Autologous Chondrocyte Implantation in the Knee (III-SUR.35)
New Title: was Autologous Cultured Chondrocyte Transplantation for the Knee
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Re-Reviewed |
11/20/2019
Enhanced Benefit |
Medically necessary for a select population of patients |
Changes/additions to medical necessity criteria:
- The lesion can now be a single or multiple full thickness defect of the femoral condyle and/or patella.
- No longer requires a failed arthroscopic or other surgical repair prior to this surgery.
- Individual must try and fail non-surgical management for at least 6 weeks prior to surgery.
- No knee surgery, on the affected knee, within 6 months directly before evaluation for this surgery.
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Cervical Spine Surgeries (III-SUR.37) |
Re-Reviewed |
01/20/2020 |
Medically necessary for a select population of patients |
- Added facetectomy to the definitions and to the lists of procedures that require prior authorization.
- Added synthetic ceramic-based and bioactive glass bone substitutes/fillers to the examples of procedures considered investigative and therefore not covered.
- Updated Appendix 4, Demineralized Bone (DBM) Matrix Products.
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Lumbar Spine Surgeries (III-SUR.34) |
Re-Reviewed |
01/20/2020 |
Medically necessary for a select population of patients |
- Added facetectomy to the definitions and to the lists of procedures that require prior authorization.
- Added synthetic ceramic-based and bioactive glass bone substitutes/fillers to the examples of procedures considered investigative and therefore not covered.
- Updated Appendix 4, Demineralized Bone (DBM) Matrix Products.
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Positron Emission Tomography (PET) Scan (III-DIA.12) |
Re-Reviewed |
11/20/2019
Enhanced Benefit |
Medically necessary for a select population of patients |
Changes to medical necessity criteria:
- New section for sarcoidosis. PET is medically indicated for the diagnosis or monitoring of cardiac sarcoidosis and/or extracardiac sarcoidosis.
- PET is now medically indicated to differentiate diagnosis of fronto-temporal dementia (FTD) from Alzheimer disease (AD) when ordered by a neurologist and when the results will impact the treatment plan.
- Note: PET to diagnosis Alzheimer’s disease or dementia continues to be investigative and not covered.
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Spinal Cord Stimulation of the Dorsal Column for Treatment of Pain (III-DEV.23) |
Re-Reviewed |
01/20/2020 |
Medically necessary for a select population of patients |
Changes to medical necessity criteria:
- Added Protégé™ System (St. Jude Medical) to the examples of FDA approved devices.
- Removed the following contraindication: Administration of anticoagulant or antiplatelet therapy.
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Varicose Vein and Venous Insufficiency Treatments (III-SUR.26) |
Re-Reviewed |
11/20/2019
Enhanced Benefit |
Medically necessary for a select population of patients |
Change to Definitions:
Endovenous radiofrequency (RF) ablation and endovenous laser: added a statement that if more than one vein on the same leg needs to be ablated, they may be treated during the same visit.
Changes to Benefit Considerations:
- Sclerotherapy limitation was increased from one visit to two visits per leg within a 6 month period.
- Radiofrequency/laser ablation is limited to one visit per leg within a 6 month period.
- Additional visits for both sclerotherapy and ablation will require review by the medical director to determine medical necessity.
Changes to medical necessity criteria:
- Will no longer require a trial of compression stockings for any of the vein procedures listed.
- For treatment of significant small varicose veins, reflux duration is no longer required. However, a venous duplex scan will continue to be required to check for saphenous reflux/incompetence.
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