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Treatment &
Diagnosis:
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Digital Breast
Tomosynthesis (DBT) for Breast Cancer Screening
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Effective Date:
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January 1, 2020.
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Termination
Date:
|
December 31,
2024.
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Preauthorization:
|
Not
required.
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Coverage Guidelines:
|
Digital Breast
Tomosynthesis (DBT), also known as three-dimensional mammography,
for breast cancer screening may be covered annually instead of the
conventional two-dimensional screening mammography.
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|
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For all women
beginning at age 40. Covered annually beginning at age 30 for women
who have a 15% or greater lifetime risk of breast cancer (according
to risk assessment tools based on family history such as the Gail
model, the Claus model, and the Tyrer-Cuzick model), or who have
any of the following risk factors:
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• History of breast
cancer, Ductal Carcinoma In Situ (DCIS), Lobular Carcinoma In Situ
(LCIS), Atypical Ductal Hyperplasia (ADH), or Atypical Lobular Hyperplasia
(ALH);
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• Extremely dense
breasts when viewed by mammogram;
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|
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• Known BRCA1
or BRCA2 gene mutation;
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• First-degree
relative (parent, child, sibling) with a BRCA1 or BRCA2 gene mutation,
and have not had genetic testing themselves;
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• Radiation therapy
to the chest between the ages of 10 and 30 years; or
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|
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• History of Li-Fraumeni,
Cowden, or Bannayan-Riley-Ruvalcaba syndrome, or a first-degree
relative with a history of one of these syndromes.
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|
|
TED Special
Processing Code: DB
|
|
|
|
Treatment &
Diagnosis:
|
Platelet Rich
Plasma Injections for the treatment of Musculoskeletal Conditions
|
|
Effective Date:
|
October 1, 2019.
|
|
Termination
Date:
|
September 30,
2024.
|
|
Preauthorization:
|
Not
required.
|
|
Coverage Guidelines:
|
Platelet Rich
Plasma (PRP) injections (Current Procedural Terminology (CPT) 0232T)
is covered when the following criteria are met:
|
|
|
• Patient is diagnosed
with mild to moderate chronic osteoarthritis of the knee; AND
|
|
|
|
• Conservative treatment such as physical
therapy, diet and exercise, has been unsuccessful after three months
or is contraindicated; AND
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|
|
|
• Radiographic evidence of osteoarthritis.
|
|
|
OR
|
|
|
• Patient is diagnosed
with lateral epicondylitis; AND
|
|
|
|
• Evidence of diagnosis on physical exam.
|
|
|
|
• Radiographic exam not required.
|
|
|
|
• Conservative treatment such as physical
and occupational therapy has been unsuccessful after three months
or is contraindicated.
|
|
|
TED Special
Processing Code: MC
|
|
|
Note: PRP shall
be prepared and stored in accordance with U.S. Food and Drug Administration
(FDA) regulation titled “Additional Standards for Human Blood and
Blood Products” found in 21 CFR, Section 640.34(D) Processing.
|
|
|
|
Treatment &
Diagnosis:
|
Open, Arthroscopic
and Combined Hip; Surgical for the treatment of Femoroacetabular
Impingement (FAI)
|
|
Effective Date:
|
January 1, 2016.
|
|
Termination
Date:
|
December 31,
2018.
|
|
Preauthorization:
|
Required.
|
|
Coverage Guidelines:
|
Open, arthroscopic
and combined hip surgery is covered when the following criteria
are met:
|
|
|
• Moderate to severe and persistent activity
limiting hip pain that is worsened by flexion activities.
|
|
|
• Physical examination consistent with the
diagnosis of FAI with at least one positive test required:
|
|
|
|
• Positive impingement
sign (pain when bringing the knee up towards the chest and then
rotating it inward towards the opposite shoulder); or
|
|
|
|
• Flexion Abduction
External Rotation (FABER) provocation test (the test is positive
if it elicits similar pain as complained by the patient or the range
of motion of the hip is significantly decreased compared to the
contra lateral hip); or
|
|
|
|
• Posterior inferior
impingement test (the test is positive if it elicits similar pain
as complained by the patient).
|
|
|
• Failure to improve with greater
than three months of conservative treatment (e.g., physical therapy, activity
modification, non-steroidal anti-inflammatory medications, intra-articular
injection, etc.). Requests shall include what conservative treatments
were used and how long; and
|
|
|
• Radiographic evidence of FAI:
|
|
|
|
• CAM:
|
|
|
|
1. Pistol-grip
deformity (characterized on radiographs by flattening of the usually
concave surface of the lateral aspect of the femoral head due to
an abnormal extension of the more horizontally oriented femoral
epiphysis); or
|
|
|
|
2. Alpha angle
greater than 50 degrees (measurement of an abnormal alpha angle
from an oblique axial image along the femoral neck); or
|
|
|
|
• Pincer:
|
|
|
|
1. Coxa profunda
(floor of the fossa acetabuli touching or overlapping the ilioischial
line medially); or
|
|
|
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2. Acetabular
retroversion (the alignment of the mouth of the acetabulum does
not face the normal anterolateral direction, but inclines more posterolaterally);
or
|
|
|
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3. Os acetabuli
(an ossicle located at the acetabular rim); or
|
|
|
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4. Protrusio
acetabuli (an anteroposterior radiograph of the pelvis that demonstrates
a center-edge angle greater than 40 degrees and medicalization of
the medial wall of the acetabulum past the ilioischial line); and
|
|
|
Absence of advanced
arthritis (i.e., Tönnis Grade 2 [small cysts, moderate joint space
narrowing, moderate loss of head sphericity] or Tönnis Grade 3 [large
cysts, severe joint space narrowing, severe deformity of the head]).
|
|
|
Inclusion criteria
must be documented.
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