAllothersurgicalproceduresforthesoleoradjunctivetreatmentofobstructivesleepapneaupperairwayresistance

syndrome including but not limited to 1 Uvulectomy 2Laser-assisteduvulopalatoplasty(LAUP) 3Radiofrequencyvolumetricreductionofthepalataltissues 4Radiofrequencyvolumetrictissuereductionofthetonguewithorwithoutradiofrequencyreductionofthepalatal

tissues 5Palatalstiffeningproceduresincludingbutnotlimitedtocautery-assistedpalatalstiffeningoperationandthe

implantation of palatal implants 6 Tongue base suspension 7 Implantable hypoglossal nerve stimulators Respiratory Syncytial Virus (RSV) Prophylaxis bull INITIALRSVSEASON Theuseofimmuneprophylaxis(egpalivizumab[Synagis])forRSVfortheinitialRSVseasonmaybeconsideredMEDICALLYNECESSARYwhenthefollowingcriteriaaremet

A ChronicLungDisease(CLD)ofPrematurity 1Infantwasbornatlt32weeks0daysgestationAND 2Infantisle12monthsofageattheonsetofRSVseasonAND 3Infantrequiresgt21oxygenforatleastthefirst28daysafterbirth B Congenital Heart Disease (CHD) 1 Infant is le12monthsofageattheonsetofRSVseasonANDmeetsONEofthefollowing

medICAL ANd BeHAVIorAL HeALTH poLICY updATe

September 2015 17

medICAL ANd BeHAVIorAL HeALTH poLICY updATe

a AcyanoticCHDwhentheinfantisreceivingmedicationtocontrolcongestiveheartfailureandwillrequireacardiacsurgicalprocedureOR

b CyanoticCHDwhenpalivizumabisrecommendedafterconsultationwithapediatriccardiologistOR c Diagnosis of moderate to severe pulmonary hypertension OR 2Childislt24monthsofageattheonsetofRSVseasonANDmeetsONEofthefollowing a ChildundergoescardiactransplantationduringtheRSVseasonOR b ChildisreceivingRSVprophylaxisandcontinuestorequireprophylaxisafterasurgicalprocedureinvolving cardiac bypass or at the conclusion of extracorporeal membrane oxygenation C AnatomicPulmonaryAbnormalitiesORNeuromuscularDisorder(egcerebralpalsymusculardystrophy) 1 Infant is le12monthsofageattheonsetofRSVseasonAND 2Infanthasimpairedabilitytoclearsecretionsfromtheupperairway D Cystic Fibrosis 1 Infant is le12monthsofageattheonsetofRSVseasonwithevidenceofCLDandormalnutrition E Immunocompromised Status 1Childislt24monthsofageattheonsetofRSVseasonAND 2Childisprofoundlyimmunocompromised(egduetosolidorgantransplantationhematopoieticstem-cell

transplantation or chemotherapy) F Prematurity without CLD or CHD 1Infantwasbornatlt29weeks0daysgestation(ie28weeks6daysorless)AND 2Infantislt12monthsofageattheonsetofRSVseasonbull SECONDRSVSEASON Theuseofimmuneprophylaxis(egpalivizumab[Synagis])forRSVforthepatientrsquossecondyearoftreatmentmaybeconsideredMEDICALLYNECESSARYwhenthefollowingcriteriaaremet

A CLDofPrematurity 1Childwasbornatlt32weeks0daysgestationAND 2Childis12monthstolt24monthsofageattheonsetofthesecondRSVseasonAND 3ChildcontinuestorequireatleastONEofthefollowingwithinsix(6)monthsofthestartofthesecondRSV season a SupplementaloxygenOR b ChronicsystemiccorticosteroidtherapyOR c DiuretictherapyOR d Bronchodilator therapy B Cystic Fibrosis 1Childis12monthstolt24monthsofageattheonsetofthesecondRSVseasonwithevidenceofCLDandor malnutritionbull AdministrationofRSVProphylaxis A Whentheappropriatecriteriaabovearemetamaximumoffive(5)monthlydosesofpalivizumab(Synagisreg)will

becoveredperRSVseason(definedasNovember1stthroughMarch31st) B Thefirstmonthlydoseofpalivizumab(Synagisreg)willbeapprovedforcoverageofadministrationonorafter

November 1st C Apost-operativedoseofpalivizumab(Synagisreg)willbecoveredforchildrenlt24monthswhoarereceiving

RSVprophylaxisandcontinuetorequireprophylaxisafterasurgicalprocedureinvolvingcardiacbypassorattheconclusion of extracorporeal membrane oxygenation

September 2015 18

Chromosomal Microarray Analysis and Next Generation Sequencing to Evaluate Patients with Developmental DelayIntellectual Disability or Autism Spectrum Disorders bullChromosomalmicroarrayanalysismaybeconsideredMEDICALLYNECESSARYfordiagnosingageneticabnormalityin

children with apparent nonsyndromic cognitive developmental delayintellectual disability (DDID) or autism spectrum disorder(ASD)accordingtoacceptedDiagnosticandStatisticalManualofMentalDisorders(DSM)criteriawhenALLof the following conditions are met

AAnyindicatedbiochemicaltestsformetabolicdiseasehavebeenperformedandresultsarenon-diagnosticAND BFMR1geneanalysis(forFragileX)whenclinicallyindicatedisnegativeAND CASDorapparentnon-syndromicDDIDinachildwithmultipleanomaliesnotspecifictoawell-delineatedgenetic

syndromeasdefinedaboveAND DTheresultsofthegenetictestinghavethepotentialtoimpacttheclinicalmanagementofthepatientAND E Testing is requested after the parent(s) andor legal guardian(s) have been engaged in face-to-face genetic

counseling with a healthcare professional who has the appropriate genetics training and experience and is independent of the laboratory performing the test

bullChromosomalmicroarrayanalysisisconsideredINVESTIGATIVEforthefollowingduetoalackofclinicalevidencedemonstrating its impact on improved health outcomes

A Allothercasesofsuspectedgeneticabnormalityinchildrenwithdevelopmentaldelayintellectualdisabilityorautism spectrum disorder

B To confirm the diagnosis of a disorder or syndrome that is routinely diagnosed based on clinical evaluation alone Theseincludebutarenotlimitedtoattentiondeficithyperactivitydisorder(ADHD)learningdisabilitygrowthretardation or speech delay

C Population screeningbullPaneltestingusingnext-generationsequencingisconsideredINVESTIGATIVEinallcasesofsuspectedgeneticabnormalityinchildrenwithDDIDorASD

Spinal Fusion Lumbar bullLumbarspinalfusionmaybeconsideredMEDICALLYNECESSARYforanyofthefollowingindicationswhenacorrelativeabnormalityisconfirmedbyimagingstudies(egx-rayCTMRI)

A Epiduralcompressionorvertebraldestructionfromatumor B Neural compression after spinal fracture C Instability after debridement for infection D Spinal infections (eg osteomyelitis spinal tuberculosis) E Severe or rapidly progressive neurological deficit (eg motor loss sensory loss neurogenic claudication or cauda

equina syndrome) F IdiopathicscoliosiswhenEITHERofthefollowingcriteriaaremet 1ScolioticcurvewithaCobbanglegt45degreesinchildrenwhoareskeletallyimmatureOR 2ScolioticcurvewithaCobbanglegt50degreesresultinginfunctionalimpairmentinskeletallymatureindividuals G Symptomatic pseudarthrosisbullLumbarspinalfusionaloneorinconjunctionwithaprimarydecompressionsurgerymaybeconsideredMEDICALLYNECESSARYfortreatmentofdegenerativeconditionswithspinalinstabilitywhenALLthefollowingcriteriaaremet

A ONEofthefollowingconditionsarepresent 1Post-laminectomyinstabilityOR 2DegenerativescoliosisorkyphosisOR 3SpondylolisthesisOR

medICAL ANd BeHAVIorAL HeALTH poLICY updATe

September 2015 19

4 Spinal stenosis with spondylolisthesis AND B Documentedunremittingpainanddisabilityrefractorytointensiveconservativetherapyfor3monthsIntensive

conservativetherapymusthaveoccurredwithintheprevious12monthsANDmustincludeALLofthefollowing 1Anactiveorganizedandprogressivestrengthandflexibilityprogram NOTEIfapatientisunabletocompletephysicaltherapy(PT)duetoprogressivelyworseningpainanddisability the case will be reviewed on an individual basis by an internal physician reviewer (See Documentation Submission section)AND 2Aminimumoftwosessionsperweekoverthe3-monthperiodAND 3FunctionalassessmentasmeasuredbytheOswestryDisabilityIndex(ODI)demonstratingONEofthe following a Lessthan30improvementintheODIscorebetweenthefirstandlastphysicaltherapysessionOR b ContinuedODIscoreofgreaterthanorequalto40attheconclusionofphysicaltherapy AND 4Aneducationalcomponentthatdealswithpatientexpectationsandperceptionsaswellastheanatomicsources of back pain AND C Diagnosticimaging(egx-rayCTMRI)obtainedwithintheprevious12monthsdemonstratesspinalinstability(gt

3mmoftranslationandor10degreesormoreofangulationofonevertebracomparedtotheadjacentvertebrainaspinal motion segment)

bullLumbarspinalfusioninconjunctionwithadecompressionsurgerymaybeconsideredMEDICALLYNECESSARYinthetreatmentofcertaindegenerativeconditionswithoutexistinginstabilitywhenALLthefollowingcriteriaaremet

A ONEofthefollowingconditionsarepresent 1SpinalstenosisOR 2RecurrentspinalstenosisatthesamesegmentOR 3Recurrentdischerniationwithfailedlaminectomy AND B Documentedunremittingpainanddisabilityrefractorytointensiveconservativetherapyfor3monthsIntensive

conservativetherapymusthaveoccurredwithintheprevious12monthsANDmustincludeALLofthefollowing 1Anactiveorganizedandprogressivestrengthandflexibilityprogram NOTEIfapatientisunabletocompletephysicaltherapy(PT)duetoprogressivelyworseningpainanddisability the case will be reviewed on an individual basis by an internal physician reviewer (See Documentation Submission section) AND 2Aminimumoftwosessionsperweekoverthe3-monthperiodAND 3FunctionalassessmentasmeasuredbytheOswestryDisabilityIndex(ODI)demonstratingONEofthe

following a Lessthan30improvementintheODIscorebetweenthefirstandlastphysicaltherapysessionOR b ContinuedODIscoreofgreaterthanorequalto40attheconclusionofphysicaltherapy AND 4Aneducationalcomponentthatdealswithpatientexpectationsandperceptionsaswellastheanatomicsources of back pain AND C Diagnosticimaging(egCTMRI)obtainedwithintheprevious12monthsdemonstratesspinalcordornerveroot

compression

medICAL ANd BeHAVIorAL HeALTH poLICY updATe

September 2015 20

bullLumbarspinalfusionmaybeconsideredMEDICALLYNECESSARYforchronic(presentforatleast6ndash12months)discogenicbackpainwithoutinstabilitywhenALLthefollowingcriteriaaremet

A Documentedunremittingpainanddisabilityrefractorytointensiveconservativetherapyforatleast3months Intensiveconservativetherapymusthaveoccurredwithintheprevious12monthsANDmustincludeALLofthefollowing

1Anti-inflammatorymedicationandanalgesicsunlesscontraindicatedAND 2TherapeuticinjectionsAND 3Anactiveorganizedandprogressivestrengthandflexibilityprogram NOTEIfapatientisunabletocompletephysicaltherapy(PT)duetoprogressivelyworseningpainanddisability

the case will be reviewed on an individual basis by an internal physician reviewer (See Documentation Submission section)

AND 4Aminimumoftwosessionsperweekoverthe3-monthperiodAND 5FunctionalassessmentasmeasuredbytheOswestryDisabilityIndex(ODI)demonstratingONEofthe

following a Lessthan30improvementintheODIscorebetweenthefirstandlastphysicaltherapysessionOR b ContinuedODIscoreofgreaterthanorequalto40attheconclusionofphysicaltherapy 6Aneducationalcomponentthatdealswithpatientexpectationsandperceptionsaswellastheanatomicsources

of back pain AND B Absenceofuntreatedunderlyingcontributorymentalhealthconditionsorpsychosocialissuesincludingbutnot

limited to depression or drug or alcohol abuse AND C Diagnosticimaging(egMRICT)obtainedwithintheprevious12monthsdemonstratesdegenerativediscdisease

limitedto1ndash2disclevelsbull Documentation supporting the medical necessity criteria described in the policy must be included in the prior authorizationInadditionthefollowingdocumentationmustalsobesubmitted

