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    Admission Review with minimal information

    Policy PDF

    Policy Name: Admission Review with minimal information

    Policy Number: CMO 502

    Effective Date of current policy: 9/1/2018

    Description and Scope

    This policy applies to inpatient acute admissions where insufficient medical information is obtained.

    Position Statement

    In order to determine the medical necessity of an admission, Affinity Health Plan requires sufficient information to use MCG guidelines. Without enough information, the admission will be denied as not medically necessary. In particular, if Affinity Health Plan is given only the diagnosis, and no further information is submitted after reasonable attempts by the plan to get further information, the admission will be denied as not medically necessary.

    Definitions

    MCG guidelines are nationally recognized, evidence-based criteria that are used to determine medical necessity of a hospital admission as well as other treatments.

    Coding

    Not applicable

    References

    Medical Policy Committee History and Revisions


    Date

    Action

    July 24, 2018

    Initial approval by Medical Policy and Benefits Committee

    Allergy Immunotherapy

    Policy PDF

    Policy Name: Allergy Immunotherapy

    Policy Number: CMO 506

    Effective Date of current policy:   8/2018

    Description and Scope

    This policy establishes guidelines for medical necessity and appropriate billing for the supervision of preparation and provision of antigens for allergy immunotherapy given by subcutaneous injection.

    This policy does not apply to Medicare Advantage members.

    Position Statement

    Allergy immunotherapy by subcutaneous injection is considered medically necessary for patients with significant allergy symptoms (allergic asthma, allergic rhinitis, allergic conjunctivitis, and hypersensitivity to stinging insects) that could not be adequately treated by medications or by avoidance of the allergen.

    Allergy immunotherapy to treat chronic urticaria, angioedema, food allergies, migraines, non-allergic rhinitis, and non-allergic asthma is considered experimental/investigational.

    Allergy immunotherapy is limited to a one year supply. The CPT code 95165 requires prior authorization when more than 120 units are billed in one year. The medical information to document the medical necessity of more than 120 units/year should include:

    1. Number of treatment sets ordered, with the mix of antigens in each set and clear documentation explaining the clinical reason for separate treatment sets, and
    2. Number of doses planned per treatment set with clear documentation of the medical necessity of more than 28 doses per treatment set, and
    3. The planned dosage schedule.

    Background

    Allergen immunotherapy is a treatment program for individuals who have hypersensitivity to one or more allergens. The objective of the therapy is to lesson or diminish symptoms when the individual is exposed to the allergen in the future. Immunotherapy consists of injections that contain progressively larger amounts of allergen until the individual is able to continue on a maintenance dose level.

    Definitions

    Allergy: A reaction by the body to something that does not bother most other people. Allergen: A substance  to which the body’s immune system reacts to.

    Allergy Immunotherapy:  Giving a specific allergen to reduce the immune system’s response.

    Angioedema: Swelling of tissues in the body. The swelling of the skin is called urticaria.

    Conjunctivitis: The inflammation of the membrane that lines the eyelid and covers the white portion of the eye.

    Hypersensitivity: A reaction by the body to an irritant or drug that is more extreme than the reaction of most other people.

    Rhinitis: Runny nose, sneezing, or itching of the nose.

    Subcutaneous:  Under the skin.

    Urticaria: A rash of red raised areas on the skin that usually itch; hives.

    Coding  

    Inclusion of a code in the following list does not imply that the procedure is medically necessary or that the code represents a covered benefit. Codes used to identify services associated with this policy may include (but may not be limited to) the following:

    95165 Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; single or multiple antigens (specify number of doses).

    References

    Allergy Immunotherapy-Provision of Antigens, CPT Assistant, April 2000, pg. 4.

    Practice Parameters for Allergen Immunotherapy , Chapter 12: Immunotherapy Schedules and Doses, American Academy of Allergy, Asthma and Immunology (AAAI), V90 Number 1t, January 2003.

    Medical Policy Committee History and Revisions

    Date

    Action

     

     

    Cosmetic Services

    Policy PDF

    Policy Name: Cosmetic Services

    Policy Number: CMO 500

    Effective Date of current policy: 9/1/2018

    Description and Scope

    This policy applies to procedures that primarily affect the appearance of the member. Specific policies that should be consulted include:

    • MCG Mastectomy for Gynecomastia, MCG Reduction, Mammoplasty
    • MCG Abdominoplasty, MCG Panniculectomy, MCG Rhinoplasty
    • MCG Sclerotherapy, Leg Veins
    • MCG Blepharoplasty, Canthoplasty, and Related Procedures, Affinity Medical Policy on Gender Dysphoria

    This policy does not apply to Medicare Advantage members.

    Position Statement

    Treatments that primarily affect the appearance are considered medically necessary only in the following circumstances:

    • The reason for the treatment is to correct a significant congenital defect or anomaly that is beyond normal human variation. An example of this is laser therapy for a significant port wine stain on the face, or
    • The reason for the treatment is reconstructive; that is, correcting an abnormal appearance due to injury, disease, or treatment. An example of this is breast reconstruction following mastectomy, or
    • The treatment is part of a medically necessary procedure. An example of this is tattooing to allow for radiation therapy, or
    • Genitalia or breast surgery for members with gender dysphoria. Please see Policy: Gender Reassignment Surgery for details and for medical necessity criteria.

    Cosmetic treatments are usually not considered eligible for coverage. This includes, but is not limited to, treatments, drugs, products, hospital/facility charges, anesthesia, pathology/lab fees, radiology fees and professional fees by the surgeon, assistant surgeon, consultants and attending physicians.

    Background

    Therapy to change appearance is commonplace. Unwanted hair is treated with creams, medications, electrolysis, and lasers. Baldness is treated with creams and oral medications. Wrinkles, acne scars, uneven pigmentation, thin lips, and aging skin are treated with creams, dermal fillers, lasers, and botulinum toxin. An unprepossessing jawline is treated with genioplasty. Spider veins (telangiectasia) are treated with lasers or a sclerosing solution. Some people have liposuction, treatment of inverted nipples, or removal of accessary nipples. These treatments are considered cosmetic and not medically necessary, except as noted above.

