Showing posts with label CPT codes. Show all posts
Showing posts with label CPT codes. Show all posts

Saturday, December 8, 2018

CPT 0345T, 0483T, 0484T, 33418, 33419 - Transcatheter Mitral Valve Repair

Code Description CPT

0345T Transcatheter mitral valve repair percutaneous approach via the coronary sinus

0483T Transcatheter mitral valve implantation/replacement (TMVI) with prosthetic valve; percutaneous approach, including transseptal puncture, when performed (new code effective 1/1/18)

0484T Transcatheter mitral valve implantation/replacement (TMVI) with prosthetic valve; transthoracic exposure (eg, thoracotomy, transapical) (new code effective 1/1/18)

33418 Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; initial prosthesis

33419 Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; additional prosthesis(es) during same session (List separately in addition to code for primary procedure)
 

Transcatheter Mitral Valve Repair

Introduction


The heart has four chambers, two upper and two lower. The mitral valve is between the upper and lower left chambers. After blood has been pumped from the upper left chamber to the lower left chamber, the mitral valve closes. The mitral valve is made up of small pieces of tissue called leaflets. If the leaflets don’t close properly when the left lower chamber pumps blood out to the body some of the blood can leak back into the upper left chamber. This is known as mitral valve regurgitation. Medication can be used to help manage the symptoms of mitral valve regurgitation. Open heart surgery is a treatment option. If a person is too sick for surgery, a nonsurgical procedure may be used to place a clip to close the leaky mitral valve. In this procedure, a long, hollow tube (a catheter) is threaded through a specific vein into the heart. The catheter then becomes the pathway for getting the clip to the mitral valve. Imaging is used to make sure the device is correctly placed. This policy describes when transcatheter mitral valve repair is considered medically necessary.

Note: The Introduction section is for your general knowledge and is not to be taken as policy coverage criteria. The rest of the policy uses specific words and concepts familiar to medical professionals. It is intended for providers. A provider can be a person, such as a doctor, nurse, psychologist, or dentist. A provider also can be a place where medical care is given, like a hospital, clinic, or lab. This policy informs them about when a service may be covered.

Policy Coverage Criteria Service Medical Necessity Transcatheter mitral valve repair (eg, MitraClip® Clip Delivery System)

Transcatheter mitral valve repair using a device approved by the U.S. Food and Drug Administration for use in mitral valve repair may be considered medically necessary for patients with symptomatic, primary mitral regurgitation who are considered at prohibitive risk for open surgery. Prohibitive risk for open mitral valve repair surgery may be determined based on:


* The documented presence of a Society for Thoracic Surgeons predicted mortality risk of 12% or greater AND/OR

* The documented presence of a logistic EuroSCORE of 20% or greater

Transcatheter mitral valve repair is considered investigational in all other situations.

Documentation Requirements

The patient’s medical records submitted for review for all conditions should document that medical necessity criteria are met. The record should include the following:
* Name of the Food and Drug Administration (FDA) approved device to be used
* Documentation that patient has symptomatic primary mitral regurgitation AND
* Patient is at greater risk for open mitral valve repair surgery based on:
o The documented presence of a Society for Thoracic Surgeons predicted mortality risk of 12% or greater AND/OR
o The documented presence of a logistic EuroSCORE of 20% or greater


Related Information

Indications for Use


The FDA summary of safety and effectiveness data (SSED) from 2013 states the indications for use below: The MitraClip Clip Delivery System is indicated for the percutaneous reduction of significant symptomatic mitral regurgitation (MR of 3+ or greater) due to primary abnormality of the mitral apparatus [degenerative MR] in patients who have been determined to be at prohibitive risk for mitral valve surgery by a heart team that includes a cardiac surgeon experienced in mitral valve surgery and a cardiologist experienced in mitral valve disease, and in whom existing comorbidities would not preclude the expected benefit from reduction of the mitral regurgitation.12

Repair Device

MitraClip® Clip Delivery System has the U.S. Food and Drug Administration (FDA) approval for the treatment of severe symptomatic degenerative mitral regurgitation (see Regulatory Status).