1 Written report from a radiologist describing findings from spinal diagnostic imaging studies 2 Intensiveconservativetherapy bull DocumentationfromthephysicaltherapistmustincludeOswestryDisabilityIndex(ODI)scores bull Ifapatientisunabletocompletephysicaltherapy(PT)duetoprogressivelyworseningsymptomsofpainand

disability the case will be reviewed on an individual basis by an internal physician reviewer Documentation must be submitted from the physical therapist describing the patientrsquos inability to complete PT

3 Forpatientswithchronicdiscogenicbackpainwithoutinstability(policysectionIV)documentationregardingthe absence of untreated underlying contributory mental health conditions or psychosocial issues including but not limited to depression or drug or alcohol abuse must be submitted by the patientrsquos primary care physician or a Mental Health Professional The Mental Health Professional must meet the Minnesota Department of Human ServicesqualificationsassetforthinMinnStatsect245462subd18(2013)andMinnStatsect2454871subd27(2013)

medICAL ANd BeHAVIorAL HeALTH poLICY updATe

September 2015 21

Policies inactivatedNone There was no Medical and behavioral Health Policy Activity for July 2015

Policies reviewed with no changes in May 2015 and June 2015

Acupuncture

Artificial Intervertebral Disc Cervical Spine

Belimumab

Cardiovascular Disease Risk Assessment and Management Laboratory Evaluation of Non-Traditional Lipid and

Nonlipid Biomarkers

Cellular Immunotherapy for Prostate Cancer

Chelation Therapy

Computerized Dynamic Posturography

Continuous and Intermittent Glucose Monitoring of Interstitial Fluid

Cytochrome P450 Genotyping

Digital Breast Tomosynthesis

Electrocardiographic (ECG) Body Surface Mapping

Endoscopic Radiofrequency Ablation or Cryoablation for Barrettrsquos Esophagus

Epidermal Growth-Factor Receptor (EGFR) Analysis for Non-small Cell Lung Cancer

HP Acthar Gel (Repository Corticotropin)

Hematopoietic Stem-Cell Transplantation for Non-Hodgkin Lymphomas

Hematopoietic Stem-Cell Transplantation for Primary Amyloidosis

Hematopoietic Stem-Cell Transplantation for Waldenstrom Macroglobulinemia

Image-Guided Minimally Invasive Lumbar Decompression for Spinal Stenosis

Liposuction

Lung Cancer Screening Using Computed Tomography (CT)

Mastopexy

Microprocessor-Controlled Prosthesis for the Lower Limb

Myoelectric Prosthesis for the Upper Limb

Organ Transplantation

Percutaneous and Endoscopic Techniques for Disc Decompression

September 2015 22

Medical and Behavioral Health Policy Update

NetworkManagementR317 POBox64560 StPaulMN55164-0560

Provider Press is posted on our website quarterly for business office staff of multi-specialty clinics physicians public health agencies DME providers chiropractors podiatrists physical therapists occupational therapists optometrists and behavioral health professionalsproviders Direct inquiries to

NetworkManagementR317Editor Holly BatchelderPOBox64560StPaulMN55164-0560(651)662-2014tollfree1-800-382-2000ext22014

AdvisorsFaithBauerCPCCPC-HCPC-PJeannieHarpCPCJanineUtechtCPCCPC-HCPC-PCPMAandKarenKiemeleMPH

Information in Provider Press is a general outline Provider and member contracts determine benefits

CPT-4codesnotedareAMAcopyrighted

0915

Peripheral Nerve Stimulation of the Trunk or Limbs for Treatment of Pain

Rhinomanometry and AcousticOptical Rhinometry

Sleep Studies Polysomnograms in Children and Adolescents

Spinal Unloading Devices Patient-Operated

Stem-Cell Therapy for Peripheral Arterial Disease

Subcutaneous Hormone Pellets

Surgical Interruption of Pelvic Nerve Pathways for Primary and Secondary Dysmenorrhea

Systems Pathology Testing for Predicting Risk of Recurrence in Prostate Cancer

Urine Drug Testing for Substance Abuse Treatment and Chronic Pain Management

Wireless Gastric Motility Monitoring

September 2015 15

C Bi-levelPositiveAirwayPressure(BiPAP) BiPAPmaybeconsideredMEDICALLYNECESSARYinpatientswho 1MeetthecriteriaforCPAPAND 2HavefailedapriortrialofCPAPOR 3ForwhomBiPAPisfoundtobemoreeffectivethanCPAPinthesleeplaboratory D Auto-AdjustingPAP(APAP) APAPmaybeconsideredMEDICALLYNECESSARYinpatientswho 1MeetthecriteriaforCPAPaboveAND 2HaveacontraindicationtoCPAPhavefailedapriortrialofCPAPORareundergoingatrialofAPAPtotitrate CPAP AND 3Havenoevidencebyhistoryorphysicalexaminationofthefollowingconditions a Central sleep apnea b Congestive heart failure c Chronic pulmonary disease such as chronic obstructive pulmonary disease d Pulmonary hypertension e Obesityhypoventilationsyndromeorotherconditionwhichmaycausenocturnalarterialoxyhemoglobin desaturationbull Surgical Management A Uvulopalatopharyngoplasty(UPPP) UPPPmaybeconsideredMEDICALLYNECESSARYwhenallthefollowingcriteriaaremet 1PresenceofsignificantunexplainedcorpulmonaleorcardiacarrhythmiaresultingfromdocumentedOSA OR 2AnAHIorRDIof15eventsperhourorgreateroranAHIorRDIbetween5and14withdocumented

hypertension ischemic heart disease or history of stroke AND a BMI less than 40 AND bAtrialoforalappliancetherapyhasfailedorthepatientisnotacandidateforanoralappliance AND c PatienthasnotrespondedtoordoesnottolerateCPAPBiPAPorAPAPfollowingaminimumof4hoursper nightforthree(3)monthsofPAPusage B Maxillofacial Procedures Maxillofacial surgical procedures such as inferior sagittal mandibular osteotomy and genioglossal advancement

withorwithouthyoidmyotomyandsuspensionormandibular-maxillaryadvancement(MMA)maybeconsideredMEDICALLYNECESSARYwhenthefollowingcriteriaaremet

1PresenceofsignificantunexplainedcorpulmonaleorcardiacarrhythmiaresultingfromdocumentedOSA OR 2AnAHIorRDIof15eventsperhourorgreateroranAHIorRDIbetween5and14withdocumented

hypertension ischemic heart disease or history of stroke AND a Objectiveevidenceofhypopharyngealobstructiondocumentedbyeitherfiberopticexaminationor cephalometric radiographs AND

medICAL ANd BeHAVIorAL HeALTH poLICY updATe

September 2015 16

b PatienthasnotrespondedtoordoesnottolerateCPAPBiPAPorAPAPfollowingaminimumof4hourspernightforthree(3)monthsofPAPusage

bull Treatment of Snoring TreatmentofsnoringisconsideredNOTMEDICALLYNECESSARYbecausesimplesnoringintheabsenceof

documented obstructive sleep apnea is not considered a medical condition Therefore all procedures for the sole or adjunctivetreatmentofsnoringareconsideredNOTMEDICALLYNECESSARYincludingbutnotlimitedto

A Uvulopalatopharyngoplasty(UPPP) B Uvulectomy C Laser-assisteduvulopalatoplasty(LAUP) D Radiofrequencyvolumetricreductionofthepalataltissues E Radiofrequencyvolumetrictissuereductionofthetonguewithorwithoutradiofrequencyreductionofthepalatal

tissues F Palatal stiffening procedures including but not limited to cautery-assisted palatal stiffening operation and the

implantation of palatal implants G Tongue base suspensionbull Investigative Indications ThefollowingtreatmentsareconsideredINVESTIGATIVEduetoalackofevidencedemonstratingimprovedhealth outcomes AUPPPforanyconditionotherthanobstructivesleepapneaorsnoring B ExpiratoryPositiveAirwayPressure(EPAP)includingtheProventregdevice C OralpressuretherapydevicesincludingbutnotlimitedtotheWinxTMsystem D Atrialpacing EAllothersurgicalproceduresforthesoleoradjunctivetreatmentofobstructivesleepapneaupperairwayresistance

syndrome including but not limited to 1 Uvulectomy 2Laser-assisteduvulopalatoplasty(LAUP) 3Radiofrequencyvolumetricreductionofthepalataltissues 4Radiofrequencyvolumetrictissuereductionofthetonguewithorwithoutradiofrequencyreductionofthepalatal

tissues 5Palatalstiffeningproceduresincludingbutnotlimitedtocautery-assistedpalatalstiffeningoperationandthe

implantation of palatal implants 6 Tongue base suspension 7 Implantable hypoglossal nerve stimulators Respiratory Syncytial Virus (RSV) Prophylaxis bull INITIALRSVSEASON Theuseofimmuneprophylaxis(egpalivizumab[Synagis])forRSVfortheinitialRSVseasonmaybeconsideredMEDICALLYNECESSARYwhenthefollowingcriteriaaremet

A ChronicLungDisease(CLD)ofPrematurity 1Infantwasbornatlt32weeks0daysgestationAND 2Infantisle12monthsofageattheonsetofRSVseasonAND 3Infantrequiresgt21oxygenforatleastthefirst28daysafterbirth B Congenital Heart Disease (CHD) 1 Infant is le12monthsofageattheonsetofRSVseasonANDmeetsONEofthefollowing

medICAL ANd BeHAVIorAL HeALTH poLICY updATe

September 2015 17

medICAL ANd BeHAVIorAL HeALTH poLICY updATe

a AcyanoticCHDwhentheinfantisreceivingmedicationtocontrolcongestiveheartfailureandwillrequireacardiacsurgicalprocedureOR

b CyanoticCHDwhenpalivizumabisrecommendedafterconsultationwithapediatriccardiologistOR c Diagnosis of moderate to severe pulmonary hypertension OR 2Childislt24monthsofageattheonsetofRSVseasonANDmeetsONEofthefollowing a ChildundergoescardiactransplantationduringtheRSVseasonOR b ChildisreceivingRSVprophylaxisandcontinuestorequireprophylaxisafterasurgicalprocedureinvolving cardiac bypass or at the conclusion of extracorporeal membrane oxygenation C AnatomicPulmonaryAbnormalitiesORNeuromuscularDisorder(egcerebralpalsymusculardystrophy) 1 Infant is le12monthsofageattheonsetofRSVseasonAND 2Infanthasimpairedabilitytoclearsecretionsfromtheupperairway D Cystic Fibrosis 1 Infant is le12monthsofageattheonsetofRSVseasonwithevidenceofCLDandormalnutrition E Immunocompromised Status 1Childislt24monthsofageattheonsetofRSVseasonAND 2Childisprofoundlyimmunocompromised(egduetosolidorgantransplantationhematopoieticstem-cell

transplantation or chemotherapy) F Prematurity without CLD or CHD 1Infantwasbornatlt29weeks0daysgestation(ie28weeks6daysorless)AND 2Infantislt12monthsofageattheonsetofRSVseasonbull SECONDRSVSEASON Theuseofimmuneprophylaxis(egpalivizumab[Synagis])forRSVforthepatientrsquossecondyearoftreatmentmaybeconsideredMEDICALLYNECESSARYwhenthefollowingcriteriaaremet

A CLDofPrematurity 1Childwasbornatlt32weeks0daysgestationAND 2Childis12monthstolt24monthsofageattheonsetofthesecondRSVseasonAND 3ChildcontinuestorequireatleastONEofthefollowingwithinsix(6)monthsofthestartofthesecondRSV season a SupplementaloxygenOR b ChronicsystemiccorticosteroidtherapyOR c DiuretictherapyOR d Bronchodilator therapy B Cystic Fibrosis 1Childis12monthstolt24monthsofageattheonsetofthesecondRSVseasonwithevidenceofCLDandor malnutritionbull AdministrationofRSVProphylaxis A Whentheappropriatecriteriaabovearemetamaximumoffive(5)monthlydosesofpalivizumab(Synagisreg)will

becoveredperRSVseason(definedasNovember1stthroughMarch31st) B Thefirstmonthlydoseofpalivizumab(Synagisreg)willbeapprovedforcoverageofadministrationonorafter

November 1st C Apost-operativedoseofpalivizumab(Synagisreg)willbecoveredforchildrenlt24monthswhoarereceiving

RSVprophylaxisandcontinuetorequireprophylaxisafterasurgicalprocedureinvolvingcardiacbypassorattheconclusion of extracorporeal membrane oxygenation

September 2015 18

Chromosomal Microarray Analysis and Next Generation Sequencing to Evaluate Patients with Developmental DelayIntellectual Disability or Autism Spectrum Disorders bullChromosomalmicroarrayanalysismaybeconsideredMEDICALLYNECESSARYfordiagnosingageneticabnormalityin

children with apparent nonsyndromic cognitive developmental delayintellectual disability (DDID) or autism spectrum disorder(ASD)accordingtoacceptedDiagnosticandStatisticalManualofMentalDisorders(DSM)criteriawhenALLof the following conditions are met