    Certain treatments may be medically necessary or cosmetic depending upon the circumstances. Chemical peels are medically necessary when used to treat pre-malignant lesions that have not responded to standard topical and oral therapies.

    Some examples of cosmetic and not medically necessary treatments include (but are not limited to):

    • Chemical peels, including for treatment of acne, acne scars, or pigmentation, cpt codes 15788- 15793 and 17360.
    • Dermabrasion for treatment of acne, acne scars, or pigmentation, cpt codes 15780 – 15783.
    • Ear piercing and repair of a pierced earlobe or pierced body part.
    • Breast augmentation (when not used to treat gender dysphoria)
    • Treatment of diastasis recti

    Definitions

    Cosmetic Services are services whose primary function is to change an appearance which is within normal human anatomic variation. Accessory nipples, acne scars, and irregular pigmentation are examples of normal human anatomic variation. Common anticipated side effects of cosmetic surgery (for example, nausea and vomiting that results in a hospital stay) are considered part of the cosmetic surgery procedure. Surgery needed to improve the function of an abnormal body part is not considered cosmetic.

    Reconstructive surgery is surgery intended to restore appearance that is abnormal because of congenital anomalies (for example, cleft lip), trauma, disease, or its treatment. Surgery to correct an unpleasing outcome from cosmetic surgery is not considered reconstructive.

    Coding

    Inclusion of a code in the following list does not imply that the procedure is medically necessary or that the code represents a covered benefit. Codes used to identify services associated with this policy may include (but may not be limited to) the following:

    • 11200 Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions
    • 11201 Removal of skin tags; each additional 10 lesions
    • 11950 Subcutaneous injection of filling material (eg, collagen); 1 cc or less
    • 11951 Subcutaneous injection of filling material (eg, collagen); 1.1 to 5.0 cc
    • 11952 Subcutaneous injection of filling material (eg, collagen); 5.1 to 10.0 cc
    • 11954 Subcutaneous injection of filling material (eg, collagen); over 10.0 cc
    • 15775 Punch graft for hair transplant; 1 to 15 punch grafts
    • 15776 Punch graft for hair transplant; more than 15 punch grafts
    • 15780 Dermabrasion; total face (e.g. for acne scarring, fine wrinkling, rhytids, general keratosis)
    • 15781 Dermabrasion, segmental, face
    • 15782 Dermabrasion, regional, other than face
    • 15783 Dermabrasion, superficial, any site, (eg, tattoo removal)
    • 15786 Abrasion; single lesion (eg, keratosis, scar)
    • 15787 Abrasion; each additional four lesions or less
    • 15788 Chemical peel, facial; epidermal
    • 15789 Chemical peel, facial; dermal
    • 15790 Chemical peel; total face
    • 15791 Chemical peel; face, hand or elsewhere
    • 15792 Chemical peel, nonfacial; epidermal
    • 15793 Chemical peel, nonfacial; dermal 
    • 15810 Salabrasion; 20 sq cm or less
    • 15811 Salabrasion; over 20 sq cm
    • 15819 Cervicoplasty
    • 15820 Blepharoplasty, lower eyelid;
    • 15821 Blepharoplasty, lower eyelid; with extensive herniated fat pad
    • 15824 Rhytidectomy; forehead
    • 15825 Rhytidectomy; neck with platysmal tightening (platysmal flap, P-flap)
    • 15826 Rhytidectomy; glabellar frown lines
    • 15828 Rhytidectomy; cheek, chin, and neck
    • 15829 Rhytidectomy; superficial musculoaponeurotic system (SMAS) flap
    • 15832 Excision, excessive skin and subcutaneous tissue (including lipectomy); thigh
    • 15833 Excision, excessive skin and subcutaneous tissue (including lipectomy); leg
    • 15834 Excision, excessive skin and subcutaneous tissue (including lipectomy); hip
    • 15835 Excision, excessive skin and subcutaneous tissue (including lipectomy); buttock
    • 15836 Excision, excessive skin and subcutaneous tissue (including lipectomy); arm
    • 15837 Excision, excessive skin and subcutaneous tissue (including lipectomy); forearm or hand
    • 15838 Excision, excessive skin and subcutaneous tissue (including lipectomy); submental fat pad
    • 15839 Excision, excessive skin and subcutaneous tissue (including lipectomy); other area
    • 15876 Suction assisted lipectomy; head and neck
    • 15877 Suction assisted lipectomy; trunk
    • 15878 Suction assisted lipectomy; upper extremity
    • 15879 Suction assisted lipectomy; lower extremity
    • 17106 Destruction of cutaneous vascular proliferative lesions (eg, laser technique); less than 10 sq cm
    • 17107 Destruction of cutaneous vascular proliferative lesions (eg, laser technique); 10.0 to 50.0 sq cm
    • 17108 Destruction of cutaneous vascular proliferative lesions (eg, laser technique); over 50.0 sq cm
    • 17340 Cryotherapy (CO2 slush, liquid N2) for acne
    • 17360 Chemical exfoliation for acne (eg, acne paste, acid)
    • 17380 Electrolysis epilation, each ½ hour
    • 19120 Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion (except 19300), open, male or female, 1 or more lesions
    • 19316 Mastopexy
    • 19355 Correction of inverted nipples
    • 21120 Genioplasty; augmentation (autograft, allograft, prosthetic material)
    • 21121 Genioplasty; sliding osteotomy, single piece
    • 21122 Genioplasty; sliding osteotomies, 2 or more osteotomies (e.g., wedge excision or bone wedge reversal for asymmetrical chin)
    •  21123 Genioplasty; sliding, augmentation with interpositional bone grafts (includes obtaining autografts)
    • 21125 Augmentation, mandibular body or angle; prosthetic material
    • 21127 Augmentation, mandibular body or angle; with bone graft, onlay or interpositional (includes obtaining autograft)
    • 30400 Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip
    • 30410 Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip
    • 30420 Rhinoplasty, primary; including major septal repair
    • 30430 Rhinoplasty, secondary; minor revision (small amount of nasal tip work)
    • 30435 Rhinoplasty, secondary; intermediate revision (bony work with osteotomies)
    • 30450 Rhinoplasty, secondary; major revision (nasal tip work and osteotomies)
    • 36468 Single or multiple injections of sclerosing solutions, spider veins (telangiectasia); limb or trunk
    • 36469 Single or multiple injections of sclerosing solutions, spider veins (telangiectasia); face
    • 36470 Injection of sclerosing solution; single vein
    • 36471 Injection of sclerosing solution; multiple veins, same leg
    • 69090 Ear piercing
    • 69300 Otoplasty, protruding ear, with or without size reduction
    • S0800 Laser in situ keratomileusis
    • S0810 Photorefractive keratectomy
    • S0812 Phototherapeutic keratectomy
    • 65760 Keratomileusis
    • 65765 Keratophakia
    • 65767 Epikeratoplasty
    • 65771 Radial keratotomy
    • 67901 Repair of blepharoptosis; frontalis muscle technique with suture or other material (eg, banked fascia)
    • 67902 Repair of blepharoptosis; frontalis muscle technique with autologous fascial sling (includes obtaining fascia)
    • 67903 Repair of blepharoptosis; (tarso) levator resection or advancement, internal approach 67904   Repair of blepharoptosis; (tarso) levator resection or advancement, external approach
    • 67906 Repair of blepharoptosis; superior rectus technique with fascial sling (includes obtaining fascia)
    • 67908 Repair of blepharoptosis; conjunctivo-tarso-Muller's muscle-levator resection (eg, Fasanella- Servat type)

