Medical Policy and Clinical Guidelines Updates - April 2019*

Title

Change

Effective date

CG-SURG-94 Keratoprosthesis

• Content moved from SURG.00115

3/21/19

*CG-SURG-95  Sacral Nerve Stimulation and Percutaneous Tibial Nerve Stimulation for Urinary and Fecal Incontinence; Urinary Retention

• Content moved from SURG.00117

• Previous title: Sacral Nerve Stimulation (SNS) and Percutaneous Tibial Nerve Stimulation (PTNS) for Urinary and Fecal Incontinence; Urinary Retention

3/21/19

MED.00110 Growth Factors, Silver-based Products and Autologous Tissues for Wound Treatment and Soft Tissue Grafting

• Added bioengineered autologous skin-derived products (for example, SkinTE) as Investigational and not medically necessary for all indications.

• Existing HCPCS code Q4200 for Skin TE will be considered Investigational & Not Medically Necessary

7/1/19

MED.00126 Fractional Exhaled Nitric Oxide and Exhaled Breath Condensate Measurements for Respiratory Disorders

• Added nasal nitric oxide as Investigational & Not medically necessary in the diagnosis and monitoring of asthma and other respiratory disorders

7/1/19

*SURG.00037 Treatment of Varicose Veins (Lower Extremities)

• Replaced "non-surgical management" with "conservative therapy" in the MN criteria

• Added sclerotherapy used in conjunction with a balloon catheter (for example, KAVS procedure) as INV&NMN

• Existing CPT Category III code 0524T will be considered as Investigational & Not Medically Necessary

7/1/19

TRANS.00035 Mesenchymal Stem Cell Therapy for the Treatment of Joint and Ligament Disorders, Autoimmune, Inflammatory and Degenerative Diseases

• Previous title: Mesenchymal Stem Cell Therapy For Orthopedic Indications

• Expanded the document's scope to address non-FDA approved uses of mesenchymal stem cell therapy

• Revised Position Statement: “Mesenchymal stem cell therapy is considered Investigational & Not medically necessary for the treatment of joint and ligament disorders caused by injury or degeneration as well as autoimmune, inflammatory and degenerative diseases”

7/1/19

Title

Change

Effective date

Lab.00036 Multiplex Autoantigen Microarray Testing for Systemic Lupus Erythematosus

• Multiplex autoantigen microarray testing to screen for, diagnose, or manage systemic lupus erythematous is considered Investigational & Not Medically Necessary

• Existing PLA code 0062U will be considered Investigational & Not Medically Necessary

7/1/19