AAnyindicatedbiochemicaltestsformetabolicdiseasehavebeenperformedandresultsarenon-diagnosticAND BFMR1geneanalysis(forFragileX)whenclinicallyindicatedisnegativeAND CASDorapparentnon-syndromicDDIDinachildwithmultipleanomaliesnotspecifictoawell-delineatedgenetic

syndromeasdefinedaboveAND DTheresultsofthegenetictestinghavethepotentialtoimpacttheclinicalmanagementofthepatientAND E Testing is requested after the parent(s) andor legal guardian(s) have been engaged in face-to-face genetic

counseling with a healthcare professional who has the appropriate genetics training and experience and is independent of the laboratory performing the test

bullChromosomalmicroarrayanalysisisconsideredINVESTIGATIVEforthefollowingduetoalackofclinicalevidencedemonstrating its impact on improved health outcomes

A Allothercasesofsuspectedgeneticabnormalityinchildrenwithdevelopmentaldelayintellectualdisabilityorautism spectrum disorder

B To confirm the diagnosis of a disorder or syndrome that is routinely diagnosed based on clinical evaluation alone Theseincludebutarenotlimitedtoattentiondeficithyperactivitydisorder(ADHD)learningdisabilitygrowthretardation or speech delay

C Population screeningbullPaneltestingusingnext-generationsequencingisconsideredINVESTIGATIVEinallcasesofsuspectedgeneticabnormalityinchildrenwithDDIDorASD

Spinal Fusion Lumbar bullLumbarspinalfusionmaybeconsideredMEDICALLYNECESSARYforanyofthefollowingindicationswhenacorrelativeabnormalityisconfirmedbyimagingstudies(egx-rayCTMRI)

A Epiduralcompressionorvertebraldestructionfromatumor B Neural compression after spinal fracture C Instability after debridement for infection D Spinal infections (eg osteomyelitis spinal tuberculosis) E Severe or rapidly progressive neurological deficit (eg motor loss sensory loss neurogenic claudication or cauda

equina syndrome) F IdiopathicscoliosiswhenEITHERofthefollowingcriteriaaremet 1ScolioticcurvewithaCobbanglegt45degreesinchildrenwhoareskeletallyimmatureOR 2ScolioticcurvewithaCobbanglegt50degreesresultinginfunctionalimpairmentinskeletallymatureindividuals G Symptomatic pseudarthrosisbullLumbarspinalfusionaloneorinconjunctionwithaprimarydecompressionsurgerymaybeconsideredMEDICALLYNECESSARYfortreatmentofdegenerativeconditionswithspinalinstabilitywhenALLthefollowingcriteriaaremet

A ONEofthefollowingconditionsarepresent 1Post-laminectomyinstabilityOR 2DegenerativescoliosisorkyphosisOR 3SpondylolisthesisOR

medICAL ANd BeHAVIorAL HeALTH poLICY updATe

September 2015 19

4 Spinal stenosis with spondylolisthesis AND B Documentedunremittingpainanddisabilityrefractorytointensiveconservativetherapyfor3monthsIntensive

conservativetherapymusthaveoccurredwithintheprevious12monthsANDmustincludeALLofthefollowing 1Anactiveorganizedandprogressivestrengthandflexibilityprogram NOTEIfapatientisunabletocompletephysicaltherapy(PT)duetoprogressivelyworseningpainanddisability the case will be reviewed on an individual basis by an internal physician reviewer (See Documentation Submission section)AND 2Aminimumoftwosessionsperweekoverthe3-monthperiodAND 3FunctionalassessmentasmeasuredbytheOswestryDisabilityIndex(ODI)demonstratingONEofthe following a Lessthan30improvementintheODIscorebetweenthefirstandlastphysicaltherapysessionOR b ContinuedODIscoreofgreaterthanorequalto40attheconclusionofphysicaltherapy AND 4Aneducationalcomponentthatdealswithpatientexpectationsandperceptionsaswellastheanatomicsources of back pain AND C Diagnosticimaging(egx-rayCTMRI)obtainedwithintheprevious12monthsdemonstratesspinalinstability(gt

3mmoftranslationandor10degreesormoreofangulationofonevertebracomparedtotheadjacentvertebrainaspinal motion segment)

bullLumbarspinalfusioninconjunctionwithadecompressionsurgerymaybeconsideredMEDICALLYNECESSARYinthetreatmentofcertaindegenerativeconditionswithoutexistinginstabilitywhenALLthefollowingcriteriaaremet

A ONEofthefollowingconditionsarepresent 1SpinalstenosisOR 2RecurrentspinalstenosisatthesamesegmentOR 3Recurrentdischerniationwithfailedlaminectomy AND B Documentedunremittingpainanddisabilityrefractorytointensiveconservativetherapyfor3monthsIntensive

conservativetherapymusthaveoccurredwithintheprevious12monthsANDmustincludeALLofthefollowing 1Anactiveorganizedandprogressivestrengthandflexibilityprogram NOTEIfapatientisunabletocompletephysicaltherapy(PT)duetoprogressivelyworseningpainanddisability the case will be reviewed on an individual basis by an internal physician reviewer (See Documentation Submission section) AND 2Aminimumoftwosessionsperweekoverthe3-monthperiodAND 3FunctionalassessmentasmeasuredbytheOswestryDisabilityIndex(ODI)demonstratingONEofthe

following a Lessthan30improvementintheODIscorebetweenthefirstandlastphysicaltherapysessionOR b ContinuedODIscoreofgreaterthanorequalto40attheconclusionofphysicaltherapy AND 4Aneducationalcomponentthatdealswithpatientexpectationsandperceptionsaswellastheanatomicsources of back pain AND C Diagnosticimaging(egCTMRI)obtainedwithintheprevious12monthsdemonstratesspinalcordornerveroot

compression

medICAL ANd BeHAVIorAL HeALTH poLICY updATe

September 2015 20

bullLumbarspinalfusionmaybeconsideredMEDICALLYNECESSARYforchronic(presentforatleast6ndash12months)discogenicbackpainwithoutinstabilitywhenALLthefollowingcriteriaaremet

A Documentedunremittingpainanddisabilityrefractorytointensiveconservativetherapyforatleast3months Intensiveconservativetherapymusthaveoccurredwithintheprevious12monthsANDmustincludeALLofthefollowing

1Anti-inflammatorymedicationandanalgesicsunlesscontraindicatedAND 2TherapeuticinjectionsAND 3Anactiveorganizedandprogressivestrengthandflexibilityprogram NOTEIfapatientisunabletocompletephysicaltherapy(PT)duetoprogressivelyworseningpainanddisability

the case will be reviewed on an individual basis by an internal physician reviewer (See Documentation Submission section)

AND 4Aminimumoftwosessionsperweekoverthe3-monthperiodAND 5FunctionalassessmentasmeasuredbytheOswestryDisabilityIndex(ODI)demonstratingONEofthe

following a Lessthan30improvementintheODIscorebetweenthefirstandlastphysicaltherapysessionOR b ContinuedODIscoreofgreaterthanorequalto40attheconclusionofphysicaltherapy 6Aneducationalcomponentthatdealswithpatientexpectationsandperceptionsaswellastheanatomicsources

of back pain AND B Absenceofuntreatedunderlyingcontributorymentalhealthconditionsorpsychosocialissuesincludingbutnot

limited to depression or drug or alcohol abuse AND C Diagnosticimaging(egMRICT)obtainedwithintheprevious12monthsdemonstratesdegenerativediscdisease

limitedto1ndash2disclevelsbull Documentation supporting the medical necessity criteria described in the policy must be included in the prior authorizationInadditionthefollowingdocumentationmustalsobesubmitted

1 Written report from a radiologist describing findings from spinal diagnostic imaging studies 2 Intensiveconservativetherapy bull DocumentationfromthephysicaltherapistmustincludeOswestryDisabilityIndex(ODI)scores bull Ifapatientisunabletocompletephysicaltherapy(PT)duetoprogressivelyworseningsymptomsofpainand

disability the case will be reviewed on an individual basis by an internal physician reviewer Documentation must be submitted from the physical therapist describing the patientrsquos inability to complete PT

3 Forpatientswithchronicdiscogenicbackpainwithoutinstability(policysectionIV)documentationregardingthe absence of untreated underlying contributory mental health conditions or psychosocial issues including but not limited to depression or drug or alcohol abuse must be submitted by the patientrsquos primary care physician or a Mental Health Professional The Mental Health Professional must meet the Minnesota Department of Human ServicesqualificationsassetforthinMinnStatsect245462subd18(2013)andMinnStatsect2454871subd27(2013)

medICAL ANd BeHAVIorAL HeALTH poLICY updATe

September 2015 21

Policies inactivatedNone There was no Medical and behavioral Health Policy Activity for July 2015

Policies reviewed with no changes in May 2015 and June 2015

Acupuncture

Artificial Intervertebral Disc Cervical Spine

Belimumab

Cardiovascular Disease Risk Assessment and Management Laboratory Evaluation of Non-Traditional Lipid and

Nonlipid Biomarkers

Cellular Immunotherapy for Prostate Cancer

Chelation Therapy

Computerized Dynamic Posturography

Continuous and Intermittent Glucose Monitoring of Interstitial Fluid

Cytochrome P450 Genotyping

Digital Breast Tomosynthesis

Electrocardiographic (ECG) Body Surface Mapping

Endoscopic Radiofrequency Ablation or Cryoablation for Barrettrsquos Esophagus

Epidermal Growth-Factor Receptor (EGFR) Analysis for Non-small Cell Lung Cancer

HP Acthar Gel (Repository Corticotropin)

Hematopoietic Stem-Cell Transplantation for Non-Hodgkin Lymphomas

Hematopoietic Stem-Cell Transplantation for Primary Amyloidosis

Hematopoietic Stem-Cell Transplantation for Waldenstrom Macroglobulinemia

Image-Guided Minimally Invasive Lumbar Decompression for Spinal Stenosis

Liposuction

Lung Cancer Screening Using Computed Tomography (CT)

Mastopexy

Microprocessor-Controlled Prosthesis for the Lower Limb

Myoelectric Prosthesis for the Upper Limb

Organ Transplantation

Percutaneous and Endoscopic Techniques for Disc Decompression

September 2015 22

Medical and Behavioral Health Policy Update

NetworkManagementR317 POBox64560 StPaulMN55164-0560

Provider Press is posted on our website quarterly for business office staff of multi-specialty clinics physicians public health agencies DME providers chiropractors podiatrists physical therapists occupational therapists optometrists and behavioral health professionalsproviders Direct inquiries to

NetworkManagementR317Editor Holly BatchelderPOBox64560StPaulMN55164-0560(651)662-2014tollfree1-800-382-2000ext22014

AdvisorsFaithBauerCPCCPC-HCPC-PJeannieHarpCPCJanineUtechtCPCCPC-HCPC-PCPMAandKarenKiemeleMPH

Information in Provider Press is a general outline Provider and member contracts determine benefits

CPT-4codesnotedareAMAcopyrighted

0915

Peripheral Nerve Stimulation of the Trunk or Limbs for Treatment of Pain

Rhinomanometry and AcousticOptical Rhinometry

Sleep Studies Polysomnograms in Children and Adolescents

Spinal Unloading Devices Patient-Operated

Stem-Cell Therapy for Peripheral Arterial Disease

Subcutaneous Hormone Pellets

Surgical Interruption of Pelvic Nerve Pathways for Primary and Secondary Dysmenorrhea

Systems Pathology Testing for Predicting Risk of Recurrence in Prostate Cancer

Urine Drug Testing for Substance Abuse Treatment and Chronic Pain Management

Wireless Gastric Motility Monitoring

September 2015 16

b PatienthasnotrespondedtoordoesnottolerateCPAPBiPAPorAPAPfollowingaminimumof4hourspernightforthree(3)monthsofPAPusage

bull Treatment of Snoring TreatmentofsnoringisconsideredNOTMEDICALLYNECESSARYbecausesimplesnoringintheabsenceof

documented obstructive sleep apnea is not considered a medical condition Therefore all procedures for the sole or adjunctivetreatmentofsnoringareconsideredNOTMEDICALLYNECESSARYincludingbutnotlimitedto