    References

    Medical Policy Committee History and Revisions

    Date

    Action

    July 24, 2018

    Initial approval by Medical Policy and Benefits Committee

    Cryotherapy

    Policy PDF

    Policy Name: Cryotherapy

    Policy Number: CMO 501

    Effective Date of current policy: 9/1/2018

    Description and Scope

    This policy refers to treatments of medical conditions with cryotherapy (the destruction of tissue by freezing).

    Position Statement

    Affinity Health Plan considers cryotherapy medically necessary in some circumstances where evidence based medicine has proved benefit. Affinity Health Plan considers cryotherapy experimental and investigational where there is insufficient evidence that cryotherapy is safe and effective for this indication. Cryotherapy can be considered medically necessary for treatment of the following conditions:

    • cervical intraepithelial neoplasia
    • uterine bleeding (exclude cancer, pre-cancer or hyperplasia) for menorrhagia or excessive bleeding (as an alternative to hysterectomy)
    • isolated colorectal cancer liver metastases
    • isolated hepatocellular carcinoma (unresectable)
    • unresectable neuroendocrine tumors metastatic to the liver
    • prostate cancer as a primary therapy alternative to surgery or irradiation in individuals with localized disease (T1 or T2 [organ confined] or T3 [locally advanced]) or as salvage therapy for recurrent cancer following failure of radiation therapy
    • malignant endobronchial obstruction
    • renal cell carcinoma, up to 4-cm in size, when any of the following criteria is met:
      • Persons who are considered high-risk surgical candidates; or
      • Persons with renal insufficiency, as defined by a glomerular filtration rate of less than or equal to 60 ml/min/m2; or
      • Persons with a solitary kidney
    • atrial fibrillation
    • skin lesions if either of the following criteria are met:
    • biopsy suggests or clinically the lesion is indicative of pre-malignancy or malignancy, or
    • the lesion restricts vision or obstructs a body orifice
    • low-risk superficial basal cell carcinoma, and squamous cell carcinoma in situ (Bowen disease), where surgery or radiation is contraindicated or impractical
    • soft tissue sarcoma of the extremities or the trunk in symptomatic persons with disseminated metastases

    Affinity Health Plan considers cryotherapy experimental and investigational for any other indication based on lack of sufficient supportive evidence, including:

    • Plantar fasciitis Plantar fibroma Barrett’s esophagus
    • Benign prostatic hypertrophy neck pain
    • Back pain
    • Varicose veins or venous valvular incompetence
    • Breast cancer
    • Breast fibroadenoma

    Definitions

    NOT APPLICABLE

    Background

    Definitions: Cryotherapy, also called cryosurgery, cryoablation, percutaneous cryotherapy or targeted cryoablation therapy, is a minimally invasive treatment that uses extreme cold to freeze and destroy diseased tissue, including cancer some cells. Several cryogens such as liquid nitrogen, nitrous oxide and carbon dioxide are available, but liquid nitrogen is the most commonly used.

    Coding

    Inclusion of a code in the following list does not imply that the procedure is medically necessary or that the code represents a covered benefit. Codes used to identify services associated with this policy may include (but may not be limited to) the following:

    • 0441T Ablation, percutaneous, cryoablation, includes imaging guidance, lower extremity distal/peripheral nerve
    • 20982 Ablation therapy for reduction or eradication of 1 or more bone tumors (eg, metastasis) including adjacent soft tissue when involved by tumor extension, percutaneous, including imaging guidance when performed; radiofrequency
    • 20983 Ablation therapy for reduction or eradication of 1 or more bone tumors (eg, metastasis) including adjacent soft tissue when involved by tumor extension, percutaneous, including imaging guidance when performed; cryoablation
    • 31641 Bronchoscopy (rigid or flexible); with destruction of tumor or relief of stenosis by any method other than excision (e.g., laser therapy, cryotherapy)
    • 32994 Ablation therapy for reduction or eradication of 1 or more pulmonary tumor(s) including pleura or chest wall when involved by tumor extension, percutaneous, including imaging guidance when performed, unilateral; cryoablation
    • 33254 Operative tissue ablation and reconstruction of atria, limited (eg, modified maze procedure) 33256 Operative tissue ablation and reconstruction of atria, extensive (eg, maze procedure); with cardiopulmonary bypass
    • + 33257 Operative tissue ablation and reconstruction of atria, performed at the time of other cardiac procedure(s), limited (eg, modified maze procedure) (List separately in addition to code for primary procedure)
    • + 33259 Operative tissue ablation and reconstruction of atria, performed at the time of other cardiac procedure(s), extensive (eg, maze procedure), with cardiopulmonary bypass (List separately in addition to code for primary procedure)
    • 50250 Ablation, open, 1 or more renal mass lesion(s), cryosurgical, including intraoperative ultrasound guidance and monitoring, if performed
    • 50593   Ablation, renal tumor(s), unilateral, percutaneous, cryotherapy
    • 55873 Cryosurgical ablation of the prostate (includes ultrasonic guidance for interstitial cryosurgical probe placement)
    • 57511   Cautery of cervix; cryocautery, initial or repeat
    • 64600 Destruction by neurolytic agent, trigeminal nerve; supraorbital, infraorbital, mental, or inferior alveolar branch [cryoablation of chronic headaches]
    • +93657 Additional linear or focal intracardiac catheter ablation of the left or right atrium for treatment of atrial fibrillation remaining after completion of pulmonary vein isolation (List separately in addition to code for primary procedure)

    References

    Public Health Law, Sections 201 and 206 and Social Services Law, Sections 363-a and 365-a(2) New York Codes, Rules and Regulations Title 18 Section 505.2(l)

    Medical Policy Committee History and Revisions

    Date

    Action

    July 24, 2018

    Initial approval by Medical Policy and Benefits Committee

    Gender Dysphoria

    Policy PDF

    Policy Name: Gender Dysphoria

    Policy Number: CMO 503

    Effective Date of current policy: 9/1/2018

    Description and Scope

    This policy applies to hormone therapy and surgical treatments for gender dysphoria for members of Medicaid managed care and Health and Recovery Plans (HARP).

    Position Statement

    Affinity Health Plan follows the NYS Department of Health (DOH) coverage criteria for utilization management of hormone therapy and surgery for the treatment of gender dysphoria as written in 18 NYCRR 505.2(l) as well as any other relevant statutes, regulations, and coverage guidance written by NYS DOH.

    Gonadotropin-releasing hormone agents (pubertal suppressants), as well as cross-sex hormones for those under 18, whether or not in preparation for gender reassignment surgery, are medically necessary when a qualified medical professional determines that an individual.

    • meets the criteria for a diagnosis of gender dysphoria, and
    • has experienced puberty to at least Tanner stage 2, and pubertal changes have resulted in an increase in gender dysphoria, and
    • does not suffer from a psychiatric comorbidity that interferes with the diagnostic work-up or treatment, and
    • has adequate psychological and social support during treatment, and
    • demonstrates knowledge and understanding of the expected outcomes of treatment with pubertal suppressants and cross-sex hormones, as well as the medical and social risks and benefits of sex reassignment.

    Cross-sex hormones for patients who are eighteen years of age and older are medically necessary when a qualified medical professional determines that the individual requires such hormones.

    Gender reassignment surgery, as defined in the definitions section, is medically necessary for an individual who has letters from two qualified New York State licensed health professionals who have independently assessed the individual and are referring the individual for the surgery. One of these letters must be from a psychiatrist, psychologist, psychiatric nurse practitioner, or licensed clinical social worker with whom the individual has an established and ongoing relationship. The other letter may be from a psychiatrist, psychologist, physician, psychiatric nurse practitioner, or licensed clinical social worker acting within the scope of his or her practice, who has only had an evaluative role with the individual. Together, the letters must establish that the individual:

    • has a persistent and well-documented case of gender dysphoria;
    • has received hormone therapy appropriate to the individual's gender goals, which shall be for a minimum of 12 months in the case of an individual seeking genital surgery, unless such therapy is medically contraindicated or the individual is otherwise unable to take hormones;
    • has lived for 12 months in a gender role congruent with the individual’s gender identity, and has received mental health counseling, as deemed medically necessary, during that time;
    • has no other significant medical or mental health conditions that would be a contraindication to gender reassignment surgery, or if so, that those are reasonably well-controlled prior to the gender reassignment surgery; and
    • has the capacity to make a fully informed decision and to consent to the treatment.

    Other surgery and procedures, including but not limited to abdominoplasty, liposuction, facelift, nose reshaping, collagen injections, and chin, nose, cheek, and calf implants, are considered cosmetic. They may be considered for medical necessity on a case by case basis should they be required to treat a particular patient’s gender dysphoria as opposed to a particular patient’s dissatisfaction with his or her appearance.

    All legal and program requirements related to providing and claiming reimbursement for sterilization procedures must be followed when transgender care involves sterilization.

    At least one attempt to conduct a peer to peer consultation with the ordering provider will be made prior to issuing an adverse determination.

    Background

    NOT APPLICABLE

    Definitions  

    Gender reassignment surgery consists of any of the following:

    • mastectomy, hysterectomy, salpingectomy, oophorectomy, vaginectomy, urethroplasty, metoidioplasty, phalloplasty, scrotoplasty, penectomy, orchiectomy, vaginoplasty, labiaplasty, clitoroplasty, and/or placement of a testicular prosthesis and penile prosthesis;
    • breast augmentation, provided that: the patient has completed a minimum of 24 months of hormone therapy, during which time breast growth has been negligible; or hormone therapy is medically contraindicated; or the patient is otherwise unable to take hormones;
    • electrolysis when required for vaginoplasty or phalloplasty; and
    • such other surgeries, services, and procedures as may be specified by the NYS DOH. Tanner Stage is a scale of physical sexual maturity rating in adolescents.