Evidence Review Description

Transcatheter mitral valve repair (TMVR) is an alternative to surgical therapy for mitral regurgitation (MR). MR is a common valvular heart disease that can result from a primary structural abnormality of the mitral valve (MV) complex or a secondary dilatation of an anatomically normal MV due to a dilated left ventricle caused by ischemic or dilated cardiomyopathy. Surgical therapy may be underutilized, particularly in patients with multiple comorbidities, suggesting that there is an unmet need for less invasive procedures for MV repair. One device, MitraClip, has approval from the U.S. Food and Drug Administration for the treatment of severe symptomatic MR due to a primary abnormality of the MV (primary MR) in patients considered at prohibitive risk for surgery.

Background

Mitral Regurgitation

Epidemiology and Classification


Mitral regurgitation (MR) is the second most common valvular heart disease, occurring in 7% of  people older than age 75 years and accounting for 24% of all patients with valvular heart disease.1-2

Patients with MR generally fall into 2 categories — primary (also called degenerative) and secondary (also called functional) MR. Primary MR results from a primary structural abnormality in the valve, which causes it to leak. This leak may result from a floppy leaflet (called prolapse) or a ruptured cord that caused the leaflet to detach partially (called flail).3 Because the primary cause is a structural abnormality, most cases of primary MR are surgically corrected. In contrast, secondary MR results from left ventricular dilatation due to ischemic or dilated cardiomyopathy. This causes the mitral value (MV) leaflets not to coapt or meet in the center.4 Because the valves are structurally normal in secondary MR, correcting the dilated left ventricular using medical therapy is the primary treatment strategy used in the United States.

MR severity is classified as mild, moderate, or severe disease on the basis of echocardiographic and/or angiographic findings (1+, 2+, and 3-4+ angiographic grade, respectively). MR with accompanying valvular incompetence leads to left ventricular volume overload with secondary ventricular remodeling, myocardial dysfunction, and left heart failure. Clinical signs and symptoms of dyspnea and orthopnea may also present in patients with valvular dysfunction.4 Standard Management

Medical Management

Medical management has a primary role in secondary MR. Patients with chronic secondary MR  should receive standard therapy for heart failure with reduced ejection fraction; standardmanagement includes angiotensin converting enzyme inhibitor (or angiotensin II receptor blocker or angiotensin receptor-neprilysin inhibitor), *-blocker and mineralocorticoid receptor antagonist, and diuretic therapy as needed to treat volume overload.3,4

Surgical Management

In symptomatic patients with primary MR, surgery is the main therapy. In most cases, MV repair is preferred over replacement, as long as the valve is suitable for repair and personnel with appropriate surgical expertise are available. The American College of Cardiology and the American Heart Association have issued joint guidelines for the surgical management of MV, which are outlined in Table 1.3

Table 1. Guidelines on Mitral Value Surgery Recommendation COR LOE

MV surgery is recommended for the symptomatic patient with acute severe MR. I B
MV surgery is beneficial for patients with chronic severe MR and NYHA functional class II, III, or IV symptoms in the absence of severe LV dysfunction (severe LV dysfunction is defined as ejection fraction less than 0.30) and/or end-systolic dimension greater than 55 mm. I B
MV surgery is beneficial for asymptomatic patients with chronic severe MR and mild-tomoderate
LV dysfunction, ejection fraction 0.30 to 0.60, and/or end systolic dimension greater than or equal to 40 mm. I B
MV repair is recommended over MV replacement in the majority of patients with severe chronic
MR who require surgery, and patients should be referred to surgical centers experienced in MV I C

Tuesday, November 27, 2018

CPT 33340 - Percutaneous Left Atrial Appendage Closure Devices

Coding Code Description CPT

33340 Percutaneous transcatheter closure of the left atrial appendage with endocardial implant, including fluoroscopy, transseptal puncture, catheter placement(s), left atrial angiography, left atrial appendage angiography, when performed, and radiological supervision and interpretation