A Uvulopalatopharyngoplasty(UPPP) B Uvulectomy C Laser-assisteduvulopalatoplasty(LAUP) D Radiofrequencyvolumetricreductionofthepalataltissues E Radiofrequencyvolumetrictissuereductionofthetonguewithorwithoutradiofrequencyreductionofthepalatal

tissues F Palatal stiffening procedures including but not limited to cautery-assisted palatal stiffening operation and the

implantation of palatal implants G Tongue base suspensionbull Investigative Indications ThefollowingtreatmentsareconsideredINVESTIGATIVEduetoalackofevidencedemonstratingimprovedhealth outcomes AUPPPforanyconditionotherthanobstructivesleepapneaorsnoring B ExpiratoryPositiveAirwayPressure(EPAP)includingtheProventregdevice C OralpressuretherapydevicesincludingbutnotlimitedtotheWinxTMsystem D Atrialpacing EAllothersurgicalproceduresforthesoleoradjunctivetreatmentofobstructivesleepapneaupperairwayresistance

syndrome including but not limited to 1 Uvulectomy 2Laser-assisteduvulopalatoplasty(LAUP) 3Radiofrequencyvolumetricreductionofthepalataltissues 4Radiofrequencyvolumetrictissuereductionofthetonguewithorwithoutradiofrequencyreductionofthepalatal

tissues 5Palatalstiffeningproceduresincludingbutnotlimitedtocautery-assistedpalatalstiffeningoperationandthe

implantation of palatal implants 6 Tongue base suspension 7 Implantable hypoglossal nerve stimulators Respiratory Syncytial Virus (RSV) Prophylaxis bull INITIALRSVSEASON Theuseofimmuneprophylaxis(egpalivizumab[Synagis])forRSVfortheinitialRSVseasonmaybeconsideredMEDICALLYNECESSARYwhenthefollowingcriteriaaremet

A ChronicLungDisease(CLD)ofPrematurity 1Infantwasbornatlt32weeks0daysgestationAND 2Infantisle12monthsofageattheonsetofRSVseasonAND 3Infantrequiresgt21oxygenforatleastthefirst28daysafterbirth B Congenital Heart Disease (CHD) 1 Infant is le12monthsofageattheonsetofRSVseasonANDmeetsONEofthefollowing

medICAL ANd BeHAVIorAL HeALTH poLICY updATe

September 2015 17

medICAL ANd BeHAVIorAL HeALTH poLICY updATe

a AcyanoticCHDwhentheinfantisreceivingmedicationtocontrolcongestiveheartfailureandwillrequireacardiacsurgicalprocedureOR

b CyanoticCHDwhenpalivizumabisrecommendedafterconsultationwithapediatriccardiologistOR c Diagnosis of moderate to severe pulmonary hypertension OR 2Childislt24monthsofageattheonsetofRSVseasonANDmeetsONEofthefollowing a ChildundergoescardiactransplantationduringtheRSVseasonOR b ChildisreceivingRSVprophylaxisandcontinuestorequireprophylaxisafterasurgicalprocedureinvolving cardiac bypass or at the conclusion of extracorporeal membrane oxygenation C AnatomicPulmonaryAbnormalitiesORNeuromuscularDisorder(egcerebralpalsymusculardystrophy) 1 Infant is le12monthsofageattheonsetofRSVseasonAND 2Infanthasimpairedabilitytoclearsecretionsfromtheupperairway D Cystic Fibrosis 1 Infant is le12monthsofageattheonsetofRSVseasonwithevidenceofCLDandormalnutrition E Immunocompromised Status 1Childislt24monthsofageattheonsetofRSVseasonAND 2Childisprofoundlyimmunocompromised(egduetosolidorgantransplantationhematopoieticstem-cell

transplantation or chemotherapy) F Prematurity without CLD or CHD 1Infantwasbornatlt29weeks0daysgestation(ie28weeks6daysorless)AND 2Infantislt12monthsofageattheonsetofRSVseasonbull SECONDRSVSEASON Theuseofimmuneprophylaxis(egpalivizumab[Synagis])forRSVforthepatientrsquossecondyearoftreatmentmaybeconsideredMEDICALLYNECESSARYwhenthefollowingcriteriaaremet

A CLDofPrematurity 1Childwasbornatlt32weeks0daysgestationAND 2Childis12monthstolt24monthsofageattheonsetofthesecondRSVseasonAND 3ChildcontinuestorequireatleastONEofthefollowingwithinsix(6)monthsofthestartofthesecondRSV season a SupplementaloxygenOR b ChronicsystemiccorticosteroidtherapyOR c DiuretictherapyOR d Bronchodilator therapy B Cystic Fibrosis 1Childis12monthstolt24monthsofageattheonsetofthesecondRSVseasonwithevidenceofCLDandor malnutritionbull AdministrationofRSVProphylaxis A Whentheappropriatecriteriaabovearemetamaximumoffive(5)monthlydosesofpalivizumab(Synagisreg)will

becoveredperRSVseason(definedasNovember1stthroughMarch31st) B Thefirstmonthlydoseofpalivizumab(Synagisreg)willbeapprovedforcoverageofadministrationonorafter

November 1st C Apost-operativedoseofpalivizumab(Synagisreg)willbecoveredforchildrenlt24monthswhoarereceiving

RSVprophylaxisandcontinuetorequireprophylaxisafterasurgicalprocedureinvolvingcardiacbypassorattheconclusion of extracorporeal membrane oxygenation

September 2015 18

Chromosomal Microarray Analysis and Next Generation Sequencing to Evaluate Patients with Developmental DelayIntellectual Disability or Autism Spectrum Disorders bullChromosomalmicroarrayanalysismaybeconsideredMEDICALLYNECESSARYfordiagnosingageneticabnormalityin

children with apparent nonsyndromic cognitive developmental delayintellectual disability (DDID) or autism spectrum disorder(ASD)accordingtoacceptedDiagnosticandStatisticalManualofMentalDisorders(DSM)criteriawhenALLof the following conditions are met

AAnyindicatedbiochemicaltestsformetabolicdiseasehavebeenperformedandresultsarenon-diagnosticAND BFMR1geneanalysis(forFragileX)whenclinicallyindicatedisnegativeAND CASDorapparentnon-syndromicDDIDinachildwithmultipleanomaliesnotspecifictoawell-delineatedgenetic

syndromeasdefinedaboveAND DTheresultsofthegenetictestinghavethepotentialtoimpacttheclinicalmanagementofthepatientAND E Testing is requested after the parent(s) andor legal guardian(s) have been engaged in face-to-face genetic

counseling with a healthcare professional who has the appropriate genetics training and experience and is independent of the laboratory performing the test

bullChromosomalmicroarrayanalysisisconsideredINVESTIGATIVEforthefollowingduetoalackofclinicalevidencedemonstrating its impact on improved health outcomes

A Allothercasesofsuspectedgeneticabnormalityinchildrenwithdevelopmentaldelayintellectualdisabilityorautism spectrum disorder

B To confirm the diagnosis of a disorder or syndrome that is routinely diagnosed based on clinical evaluation alone Theseincludebutarenotlimitedtoattentiondeficithyperactivitydisorder(ADHD)learningdisabilitygrowthretardation or speech delay

C Population screeningbullPaneltestingusingnext-generationsequencingisconsideredINVESTIGATIVEinallcasesofsuspectedgeneticabnormalityinchildrenwithDDIDorASD

Spinal Fusion Lumbar bullLumbarspinalfusionmaybeconsideredMEDICALLYNECESSARYforanyofthefollowingindicationswhenacorrelativeabnormalityisconfirmedbyimagingstudies(egx-rayCTMRI)

A Epiduralcompressionorvertebraldestructionfromatumor B Neural compression after spinal fracture C Instability after debridement for infection D Spinal infections (eg osteomyelitis spinal tuberculosis) E Severe or rapidly progressive neurological deficit (eg motor loss sensory loss neurogenic claudication or cauda

equina syndrome) F IdiopathicscoliosiswhenEITHERofthefollowingcriteriaaremet 1ScolioticcurvewithaCobbanglegt45degreesinchildrenwhoareskeletallyimmatureOR 2ScolioticcurvewithaCobbanglegt50degreesresultinginfunctionalimpairmentinskeletallymatureindividuals G Symptomatic pseudarthrosisbullLumbarspinalfusionaloneorinconjunctionwithaprimarydecompressionsurgerymaybeconsideredMEDICALLYNECESSARYfortreatmentofdegenerativeconditionswithspinalinstabilitywhenALLthefollowingcriteriaaremet

A ONEofthefollowingconditionsarepresent 1Post-laminectomyinstabilityOR 2DegenerativescoliosisorkyphosisOR 3SpondylolisthesisOR

medICAL ANd BeHAVIorAL HeALTH poLICY updATe

September 2015 19

4 Spinal stenosis with spondylolisthesis AND B Documentedunremittingpainanddisabilityrefractorytointensiveconservativetherapyfor3monthsIntensive

conservativetherapymusthaveoccurredwithintheprevious12monthsANDmustincludeALLofthefollowing 1Anactiveorganizedandprogressivestrengthandflexibilityprogram NOTEIfapatientisunabletocompletephysicaltherapy(PT)duetoprogressivelyworseningpainanddisability the case will be reviewed on an individual basis by an internal physician reviewer (See Documentation Submission section)AND 2Aminimumoftwosessionsperweekoverthe3-monthperiodAND 3FunctionalassessmentasmeasuredbytheOswestryDisabilityIndex(ODI)demonstratingONEofthe following a Lessthan30improvementintheODIscorebetweenthefirstandlastphysicaltherapysessionOR b ContinuedODIscoreofgreaterthanorequalto40attheconclusionofphysicaltherapy AND 4Aneducationalcomponentthatdealswithpatientexpectationsandperceptionsaswellastheanatomicsources of back pain AND C Diagnosticimaging(egx-rayCTMRI)obtainedwithintheprevious12monthsdemonstratesspinalinstability(gt

3mmoftranslationandor10degreesormoreofangulationofonevertebracomparedtotheadjacentvertebrainaspinal motion segment)

bullLumbarspinalfusioninconjunctionwithadecompressionsurgerymaybeconsideredMEDICALLYNECESSARYinthetreatmentofcertaindegenerativeconditionswithoutexistinginstabilitywhenALLthefollowingcriteriaaremet

A ONEofthefollowingconditionsarepresent 1SpinalstenosisOR 2RecurrentspinalstenosisatthesamesegmentOR 3Recurrentdischerniationwithfailedlaminectomy AND B Documentedunremittingpainanddisabilityrefractorytointensiveconservativetherapyfor3monthsIntensive

conservativetherapymusthaveoccurredwithintheprevious12monthsANDmustincludeALLofthefollowing 1Anactiveorganizedandprogressivestrengthandflexibilityprogram NOTEIfapatientisunabletocompletephysicaltherapy(PT)duetoprogressivelyworseningpainanddisability the case will be reviewed on an individual basis by an internal physician reviewer (See Documentation Submission section) AND 2Aminimumoftwosessionsperweekoverthe3-monthperiodAND 3FunctionalassessmentasmeasuredbytheOswestryDisabilityIndex(ODI)demonstratingONEofthe

following a Lessthan30improvementintheODIscorebetweenthefirstandlastphysicaltherapysessionOR b ContinuedODIscoreofgreaterthanorequalto40attheconclusionofphysicaltherapy AND 4Aneducationalcomponentthatdealswithpatientexpectationsandperceptionsaswellastheanatomicsources of back pain AND C Diagnosticimaging(egCTMRI)obtainedwithintheprevious12monthsdemonstratesspinalcordornerveroot

compression

medICAL ANd BeHAVIorAL HeALTH poLICY updATe

September 2015 20

bullLumbarspinalfusionmaybeconsideredMEDICALLYNECESSARYforchronic(presentforatleast6ndash12months)discogenicbackpainwithoutinstabilitywhenALLthefollowingcriteriaaremet

A Documentedunremittingpainanddisabilityrefractorytointensiveconservativetherapyforatleast3months Intensiveconservativetherapymusthaveoccurredwithintheprevious12monthsANDmustincludeALLofthefollowing

1Anti-inflammatorymedicationandanalgesicsunlesscontraindicatedAND 2TherapeuticinjectionsAND 3Anactiveorganizedandprogressivestrengthandflexibilityprogram NOTEIfapatientisunabletocompletephysicaltherapy(PT)duetoprogressivelyworseningpainanddisability

the case will be reviewed on an individual basis by an internal physician reviewer (See Documentation Submission section)

AND 4Aminimumoftwosessionsperweekoverthe3-monthperiodAND 5FunctionalassessmentasmeasuredbytheOswestryDisabilityIndex(ODI)demonstratingONEofthe

following a Lessthan30improvementintheODIscorebetweenthefirstandlastphysicaltherapysessionOR b ContinuedODIscoreofgreaterthanorequalto40attheconclusionofphysicaltherapy 6Aneducationalcomponentthatdealswithpatientexpectationsandperceptionsaswellastheanatomicsources

of back pain AND B Absenceofuntreatedunderlyingcontributorymentalhealthconditionsorpsychosocialissuesincludingbutnot

limited to depression or drug or alcohol abuse AND C Diagnosticimaging(egMRICT)obtainedwithintheprevious12monthsdemonstratesdegenerativediscdisease

limitedto1ndash2disclevelsbull Documentation supporting the medical necessity criteria described in the policy must be included in the prior authorizationInadditionthefollowingdocumentationmustalsobesubmitted

