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We are interested in hearing what you have to say. What thoughts or opinions do you have on these coverage guidelines?
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PROVIDE FEEDBACK
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| Click here to learn how the coverage guidelines were developed. |
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Search Results
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Abdominoplasty (Panniculectomy, Abdominal Suction-Assisted Lipectomy or Liposuction)
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Abdominoplasty, also known as a tummy tuck, is a surgical procedure involving the removal of excess skin and fat from the middle and lower abdomen in order to tighten the abdominal wall muscles. A panniculectomy is a surgical procedure designed to remove a panniculus (excess ?apron? or accumulation of fat) from the abdomen and generally does not include tightening of the abdominal muscles. Abdominal suction-assisted lipectomy or liposuction is a surgical procedure designed simply to remove fat under the abdominal skin to improve appearance. |
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Actiq (oral transmucosal fentanyl citrate)
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Actiq, also called oral transmucosal fentanyl citrate (OTFC), is a powerful narcotic used to relieve breakthrough pain in cancer patients who are already receiving opioids and are tolerant of opioid therapy for their underlying persistent cancer pain. Each OTFC unit is a lozenge containing fentanyl. The lozenge allows drug delivery through the oral mucosa resulting in rapid pain relief. |
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Acupuncture
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Acupuncture is a Chinese medical practice that involves the insertion of hair-thin needles into nonanatomic energy channels, called meridians. Acupuncture has been used as a way to control nausea and vomiting, pain, and addictive behaviors. |
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Air Ambulance
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Air medical services transport critically ill or injured patients via air ambulance to a medical facility. |
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Amevive (alefacept)
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Amevive (alefacept) is a biologic drug indicated for the treatment of moderate-to-severe chronic plaque psoriasis. Amevive blocks and eliminates certain T-cells that play a role in psoriasis |
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Amniotic Membrane (AM) Transplantation of the Eye
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Amniotic membrane (AM) transplantation is a procedure that utilizes amniotic membrane tissue to reconstruct damaged ocular surfaces and promote healing of corneal, conjunctival and eyelid tissues after injury due to trauma, disease or surgery. |
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Aranesp
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Darbepoetin alfa is an erythropoiesis stimulating protein, closely related to erythropoietin, that is produced in Chinese hamster ovary cells by recombinant DNA technology. Darbepoetin alfa is a 165-amino acid protein that differes from recombinant human erythropoietin (epoetin alfa) in containing 5 N-linked oligosaccharide chains, whereas epoetin alfa contains 3 chains. The two additional N-glycosylation sites result from amino acid substitutions in the erythropoietin peptide backbone. The additional carbohydrate chains increase the approximate molecular weight of the glycoprotein from 30,000 to 37,000 daltons. Darbepoetin alfa is formulated as a sterile, colorless, preservative-free protein solution for intravenous or subcutaneous administration. |
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Artificial Intervertebral Disc Replacement
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Artificial intervertebral disc replacement is a medical device used as an alternative to spinal fusion in patients with degenerative disc disease (DDD). Also known as the Charite? Artificial Disc, the design of the device allows the spine to move.
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Autism-Related Services
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Autism is a biologically based neurodevelopmental disability that develops prior to age three. Autism is referred to as a developmental disability. An autistic child is unable to use language meaningfully or to process information from the environment. In addition to social and communicative deficits, characteristics of autism include language-based cognitive deficits, restricted and repetitive behaviors and interests and a predictable clinical course. Autism can range from mild disorders that are amenable to therapy, resulting in individuals becoming functional, independent adults to the severely impaired, who usually have significant mental retardation requiring long-term care. |
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Back Braces
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Back bracing supports the back following injury or surgery and may decrease associated back pain. |
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Bariatric Revision Surgery
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Revisional bariatric surgery is a repeat bariatric surgical procedure performed in patients who fail to achieve adequate weight loss following an initial bariatric surgical procedure. Revised surgery is also performed on patients who lose adequate weight with an initial bariatric surgery, then re-gain the weight.
Revisional bariatric surgery may also be performed due to early complications of the initial surgery. This guideline does not address revisional surgery for this indication. This guideline was written to address the issue of repeat bariatric surgery to enhance weight loss following initial surgery and patients who re-gain weight due to non-compliance following initial surgery.
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Birmingham Hip Resurfacing System
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The Birmingham Hip Resurfacing (BHR) System is a metal on metal resurfacing system that was designed as an alternative to traditional total hip replacement (THR). The ball of the femur is resurfaced with a metal shell rather than being removed and replaced and the damaged surface of the hip socket is also resurfaced.
The BHR System conserves more of the patient?s own bone and is intended for patients who may not be suitable for total hip replacement due to their relatively young age or increased activity level because of increased possibility of requiring future hip join revision.