Percutaneous Left Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation

Introduction


The heart is divided into two upper and two lower chambers. Atrial fibrillation, also called a-fib, occurs when the heart’s upper chambers beat irregularly—and often rapidly. Because blood isn’t pumped out the way that it should be, blood tends to pool in these two upper chambers. Thepooling blood increases the risk of blood clots in the area of the heart called the left atrial appendage. If a blood clot comes loose, it may travel to the brain and cause a stroke. Blood thinners are the usual method of preventing blood clots in people with a-fib. If taking a blood thinner poses too much risk or a person can’t tolerate this medication, placing a device in the heart is a different way of helping to prevent stroke. This device seals off the left atrial appendage. Should a clot develop, the device blocks it from entering the bloodstream. This policy describes when a left atrial appendage closure device is considered medically necessary.

Note: The Introduction section is for your general knowledge and is not to be taken as policy coverage criteria. The rest of the policy uses specific words and concepts familiar to medical professionals. It is intended for  providers. A provider can be a person, such as a doctor, nurse, psychologist, or dentist. A provider also can be a place where medical care is given, like a hospital, clinic, or lab. This policy informs them about when a service may be covered.

Policy Coverage Criteria Device Medical Necessity Percutaneous left atrial appendage closure device (eg, the Watchman)

The use of a device with U.S. Food and Drug Administration (FDA) approval for percutaneous left atrial appendage closure (eg, the Watchman) may be considered medically necessary for the prevention of stroke in patients with atrial fibrillation when the following criteria are met:

* There is an increased risk of stroke and systemic embolism based on CHADS2 or CHA2DS2-VASc score and systemic anticoagulation therapy is recommended AND

* The long-term risks of systemic anticoagulation outweigh the risks of the device implantation (see Related Information) The use of a device with FDA approval for percutaneous left atrial appendage closure (eg, the Watchman) for stroke prevention in patients who do not meet the above criteria is considered investigational.

Device InvestigationalOther percutaneous left atrial appendage closure devices

The use of other percutaneous left atrial appendage closure devices, including but not limited to the Lariat and Amplatzer devices, for stroke prevention in patients with atrial fibrillation is considered investigational.

Documentation Requirements

The patient’s medical records submitted for review for all conditions should document that medical necessity criteria are met. The record should include ALL of the following:
* Name of the Food and Drug Administration (FDA) device to be used
* CHADS2 or CHA2DS2-VASc score documenting patient’s increased risk of stroke and systemic embolism
* Documentation that systemic anticoagulation therapy is recommended AND the long-term risks of systemic anticoagulation outweigh the risks of the device implantation



Related Information

The balance of risks and benefits associated with implantation of the Watchman device for stroke prevention, as an alternative to systemic anticoagulation with warfarin, must be made on an individual basis.

Bleeding is the primary risk associated with systemic anticoagulation. A number of risk scores have been developed to estimate the risk of significant bleeding in patients treated with systemic anticoagulation. An example is the HAS-BLED score, which has been validated to assess the annual risk of significant bleeding in patients with atrial fibrillation treated with warfarin (Pisters et al, 2010). The score ranges from 0 to 9, based on a number of clinical characteristics (see Table 1).

Table 1: Clinical Components of the HAS-BLED Bleeding Risk Score Letter Clinical Characteristic Points Awarded

H Hypertension 1
A Abnormal renal and liver function (1 point each) 1 or 2
S Stroke 1
B Bleeding 1
L Labile international normalized ratios 1
E Elderly (>65 y) 1


Letter Clinical Characteristic Points Awarded D Drugs or alcohol (1 point each) 1 or 2 Adapted from Pisters et al (2010) Risk of major bleeding in patients with scores of 3, 4, and 5 has been reported at 3.74 per 100 patient-years, 8.70 per 100 patient-years, and 12.5 per 100 patient-years, respectively. Scores of 3 or greater are considered to be associated with a high risk of bleeding, potentially signaling the need for closer monitoring of patients for adverse risks, closer monitoring of international normalized ratio, or differential dose selections of oral anticoagulants or aspirin (January et al, 2014).