1 Written report from a radiologist describing findings from spinal diagnostic imaging studies 2 Intensiveconservativetherapy bull DocumentationfromthephysicaltherapistmustincludeOswestryDisabilityIndex(ODI)scores bull Ifapatientisunabletocompletephysicaltherapy(PT)duetoprogressivelyworseningsymptomsofpainand

disability the case will be reviewed on an individual basis by an internal physician reviewer Documentation must be submitted from the physical therapist describing the patientrsquos inability to complete PT

3 Forpatientswithchronicdiscogenicbackpainwithoutinstability(policysectionIV)documentationregardingthe absence of untreated underlying contributory mental health conditions or psychosocial issues including but not limited to depression or drug or alcohol abuse must be submitted by the patientrsquos primary care physician or a Mental Health Professional The Mental Health Professional must meet the Minnesota Department of Human ServicesqualificationsassetforthinMinnStatsect245462subd18(2013)andMinnStatsect2454871subd27(2013)

medICAL ANd BeHAVIorAL HeALTH poLICY updATe

September 2015 21

Policies inactivatedNone There was no Medical and behavioral Health Policy Activity for July 2015

Policies reviewed with no changes in May 2015 and June 2015

Acupuncture

Artificial Intervertebral Disc Cervical Spine

Belimumab

Cardiovascular Disease Risk Assessment and Management Laboratory Evaluation of Non-Traditional Lipid and

Nonlipid Biomarkers

Cellular Immunotherapy for Prostate Cancer

Chelation Therapy

Computerized Dynamic Posturography

Continuous and Intermittent Glucose Monitoring of Interstitial Fluid

Cytochrome P450 Genotyping

Digital Breast Tomosynthesis

Electrocardiographic (ECG) Body Surface Mapping

Endoscopic Radiofrequency Ablation or Cryoablation for Barrettrsquos Esophagus

Epidermal Growth-Factor Receptor (EGFR) Analysis for Non-small Cell Lung Cancer

HP Acthar Gel (Repository Corticotropin)

Hematopoietic Stem-Cell Transplantation for Non-Hodgkin Lymphomas

Hematopoietic Stem-Cell Transplantation for Primary Amyloidosis

Hematopoietic Stem-Cell Transplantation for Waldenstrom Macroglobulinemia

Image-Guided Minimally Invasive Lumbar Decompression for Spinal Stenosis

Liposuction

Lung Cancer Screening Using Computed Tomography (CT)

Mastopexy

Microprocessor-Controlled Prosthesis for the Lower Limb

Myoelectric Prosthesis for the Upper Limb

Organ Transplantation

Percutaneous and Endoscopic Techniques for Disc Decompression

September 2015 22

Medical and Behavioral Health Policy Update

NetworkManagementR317 POBox64560 StPaulMN55164-0560

Provider Press is posted on our website quarterly for business office staff of multi-specialty clinics physicians public health agencies DME providers chiropractors podiatrists physical therapists occupational therapists optometrists and behavioral health professionalsproviders Direct inquiries to

NetworkManagementR317Editor Holly BatchelderPOBox64560StPaulMN55164-0560(651)662-2014tollfree1-800-382-2000ext22014

AdvisorsFaithBauerCPCCPC-HCPC-PJeannieHarpCPCJanineUtechtCPCCPC-HCPC-PCPMAandKarenKiemeleMPH

Information in Provider Press is a general outline Provider and member contracts determine benefits

CPT-4codesnotedareAMAcopyrighted

0915

Peripheral Nerve Stimulation of the Trunk or Limbs for Treatment of Pain

Rhinomanometry and AcousticOptical Rhinometry

Sleep Studies Polysomnograms in Children and Adolescents

Spinal Unloading Devices Patient-Operated

Stem-Cell Therapy for Peripheral Arterial Disease

Subcutaneous Hormone Pellets

Surgical Interruption of Pelvic Nerve Pathways for Primary and Secondary Dysmenorrhea

Systems Pathology Testing for Predicting Risk of Recurrence in Prostate Cancer

Urine Drug Testing for Substance Abuse Treatment and Chronic Pain Management

Wireless Gastric Motility Monitoring

September 2015 17

medICAL ANd BeHAVIorAL HeALTH poLICY updATe

a AcyanoticCHDwhentheinfantisreceivingmedicationtocontrolcongestiveheartfailureandwillrequireacardiacsurgicalprocedureOR

b CyanoticCHDwhenpalivizumabisrecommendedafterconsultationwithapediatriccardiologistOR c Diagnosis of moderate to severe pulmonary hypertension OR 2Childislt24monthsofageattheonsetofRSVseasonANDmeetsONEofthefollowing a ChildundergoescardiactransplantationduringtheRSVseasonOR b ChildisreceivingRSVprophylaxisandcontinuestorequireprophylaxisafterasurgicalprocedureinvolving cardiac bypass or at the conclusion of extracorporeal membrane oxygenation C AnatomicPulmonaryAbnormalitiesORNeuromuscularDisorder(egcerebralpalsymusculardystrophy) 1 Infant is le12monthsofageattheonsetofRSVseasonAND 2Infanthasimpairedabilitytoclearsecretionsfromtheupperairway D Cystic Fibrosis 1 Infant is le12monthsofageattheonsetofRSVseasonwithevidenceofCLDandormalnutrition E Immunocompromised Status 1Childislt24monthsofageattheonsetofRSVseasonAND 2Childisprofoundlyimmunocompromised(egduetosolidorgantransplantationhematopoieticstem-cell

transplantation or chemotherapy) F Prematurity without CLD or CHD 1Infantwasbornatlt29weeks0daysgestation(ie28weeks6daysorless)AND 2Infantislt12monthsofageattheonsetofRSVseasonbull SECONDRSVSEASON Theuseofimmuneprophylaxis(egpalivizumab[Synagis])forRSVforthepatientrsquossecondyearoftreatmentmaybeconsideredMEDICALLYNECESSARYwhenthefollowingcriteriaaremet

A CLDofPrematurity 1Childwasbornatlt32weeks0daysgestationAND 2Childis12monthstolt24monthsofageattheonsetofthesecondRSVseasonAND 3ChildcontinuestorequireatleastONEofthefollowingwithinsix(6)monthsofthestartofthesecondRSV season a SupplementaloxygenOR b ChronicsystemiccorticosteroidtherapyOR c DiuretictherapyOR d Bronchodilator therapy B Cystic Fibrosis 1Childis12monthstolt24monthsofageattheonsetofthesecondRSVseasonwithevidenceofCLDandor malnutritionbull AdministrationofRSVProphylaxis A Whentheappropriatecriteriaabovearemetamaximumoffive(5)monthlydosesofpalivizumab(Synagisreg)will

becoveredperRSVseason(definedasNovember1stthroughMarch31st) B Thefirstmonthlydoseofpalivizumab(Synagisreg)willbeapprovedforcoverageofadministrationonorafter

November 1st C Apost-operativedoseofpalivizumab(Synagisreg)willbecoveredforchildrenlt24monthswhoarereceiving

RSVprophylaxisandcontinuetorequireprophylaxisafterasurgicalprocedureinvolvingcardiacbypassorattheconclusion of extracorporeal membrane oxygenation

September 2015 18

Chromosomal Microarray Analysis and Next Generation Sequencing to Evaluate Patients with Developmental DelayIntellectual Disability or Autism Spectrum Disorders bullChromosomalmicroarrayanalysismaybeconsideredMEDICALLYNECESSARYfordiagnosingageneticabnormalityin

children with apparent nonsyndromic cognitive developmental delayintellectual disability (DDID) or autism spectrum disorder(ASD)accordingtoacceptedDiagnosticandStatisticalManualofMentalDisorders(DSM)criteriawhenALLof the following conditions are met

AAnyindicatedbiochemicaltestsformetabolicdiseasehavebeenperformedandresultsarenon-diagnosticAND BFMR1geneanalysis(forFragileX)whenclinicallyindicatedisnegativeAND CASDorapparentnon-syndromicDDIDinachildwithmultipleanomaliesnotspecifictoawell-delineatedgenetic

syndromeasdefinedaboveAND DTheresultsofthegenetictestinghavethepotentialtoimpacttheclinicalmanagementofthepatientAND E Testing is requested after the parent(s) andor legal guardian(s) have been engaged in face-to-face genetic

counseling with a healthcare professional who has the appropriate genetics training and experience and is independent of the laboratory performing the test

bullChromosomalmicroarrayanalysisisconsideredINVESTIGATIVEforthefollowingduetoalackofclinicalevidencedemonstrating its impact on improved health outcomes

A Allothercasesofsuspectedgeneticabnormalityinchildrenwithdevelopmentaldelayintellectualdisabilityorautism spectrum disorder

B To confirm the diagnosis of a disorder or syndrome that is routinely diagnosed based on clinical evaluation alone Theseincludebutarenotlimitedtoattentiondeficithyperactivitydisorder(ADHD)learningdisabilitygrowthretardation or speech delay

C Population screeningbullPaneltestingusingnext-generationsequencingisconsideredINVESTIGATIVEinallcasesofsuspectedgeneticabnormalityinchildrenwithDDIDorASD

Spinal Fusion Lumbar bullLumbarspinalfusionmaybeconsideredMEDICALLYNECESSARYforanyofthefollowingindicationswhenacorrelativeabnormalityisconfirmedbyimagingstudies(egx-rayCTMRI)

A Epiduralcompressionorvertebraldestructionfromatumor B Neural compression after spinal fracture C Instability after debridement for infection D Spinal infections (eg osteomyelitis spinal tuberculosis) E Severe or rapidly progressive neurological deficit (eg motor loss sensory loss neurogenic claudication or cauda

equina syndrome) F IdiopathicscoliosiswhenEITHERofthefollowingcriteriaaremet 1ScolioticcurvewithaCobbanglegt45degreesinchildrenwhoareskeletallyimmatureOR 2ScolioticcurvewithaCobbanglegt50degreesresultinginfunctionalimpairmentinskeletallymatureindividuals G Symptomatic pseudarthrosisbullLumbarspinalfusionaloneorinconjunctionwithaprimarydecompressionsurgerymaybeconsideredMEDICALLYNECESSARYfortreatmentofdegenerativeconditionswithspinalinstabilitywhenALLthefollowingcriteriaaremet

A ONEofthefollowingconditionsarepresent 1Post-laminectomyinstabilityOR 2DegenerativescoliosisorkyphosisOR 3SpondylolisthesisOR

medICAL ANd BeHAVIorAL HeALTH poLICY updATe

September 2015 19

4 Spinal stenosis with spondylolisthesis AND B Documentedunremittingpainanddisabilityrefractorytointensiveconservativetherapyfor3monthsIntensive

conservativetherapymusthaveoccurredwithintheprevious12monthsANDmustincludeALLofthefollowing 1Anactiveorganizedandprogressivestrengthandflexibilityprogram NOTEIfapatientisunabletocompletephysicaltherapy(PT)duetoprogressivelyworseningpainanddisability the case will be reviewed on an individual basis by an internal physician reviewer (See Documentation Submission section)AND 2Aminimumoftwosessionsperweekoverthe3-monthperiodAND 3FunctionalassessmentasmeasuredbytheOswestryDisabilityIndex(ODI)demonstratingONEofthe following a Lessthan30improvementintheODIscorebetweenthefirstandlastphysicaltherapysessionOR b ContinuedODIscoreofgreaterthanorequalto40attheconclusionofphysicaltherapy AND 4Aneducationalcomponentthatdealswithpatientexpectationsandperceptionsaswellastheanatomicsources of back pain AND C Diagnosticimaging(egx-rayCTMRI)obtainedwithintheprevious12monthsdemonstratesspinalinstability(gt

3mmoftranslationandor10degreesormoreofangulationofonevertebracomparedtotheadjacentvertebrainaspinal motion segment)

bullLumbarspinalfusioninconjunctionwithadecompressionsurgerymaybeconsideredMEDICALLYNECESSARYinthetreatmentofcertaindegenerativeconditionswithoutexistinginstabilitywhenALLthefollowingcriteriaaremet