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Bone Density Testing
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Bone mineral density (BMD) testing evaluates bone loss in patients with strong risk factors for osteoporosis; to diagnose suspected osteomalacia or osteodystrophies; and to examine changes in bone associated with disease progression or response to therapy. |
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Bone Growth Stimulators
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Bone growth stimulation is used to assist the healing of fresh or nonunion/delayed union bone fractures. Bone growth stimulation is performed via electrical or ultrasound stimulation through invasive, semi-invasive, or noninvasive means. Interferential therapy has also been mentioned as a bone growth stimulator. Interferential therapy is a specific type of transcutaneous electrotherapy in which two slightly different, medium-frequency alternating currents are applied simultaneously through electrodes placed on the skin overlying the affected area of the body. |
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Boniva (Ibandronate) Injection
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Boniva injection is the first intravenous (IV) medication approved by the U.S. Food and Drug Administration (FDA) for the treatment of postmenopausal osteoporosis. Boniva injection belongs to the bisphosphonate class of drugs and is administered to patients once every 3 months.
The action of ibandronate on bone tissue is based on its affinity for hydroxyapatite, which is part of the mineral matrix of bone. Ibandronate inhibits osteoclast activity and reduces bone resorption and turnover. In postmenopausal women, it reduces the elevated rate of bone turnover, leading to, on average, a net gain in bone mass.
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Botulinum Toxin
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Botulinum toxin (BTX), administered in small doses, controls muscle spasms by temporarily weakening or paralyzing nerves. Other names for botulinum toxin include: BTX-A, known commercially as Botox; BTX-B known commercially as Myobloc. |
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Breast MRI
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In the past, MRI has been utilized for examinations of the internal organs or musculoskeletal system. However, in the mid-1990?s researchers began to investigate the use of MRI for breast cancer detection/diagnosis. In March 2007 the American Cancer Society published its recommended guidelines for use of the MRI for breast screening. |
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Breath Tests for Airway Inflammation
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Exhaled breath tests are non-invasive techniques proposed to verify markers for airway inflammation. Mainly used for the management of asthma, exhaled breath tests may also be used to evaluate other respiratory disorders that have an inflammatory component. |
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Capsule Endoscopy
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Capsule endoscopy is a diagnostic procedure performed to visualize the esophagus or small bowel. The PillCam SB (small bowel) Capsule Endoscopy, formerly known as the Given Diagnostic System, is a noninvasive diagnostic imaging device for use in viewing the small bowel. The PillCam ESO (esophageal) is intended for use as a diagnostic tool in the detection of abnormalities of the esophagus, such as gastroesophageal reflux disease (GERD), Barrett?s esophagus, and esophageal varices. |
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Cardiac Rehabilitation
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Cardiac rehabilitation is the process of supervised exercise and education that leads the post-coronary patient to improved exercise capacity and risk factor management. |
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Carticel
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Autologous chondrocyte transplantation (ACT) or autologous chondrocyte implantation (ACI) is a procedure utilized to treat traumatic cartilage defects of the knee joint. Chondrocytes (cartilage cells) are biopsied during arthroscopy (introduction of a thin fiberoptic scope into the knee to allow direct visualization of internal structures) and cultured in a laboratory. After 14 to 21 days, a surgeon performs an arthrotomy (incision into the knee joint), and injects the cultured chondrocytes under a periosteal flat at the site of the defect. The injected chondrocytes are intended to create new cartilage development in the knee joint. |
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Celiac Plexus Block
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Celiac plexus block (CPB) or neurolysis (CPN) are established techniques for relieving pain associated with cancers of the upper abdomen, particularly pancreatic cancer. The celiac plexus is primarily a sympathetic nervous system structure that transmits both visceral afferent and efferent information for the majority of the upper abdominal viscera.
CPB may also be referred to as splanchnic nerve block.
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Chemotherapy Administration in the Home
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Home chemotherapy is a safe and acceptable alternative to outpatient and inpatient hospital treatment. Home-based therapy is not possible or appropriate for all patients. Complex or prolonged chemotherapy regimens or those associated with a risk of an immediate serious complication are more appropriately administered at a hospital. However, many commonly administered chemotherapy regimens are suitable for administration in the home. |
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Cochlear Implants, Auditory Brainstem Implants
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A cochlear implant is an electronic device that can provide improved speech and hearing communication abilities for people who have severe to profound hearing loss in both ears. The implant is surgically placed under the skin behind the ear. It generally consists of four parts: a microphone, which picks up sound from the environment; a speech processor, which is externally worn or carried and arranges the sound transmitted by the microphone; a receiver/stimulator that receives signals from the speech processor and converts them into electrical impulses; and electrode(s), which collect the impulses from the stimulator and sends them to the brain. |
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Consensus Interferon for Chronic Hepatitis C
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Interferon alfacon-1 (consensus interferon) is a nonnaturally occurring, synthetic recombinant type-1 interferon used to treat chronic hepatitis C administered by subcutaneous injection. Consensus interferon was developed by assigning the most commonly observed amino acid of several natural interferon alfa subtypes to develop a novel type I interferon.