Evidence Review Description

Stroke prevention in atrial fibrillation (AF) is an important goal of treatment. Treatment with anticoagulant medications is the most common approach to stroke prevention. Most embolic strokes originate from the left atrial appendage; therefore, occlusion of the left atrial appendage may offer a nonpharmacologic alternative to anticoagulant medications for this purpose. Multiple percutaneously deployed devices are being investigated for left atrial appendage closure (LAAC). One left atrial appendage device (the Watchman device) has approval from the U.S. Food and Drug Administration for stroke prevention in patients with AF.


Background

Stroke


Stroke is the most serious complication of atrial fibrillation (AF). The estimated incidence of stroke in nontreated patients with AF is 5% per year. Stroke associated with AF is primarily embolic in nature, tends to be more severe than the typical ischemic stroke, and causes higher  rates of mortality and disability. As a result, stroke prevention is one of the main goals of AF treatment.

Stroke in AF occurs primarily as a result of thromboembolism from the left atrium. The lack of atrial contractions in AF leads to blood stasis in the left atrium, and this low flow state increases the risk for thrombosis. The area of the left atrium with the lowest blood flow in AF, and, therefore, the highest risk of thrombosis, is the left atrial appendage (LAA). It has been estimated that 90% of left atrial thrombi occur in the LAA.

Treatment Pharmacologic

The main treatment for stroke prevention in AF is anticoagulation, which has proven efficacy. The risk for stroke among patients with AF is evaluated using several factors. Two commonly used scores, the CHADS2 and the CHADS2-VASc score, are described below in Table 2. Warfarin is the predominant anticoagulation agent in clinical use. A number of newer anticoagulant medications, including dabigatran, rivaroxaban, and apixaban, have recently received U.S.

Food and Drug Administration (FDA) approval for stroke prevention in nonvalvular AF and have demonstrated noninferiority to warfarin in clinical trials. While anticoagulation is effective for stroke prevention, it carries an increased risk of bleeding. Also, warfarin requires frequent monitoring and adjustments, as well as lifestyle changes. Dabigatran does not require monitoring. However, unlike warfarin, the antithrombotic effects of dabigatran are not reversible with any currently available hemostatic drugs. Guidelines from the American College of Chest Physicians (2012) have recommended the use of oral anticoagulation for patients with AF who are at high risk of stroke (ie, CHADS2 score =2), with more individualized choice of antithrombotic therapy in patients with lower stroke risk.1

Table 2. CHADS2 and CHADS2-VASc Scores to Predict Ischemic Stroke Risk in Patients with Atrial Fibrillation

Letter Clinical Characteristics Points

Awarded


C Congestive heart failure (signs/symptoms of heart failure confirmed with objective evidence of cardiac dysfunction) 1
H Hypertension (resting blood pressure >140/90 mmHg on at least 2 occasions or current antihypertensive pharmacologic treatment)
1 A Age =75 y


Bleeding is the primary risk associated with systemic anticoagulation. Risk scores have been developed to estimate the risk of significant bleeding in patients treated with systemic anticoagulation, such as the HAS-BLED score, which has been validated to assess the annual risk of significant bleeding in patients with AF treated with warfarin.3 The score ranges from 0 to 9, based on a number of clinical characteristics, including the presence of hypertension, renal and liver function, history of stroke, bleeding, labile international normalized ratios, age, and drug/alcohol use. Scores of 3 or greater are considered to be associated with high risk of bleeding, potentially signaling the need for closer monitoring of patients for adverse risks, closer monitoring of international normalized ratios, or differential dose selections of oral anticoagulants or aspirin.2

Surgery

Surgical removal, or exclusion, of the LAA is often performed in patients with AF who are undergoing open heart surgery for other reasons. Percutaneous left atrial appendage closure (LAAC) closure devices have been developed as a nonpharmacologic alternative to anticoagulation for stroke prevention in AF. The devices may prevent stroke by occluding the LAA, thus preventing thrombus formation.