A ONEofthefollowingconditionsarepresent 1SpinalstenosisOR 2RecurrentspinalstenosisatthesamesegmentOR 3Recurrentdischerniationwithfailedlaminectomy AND B Documentedunremittingpainanddisabilityrefractorytointensiveconservativetherapyfor3monthsIntensive

conservativetherapymusthaveoccurredwithintheprevious12monthsANDmustincludeALLofthefollowing 1Anactiveorganizedandprogressivestrengthandflexibilityprogram NOTEIfapatientisunabletocompletephysicaltherapy(PT)duetoprogressivelyworseningpainanddisability the case will be reviewed on an individual basis by an internal physician reviewer (See Documentation Submission section) AND 2Aminimumoftwosessionsperweekoverthe3-monthperiodAND 3FunctionalassessmentasmeasuredbytheOswestryDisabilityIndex(ODI)demonstratingONEofthe

following a Lessthan30improvementintheODIscorebetweenthefirstandlastphysicaltherapysessionOR b ContinuedODIscoreofgreaterthanorequalto40attheconclusionofphysicaltherapy AND 4Aneducationalcomponentthatdealswithpatientexpectationsandperceptionsaswellastheanatomicsources of back pain AND C Diagnosticimaging(egCTMRI)obtainedwithintheprevious12monthsdemonstratesspinalcordornerveroot

compression

medICAL ANd BeHAVIorAL HeALTH poLICY updATe

September 2015 20

bullLumbarspinalfusionmaybeconsideredMEDICALLYNECESSARYforchronic(presentforatleast6ndash12months)discogenicbackpainwithoutinstabilitywhenALLthefollowingcriteriaaremet

A Documentedunremittingpainanddisabilityrefractorytointensiveconservativetherapyforatleast3months Intensiveconservativetherapymusthaveoccurredwithintheprevious12monthsANDmustincludeALLofthefollowing

1Anti-inflammatorymedicationandanalgesicsunlesscontraindicatedAND 2TherapeuticinjectionsAND 3Anactiveorganizedandprogressivestrengthandflexibilityprogram NOTEIfapatientisunabletocompletephysicaltherapy(PT)duetoprogressivelyworseningpainanddisability

the case will be reviewed on an individual basis by an internal physician reviewer (See Documentation Submission section)

AND 4Aminimumoftwosessionsperweekoverthe3-monthperiodAND 5FunctionalassessmentasmeasuredbytheOswestryDisabilityIndex(ODI)demonstratingONEofthe

following a Lessthan30improvementintheODIscorebetweenthefirstandlastphysicaltherapysessionOR b ContinuedODIscoreofgreaterthanorequalto40attheconclusionofphysicaltherapy 6Aneducationalcomponentthatdealswithpatientexpectationsandperceptionsaswellastheanatomicsources

of back pain AND B Absenceofuntreatedunderlyingcontributorymentalhealthconditionsorpsychosocialissuesincludingbutnot

limited to depression or drug or alcohol abuse AND C Diagnosticimaging(egMRICT)obtainedwithintheprevious12monthsdemonstratesdegenerativediscdisease

limitedto1ndash2disclevelsbull Documentation supporting the medical necessity criteria described in the policy must be included in the prior authorizationInadditionthefollowingdocumentationmustalsobesubmitted

1 Written report from a radiologist describing findings from spinal diagnostic imaging studies 2 Intensiveconservativetherapy bull DocumentationfromthephysicaltherapistmustincludeOswestryDisabilityIndex(ODI)scores bull Ifapatientisunabletocompletephysicaltherapy(PT)duetoprogressivelyworseningsymptomsofpainand

disability the case will be reviewed on an individual basis by an internal physician reviewer Documentation must be submitted from the physical therapist describing the patientrsquos inability to complete PT

3 Forpatientswithchronicdiscogenicbackpainwithoutinstability(policysectionIV)documentationregardingthe absence of untreated underlying contributory mental health conditions or psychosocial issues including but not limited to depression or drug or alcohol abuse must be submitted by the patientrsquos primary care physician or a Mental Health Professional The Mental Health Professional must meet the Minnesota Department of Human ServicesqualificationsassetforthinMinnStatsect245462subd18(2013)andMinnStatsect2454871subd27(2013)

medICAL ANd BeHAVIorAL HeALTH poLICY updATe

September 2015 21

Policies inactivatedNone There was no Medical and behavioral Health Policy Activity for July 2015

Policies reviewed with no changes in May 2015 and June 2015

Acupuncture

Artificial Intervertebral Disc Cervical Spine

Belimumab

Cardiovascular Disease Risk Assessment and Management Laboratory Evaluation of Non-Traditional Lipid and

Nonlipid Biomarkers

Cellular Immunotherapy for Prostate Cancer

Chelation Therapy

Computerized Dynamic Posturography

Continuous and Intermittent Glucose Monitoring of Interstitial Fluid

Cytochrome P450 Genotyping

Digital Breast Tomosynthesis

Electrocardiographic (ECG) Body Surface Mapping

Endoscopic Radiofrequency Ablation or Cryoablation for Barrettrsquos Esophagus

Epidermal Growth-Factor Receptor (EGFR) Analysis for Non-small Cell Lung Cancer

HP Acthar Gel (Repository Corticotropin)

Hematopoietic Stem-Cell Transplantation for Non-Hodgkin Lymphomas

Hematopoietic Stem-Cell Transplantation for Primary Amyloidosis

Hematopoietic Stem-Cell Transplantation for Waldenstrom Macroglobulinemia

Image-Guided Minimally Invasive Lumbar Decompression for Spinal Stenosis

Liposuction

Lung Cancer Screening Using Computed Tomography (CT)

Mastopexy

Microprocessor-Controlled Prosthesis for the Lower Limb

Myoelectric Prosthesis for the Upper Limb

Organ Transplantation

Percutaneous and Endoscopic Techniques for Disc Decompression

September 2015 22

Medical and Behavioral Health Policy Update

NetworkManagementR317 POBox64560 StPaulMN55164-0560

Provider Press is posted on our website quarterly for business office staff of multi-specialty clinics physicians public health agencies DME providers chiropractors podiatrists physical therapists occupational therapists optometrists and behavioral health professionalsproviders Direct inquiries to

NetworkManagementR317Editor Holly BatchelderPOBox64560StPaulMN55164-0560(651)662-2014tollfree1-800-382-2000ext22014

AdvisorsFaithBauerCPCCPC-HCPC-PJeannieHarpCPCJanineUtechtCPCCPC-HCPC-PCPMAandKarenKiemeleMPH

Information in Provider Press is a general outline Provider and member contracts determine benefits

CPT-4codesnotedareAMAcopyrighted

0915

Peripheral Nerve Stimulation of the Trunk or Limbs for Treatment of Pain

Rhinomanometry and AcousticOptical Rhinometry

Sleep Studies Polysomnograms in Children and Adolescents

Spinal Unloading Devices Patient-Operated

Stem-Cell Therapy for Peripheral Arterial Disease

Subcutaneous Hormone Pellets

Surgical Interruption of Pelvic Nerve Pathways for Primary and Secondary Dysmenorrhea

Systems Pathology Testing for Predicting Risk of Recurrence in Prostate Cancer

Urine Drug Testing for Substance Abuse Treatment and Chronic Pain Management

Wireless Gastric Motility Monitoring

September 2015 18

Chromosomal Microarray Analysis and Next Generation Sequencing to Evaluate Patients with Developmental DelayIntellectual Disability or Autism Spectrum Disorders bullChromosomalmicroarrayanalysismaybeconsideredMEDICALLYNECESSARYfordiagnosingageneticabnormalityin

children with apparent nonsyndromic cognitive developmental delayintellectual disability (DDID) or autism spectrum disorder(ASD)accordingtoacceptedDiagnosticandStatisticalManualofMentalDisorders(DSM)criteriawhenALLof the following conditions are met

AAnyindicatedbiochemicaltestsformetabolicdiseasehavebeenperformedandresultsarenon-diagnosticAND BFMR1geneanalysis(forFragileX)whenclinicallyindicatedisnegativeAND CASDorapparentnon-syndromicDDIDinachildwithmultipleanomaliesnotspecifictoawell-delineatedgenetic

syndromeasdefinedaboveAND DTheresultsofthegenetictestinghavethepotentialtoimpacttheclinicalmanagementofthepatientAND E Testing is requested after the parent(s) andor legal guardian(s) have been engaged in face-to-face genetic

counseling with a healthcare professional who has the appropriate genetics training and experience and is independent of the laboratory performing the test

bullChromosomalmicroarrayanalysisisconsideredINVESTIGATIVEforthefollowingduetoalackofclinicalevidencedemonstrating its impact on improved health outcomes

A Allothercasesofsuspectedgeneticabnormalityinchildrenwithdevelopmentaldelayintellectualdisabilityorautism spectrum disorder

B To confirm the diagnosis of a disorder or syndrome that is routinely diagnosed based on clinical evaluation alone Theseincludebutarenotlimitedtoattentiondeficithyperactivitydisorder(ADHD)learningdisabilitygrowthretardation or speech delay

C Population screeningbullPaneltestingusingnext-generationsequencingisconsideredINVESTIGATIVEinallcasesofsuspectedgeneticabnormalityinchildrenwithDDIDorASD

Spinal Fusion Lumbar bullLumbarspinalfusionmaybeconsideredMEDICALLYNECESSARYforanyofthefollowingindicationswhenacorrelativeabnormalityisconfirmedbyimagingstudies(egx-rayCTMRI)

A Epiduralcompressionorvertebraldestructionfromatumor B Neural compression after spinal fracture C Instability after debridement for infection D Spinal infections (eg osteomyelitis spinal tuberculosis) E Severe or rapidly progressive neurological deficit (eg motor loss sensory loss neurogenic claudication or cauda

equina syndrome) F IdiopathicscoliosiswhenEITHERofthefollowingcriteriaaremet 1ScolioticcurvewithaCobbanglegt45degreesinchildrenwhoareskeletallyimmatureOR 2ScolioticcurvewithaCobbanglegt50degreesresultinginfunctionalimpairmentinskeletallymatureindividuals G Symptomatic pseudarthrosisbullLumbarspinalfusionaloneorinconjunctionwithaprimarydecompressionsurgerymaybeconsideredMEDICALLYNECESSARYfortreatmentofdegenerativeconditionswithspinalinstabilitywhenALLthefollowingcriteriaaremet

A ONEofthefollowingconditionsarepresent 1Post-laminectomyinstabilityOR 2DegenerativescoliosisorkyphosisOR 3SpondylolisthesisOR

medICAL ANd BeHAVIorAL HeALTH poLICY updATe

September 2015 19

4 Spinal stenosis with spondylolisthesis AND B Documentedunremittingpainanddisabilityrefractorytointensiveconservativetherapyfor3monthsIntensive

conservativetherapymusthaveoccurredwithintheprevious12monthsANDmustincludeALLofthefollowing 1Anactiveorganizedandprogressivestrengthandflexibilityprogram NOTEIfapatientisunabletocompletephysicaltherapy(PT)duetoprogressivelyworseningpainanddisability the case will be reviewed on an individual basis by an internal physician reviewer (See Documentation Submission section)AND 2Aminimumoftwosessionsperweekoverthe3-monthperiodAND 3FunctionalassessmentasmeasuredbytheOswestryDisabilityIndex(ODI)demonstratingONEofthe following a Lessthan30improvementintheODIscorebetweenthefirstandlastphysicaltherapysessionOR b ContinuedODIscoreofgreaterthanorequalto40attheconclusionofphysicaltherapy AND 4Aneducationalcomponentthatdealswithpatientexpectationsandperceptionsaswellastheanatomicsources of back pain AND C Diagnosticimaging(egx-rayCTMRI)obtainedwithintheprevious12monthsdemonstratesspinalinstability(gt

3mmoftranslationandor10degreesormoreofangulationofonevertebracomparedtotheadjacentvertebrainaspinal motion segment)

bullLumbarspinalfusioninconjunctionwithadecompressionsurgerymaybeconsideredMEDICALLYNECESSARYinthetreatmentofcertaindegenerativeconditionswithoutexistinginstabilitywhenALLthefollowingcriteriaaremet

A ONEofthefollowingconditionsarepresent 1SpinalstenosisOR 2RecurrentspinalstenosisatthesamesegmentOR 3Recurrentdischerniationwithfailedlaminectomy AND B Documentedunremittingpainanddisabilityrefractorytointensiveconservativetherapyfor3monthsIntensive

conservativetherapymusthaveoccurredwithintheprevious12monthsANDmustincludeALLofthefollowing 1Anactiveorganizedandprogressivestrengthandflexibilityprogram NOTEIfapatientisunabletocompletephysicaltherapy(PT)duetoprogressivelyworseningpainanddisability the case will be reviewed on an individual basis by an internal physician reviewer (See Documentation Submission section) AND 2Aminimumoftwosessionsperweekoverthe3-monthperiodAND 3FunctionalassessmentasmeasuredbytheOswestryDisabilityIndex(ODI)demonstratingONEofthe

following a Lessthan30improvementintheODIscorebetweenthefirstandlastphysicaltherapysessionOR b ContinuedODIscoreofgreaterthanorequalto40attheconclusionofphysicaltherapy AND 4Aneducationalcomponentthatdealswithpatientexpectationsandperceptionsaswellastheanatomicsources of back pain AND C Diagnosticimaging(egCTMRI)obtainedwithintheprevious12monthsdemonstratesspinalcordornerveroot

compression

medICAL ANd BeHAVIorAL HeALTH poLICY updATe

September 2015 20

bullLumbarspinalfusionmaybeconsideredMEDICALLYNECESSARYforchronic(presentforatleast6ndash12months)discogenicbackpainwithoutinstabilitywhenALLthefollowingcriteriaaremet

