|
Treatment &
Diagnosis:
|
Ablative Fractional
Laser (AFL) treatment including Carbon Dioxide Laser and Erbium:
Yttrium-Aluminum Garnet Laser for symptomatic scars resulting from
burns and other trauma
|
|
Effective Date:
|
February 24,
2021.
|
|
Termination Date:
|
February 23,
2026.
|
|
Preauthorization:
|
Not required.
|
|
Coverage Guidelines:
|
AFL (CPT 0479T
and 0480T) for the treatment of symptomatic burns and scars is covered
for one or more of the following symptoms: itch, burn, pain, tightness,
ulcerations or physical functional impairment.
|
|
|
Examples of physical
functional impairment include, but are not limited to: decreased
range of motion with use of associated body part; problems with
communication, respiration, eating, swallowing; visual impairments;
skin integrity; distortion of nearby body parts; or obstruction
of an orifice.
|
|
|
EXCLUSIONS:
|
|
|
• AFL
treatments for social, emotional and psychological impairment or
potential impairments are excluded.
|
|
|
• AFL
treatments performed solely for cosmetic purpose is excluded unless
otherwise covered under Chapter 4, Section 2.1.
|
|
|
TED Special Processing
Code: AT
|
|
Reimbursement:
|
The contractor
shall reimburse CPT codes 0479T/0480T for professional services
at rates equivalent to the CPT codes 17280/17286. The contractor
shall update the reimbursement rates for CPT codes 0479T/0480T each
time TRICARE updates the CHAMPUS Maximum Allowable Charge (CMAC)
rates for CPT codes 17280/17286.
|
|
|
|
Treatment & Diagnosis:
|
Digital Breast Tomosynthesis
(DBT) for Breast Cancer Screening
|
|
Effective Date:
|
January 1, 2020.
|
|
Termination Date:
|
December 31, 2024.
|
|
Preauthorization:
|
Not required.
|
|
Coverage Guidelines:
|
Digital Breast Tomosynthesis
(DBT), also known as three-dimensional mammography, for breast cancer
screening (Current Procedural Terminology (CPT) procedure codes
77063 and 77067) may be covered annually instead of the conventional
two-dimensional screening mammography.
|
|
|
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:
|
|
|
• History of breast cancer, Ductal
Carcinoma In Situ (DCIS), Lobular Carcinoma In Situ (LCIS), Atypical Ductal
Hyperplasia (ADH), or Atypical Lobular Hyperplasia (ALH);
|
|
|
• Extremely dense breasts when
viewed by mammogram;
|
|
|
• Known BRCA1 or BRCA2 gene mutation;
|
|
|
• First-degree relative (parent,
child, sibling) with a BRCA1 or BRCA2 gene mutation, and have not had
genetic testing themselves;
|
|
|
• Radiation therapy to the chest
between the ages of 10 and 30 years; or
|
|
|
• History of Li-Fraumeni, Cowden,
or Bannayan-Riley-Ruvalcaba syndrome, or a first-degree relative with
a history of one of these syndromes.
|
|
|
The contractor shall cover
DBT under the provisional coverage policy as a primary preventive
breast cancer screening otherwise covered under 32 CFR 199.4(e)(28). Thus, the contractor
shall not charge copayments or cost-shares associated with this
service. The contractor shall not charge TRICARE Select enrollees
a cost-share when the enrollee receives this service from network
or non-network providers. The contractor shall not require TRICARE
Prime enrollees to have a referral or authorization when the enrollee
receives this service from any network provider within their region
of enrollment. If a TRICARE Prime clinical preventive service is
not available from a network provider (e.g., a network provider
is not available within prescribed access parameters), the contractor
shall allow an enrollee to receive the service from a non-network
provider with a referral from the Primary Care Manager (PCM). If
a TRICARE Prime enrollee uses a non-network provider without first
obtaining a referral from the PCM, the contractor shall apply the
Point of Service (POS) option for payment. |
|
|
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 (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
|
|
|
|
• 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
|
|
|
|
2. Acetabular retroversion
(the alignment of the mouth of the acetabulum does not face the normal
anterolateral direction, but inclines more posterolaterally); or
|
|
|
|
3. Os acetabuli (an ossicle
located at the acetabular rim); or
|
|
|
|
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.
|