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Medical Policies - Procedures
| Procedures |
| Policy ID |
Subject |
58 |
Radiofrequency Thermal Facet Neural Ablation(RFT or facet neurotomy or facet rhizotomy)
Determination:
Molina Healthcare of New Mexico covers neural ablation for treatment of patients with intractable cervical or back pain with or without sciatica when ALL of the following are met:
- Patient has experienced severe pain limiting activities of daily living for at least 6 months; and
- Patient has had no prior spinal fusion surgery; and
- Neuroradiologic studies fail to confirm disc herniation; and
- Patient has no significant narrowing of the vertebral canal or spinal instability requiring surgery; and
- Patient has tried and failed conservative treatments such as bed rest, back supports, physiotherapy, correction of postural abnormality, and pharmacotherapies (e.g. anti-inflammatory agent, analgeics and muscle relaxants); and
- Trial of facet medial branch nerve block injections has eliminated the pain.
Only 1 treatment procedure per level per side is medically necessary and covered in a 12-month period.
References:
Hayes WS: Radiofrequency Ablation for Back Pain. Hayes Medical Technology Directory Review. 1999; RADI0101.17
Cho J, et al: Percutaneous radiofrequency lumbar facet rhizotomy in mechanical low back pain syndrome. Stereotact Funct Neurosurg. 1997;68(1-4 Pt1):212-217.
Lord SM, et al: Percutaneous radio-frequency neurotomy for chronic cervical zygapophyseal-joint pain. N Engl J Med. 1996;335:1721-1726.
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77 |
Work Hardening Programs
Determination:
Molina Healthcare of New Mexico does not cover work hardening programs as they are considered vocational training and not treatment of illness, injury, or other medical conditions.
References:
Schonstein E, Kenny DT, Keating J, et al. Work conditioning, work hardening and functional restoration for workers with back and neck pain (Cochrane Review) {In Process Citation} Cochrane Database Syst Rev (England), 2003, (1) pCD001822.
Joy JM, Lowy J, Mansoor JK Increased pain tolerance as an indicator of return to work in low-back injuries after work hardening. Am J Occup Ther (United States), Mar-Apr 2001, 55 (2) p200-5.
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78 |
Nebulized Anti-infective Sinusitis Therapy
Determination:
Molina Healthcare of New Mexico does not cover aerosolized antiinfective treatment for Sinusitis because there is no adequate published clinical evidence of the effectiveness of Aerosolized Antiinfectives in the treatment of sinusitis.
References:
SinusPharmacy. SinuNEB [website]. Carpinteria, CA: SinusPharmacy Inc.; 2001. http://www.sinuneb.com (accessed January 2003).
Scheinberg PA, Otsuhi A. Nebulized antibiotics for the treatment of acute exacerbations of chronic rhinosinusitis. Ear Nose Throat J. 2002; 81(9):648-652.
Desrosiers MY, Salas-Prato M. Treatment of chronic rhinosinusitis refractory to other treatments with topical antibiotic therapy delivered by means of a large-particle nebulizer: results of a controlled trial. Otolaryngol Head Neck Surg. 2001; 125(3):265-269.
Brooks I, Gooch WM 3rd, Jenkins SG, et al. Medical management of acute bacterial sinusitis. Recommendations of a clinical advisory committee on pediatric and adult sinusitis. Ann Otol Rhinol Laryngol Suppl. 2000; 182:2-20.
Antimicrobial treatment guidelines for acute bacterial rhinosinusitis. Sinus and Allergy Health Partnership. Otolaryngol Head Neck Surg. 2000; 123(1 Pt2):5-31.
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82 |
Orthognathic Surgery
Determination:
Orthognathic Surgery is the revision by ostectomy, osteotomy or osteoplasty of the upper jaw (maxilla) and/or the lower jaw (mandible) intended to alter the relationship of the jaws and teeth. Orthodontic treatment is usually required prior to orthognathic surgery. Expenses associated with the orthodontic phase of care are not covered under our medical plans (both pre- and post- surgical) as they are considered dental in nature.
Documentation and Referral Requirements
Molina Healthcare of New Mexico will extend coverage under our medical plan for orthognathic surgery to correct jaw and cranio-facial deformities causing significant functional impairment. The evidence for significant functional impairment will be provided by the treating practitioners.