A Documentedunremittingpainanddisabilityrefractorytointensiveconservativetherapyforatleast3months Intensiveconservativetherapymusthaveoccurredwithintheprevious12monthsANDmustincludeALLofthefollowing

1Anti-inflammatorymedicationandanalgesicsunlesscontraindicatedAND 2TherapeuticinjectionsAND 3Anactiveorganizedandprogressivestrengthandflexibilityprogram NOTEIfapatientisunabletocompletephysicaltherapy(PT)duetoprogressivelyworseningpainanddisability

the case will be reviewed on an individual basis by an internal physician reviewer (See Documentation Submission section)

AND 4Aminimumoftwosessionsperweekoverthe3-monthperiodAND 5FunctionalassessmentasmeasuredbytheOswestryDisabilityIndex(ODI)demonstratingONEofthe

following a Lessthan30improvementintheODIscorebetweenthefirstandlastphysicaltherapysessionOR b ContinuedODIscoreofgreaterthanorequalto40attheconclusionofphysicaltherapy 6Aneducationalcomponentthatdealswithpatientexpectationsandperceptionsaswellastheanatomicsources

of back pain AND B Absenceofuntreatedunderlyingcontributorymentalhealthconditionsorpsychosocialissuesincludingbutnot

limited to depression or drug or alcohol abuse AND C Diagnosticimaging(egMRICT)obtainedwithintheprevious12monthsdemonstratesdegenerativediscdisease

limitedto1ndash2disclevelsbull Documentation supporting the medical necessity criteria described in the policy must be included in the prior authorizationInadditionthefollowingdocumentationmustalsobesubmitted

1 Written report from a radiologist describing findings from spinal diagnostic imaging studies 2 Intensiveconservativetherapy bull DocumentationfromthephysicaltherapistmustincludeOswestryDisabilityIndex(ODI)scores bull Ifapatientisunabletocompletephysicaltherapy(PT)duetoprogressivelyworseningsymptomsofpainand

disability the case will be reviewed on an individual basis by an internal physician reviewer Documentation must be submitted from the physical therapist describing the patientrsquos inability to complete PT

3 Forpatientswithchronicdiscogenicbackpainwithoutinstability(policysectionIV)documentationregardingthe absence of untreated underlying contributory mental health conditions or psychosocial issues including but not limited to depression or drug or alcohol abuse must be submitted by the patientrsquos primary care physician or a Mental Health Professional The Mental Health Professional must meet the Minnesota Department of Human ServicesqualificationsassetforthinMinnStatsect245462subd18(2013)andMinnStatsect2454871subd27(2013)

medICAL ANd BeHAVIorAL HeALTH poLICY updATe

September 2015 21

Policies inactivatedNone There was no Medical and behavioral Health Policy Activity for July 2015

Policies reviewed with no changes in May 2015 and June 2015

Acupuncture

Artificial Intervertebral Disc Cervical Spine

Belimumab

Cardiovascular Disease Risk Assessment and Management Laboratory Evaluation of Non-Traditional Lipid and

Nonlipid Biomarkers

Cellular Immunotherapy for Prostate Cancer

Chelation Therapy

Computerized Dynamic Posturography

Continuous and Intermittent Glucose Monitoring of Interstitial Fluid

Cytochrome P450 Genotyping

Digital Breast Tomosynthesis

Electrocardiographic (ECG) Body Surface Mapping

Endoscopic Radiofrequency Ablation or Cryoablation for Barrettrsquos Esophagus

Epidermal Growth-Factor Receptor (EGFR) Analysis for Non-small Cell Lung Cancer

HP Acthar Gel (Repository Corticotropin)

Hematopoietic Stem-Cell Transplantation for Non-Hodgkin Lymphomas

Hematopoietic Stem-Cell Transplantation for Primary Amyloidosis

Hematopoietic Stem-Cell Transplantation for Waldenstrom Macroglobulinemia

Image-Guided Minimally Invasive Lumbar Decompression for Spinal Stenosis

Liposuction

Lung Cancer Screening Using Computed Tomography (CT)

Mastopexy

Microprocessor-Controlled Prosthesis for the Lower Limb

Myoelectric Prosthesis for the Upper Limb

Organ Transplantation

Percutaneous and Endoscopic Techniques for Disc Decompression

September 2015 22

Medical and Behavioral Health Policy Update

NetworkManagementR317 POBox64560 StPaulMN55164-0560

Provider Press is posted on our website quarterly for business office staff of multi-specialty clinics physicians public health agencies DME providers chiropractors podiatrists physical therapists occupational therapists optometrists and behavioral health professionalsproviders Direct inquiries to

NetworkManagementR317Editor Holly BatchelderPOBox64560StPaulMN55164-0560(651)662-2014tollfree1-800-382-2000ext22014

AdvisorsFaithBauerCPCCPC-HCPC-PJeannieHarpCPCJanineUtechtCPCCPC-HCPC-PCPMAandKarenKiemeleMPH

Information in Provider Press is a general outline Provider and member contracts determine benefits

CPT-4codesnotedareAMAcopyrighted

0915

Peripheral Nerve Stimulation of the Trunk or Limbs for Treatment of Pain

Rhinomanometry and AcousticOptical Rhinometry

Sleep Studies Polysomnograms in Children and Adolescents

Spinal Unloading Devices Patient-Operated

Stem-Cell Therapy for Peripheral Arterial Disease

Subcutaneous Hormone Pellets

Surgical Interruption of Pelvic Nerve Pathways for Primary and Secondary Dysmenorrhea

Systems Pathology Testing for Predicting Risk of Recurrence in Prostate Cancer

Urine Drug Testing for Substance Abuse Treatment and Chronic Pain Management

Wireless Gastric Motility Monitoring

September 2015 19

4 Spinal stenosis with spondylolisthesis AND B Documentedunremittingpainanddisabilityrefractorytointensiveconservativetherapyfor3monthsIntensive

conservativetherapymusthaveoccurredwithintheprevious12monthsANDmustincludeALLofthefollowing 1Anactiveorganizedandprogressivestrengthandflexibilityprogram NOTEIfapatientisunabletocompletephysicaltherapy(PT)duetoprogressivelyworseningpainanddisability the case will be reviewed on an individual basis by an internal physician reviewer (See Documentation Submission section)AND 2Aminimumoftwosessionsperweekoverthe3-monthperiodAND 3FunctionalassessmentasmeasuredbytheOswestryDisabilityIndex(ODI)demonstratingONEofthe following a Lessthan30improvementintheODIscorebetweenthefirstandlastphysicaltherapysessionOR b ContinuedODIscoreofgreaterthanorequalto40attheconclusionofphysicaltherapy AND 4Aneducationalcomponentthatdealswithpatientexpectationsandperceptionsaswellastheanatomicsources of back pain AND C Diagnosticimaging(egx-rayCTMRI)obtainedwithintheprevious12monthsdemonstratesspinalinstability(gt

3mmoftranslationandor10degreesormoreofangulationofonevertebracomparedtotheadjacentvertebrainaspinal motion segment)

bullLumbarspinalfusioninconjunctionwithadecompressionsurgerymaybeconsideredMEDICALLYNECESSARYinthetreatmentofcertaindegenerativeconditionswithoutexistinginstabilitywhenALLthefollowingcriteriaaremet

A ONEofthefollowingconditionsarepresent 1SpinalstenosisOR 2RecurrentspinalstenosisatthesamesegmentOR 3Recurrentdischerniationwithfailedlaminectomy AND B Documentedunremittingpainanddisabilityrefractorytointensiveconservativetherapyfor3monthsIntensive

conservativetherapymusthaveoccurredwithintheprevious12monthsANDmustincludeALLofthefollowing 1Anactiveorganizedandprogressivestrengthandflexibilityprogram NOTEIfapatientisunabletocompletephysicaltherapy(PT)duetoprogressivelyworseningpainanddisability the case will be reviewed on an individual basis by an internal physician reviewer (See Documentation Submission section) AND 2Aminimumoftwosessionsperweekoverthe3-monthperiodAND 3FunctionalassessmentasmeasuredbytheOswestryDisabilityIndex(ODI)demonstratingONEofthe

following a Lessthan30improvementintheODIscorebetweenthefirstandlastphysicaltherapysessionOR b ContinuedODIscoreofgreaterthanorequalto40attheconclusionofphysicaltherapy AND 4Aneducationalcomponentthatdealswithpatientexpectationsandperceptionsaswellastheanatomicsources of back pain AND C Diagnosticimaging(egCTMRI)obtainedwithintheprevious12monthsdemonstratesspinalcordornerveroot

compression

medICAL ANd BeHAVIorAL HeALTH poLICY updATe

September 2015 20

bullLumbarspinalfusionmaybeconsideredMEDICALLYNECESSARYforchronic(presentforatleast6ndash12months)discogenicbackpainwithoutinstabilitywhenALLthefollowingcriteriaaremet

A Documentedunremittingpainanddisabilityrefractorytointensiveconservativetherapyforatleast3months Intensiveconservativetherapymusthaveoccurredwithintheprevious12monthsANDmustincludeALLofthefollowing

1Anti-inflammatorymedicationandanalgesicsunlesscontraindicatedAND 2TherapeuticinjectionsAND 3Anactiveorganizedandprogressivestrengthandflexibilityprogram NOTEIfapatientisunabletocompletephysicaltherapy(PT)duetoprogressivelyworseningpainanddisability

the case will be reviewed on an individual basis by an internal physician reviewer (See Documentation Submission section)

AND 4Aminimumoftwosessionsperweekoverthe3-monthperiodAND 5FunctionalassessmentasmeasuredbytheOswestryDisabilityIndex(ODI)demonstratingONEofthe

following a Lessthan30improvementintheODIscorebetweenthefirstandlastphysicaltherapysessionOR b ContinuedODIscoreofgreaterthanorequalto40attheconclusionofphysicaltherapy 6Aneducationalcomponentthatdealswithpatientexpectationsandperceptionsaswellastheanatomicsources

of back pain AND B Absenceofuntreatedunderlyingcontributorymentalhealthconditionsorpsychosocialissuesincludingbutnot

limited to depression or drug or alcohol abuse AND C Diagnosticimaging(egMRICT)obtainedwithintheprevious12monthsdemonstratesdegenerativediscdisease

limitedto1ndash2disclevelsbull Documentation supporting the medical necessity criteria described in the policy must be included in the prior authorizationInadditionthefollowingdocumentationmustalsobesubmitted

1 Written report from a radiologist describing findings from spinal diagnostic imaging studies 2 Intensiveconservativetherapy bull DocumentationfromthephysicaltherapistmustincludeOswestryDisabilityIndex(ODI)scores bull Ifapatientisunabletocompletephysicaltherapy(PT)duetoprogressivelyworseningsymptomsofpainand

disability the case will be reviewed on an individual basis by an internal physician reviewer Documentation must be submitted from the physical therapist describing the patientrsquos inability to complete PT

3 Forpatientswithchronicdiscogenicbackpainwithoutinstability(policysectionIV)documentationregardingthe absence of untreated underlying contributory mental health conditions or psychosocial issues including but not limited to depression or drug or alcohol abuse must be submitted by the patientrsquos primary care physician or a Mental Health Professional The Mental Health Professional must meet the Minnesota Department of Human ServicesqualificationsassetforthinMinnStatsect245462subd18(2013)andMinnStatsect2454871subd27(2013)

medICAL ANd BeHAVIorAL HeALTH poLICY updATe

September 2015 21

Policies inactivatedNone There was no Medical and behavioral Health Policy Activity for July 2015

Policies reviewed with no changes in May 2015 and June 2015

Acupuncture

Artificial Intervertebral Disc Cervical Spine

Belimumab

Cardiovascular Disease Risk Assessment and Management Laboratory Evaluation of Non-Traditional Lipid and

