Medical Policy Updates

Notification of Policy Revisions Effective September 29, 2017 (Posted July 28, 2017)

 

Medical Policy Revision
BRAF Gene Mutation Testing to Select Melanoma or Glioma Patients for Targeted Therapy "Notification" Extensively revised Description and Policy Guidelines sections. Under “When Covered Section” added FDA approved MEK inhibitor (cobimetinib). Under "When Not Covered" section added investigational indication: "Testing for BRAF V600 variants in patients with glioma to select patients for targeted treatment is considered investigational." Policy title changed from 'BRAF Gene Mutation Testing to Select Melanoma Patients for BRAF Inhibitor Therapy" to "BRAF Gene Mutation Testing to Select Melanoma or Glioma Patients for Targeted Therapy." Senior Medical Director review 6/2017. Reference added. Notification given 7/28/2017 for policy effective date 9/29/2017.
Drug Testing in Pain Management and Substance Abuse Treatment "Notification" "When Covered" section extensively revised. Drug testing for pain management and in the setting of substance abuse treatment may be considered medically necessary when the documentation requirement are met. Urine drug testing is limited to two (2) specimens per rolling month and twelve (12) specimens per year. Standing orders for presumptive testing must be signed and dated no more than sixty (60) days prior to the date of specimen collection. In addition, testing must meet one of the following: A. Presumptive drug testing in the setting of outpatient pain management may be medically necessary for baseline screening prior to or at initiation of treatment; OR during subsequent monitoring of treatment when testing frequency does not exceed the following limits according to the risk level of the individual: Twice a year for patients who are low or moderate risk; OR Four times a year for patients who are high risk OR Receiving an opioid dose >120 mg MED/d; OR for patients demonstrating aberrant behavior. B. Presumptive drug testing in the setting of outpatient substance abuse treatment may be medically necessary for baseline screening at initiation and for ongoing treatment at a frequency of no more than once a week for 4 weeks during stabilization and no more than one a month during maintenance. Definitive drug testing in pain management or substance abuse treatment may be considered medically necessary when the criteria noted in the policy are met. C. Definitive drug testing in pain management or substance abuse treatment may be medically necessary when the criteria noted in the policy are met. D. Definitive urine drug testing for substance abuse treatment or chronic pain management may be medically necessary when a presumptive test for the relevant drug(s) is not commercially available; and the definitive testing is performed according to the medical necessity criteria for presumptive testing described above in Section A or B. Codes 0006U, 0007U, 0011U and 0015U added. Notification given 7/28/2017 for effective date 9/29/2017.
Modifier Guidelines "Notification" Modifier 54 (surgical care only) is not appropriate to use with fracture care codes for closed treatment without manipulation in the emergency department. Notification given 7/28/2017 for policy effective date of 9/29/2017.
TENS (Transcutaneous Electrical Nerve Stimulator) "Notification" Description Section updated to include information on Scrambler Therapy. The following was added to the When TENS is Not Covered: Transcutaneous electrical modulation pain reprocessing (Scrambler therapy with use of the Calmare® pain therapy device) is considered investigational for all indications. Policy Guidelines section updated. Reference added. Notification given 7/26/2017 for policy effective date 9/29/2017.