    Coding

    Inclusion of a code in the following list does not imply that the procedure is medically necessary or  that the code represents a covered benefit. Codes used to identify services associated with this policy may include (but may not be limited to) the following:

    19301, 19303, 19304

    Mastectomy

    53430

    Urethroplasty, reconstruction of female urethra

    54125

    Amputation of penis; complete

    54400 - 54417

    Penile prosthesis

    54520

    Orchiectomy, simple (including subcapsular), with or without testicular prosthesis, scrotal or inguinal approach

    54660

    Insertion of testicular prosthesis (separate procedure)

    54690

    Laparoscopic, surgical; orchiectomy

    55175

    Scrotoplasty; simple

    55180

    complicated

    55970

    Intersex surgery; male to female [a series of staged procedures that includes male genitalia removal, penile dissection, urethral transposition, creation of vagina and labia with stent placement]

    55980

    female to male [a series of staged procedures that include penis and scrotum formation by graft, and prostheses placement]

    56625

    Vulvectomy simple; complete

    56800

    Plastic repair of introitus

    56805

    Clitoroplasty for intersex state

    56810

    Perineoplasty, repair of perineum, nonobstetrical (separate procedure)

    57106, 57107, 57110, 57111

    Vaginectomy

    57291, 57292

    Construction of artificial vagina

    57335

    Vaginoplasty for intersex state

    58150, 58180, 58260 - 58262, 58275 - 58291, 58541 - 58544, 58550 - 58554

    Hysterectomy

    58570 - 58573

    Laparoscopy, surgical, with total hysterectomy

    58661

    Laparoscopy, surgical; with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy)

    58720

    Salpingo-oophorectomy, complete or partial, unilateral or bilateral

    11950 - 11954

    Subcutaneous injection of filling material (e.g., collagen)

    15200

    Full thickness graft, free, including direct closure of donor site, trunk; 20 sq cm or less [nipple reconstruction]

    15775

    Punch graft for hair transplant; 1 to 15 punch grafts

    15776

    Punch graft for hair transplant; more than 15 punch grafts

    15780 - 15787

    Dermabrasion

    15788 - 15793

    Chemical peel

    15820 - 15823

    Blepharoplasty

    15824 - 15828

    Rhytidectomy

    15830 - 15839

    Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy

    15876 - 15879

    Suction assisted lipectomy

    17380

    Electrolysis epilation, each 30 minutes

    19316

    Mastopexy

    19318

    Reduction mammaplasty

    19324 - 19325

    Mammaplasty, augmentation

    19340

    Immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction

    19342

    Delayed insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction

    19350

    Nipple/areola reconstruction

    21087

    Nasal prosthesis

    21120 - 21123

    Genioplasty

    21125 - 21127

    Augmentation, mandibular body or angle; prosthetic material or with bone graft, onlay or interpositional (includes obtaining autograft)

    21193

    Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; without bone graft

    21194

    with bone graft (includes obtaining graft)

    21195

    Reconstruction of mandibular rami and/or body, sagittal split; without internal rigid fixation

    21196

    with internal rigid fixation

    21208

    Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant)

    21210

    Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)

    21270

    Malar augmentation, prosthetic material

    30400 - 30420

    Rhinoplasty; primary

    30430 - 30450

    Rhinoplasty; secondary

    67900

    Repair of brow ptosis (supraciliary, mid-forehead or coronal approach)

    92507

    Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual

    92508

    Treatment of speech, language, voice, communication, and/or auditory processing disorder; group, two or more individuals

    J1950

    Injection, leuprolide acetate (for depot suspension), per 3.75 mg

    J9202

    Goserelin acetate implant, per 3.6 mg

    J9217

    Leuprolide acetate (for depot suspension), 7.5 mg

    J9218

    Leuprolide acetate, per 1 mg

    J9219

    Leuprolide acetate implant, 65 mg

    S0189

    Testosterone pellet, 75 mg

    G0153

    Services performed by a qualified speech-language pathologist in the home health or hospice setting, each 15 minutes

    S9128

    Speech therapy, in the home, per diem

    References

    Health Law, Sections 201 and 206 and Social Services Law, Sections 363-a and 365-a(2) New York Codes, Rules and Regulations Title 18 Section 505.2(l)

    Medical Policy Committee History and Revisions

    Date

    Action

    July 24, 2018

    Initial approval by Medical Policy and Benefits Committee

    Interspinous and Interlaminar Stabilization/Distraction Implants

    Policy PDF

    Policy Name: Interspinous and Interlaminar Stabilization/Distraction Implants

    Policy Number: CMO 505

    Effective Date of current policy: 9/1/2018

    Description and Scope

    This policy applies to procedures that are used to relieve symptoms of lumbar spinal stenosis, a narrowing of the passages for the spinal cord and nerves.

    Position Statement

    Implanted devices for treatment of spinal stenosis are considered investigational and not medically necessary.

    Background

    Interspinous and interlaminar implants (spacers) stabilize or distract the adjacent lamina and/or spinous processes and restrict extension in order to reduce pain in patients with lumbar spinal stenosis and neurogenic claudication

    Definitions  

    Interspinous spacers are small devices implanted between the vertebral spinous processes. After implantation the device is opened or expanded to distract (open) the neural foramen and decompress the nerves. Interlaminar spacers are implanted midline between adjacent lamina and spinous processes to provide dynamic stabilization following decompressive surgery. Overall, use of interspinous or interlaminar distraction devices (spacers) used as an alternative to spinal decompression show high failure and complication rates. Greater certainty about the net health benefit of these devices may be obtained when recently completed and moderately sized RCT on decompression with and without the implants are published. The evidence at this time is insufficient to determine the effects of the technology on health outcome.