The trade name for consensus interferon is Infergen.
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Copaxone (glatiramer acetate)
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Glatiramer acetate (GA) is the first non-interferon maintenance immunotherapy for multiple sclerosis (MS). GA is a random polypeptide consisting of four amino acids in a specific molar ratio. GA is a disease-modifying drug, formerly known as copolymer-1. |
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CPAP (Continuous Positive Airway Pressure)
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Obstructive sleep apnea (OSA) is a condition characterized by periods of breathing cessation (apnea) and reduced breathing (hypopnea) due to upper airway collapse secondary to relaxation of pharyngeal dilating muscles during sleep. The number of breathing disturbances per hour of sleep, otherwise known as the apnea-hypopnea index (AHI) or respiratory distress index (RDI) is a measure of disease severity. Patients with OSA frequently complain of unrefreshing sleep, excessive daytime sleepiness, and impairment in cognitive tasks.
CPAP, a noninvasive treatment for OSA, administers low levels of continuous air pressure to prevent the collapse of the oropharynx. The CPAP apparatus consists of an airflow generator, tubing, and a facemask fitted to the patient. CPAP provides symptomatic treatment but does not correct the underlying pathological condition.
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CPAP Titration during Polysomnography
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To determine the appropriate pressure setting for CPAP, patients undergo a titration sleep study. CPAP, a noninvasive treatment for obstructive sleep apnea (OSA), administers low levels of continuous air pressure to prevent the collapse of the oropharynx. The CPAP apparatus consists of an airflow generator, tubing, and a facemask fitted to the patient. CPAP provides symptomatic treatment but does not correct the underlying pathological condition.
Split-night polysomnography (PSG) is a combination sleep study where the first half of the night provides a diagnostic baseline PSG, and if this study indicates OSA, the second half of the night is used for CPAP evaluation and titration. Split-night PSG is considered as an alternative to full-night PSG followed by a second night PSG with CPAP titration in selected patients with OSA
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Deep Brain Stimulation
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Deep brain stimulation (DBS) is used for the treatment of movement disorders and control of tremor in patients diagnosed with Parkinson?s disease (PD) or essential tremor (ET). An electrode is surgically implanted into the ventral intermediate nucleus (Vim), the internal globus pallidus (Gpi) or the subthalamic nucleus (STN) of the brain and connected to a pulse generator implanted in the chest. When activated, the system delivers a mild electrical stimulation that blocks the dysfunctional brain signals that cause tremor. The patient can activate and deactivate the device by waving a hand held magnet over the pulse generator. DBS is an alternative to pallidotomy and thalamotomy because, unlike these surgeries, DBS is reversible since no permanent lesion is created. |
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Dental Services: Anesthesia and Facility Benefit
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General anesthesia is an induced state of unconsciousness accompanied by partial or complete loss of protective reflexes, including the ability to independently maintain an airway and respond purposefully to physical stimulation or verbal command. When a child or a person of any age with a disability needs extensive dental treatment, general anesthesia may recommended making delivery of that require treatment possible in a safe and comfortable manner. |
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Diabetes Self-Management Education and Medical Nutrition Therapy
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Diabetes self-management education is the process of providing an individual with diabetes the knowledge and skills to perform self-care on a day-to-day basis.
Self-management education is delivered by an interdisciplinary team comprised of at least 1) a registered dietitian and 2) a Certified Diabetes Educator (preferred)*, who is either a registered nurse or other health professional. The education program should provide comprehensive instruction including, but not limited to, the disease process, nutrition, exercise and activity, medications, behavior change strategies, and the relationship among nutrition, exercise, medication, and blood glucose levels.
