Medical Policy Upcoming Updates

Addition to list of accepted procedures:

• Single anastomosis duodeno-ilial bypass with sleeve gastrectomy (SADI-S)
• Note: single-anastomosis duodenal switch as a stand-alone procedure (aka, stomach intestinal pylorus-sparing surgery; SIPS) continues to be investigative and therefore not covered.

Additional criteria added for individuals who have not attempted or are unable to complete the required length of conservative management prior to surgery:

• Conservative management must include either physical therapy or spinal manipulation, and documentation of either:
  • Assessment by the individual's physical therapist or spine surgeon stating the clinical reasons why conservative management is contraindicated, or
  • Assessment by the individual's physical therapist stating the clinical reasons (e.g., causes of progressive debilitating pain and/or disability) why physical therapy was not able to be complete.

• Addition of neurologic impairment to list of clinical indications.

All other criteria, including the neck disability index and Oswestry disability scores, remain unchanged.

Prior authorization is required for genetic testing for prostate cancer (PCa).

Gene expression profiling (GEP) assays, performed on prostate specimen from individuals with localized PCa, to guide subsequent management of the cancer, is medically necessary when all of the following criteria are met:

1. One of the following GEP tests:
   1. Decipher® Prostate Cancer Classifier Assay
   2. OncotypeDx® Genomic Prostate Score
   3. Prolaris®
   4. ProMark® Proteomic Prognostic Test.
2. One of the following criteria is met:
   1. If the individual has had a prostate biopsy, must meet all of the following:
      1. No previous GEP assay performed for PCa
      2. Localized adenocarcinoma of prostate (no evidence of metastasis or lymph node involvement)
      3. The individual has not received pelvic radiation or androgen deprivation therapy
      4. The individual falls into one of the following stages and risk stratifications as defined by the National Comprehensive Cancer Network (NCCN) guidelines:
         1. Low risk disease
         2. Favorable intermediate risk.
      5. The individual is a candidate for and is considering conservative therapy (active surveillance) and the test results will be used to determine treatment.
   2. If the member has had a radical prostatectomy (RP), must meet all of the following:
      1. Localized PCa (no clinical evidence of metastasis or lymph node involvement)
      2. No previous GEP assay performed for PCa
      3. The individual is being considered for postoperative secondary therapy (e.g., radiation/adjuvant therapy) due to the presence of cancer-recurrence risk factors
      4. The individual must have achieved initial PSA nadir (PSA at or below 0.2 ng/ml) within 120 days of RP surgery.
      5. The individual has not received any neo-adjuvant treatment prior to RP.
      6. The individual's surgical pathology report identified at least one adverse pathology in the surgical specimen as stated in the policy.

Additional criteria added for individuals who have not attempted or are unable to complete the required length of conservative management prior to surgery:

• Conservative management must include either physical therapy or spinal manipulation, and documentation of either:
  • Assessment by the individual's physical therapist or spine surgeon stating the clinical reasons why conservative management is contraindicated, or
  • Assessment by the individual's physical therapist stating the clinical reasons (e.g., causes of progressive debilitating pain and/or disability) why physical therapy was not able to be complete.

• Addition of neurologic impairment to list of clinical indications

All other criteria, including the Oswestry disability index scores, remain unchanged.

• Removed the medical necessity requirement that the ultrasound must be completed in a standing position.
• Several changes were made to the medical necessity criteria section that consist of combining similar vein treatments together condensing the policy. Please note that there were no changes made to the actual specific medical necessity criteria, other than that listed above.

Additional care recommendations added for routine prenatal care during the novel coronavirus pandemic (COVID-19), including:

• Consideration of virtual visits
• Masking and screening for fever and respiratory symptoms while in the clinic
• World Health Organization (WHO) recommendations on COVID-19 vaccine for pregnant women.

All other recommendations remain unchanged.