    Coding

    Inclusion of a code in the following list does not imply that the procedure is medically necessary or that the code represents a covered benefit. Codes used to identify services associated with this policy may include (but may not be limited to) the following:

    References

    • Care guidelines from MCG ACG: A-0494 (AC)
    • Interlaminar/Interspinous Process Distraction Devices for Neurogenic Claudication or Lumbar Spinal Stenosis. Center for Evidence-based Policy, Oregon Health & Science University
    • Hayes, Inc. Health Technology Brief AxiaLIF (Axial Lumbar Interbody Fusion) System (TranS1 Inc.) for Percutaneous Lumbosacral Surgery. Lansdale, PA: Archived 2015.
    • Hayes, Inc. Health Technology Brief. Coflex Interlaminar Stabilization Device (Paradigm Spine LLC) for Treatment of Lumbar Spinal Stenosis. Lansdale, PA: Updated June 2016.
    • Hayes, Inc. Health Technology Brief. eXtreme Lateral Interbody Fusion (XLIF; NuVasive Inc.) for Treatment of Degenerative Spinal Disorders. Lansdale, PA: June 2017.
    • Hayes, Inc. Health Technology Brief. Minimally Invasive Lumbar Decompression (mild; Vertos Medical Inc.) for Lumbar Spinal Stenosis. Lansdale, PA: October 2014.
    • Hayes, Inc. Health Technology Brief. Percutaneous sacroplasty for treatment of sacral insufficiency fractures. Lansdale, PA: Updated September 2014.

    Medical Policy Committee History and Revisions

    Date

    Action

    July 24, 2018

    Initial approval by Medical Policy and Benefits Committee

    Manipulation Under Anesthesia (MUA)

    Policy PDF

    Policy Name: Manipulation Under Anesthesia (MUA)

    Policy Number: CMO 507

    Effective Date of current policy:  08/2018

    Description and Scope

    This policy describes when manipulation under anesthesia (MUA) can be medically necessary.

    Position Statement

    MUA should only be performed on select patients who have failed to respond to conservative therapy. The following indications/conditions are considered medically necessary for MUA:

    • Adhesive capsulitis (e.g., frozen shoulder) when there is failure of conservative medical management including medications with or without articular injections, home exercise programs, and physical therapy; or
    • Elbow joint for arthrofibrosis following elbow surgery or fracture; or
    • Arthrofibrosis of the knee following trauma or knee surgery (e.g., total knee replacement, anterior cruciate ligament repair) with less than 90 degree range of motion 4 weeks to 6 months following surgery.

    MUA provided for the above indications/conditions consists of a SINGLE treatment session involving an isolated joint.

    Affinity Health Plan considers MUA not medically necessary and/or experimental and investigational for the following joints since there is insufficient evidence to establish its efficacy:

    • Ankle
    • Hip
    • Knee (for any condition other than for arthrofibrosis following total knee arthroplasty, knee surgery, or fracture)
    • Pelvis for diastasis or subluxation
    • Shoulder for any condition other than adhesive capsulitis
    • Spine
    • Temporomandibular
    • Toe
    • Wrist

    There is a lack of peer-reviewed published evidence supporting the need for multiple, repeat sessions of MUA for multiple body joints.

    Background  

    Manipulation under anesthesia (MUA) is intended to reduce pain and improve range of motion. It is a treatment modality that consists of manipulation and stretching procedures performed while the patient has received anesthesia (e.g., conscious sedation, general anesthesia). The rationale for this approach is that fibrotic changes in the per articular and intra-articular soft tissues hinder movement, and sometimes it is necessary to anesthetize patients to reduce muscle tone and protective reflex mechanisms so that the joints can be manipulated effectively. Those who advocate this procedure assert that it will break up adhesions within the surrounding joints and stretch the restricting fibrotic tissue to a length compatible with motion, thereby, increasing joint function and reducing pain.

    Definitions  

    Manipulation under anesthesia (MUA) is a noninvasive procedure to treat chronic pain unmanageable by other methods. MUA is designed not only to relieve pain, but also to break up excessive scar tissue. Contraindications to MUA include the following conditions:

    • Osteoporosis
    • Bone or other cancer
    • Uncontrolled diabetes
    • Heart disease or uncontrolled hypertension
    • Acute inflammatory arthritis
    • Strep or staph infection
    • Bone fracture

    Coding  

    Inclusion of a code in the following list does not imply that the procedure is medically necessary or  that the code represents a covered benefit. Codes used to identify services associated with this policy may include (but may not be limited to) the following:

    CPT 23700 MANIPULATION UNDER ANESTHESIA, SHOULDER JOINT, INCLUDING APPLICATION OF FIXATION APPARATUS (DISLOCATION EXCLUDED)

    CPT 24300 MANIPULATION, ELBOW, UNDER ANESTHESIA

    CPT 27570 MANIPULATION OF KNEE JOINT UNDER GENERAL ANESTHESIA (INCLUDES APPLICATION OF TRACTION OR OTHER FIXATION DEVICES)

    CPT 27275 Manipulation, hip joint, requiring general anesthesia CPT 25259 Manipulation, wrist, under anesthesia

    CPT 26340 Manipulation, finger joint, under anesthesia, each joint

    ICD 10 codes that Support Medical Necessity:

    M24.611 - M24.619- Opens in a new window Ankylosis, right shoulder - Ankylosis, unspecified shoulder M24.621 - M24.629- Opens in a new window Ankylosis, right elbow - Ankylosis, unspecified elbow M66.211 - M66.219- Opens in a new window Spontaneous rupture of extensor tendons, right shoulder - Spontaneous rupture of extensor tendons, unspecified shoulder

    M66.811 - M66.819- Opens in a new window Spontaneous rupture of other tendons, right shoulder - Spontaneous rupture of other tendons, unspecified shoulder

    M75.00 - M75.02- Opens in a new window Adhesive capsulitis of unspecified shoulder - Adhesive capsulitis of left shoulder

    M75.100 - M75.122- Opens in a new window Unspecified rotator cuff tear or rupture of unspecified shoulder, not specified as traumatic - Complete rotator cuff tear or rupture of left shoulder, not specified as traumatic

    M75.30 - M75.32- Opens in a new window Calcific tendinitis of unspecified shoulder - Calcific tendinitis of left shoulder

    M75.50 - M75.52- Opens in a new window Bursitis of unspecified shoulder - Bursitis of left shoulder

    References  

    Centers for Medicare and Medicaid LCD Title Manipulation Under Anesthesia (MUA) L33594

    Medical Policy Committee History and Revisions  

    Date

    Action

     

     

    Pediatric Multidisciplinary Feeding Therapy

    Policy PDF

    Policy Name: Pediatric Multidisciplinary Feeding Therapy

    Policy Number: CMO 504

    Effective Date of current policy: 9/1/2018

    Description and Scope

    This policy describes multidisciplinary pediatric feeding therapy and the indications for treatment.

