Military Health System

2.1  Coverage for treatment of rare diseases may be considered on a case-by-case basis. In reviewing the case, the contractor is authorized to approve coverage when it is determined that the proposed treatment for the rare disease is medically necessary, including that the treatment is safe and effective.

2.2  If case review indicates that the proposed benefit for a rare disease is safe and effective for that disease, benefits may be allowed. If benefits are denied, an appropriate appealing party may request an appeal.

2.3  The contractor shall code TRICARE Encounter Data (TED) Record Special Processing Code “RD - Rare Diseases” on all TED records where the contractor has approved treatment for a rare disease. Assignment of Special Processing Code RD will allow the DHA to identify procedures approved by contractors under the Rare Diseases policy and will allow bypass of TED edit 2-160-01R when the procedure code is on the No Government Pay Procedure Code List.

2.4  The contractor shall provide a monthly report. For reporting requirements, see DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the applicable contract. The report should not include the rare disease treatments previously approved for coverage and listed herein.

2.5  Off-label use of rituximab may be considered for cost-sharing for the following treatments:

2.6  Effective May 13, 2009, Intraperitoneal Hyperthermic Chemotherapy (IPHC) (Current Procedural Terminology (CPT) codes 77600, 77605, and 96445) in conjunction with cytoreductive surgery or peritonectomy for treatment of pseudomyxoma peritonei resulting from appendiceal carcinoma may be covered on a case-by-case basis for adult patients when all of the following criteria are met:

2.7  Effective January 21, 2009, External Infusion Pumps (EIPs) for insulin may be considered for cost-sharing when the diagnosis is Cystic Fibrosis-Related Diabetes (CFRD) with fasting hyperglycemia. See Chapter 8, Section 2.3 for policy regarding EIPs.

2.8  Post-operative proton beam radiosurgery/radiotherapy (CPT codes 77520, 77522, 77523, and 77525) may be considered for cost-sharing when the diagnosis is sacral chordoma. See Chapter 5, Section 3.1 for policy regarding proton beam radiosurgery/radiotherapy.

2.9  Extracorporeal photopheresis (CPT code 36522) may be considered for cost-sharing when the diagnosis is Bronchiolitis Obliterans Syndrome (BOS) that is refractory to immunosuppressive drug treatment. See Chapter 4, Section 9.2 for policy regarding photopheresis.

2.10  Effective May 1, 2008, the off-label use of Selective Internal Radiation Therapy (SIRT) with yttrium-90 microspheres (resin or glass) may be considered for cost-sharing for the treatment of unresectable liver metastases from neuroendocrine tumors. See Chapter 5, Section 3.2 for policy regarding brachytherapy/radiation therapy.

2.11  Effective April 15, 2016, Collagen Cross-linking for the treatment of corneal ectasia due to the rare disease Keratoconus is safe and effective and may be considered for cost-sharing.

2.12  Effective June 1, 2010, Radiofrequency Ablation (RFA), when performed using a United States (US) Food and Drug Administration (FDA) approved electrosurgical cutting and coagulation device, may be considered for cost-sharing for the treatment of liver metastases from gastric cancer.

2.13  Effective September 1, 2012, the NovoTTF-100A system (Healthcare Common Procedure Coding System (HCPCS) codes A4555 and E0766) may be cost-shared for the treatment of adult patients (22 years of age or older) with recurrent glioblastoma after surgical and radiation options have been exhausted.

2.14  Effective February 4, 2011, Radiesse® Voice laryngoplasty injections may be cost-shared for the treatment of type 1 laryngeal cleft (also described as supraglottic interarytenoid defects that extend no further than the true vocal folds).

2.15  Effective November 27, 1995, Orthotopic Liver Transplantation (OLT) may be cost-shared for the treatment of Crigler-Najjar Syndrome Type I. OLT may be performed both prior to the onset of neurological symptoms or after the onset of neurological symptoms.

2.16  Effective June 5, 2013, off-label use of intravenous immune globulin for the treatment of Hashimoto’s Encephalopathy, may be considered in exceptional circumstances where there is progressive neurologic decline despite appropriate steroid therapy or where steroid therapy is contraindicated.

2.17  Effective April 30, 2009, Intrapulmonary Percussive Ventilation (IPV) may be considered for cost-sharing when the diagnosis is Cystic Fibrosis (CF). See Chapter 8, Section 16.1 for policy regarding IPVs.

2.18  Effective January 4, 2013, allogeneic hematopoietic cell transplant (CPT code 38240) may be considered for cost-sharing for the treatment of primary plasma cell leukemia.

2.19  Effective February 1, 2008, the off-label use of Photodynamic Therapy (CPT code 67221) with Visudyne (HCPCS code J3396) may be considered for cost-sharing for the treatment of retinal astrocytic hamartoma in Tuberous Sclerosis.

2.20  Effective June 25, 2014, intracranial angioplasty with stenting (CPT code 61635) of the venous sinuses may be considered for cost-sharing for the treatment of pseudotumor cerebri (also known as idiopathic intracranial hypertension and benign intracranial hypertension).

2.21  Effective February 1, 2012, OLT (CPT code 47135) may be considered for cost-sharing for the treatment of Acute Intermittent Porphyria.

2.22  Effective December 1, 2014, Photodynamic Therapy may be considered for cost-sharing for the treatment of Central Serous Chorioretinopathy.

2.23  Effective July 22, 2016, chemotherapy injections (CPT code 96542) may be considered for cost-sharing for the treatment of Central Giant Cell Granuloma (CGCG) of the mandible.

2.24  Effective July 22, 2016, Peg interferon alfa-2A/180 (HCPCS code J3490) may be considered for cost-sharing for the treatment of CGCG of the mandible.

2.25  Effective August 11, 2016, a Fluorodeoxyglucose (FDG) PET scan (CPT code 78815) may be considered for cost-sharing for the treatment of Takayasu's Arteritis (also known as aortic arch syndrome).

2.26  Effective August 22, 2016, Gammagard liquid injections (HCPCS code J1569) may be considered for cost-sharing for the treatment of branch retinal artery occlusion secondary to Susac’s Syndrome.

2.27  Effective October 13, 2016, an autologous bone marrow transplant, the harvest of autologous stem cells, and the cryopreservation of stem cells may be considered for cost-sharing for the treatment of recurrent medulloblastoma.

2.28  Effective December 15, 2016, a Magnetic Resonance-guided High Intensity Focused Ultrasound (MRgFUS) may be considered for cost-sharing for the treatment of Desmoid fibromatosis.

2.29  Effective January 24, 2017, Stereotactic Body Radiation Therapy (SBRT) (CPT codes 77435 and 77373) may be considered for cost-sharing for the treatment of a benign neoplasm of the aortic body and other paraganglia.

2.30  Effective February 16, 2016, Proton Beam Therapy (PBT) may be considered for cost-sharing for the treatment of thymoma.

3.1  The off-label use of rituximab for the treatment of pediatric linear Immunoglobulin A (IgA) dermatosis is unproven.

3.2  Proton Beam Radiation Therapy (PBRT) for the treatment of juvenile nasal angiofibroma is unproven.

3.3  TRICARE Overseas Program (TOP) beneficiaries are not subject to the requirements of this policy.