Independence has reviewed the following services as part of the policy
maintenance process. Based on the available
peer-reviewed literature and medical society guidelines, these previously
eligible services have been determined to be
not medically necessary or experimental/investigational. The changes in
coverage positions will become effective as
outlined below.
Changes effective November 1, 2016
Changes to the following policy will be posted in the Active
Notifications section of the Medical Policy Portal:
- Medical Policy #05.00.61e: Cervical Traction for In-home Use
The following coverage change will be reflected:
- HCPCS E0849, E0855, E0860: Cervical traction using a
mechanical or pneumatic device in the home setting will be considered not
medically necessary. Cervical traction has been performed to relieve muscle
spasms in the neck and shoulders and to relieve the pain of pinched nerves in
the neck. It may be administered by various techniques ranging from supine
mechanical motorized or pneumatic traction.
The following coverage changes will be communicated in the News &
Announcements section of the Medical Policy
Portal:
- CPT® 82172: Measurement of apolipoprotein
particles will be considered experimental/investigational as an adjunct to LDL
cholesterol in the risk assessment and management of cardiovascular disease.
Numerous lipid and non-lipid biomarkers have been proposed as potential risk
markers for cardiovascular disease. These biomarkers include apolipoproteins B,
AI, and E.
- CPT 86357: Quantification of natural killer (NK) cells
will be considered experimental/investigational for all indications. The
purported indications for quantification of NK cells include, but are not
limited to, biomarkers of Lyme disease progression, recurrent pregnancy loss,
adoptive immunotherapy and cellular therapy, and chronic fatigue syndrome.
- CPT 86677: Antibody testing for Helicobacter pylori will
be considered experimental/investigational for all indications. Antibody
testing may be performed to determine the presence of Helicobacter pylori (H.
pylori), a common cause of intestinal disease and suspected as a cause of
ulcerated stomach tissue. This test may be performed by enzyme-linked
immunosorbent assay or chemiluminescence assay. Carbon isotope (13C or 14C)
urea breath testing or stool antigen testing for H. pylori are clinically valid
test options. The stool antigen test is cleared by the U.S. Food and Drug
Administration (FDA) for use in the initial diagnosis, therapeutic monitoring,
and eradication confirmation in adults and children. The urea breath tests are
cleared by the FDA for the initial diagnosis and eradication confirmation in
adults.
For additional information on these changes, please review the following
news articles:
Commercial:
- Measurement of Apolipoprotein Particles (i.e., apolipoprotein B,
apolipoprotein AI, apolipoprotein E)
- Quantification of Natural Killer (NK) Cells
- Antibody Testing for Helicobacter pylori (H. pylori)
Medicare Advantage:
- Quantification of Natural Killer (NK) Cells
- Antibody Testing for Helicobacter pylori (H. pylori)
Changes effective January 1, 2017
Changes to the following policies will be posted in the Active
Notifications section of the Medical Policy Portal:
- Commercial: #12.01.01ai: Experimental/Investigational
Services
- Medicare Advantage: #MA00.005h:
Experimental/Investigational Services
These policies are being updated to reflect that the following services will
be considered experimental/investigational
as of January 1, 2017:
- HCPCS A9584: Iodine I-123 ioflupane is a
radiopharmaceutical agent used during dopamine transported
single-photon emission computed tomography. It is intended to assist in the
evaluation of adults with suspected
Parkinsonian syndromes and has been proposed to differentiate between
clinically uncertain Parkinsonian
syndromes and essential tremor.
- CPT 0159T: The use of computer-aided evaluation (CAE) in
the interpretation of contrast-enhanced magnetic
resonance imaging of the breast has been proposed as a mechanism to assist
radiologists in the interpretation of
breast MRIs.
- CPT 62291: Cervical and thoracic provocative discography
may be used to determine whether a disc is painful on
injection. It is an invasive procedure that involves the injection of
radiopaque contrasting materials (1 to 3 mL) into
the intervertebral disc, followed by computed tomography to examine the disc
abnormality.
- CPT 77605: Deep hyperthermia generated by an external
source, alone or in combination with radiation therapy,
can be administered using local and whole body techniques. Local hyperthermia
entails elevating the temperature
of superficial or subcutaneous tumors while sparing surrounding normal tissue
using either external or interstitial
modalities. Whole body hyperthermia requires the individual to be placed under
either general anesthesia or deep
sedation.
Changes to the following policies will be posted in the Active
Notifications section of the Medical Policy Portal:
- Commercial: #11.14.24a: Manipulation Under Anesthesia
- Medicare Advantage: #MA11.091a: Manipulation Under
Anesthesia
These policies are being updated to reflect that the following service will
be considered experimental/investigational as
of January 1, 2017:
- CPT 27275: Manipulation under anesthesia (MUA) for
disorders of the hip is a non-invasive treatment used to
treat acute and chronic conditions, including muscular or spinal pain. Under
anesthesia, spastic muscles are
believed to relax and diminish pain sensations, which theoretically may permit
joint manipulation through a full
range of motion.
Visit the Medical Policy Portal
to learn more about these medical policy updates. Select Accept and Go to
Medical Policy Online, then select Commercial or Medicare
Advantage under News and
Announcements and/or Active Notifications to review the complete
communication.
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Association.