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Diabetes Self-Monitoring Devices
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Glucose monitoring is the cornerstone of diabetes care. There are many devices diabetic patients may use to self-monitor glycemic status as part of their daily routine. By self-monitoring, diabetic patients can more effectively manage their condition and reduce incidence of complications. Monitoring devices range from implantable to non-invasive. The fingerstick is the standard method of self-monitoring glycemic status. A continuous glucose monitoring system monitors the glucose levels in a patient continuously over a two to three day period |
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Durable Medical Equipment (DME)
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Medical equipment covers a wide range of products used in a variety of health-care settings and includes such items as needles, syringes, walking aids, and blood glucose monitors. A medical device is any instrument, apparatus, appliance, material, or health-care product, excluding drugs, used for a patient for the purpose of diagnosis, prevention, monitoring, treatment, or alleviation of disease, injury, or handicap. |
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EEG-Video Monitoring
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Electroencephalographic (EEG)-video monitoring is the simultaneous documentation of the clinical and electroencephalographic symptoms of seizures. The patient is recorded on video to allow frequent viewing of the clinical sequence so that a patient?s symptoms can be compared to identify seizures. This technology improves patient outcome by allowing the proper identification of the symptoms for accurate diagnosis and therapy. Video-EEG monitoring is sometimes referred to as ictal EEG monitoring. |
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Electrical Bladder Stimulation for the Treatment of Urinary Incontinence
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Electrical stimulation is performed to modify bladder/sphincter actions in an effort to decrease or eliminate urinary incontinence. Electrodes are placed vaginally, anally, percutaneously, or sacrally. A mild electrical current is then applied to the pelvic floor muscles or to the lower spine. Electrical stimulation can make lower pelvic muscles stronger, thus reducing or eliminating incontinence (Appendix A describes each form of incontinence). Sacral nerve electrical stimulation for urinary incontinence applies mild electrical stimulation of the sacral nerve through a system that is surgically implanted under the skin of the abdomen. |
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Electrical Stimulators for Pain
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Transcutaneous electrical nerve stimulation (TENS) and interferential current stimulation (ICS) are the two most common forms of transcutaneous electrical stimulation used for pain management therapy. Both therapies send electrical impulses from a portable, battery-powered pulse generator using skin electrodes placed over the affected tissue. ICS differs from TENS by allowing the electrical impulses to have a deeper penetration of the tissue.
Percutaneous neuromodulation therapy (PNT) uses very fine, acupuncture-like needles inserted into the tissues surrounding the spine. Electrical current is applied to the needles which are then thought to stimulate peripheral nerves. This treatment cannot be used at home; it is intended for use by a physician.
Pulsed electrical stimulation (PES) is another non-invasive, low amplitude device designed to decrease pain and increase function in patients with osteoarthritis (OA) of the knee. The device consists of a signal generator, signal applicator, and contact elements encased in a soft wrap with a Velcro closure, which is wrapped around the affected knee.
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Enbrel (etanercept)
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Tumor necrosis factor (TNF)-alpha circulates in the bloodstream and plays an important role in the inflammatory process in the body. Overproduction of TNF-alpha may lead to some diseases associated with inflammation, such as Crohn?s disease (CD) and rheumatoid arthritis (RA).
The FDA has approved three anti-TNF-alpha biologic agents: Remicade (infliximab) (IV), Enbrel (etanercept) (SC injection), and Humira (adalimumab) (SC injection).
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Epidural Steroid Injections for Pain Management
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An epidural steroid injection (ESI) for pain management is used to relieve nerve root irritation (radicular pain or sciatica) due to bone encroachment or disk herniation in the spine. Selective or single nerve root injections refer to the specific nerve root targeted for the epidural injection; these areas can be cervical, thoracic, lumbar, and caudal. Transforaminal injections are a type of epidural injection in which fluoroscopic visualization is necessary for proper direction of the needle, and contrast medium is used to document adequate periradicular flow. |
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Erythropoietic Stimulation Therapy (Epoetin alfa and Aranesp)
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Epoetin alfa is a manufactured version of human erythropoietin (EPO). EPO is produced naturally in the body and stimulates the bone marrow to produce red blood cells. If the body does not produce enough EPO, severe anemia can occur. This often occurs in people whose kidneys are not working properly.
Epoetin alfa is marketed under the brand names Epogen and Procrit. Aranesp, darbepoetin alfa, has been recently approved by the FDA. Aranesp has a longer terminal half-life than Epoetin alfa, allowing for less frequent administration than epoetin alfa.
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Extracorporeal Immunoadsorption (Prosorba)
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Extracorporeal immunoadsorption (ECI) utilizing a Prosorba? column is performed for moderate to severe rheumatoid arthritis (RA), idiopathic thrombocytopenia purpura (ITP), thrombotic thrombocytopenic purpura (TTP), and hemolytic uremic syndrome (HUS). For those patients with RA it is performed on adult patients with long standing disease who have failed or are intolerant to disease-modifying anti-rheumatic drugs (DMARDs). |
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Facet Joint Blocks for Chronic Pain
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Facet joint blocks are performed for diagnostic as well as therapeutic purposes. Facet blocks are performed to identify and treat facet (zygapophyseal) joint syndrome as a source of low back pain and cervical pain.
Facet block may also be referred to as intraarticular or medial branch block.
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Fentora
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Fentora, fentanyl citrate buccal tablet, is a powerful narcotic analgesic used to relieve breakthrough pain in cancer patients who are already receiving opioids and are tolerant to opioid therapy for their underlying persistent cancer pain. Each buccal tablet unit contains fentanyl citrate and is supplied in five dosage strengths: 100, 200, 400, 600, and 800mcg. The tablet utilizes an effervescent reaction at the buccal mucosa for rapid absorption and pain relief. |
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