The member's primary care practitioner must provide a written explanation of how the functional impairment impedes the member's ability to chew, speak, or swallow properly.
The Oral and Maxillofacial Surgeon must provide in writing:
- the physical evidence of current skeletal or craniofacial deformity;
- a detailed description of the functional impairment that is the direct result of the skeletal abnormality;
- where orthodontic therapy alone is unable to provide a satisfactory dental occlusion;
- the member's clinical course, including dates and nature of any previous treatment.
Non-covered Diagnoses:
The following diagnoses do not produce sufficient impairment or are not shown to be effectively treated by orthognathic surgery and are not eligible for coverage by Molina Healthcare of New Mexico:
- Myofacial pain dysfunction (MPD) and/or temporomadibular joint disease (TMD):
- Malocclusion that is correctable by a non-surgical procedure such as orthodontia.
- Speech pathology; hypernasal or hyponasal speech quality, articulatoory speech disorders.
- Chin surgeries: mentoplasty or genial osteotomies/ostectomies when performed as an isolated procedure to address genial hypoplasia or hypertrophy.
- Unasthetic facial features.
- Psychosocial Impairments.
References:
McCarthy JG, Stelnicki EJ, Grayson BH. Distraction osteogensis of the mandible: A ten-year experience. Semin Orthod. 1999;5(1):3-8.
Baker NJ, David S, Barnard DW, et al. Occlusal outcome in patients undergoing orthognathic surgery with internal fixation. Br J Oral Maxillofac Surg. 1999;37(2):90-93.
Lupori JP, Van Sickels JE, Holmgreen WC. Outpatient orthognathic surgery: Review of 205 cases. J Oral Maxillofac Surg. 1997;55(6):558-563.
Pravin K P, Hongshik H, et al. Craniofacial, Orthognathic Surgery.
E Medicine. December 27, 2001. http://www.emedicine.com
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99 |
Electrothermal Arthroscopic Surgery
Determination:
Molina Healthcare of New Mexico covers electrothermal arthroscopic capsulorrhapy, also known as elecrothermally-assisted capsule shift (ETAC), for the treatment of glenohumeral joint instability in patients with recurrent, unidirectional subluxation/dislocation who meet either of the following two criteria:
- Patients with laxity in an attenuated but otherwise intact shoulder capsule without presence of other pathology (e.g. Bankart lesion); or
- Patients who need adjunctive tightening of persistent capsular laxity as part of capsulolabral repair of Bankart lesion.
Molina healthcare of New Mexico does not cover electrothermal arthroscopy for ANY of the following because it is considered experimental and investigational, as scientific evidence does not permit conclusions concerning the long-term effects on patient outcomes:
- Large Hill-Sachs lesions (greater than 20% of the humeral head) or
- A bony Bankart lesion; or
- Multidirectional instability; or
- A severely deficient or very thin capsule; or
- A humeral-side avulsion of the capsule; or
- A history of previous shoulder surgery; or
- A frozen shoulder; or
- Adhesive capsulitis; or
- Hip, knee, and ankle instability
References:
CMS's Coverage Issues Manual on the following website: http://www.hcfa.gov.
Fitzgerald BT, et al. The use of thermal capsulorrhaphy in the treatment of multidirectional instability. J Shoulder Elbow Surg. 2002 Mar-Apr; 11(2):108-13.
Wong KL, et al. Complications of thermal capsulorrhaphy of the shoulder. J Bone Joint Surg Am. 2001;83-A Suppl 2 Pt 2:151-155.
Savoie FH 3rd, Field LD. Thermal versus suture treatment of symptomatic capsular laxity. Clin Sports Med. 2000 Jan;19(1):63-75.
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100 |
Prolotherapy
Determination:
Prolotherapy refers to the injection of sclerosing solutions into joints, muscles, or ligaments. The medical effectiveness of the above therapies has not been verified by scientifically controlled studies. Molina Healthcare of New Mexico does not cover Prolotherapy for any indications.
As early as 1978, the Medical Procedures Appropriateness Program of the Council of Medical Specialty Services (CMSS), based on input from the American Academy of Orthopedic Surgeons, the American Association of Neurological Surgeons, and the American College of Physicians, concluded that Prolotherapy had not been shown to be effective. Furthermore, the clinical practice guidelines of "Acute Low Back Problems in Adults" by the Agency for Health Care Policy and Research does not recommend ligamentous and sclerosant injections in the treatment of patients with acute low back pain.
