New medical policies
Effective August 1, 2018
Ablative Procedures of Peripheral Nerves to Treat Pain, 7.01.565
This replaces policy 7.01.154. Ablative procedures of peripheral nerves to treat pain for all indications are considered investigational for the following treatments: cooled radiofrequency ablation, cryoneuroloysis (cryoablation, cryotherapy, cryoanalgesia), or radiofrequency ablation.
Gene Expression Profiling for Cutaneous Melanoma, 12.04.146
Gene expression testing is considered investigational in the evaluation of patients with suspicious pigmented lesions, patients with melanocytic lesions with indeterminate histopathologic features, and patients with cutaneous melanoma.
Note: Effective January 4, 2019, the services originally described in this policy are reviewed by AIM Specialty Health®.
Three‐Dimensional Printed Orthopedic Implants, 7.01.161
Three-dimensional printed implants are considered medically necessary for custom implants for patients with bone or joint deformity. They are considered investigational for standard and patient-matched implants.
Revised medical policies
Effective August 1, 2018
Closure Devices for Patent Foramen Ovale and Atrial Septal Defects, 2.02.09
The policy is modified to state that the percutaneous transcatheter closure of a patent foramen ovale using Amplatzer PFO Occluder may be considered medically necessary to reduce the risk of recurrent ischemic stroke if patient meets all of the specified criteria.
Cranial Electrotherapy Stimulation and Auricular Electrostimulation, 8.01.58
Electrical stimulation of the ear (also known as auricular neurostimulation) for opioid withdrawal is considered investigational.
Drug Testing in Pain Management and Substance Use Disorder Treatment Settings, 2.04.513
This policy is revised as follows:
- The criteria for testing for pain management programs are differentiated from testing for substance use disorder treatment programs.
- The specific criteria for testing for pain management programs are expanded and modified to be consistent with the Washington State AMDG guidelines.
- The specific criteria for testing for substance use disorder treatment programs are expanded and modified to be consistent with ASAM guidelines.
- All limits on the number and frequency of tests for pain management programs are modified to be consistent with the Washington State AMDG guidelines.
- All limits on the number and frequency of tests for substance use disorder treatment programs are modified to be consistent with ASAM guidelines.
- Policy title is changed.
Electrical Stimulation Devices, 1.01.507
The policy is modified to state that pulsed electrical stimulation and pulsed electromagnetic therapy are considered investigational for any indication including but not limited to the treatment of osteoarthritis, rheumatoid arthritis, neuropathic pain (diabetic peripheral neuropathy), post‐operative or non‐postoperative pain, or wounds.
Transcatheter Pulmonary Valve Implantation, 7.01.131
The policy is revised to state that transcatheter pulmonary valve implantation is considered medically necessary for patients with congenital heart disease and current right ventricular outflow tract obstruction or regurgitation when specified indications are met.
Wearable Cardioverter Defibrillators as a Bridge to Implantable Cardioverter-Defibrillator Placement, 2.02.506
The policy statements are edited for clarity. These indications are added as investigational: post coronary artery bypass graft (CABG) surgery patients, high-risk patients awaiting heart transplant, patients with newly diagnosed nonischemic cardiomyopathy, and women with peripartum cardiomyopathy. (Policy replaced with InterQual® criteria, effective July 2, 2020.)