Nonlipid Biomarkers

Cellular Immunotherapy for Prostate Cancer

Chelation Therapy

Computerized Dynamic Posturography

Continuous and Intermittent Glucose Monitoring of Interstitial Fluid

Cytochrome P450 Genotyping

Digital Breast Tomosynthesis

Electrocardiographic (ECG) Body Surface Mapping

Endoscopic Radiofrequency Ablation or Cryoablation for Barrettrsquos Esophagus

Epidermal Growth-Factor Receptor (EGFR) Analysis for Non-small Cell Lung Cancer

HP Acthar Gel (Repository Corticotropin)

Hematopoietic Stem-Cell Transplantation for Non-Hodgkin Lymphomas

Hematopoietic Stem-Cell Transplantation for Primary Amyloidosis

Hematopoietic Stem-Cell Transplantation for Waldenstrom Macroglobulinemia

Image-Guided Minimally Invasive Lumbar Decompression for Spinal Stenosis

Liposuction

Lung Cancer Screening Using Computed Tomography (CT)

Mastopexy

Microprocessor-Controlled Prosthesis for the Lower Limb

Myoelectric Prosthesis for the Upper Limb

Organ Transplantation

Percutaneous and Endoscopic Techniques for Disc Decompression

September 2015 22

Medical and Behavioral Health Policy Update

NetworkManagementR317 POBox64560 StPaulMN55164-0560

Provider Press is posted on our website quarterly for business office staff of multi-specialty clinics physicians public health agencies DME providers chiropractors podiatrists physical therapists occupational therapists optometrists and behavioral health professionalsproviders Direct inquiries to

NetworkManagementR317Editor Holly BatchelderPOBox64560StPaulMN55164-0560(651)662-2014tollfree1-800-382-2000ext22014

AdvisorsFaithBauerCPCCPC-HCPC-PJeannieHarpCPCJanineUtechtCPCCPC-HCPC-PCPMAandKarenKiemeleMPH

Information in Provider Press is a general outline Provider and member contracts determine benefits

CPT-4codesnotedareAMAcopyrighted

0915

Peripheral Nerve Stimulation of the Trunk or Limbs for Treatment of Pain

Rhinomanometry and AcousticOptical Rhinometry

Sleep Studies Polysomnograms in Children and Adolescents

Spinal Unloading Devices Patient-Operated

Stem-Cell Therapy for Peripheral Arterial Disease

Subcutaneous Hormone Pellets

Surgical Interruption of Pelvic Nerve Pathways for Primary and Secondary Dysmenorrhea

Systems Pathology Testing for Predicting Risk of Recurrence in Prostate Cancer

Urine Drug Testing for Substance Abuse Treatment and Chronic Pain Management

Wireless Gastric Motility Monitoring

September 2015 20

bullLumbarspinalfusionmaybeconsideredMEDICALLYNECESSARYforchronic(presentforatleast6ndash12months)discogenicbackpainwithoutinstabilitywhenALLthefollowingcriteriaaremet

A Documentedunremittingpainanddisabilityrefractorytointensiveconservativetherapyforatleast3months Intensiveconservativetherapymusthaveoccurredwithintheprevious12monthsANDmustincludeALLofthefollowing

1Anti-inflammatorymedicationandanalgesicsunlesscontraindicatedAND 2TherapeuticinjectionsAND 3Anactiveorganizedandprogressivestrengthandflexibilityprogram NOTEIfapatientisunabletocompletephysicaltherapy(PT)duetoprogressivelyworseningpainanddisability

the case will be reviewed on an individual basis by an internal physician reviewer (See Documentation Submission section)

AND 4Aminimumoftwosessionsperweekoverthe3-monthperiodAND 5FunctionalassessmentasmeasuredbytheOswestryDisabilityIndex(ODI)demonstratingONEofthe

following a Lessthan30improvementintheODIscorebetweenthefirstandlastphysicaltherapysessionOR b ContinuedODIscoreofgreaterthanorequalto40attheconclusionofphysicaltherapy 6Aneducationalcomponentthatdealswithpatientexpectationsandperceptionsaswellastheanatomicsources

of back pain AND B Absenceofuntreatedunderlyingcontributorymentalhealthconditionsorpsychosocialissuesincludingbutnot

limited to depression or drug or alcohol abuse AND C Diagnosticimaging(egMRICT)obtainedwithintheprevious12monthsdemonstratesdegenerativediscdisease

limitedto1ndash2disclevelsbull Documentation supporting the medical necessity criteria described in the policy must be included in the prior authorizationInadditionthefollowingdocumentationmustalsobesubmitted

1 Written report from a radiologist describing findings from spinal diagnostic imaging studies 2 Intensiveconservativetherapy bull DocumentationfromthephysicaltherapistmustincludeOswestryDisabilityIndex(ODI)scores bull Ifapatientisunabletocompletephysicaltherapy(PT)duetoprogressivelyworseningsymptomsofpainand

disability the case will be reviewed on an individual basis by an internal physician reviewer Documentation must be submitted from the physical therapist describing the patientrsquos inability to complete PT

3 Forpatientswithchronicdiscogenicbackpainwithoutinstability(policysectionIV)documentationregardingthe absence of untreated underlying contributory mental health conditions or psychosocial issues including but not limited to depression or drug or alcohol abuse must be submitted by the patientrsquos primary care physician or a Mental Health Professional The Mental Health Professional must meet the Minnesota Department of Human ServicesqualificationsassetforthinMinnStatsect245462subd18(2013)andMinnStatsect2454871subd27(2013)

medICAL ANd BeHAVIorAL HeALTH poLICY updATe

September 2015 21

Policies inactivatedNone There was no Medical and behavioral Health Policy Activity for July 2015

Policies reviewed with no changes in May 2015 and June 2015

Acupuncture

Artificial Intervertebral Disc Cervical Spine

Belimumab

Cardiovascular Disease Risk Assessment and Management Laboratory Evaluation of Non-Traditional Lipid and

Nonlipid Biomarkers

Cellular Immunotherapy for Prostate Cancer

Chelation Therapy

Computerized Dynamic Posturography

Continuous and Intermittent Glucose Monitoring of Interstitial Fluid

Cytochrome P450 Genotyping

Digital Breast Tomosynthesis

Electrocardiographic (ECG) Body Surface Mapping

Endoscopic Radiofrequency Ablation or Cryoablation for Barrettrsquos Esophagus

Epidermal Growth-Factor Receptor (EGFR) Analysis for Non-small Cell Lung Cancer

HP Acthar Gel (Repository Corticotropin)

Hematopoietic Stem-Cell Transplantation for Non-Hodgkin Lymphomas

Hematopoietic Stem-Cell Transplantation for Primary Amyloidosis

Hematopoietic Stem-Cell Transplantation for Waldenstrom Macroglobulinemia

Image-Guided Minimally Invasive Lumbar Decompression for Spinal Stenosis

Liposuction

Lung Cancer Screening Using Computed Tomography (CT)

Mastopexy

Microprocessor-Controlled Prosthesis for the Lower Limb

Myoelectric Prosthesis for the Upper Limb

Organ Transplantation

Percutaneous and Endoscopic Techniques for Disc Decompression

September 2015 22

Medical and Behavioral Health Policy Update

NetworkManagementR317 POBox64560 StPaulMN55164-0560

Provider Press is posted on our website quarterly for business office staff of multi-specialty clinics physicians public health agencies DME providers chiropractors podiatrists physical therapists occupational therapists optometrists and behavioral health professionalsproviders Direct inquiries to

NetworkManagementR317Editor Holly BatchelderPOBox64560StPaulMN55164-0560(651)662-2014tollfree1-800-382-2000ext22014

AdvisorsFaithBauerCPCCPC-HCPC-PJeannieHarpCPCJanineUtechtCPCCPC-HCPC-PCPMAandKarenKiemeleMPH

Information in Provider Press is a general outline Provider and member contracts determine benefits

CPT-4codesnotedareAMAcopyrighted

0915

Peripheral Nerve Stimulation of the Trunk or Limbs for Treatment of Pain

Rhinomanometry and AcousticOptical Rhinometry

Sleep Studies Polysomnograms in Children and Adolescents

Spinal Unloading Devices Patient-Operated

Stem-Cell Therapy for Peripheral Arterial Disease

Subcutaneous Hormone Pellets

Surgical Interruption of Pelvic Nerve Pathways for Primary and Secondary Dysmenorrhea

Systems Pathology Testing for Predicting Risk of Recurrence in Prostate Cancer

Urine Drug Testing for Substance Abuse Treatment and Chronic Pain Management

Wireless Gastric Motility Monitoring

September 2015 21

Policies inactivatedNone There was no Medical and behavioral Health Policy Activity for July 2015

Policies reviewed with no changes in May 2015 and June 2015

Acupuncture

Artificial Intervertebral Disc Cervical Spine

Belimumab

Cardiovascular Disease Risk Assessment and Management Laboratory Evaluation of Non-Traditional Lipid and

Nonlipid Biomarkers

Cellular Immunotherapy for Prostate Cancer

Chelation Therapy

Computerized Dynamic Posturography

Continuous and Intermittent Glucose Monitoring of Interstitial Fluid

Cytochrome P450 Genotyping

Digital Breast Tomosynthesis

Electrocardiographic (ECG) Body Surface Mapping

Endoscopic Radiofrequency Ablation or Cryoablation for Barrettrsquos Esophagus

Epidermal Growth-Factor Receptor (EGFR) Analysis for Non-small Cell Lung Cancer

HP Acthar Gel (Repository Corticotropin)

Hematopoietic Stem-Cell Transplantation for Non-Hodgkin Lymphomas

Hematopoietic Stem-Cell Transplantation for Primary Amyloidosis

Hematopoietic Stem-Cell Transplantation for Waldenstrom Macroglobulinemia

Image-Guided Minimally Invasive Lumbar Decompression for Spinal Stenosis

Liposuction

Lung Cancer Screening Using Computed Tomography (CT)

Mastopexy

Microprocessor-Controlled Prosthesis for the Lower Limb

Myoelectric Prosthesis for the Upper Limb

Organ Transplantation

Percutaneous and Endoscopic Techniques for Disc Decompression

September 2015 22

Medical and Behavioral Health Policy Update

NetworkManagementR317 POBox64560 StPaulMN55164-0560

Provider Press is posted on our website quarterly for business office staff of multi-specialty clinics physicians public health agencies DME providers chiropractors podiatrists physical therapists occupational therapists optometrists and behavioral health professionalsproviders Direct inquiries to

NetworkManagementR317Editor Holly BatchelderPOBox64560StPaulMN55164-0560(651)662-2014tollfree1-800-382-2000ext22014

AdvisorsFaithBauerCPCCPC-HCPC-PJeannieHarpCPCJanineUtechtCPCCPC-HCPC-PCPMAandKarenKiemeleMPH

Information in Provider Press is a general outline Provider and member contracts determine benefits

CPT-4codesnotedareAMAcopyrighted

0915

Peripheral Nerve Stimulation of the Trunk or Limbs for Treatment of Pain

Rhinomanometry and AcousticOptical Rhinometry

Sleep Studies Polysomnograms in Children and Adolescents

Spinal Unloading Devices Patient-Operated

Stem-Cell Therapy for Peripheral Arterial Disease

Subcutaneous Hormone Pellets

Surgical Interruption of Pelvic Nerve Pathways for Primary and Secondary Dysmenorrhea

Systems Pathology Testing for Predicting Risk of Recurrence in Prostate Cancer

Urine Drug Testing for Substance Abuse Treatment and Chronic Pain Management

Wireless Gastric Motility Monitoring

September 2015 22

Medical and Behavioral Health Policy Update

NetworkManagementR317 POBox64560 StPaulMN55164-0560

Provider Press is posted on our website quarterly for business office staff of multi-specialty clinics physicians public health agencies DME providers chiropractors podiatrists physical therapists occupational therapists optometrists and behavioral health professionalsproviders Direct inquiries to

NetworkManagementR317Editor Holly BatchelderPOBox64560StPaulMN55164-0560(651)662-2014tollfree1-800-382-2000ext22014

AdvisorsFaithBauerCPCCPC-HCPC-PJeannieHarpCPCJanineUtechtCPCCPC-HCPC-PCPMAandKarenKiemeleMPH

Information in Provider Press is a general outline Provider and member contracts determine benefits

CPT-4codesnotedareAMAcopyrighted

0915

Peripheral Nerve Stimulation of the Trunk or Limbs for Treatment of Pain

Rhinomanometry and AcousticOptical Rhinometry

Sleep Studies Polysomnograms in Children and Adolescents

Spinal Unloading Devices Patient-Operated

Stem-Cell Therapy for Peripheral Arterial Disease

Subcutaneous Hormone Pellets

Surgical Interruption of Pelvic Nerve Pathways for Primary and Secondary Dysmenorrhea

Systems Pathology Testing for Predicting Risk of Recurrence in Prostate Cancer

Urine Drug Testing for Substance Abuse Treatment and Chronic Pain Management

Wireless Gastric Motility Monitoring