References:
Hauser RA. Punishing the pain. Treating chronic pain with Prolotherapy. Rehab Manag. 1999; 12(2):26-28, 30. Leslie M. Injecting relief. Suffers of common aches and pains say they find relief in a new treatment called Prolotherapy. What do they know? WebMD Medical New, October 2, 2000.
Bigos S, etal. Acute Low Back Problems in Adults. Clinical Practice-Guideline No. 14, AHCPR Publication No. 95-0642, December 1994.
The Council of Medical Specialty services' (CMSS) Medical Procedure Appropriateness (MPA) program. August 1978.
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110 |
Ethanol Injection Neurolysis for Plantar Neuroma
Determination:
Molina Healthcare of New Mexico does not cover Ethanol Injection Therapy for the treatment of Plantar Neuroma because there is no adequate published clinical evidence of the effectiveness of neurolysis in the treatment of interdigital neuritis/neuroma or maetatarsalgia.
References:
Schaller T, O'Connor P, et al. Morton Neuroma. E Medicine. December 2002. http://www.emedicine.com.
Weinfeld SB, Myerson MS: Interdigital Neuritis: Diagnosis and Treatment. J Am Acad Orthop Surg 1996 Nov; 4(6): 328-335
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118 |
Poland's Syndrome: Surgical Correction
Determination:
Molina Healthcare of New Mexico covers surgical repair of severe pectus excavatum deformities when done for medical reasons in patients who meet ALL of the following criteria:
- Well documented evidence of complications arising from the sternal deformity: (complications include but may not be limited to Cardiopulmonary impairment documented by spirometry and/or cardiac function tests, frequent lower respiratory tract infections, exercise limitation).
- Diagnosis of Poland's syndrome in childhood.
- Absence (agenesis) or underdevelopment (hypoplasia) of the pectoralis major, pectoralis minor, and/or underlying skeletal structures (sternum, ribcage)
Molina Healthcare of New Mexico covers surgical reconstruction of the chest wall deformities associated with Poland's syndrome. Breast reconstruction is limited to correction of breast size variation only in conjunction with surgical correction of chest deformity (pectus excavatum).
Molina Healthcare of New Mexico does not cover reconstruction of the isolated hypoplastic breast without underlying structural abnormalities as stated above. Molina Healthcare of New Mexico also does not cover surgery to change the appearance of the unaffected breast to match the reconstructed breast.
Molina Healthcare of New Mexico does not cover surgical procedures to correct pectus carinatum. This deformity does not cause physiologic disturbances from compression of the heart or lungs.
Background:
Poland Syndrome is an extremely rare developmental disorder that is present at birth (congenital). It is characterized by absence (agenesis) or underdevelopment (hypoplasia) of sternum, ribcage, and/or certain muscles of the chest (e.g., pectoralis major, pectoralis minor, and/or other nearby muscles), and abnormally short, webbed fingers (synbrachydactyly). Additional findings may include underdevelopment or absence of one nipple (including the areola) and/or patchy hair growth under the arm (axilla). In females, one breast may also be underdeveloped (hypoplastic) or absent (amastia). In some cases, affected individuals may also exhibit underdeveloped upper ribs and/or an abnormally short arm with underdeveloped forearm bones (i.e., ulna and radius) on the affected side (ipsilateral). In most cases physical abnormalities are confined to one side of the body (unilateral). In approximately 75 percent of the cases, the right side of the body is affected. The range and severity of symptoms may vary from case to case. The exact cause of Poland Syndrome is not known.
References:
Marks MW, et. Al. Reconstruction of congenital chest wall deformities using solid silicone onlay prostheses. Chest Surg Clin N Am (United States), May 2000, 10(2) p341-55, vii
Kowlaewski J, et. Al. Long-term observation in 68 patients operated on for pectus excavatum: surgical repair of funnel chest. Ann Thorac Surg (United States), Mar 1999, 67(3) p821-4
National Organization for Rare Disorders, Inc. Poland Syndrome. NORD Rare Disease Database. New Fairfield, CT: NORD, 1996. http://www.stepstn.com.
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