    Position Statement

    • Outpatient Pediatric Multidisciplinary Intensive Feeding Programs are considered medically necessary when ALL of the following criteria are met:
      • The individual has received a comprehensive history, physical and behavioral evaluation.
      • The individual has had adequate treatment for any contributing underlying medical conditions without resolution of the feeding problem. Documentation of specific interventions attempted by the interdisciplinary team that have not resulted in improvement over the course of at least a two(2) month period.
      • A feeding disorder has been diagnosed in association with a medical, nutritional or behavioral problem.
      • The program will be provided by an interdisciplinary team that includes the following: a behavioral health therapist, speech and language pathologist/therapist, occupational therapist, registered dietitian, clinical coordinator and supervising physician.
      • An individualized treatment plan is provided that defines short term and long term objectives with measurable metrics and which reflect meaningful improvement.
      • The treatment plan must include active participation of the child’s parent or guardian.
      • Suboptimal score on nutritional assessment has been documented as indicated by any of the following:
        • Weight below the 3rd or 5th percentile for gestation-corrected age and sex on more than one occasion or
        • Weight less than 80 % of ideal weight for age, using the standard growth charts of the National Center for Health Statistics or
        • A rate of weight gain that causes a decrease in 2 or more major percentile lines over time (e.g., from 75th to 25th) or
        • A rate of daily weight gain less than that expected for age over the previous 2 months

    **Note: Regular documentation supporting significant progress toward treatment is required to determine the medical necessity of continuation of a pediatric intensive multidisciplinary feeding program.

    • Inpatient Pediatric Multidisciplinary Intensive Feeding Programs are considered medically necessary when ALL of the following criteria are met:
      • Individual meets above criteria for an outpatient pediatric intensive multi-disciplinary feeding program
      • There is documented failure or contraindication for an outpatient intensive multi-disciplinary feeding program
      • Individual is stable medically and is capable of participating in an inpatient multidisciplinary intensive feeding program
    • A pediatric intensive multidisciplinary feeding program is considered not medically necessary for any of the following:
      • When the individual’s condition is such that it would be medically appropriate to receive services in a less intensive setting (e.g., home feeding program can be utilized)
      • Treatment provided is to prevent or slow deterioration in function or prevent reoccurrences
      • Significant therapeutic improvement is not expected within two months
      • Therapy that duplicates services already being provided as part of an authorized therapy program through another therapy discipline
      • Swallowing/feeding therapy for food aversions in members that are meeting normal growth and developmental milestones
      • When coordinated multidisciplinary care is not provided or not required

    Background

    Feeding Disorders - This term refers to a condition in which a child is unable or refuses to eat and/or drink sufficient quantities of food to support normal growth for the individual age. This avoidant or restrictive food intake can result in significant organic, nutritional or emotional ramifications.

    Signs or symptoms of potential organic problems include dysphagia (difficulty swallowing), odynophagia (painful swallowing), choking, coughing or wheezing. Additional issues, although less urgent, may include growth failure, diarrhea and vomiting.

    Behavioral issues, including but not limited to developmental disabilities and autism spectrum disorder, are another major factor in treatment of feeding disorders.

    A comprehensive interdisciplinary team will usually include a behavioral health therapist, speech and language pathologist/therapist, registered dietitian, occupational therapist, clinical coordinator and supervising physician.

    Definitions

    Intensive Feeding Programs – Defined as a multidisciplinary approach to the assessment and management of complex swallowing and feeding disorders. These disorders are generally seen in younger children, unlike anorexia and bulimia which are commonly seen in adolescents and adults. However, some individuals up to the age of eighteen (18) may require the services of an intensive feeding program.

    Outpatient Intensive Feeding Program – This setting is usually the appropriate for most individuals who require multidisciplinary intensive feeding therapy.

    Inpatient Intensive Feeding Program – This setting is usually reserved for infants and children 3 years of age and under with a diagnosis of failure to thrive (FTT), [note: The American Academy of Pediatrics is moving away from the pejorative term, “Failure to Thrive”, recommending the use of “Pediatric Undernutrition”, as noted in its Bright Futures in Practice-Guidelines.], severe developmental or physical disabilities or following a surgical procedure.

    **The individual must have failed an outpatient multidisciplinary intensive feeding program or is unable to participate in an outpatient program because of a medical contraindication.

    Coding  

    Inclusion of a code in the following list does not imply that the procedure is medically necessary or that the code represents a covered benefit. Codes used to identify services associated with this policy may include (but may not be limited to) the following:

    CPT Codes

    Description

    92526

    Treatment of swallowing dysfunction and/or oral function for feeding

    99199

    Unlisted special service, procedure or report

    References

    • Peer Reviewed Publications:
    • Ayoob KT, Barresi I. Feeding disorders in children: taking an interdisciplinary approach. Pediatr Ann. 2007; 36(8):478-483.
    • Babbitt RL, Hoch TA, Coe DA, et al. Behavioral assessment and treatment of pediatric feeding disorders. J Dev Behav Pediatr. 1994; 15(4):278-291.
    • Borowitz KC, Borowitz SM. Feeding problems in infants and children: assessment and etiology. Pediatr Clin North Am. 2018 Feb;65(1):59-72.
    • Benoit D, Wang EE, Zlotkin SH. Discontinuation of enterostomy tube feeding by behavioral treatment in early childhood: a randomized controlled trial. J Pediatr. 2000; 137(4):498-503.
    • Brown J, Kim C, Lim A, et al. Successful gastrostomy tube weaning program using an intensive multidisciplinary team approach. J Pediatr Gastroenterol Nutr. 2014; 58(6):743-749.
    • Cooper-Brown L, Copeland S, Dailey S, et al. Feeding and swallowing dysfunction in genetic syndromes. Dev Disabil Res Rev. 2008; 14(2):147-157.
    • Crosby J, Duerksen DR. A prospective study of tube- and feeding-related complications in patients receiving long-term home enteral nutrition. JPEN J Parenter Enteral Nutr. 2007; 31(4):274-277.
    • Field D, Garland M, Williams K. Correlates of specific childhood feeding problems. J Paediatr Child Health. 2003; 39(4):299-304.
    • Gisel E. Interventions and outcomes for children with dysphagia. Dev Disabil Res Rev. 2008; 14(2):165- 173.
    • Greer AJ, Gulotta CS, Masler EA, Laud RB. Caregiver stress and outcomes of children with pediatric feeding disorders; Field D, Garland M, Williams K. Correlates of specific childhood feeding problems. J Paediatr Child Health. 2003; 39(4):299-304.
    • Gisel E. Interventions and outcomes for children with dysphagia. Dev Disabil Res Rev. 2008; 14(2):165- 173.
    • Greer AJ, Gulotta CS, Masler EA, Laud RB. Caregiver stress and outcomes of children with pediatric feeding disorders treated in an intensive interdisciplinary program. J Pediatr Psychol. 2008; 33(6):612- 620.
    • Kane ML. Pediatric failure to thrive. Clin Fam Pract. 2003; 5(2):293-311.
    • Kodak T, Piazza CC. Assessment and behavioral treatment of feeding and sleeping disorders in children with autism spectrum disorders. Child Adolesc Psychiatr Clin N Am. 2008; 17(4):887-905.
    • Krugman SD, Dubowitz H. Failure to thrive. Am Fam Physician. 2003; 68(5):879-884.
    • Lifschitz CH. Feeding problems in infants and children. Curr Treat Options Gastroenterol. 2001; 4(5):451- 457.
    • Manikin R, Perman JA. Pediatric feeding disorders. J Clin Gastroenterol. 2002; 30(1):34-46.
    • Marshall DD. Primary care follow-up of the neonatal intensive care unit graduate. Clin Fam Pract. 2003; 5(2):243-263.
    • Mathisen B, Worrall L, Masel J, et al. Feeding problems in infants with gastro-oesophageal reflux disease: a controlled study. J Paediatr Child Health. 1999; 35(2):163-169.
    • Piazza CC. Feeding disorders and behavior: what have we learned? Dev Disabil Res Rev. 2008; 14(2):174- 181.
    • Raynor P, Rudolf MC. Anthropometric indices of failure to thrive. Arch Dis Child. 2000; 82(5):364-365. Rogers B. Feeding method and health outcomes of children with cerebral palsy. J Pediatr. 2004; 145(2 Suppl):S28-S32.
    • Rommel N, De Meyer AM, Feenstra L, Veereman-Wauters G. The complexity of feeding problems in 700 infants and young children presenting to a tertiary care institution. J Pediatr Gastroenterol Nutr. 2003; 37(1):75-84.
    • Ross ES, Browne JV. Developmental progression of feeding skills: an approach to supporting feeding in preterm infants. Semin Neonatol. 2002; 7(6):469-475.
    • Rudolph CD, Link DT. Feeding disorders in infants and children. Pediatr Clin North Am. 2002; 49(1):97- 112.
    • Saarilehto S, Lapinleimu H, Keskinen S, et al. Growth, energy intake, and meal pattern in five-year-old children considered as poor eaters. J Pediatr. 2004; 144(3):363-367.
    • Schädler G, Süss-Burghart H, Toschke AM, et al. Feeding disorders in ex-prematures: causes--response to therapy--long term outcome. Eur J Pediatr. 2007; 166(8):803-808.
    • Schreck KA, Williams K, Smith AF. A comparison of eating behaviors between children with and without autism. J Autism Dev Disord. 2004; 34(4):433-438.
    • Sharp WG, Stubbs KH, Adams H, et al. Intensive, manual-based intervention for pediatric feeding disorders: results from a randomized pilot trial. J Pediatr Gastroenterol Nutr. 2016; 62(4):658-663. Sheppard JJ. Using motor learning approaches for treating swallowing and feeding disorders: a review. Lang Speech Hear Serv Sch. 2008; 39(2):227-236.
    • Sigman GS. Eating disorders in children and adolescents. Pediatr Clin North Am. 2003; 50(5):1139-1177. Silverman AH, Kirby M, Clifford LM, et al. Nutritional and psychosocial outcomes of gastrostomy tube- dependent children completing an intensive inpatient behavioral treatment program. J Pediatr Gastroenterol Nutr. 2013; 57(5):668-672.
    • Tack J, Talley NJ, Camilleri M, et al. Functional gastroduodenal disorders. Gastroenterology. 2006; 130(5):1466-1479.
    • Vohr BR, Wright LL, Dusick AM, et al. Neurodevelopmental and functional outcomes of extremely low birth weight infants in the National Institute of Child Health and Human Development Neonatal Research Network, 1993-1994. Pediatrics. 2000; 105(6):1216-1226.
    • Government Agency, Medical Society, and Other Authoritative Publications:
    • American Speech-Language-Hearing Association (ASHA) position statement. Roles of speech-language pathologists in swallowing and feeding disorders. 2005. Available at: http://www.asha.org/policy/ps2005-00112.htm.
    • CDC Growth Charts. Available at: http://www.cdc.gov/growthcharts/.

    Medical Policy Committee History and Revisions

    Date

    Action

    July 24, 2018

    Initial approval by Medical Policy and Benefits Committee

  • Disclaimer

    Affinity Health Plan has developed medical policies that serve as one of the sets of guidelines for coverage decisions. Benefit plans vary in coverage and some plans may not provide coverage for certain services discussed in the medical policies. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and/or federal law. Medical policy does not constitute plan authorization, nor is it an explanation of benefits. The policies are not medical advice. Affinity Health Plan reserves the right to change medical policies.