Several versions of LAA occlusion devices have been developed. The Watchman Left Atrial Appendage System (Boston Scientific) is a self-expanding nickel titanium device. It has a polyester covering and fixation barbs for attachment to the endocardium. Implantation is performed percutaneously through a catheter delivery system, using venous access and transseptal puncture to enter the left atrium. Following implantation, patients receive anticoagulation with warfarin or alternative agents for approximately 1 to 2 months. After this period, patients are maintained on antiplatelet agents (ie, aspirin  and/or clopidogrel)

indefinitely. The Lariat Loop Applicator is a suture delivery device that is intended to close a variety of surgical wounds in addition to LAAC. The Cardioblate® closure device (Medtronic) is currently being tested in clinical studies. The Amplatzer cardiac plug (St. Jude Medical), is FDAapproved for closure of atrial septal defects but not for LAAC. A second-generation device, the Amplatzer Amulet, has been developed. The Percutaneous LAA Transcatheter Occlusion device (ev3) has also been evaluated in research studies but has not received FDA approval. The Occlutech® (Occlutech) Left Atrial Appendage Occluder has received a CE mark for coverage in Europe.

Outcome Measures

The optimal study design for evaluating the efficacy of percutaneous LAAC for the prevention of stroke in AF is a randomized controlled trial that includes clinically relevant measures of health outcomes. The rate of ischemic stroke during follow-up is the primary outcome of interest, along with rates of systemic embolization, cardiac events, bleeding complications, and death. For the LAAC devices, the appropriate comparison group could be oral anticoagulation, no therapy (for patients who have a prohibitive risk for oral anticoagulation), or open surgical repair.

Although the Watchman device and other LAAC devices would ideally represent an alternative to oral anticoagulation for the prevention of stroke in patients with AF, during the postimplantation period, the device may be associated with increased thrombogenicity and, therefore, anticoagulation is used during the periprocedural period. Most studies evaluating the Watchman device have included patients who are eligible for anticoagulation. Summary of Evidence

For individuals who have AF who are at increased risk for embolic stroke who receive the Watchman percutaneous LAAC device, the evidence includes 2 RCTs and meta-analyses of these trials. Relevant outcomes are overall survival, morbid events, and treatment-related morbidity.

The most relevant evidence comes from 2 industry-sponsored RCTs that compared the Watchman device with anticoagulation alone. One trial reported noninferiority on a composite outcome of stroke, cardiovascular/unexplained death, or systemic embolism after 2 years o follow-up, with continued benefits with the Watchman device after 4 years of follow-up.

The second trial did not demonstrate noninferiority for the same composite outcome but did demonstrate noninferiority of the Watchman device to warfarin for late ischemic stroke and systemic embolization. Patient-level meta-analyses at 5-year follow-up for the 2 trials reported that the Watchman device is noninferior to warfarin on the composite outcome of stroke, systemic embolism, and cardiovascular death. Also, the Watchman was associated with lower rates in major bleeding, particularly hemorrhagic stroke, and mortality over the long term. The evidence also indicates that the Watchman device is efficacious in preventing stroke in the subset of patients with AF who are at increased risk for embolic stroke. When it is determined on an individualized basis that the long-term risk of systemic anticoagulation exceeds the procedural risk of device implantation, the net health outcome will be improved. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals who have AF who are at increased risk for embolic stroke who receive a percutaneous LAAC device other than the Watchman device (eg, the Lariat or Amplatzer), the evidence includes uncontrolled case series. Relevant outcomes are overall survival, morbid events, and treatment-related morbidity. Case series of these devices have reported high procedural success, but also numerous complications. Also, these devices do not have Food and Drug Administration approval for LAAC. The evidence is insufficient to determine the effects of the technology on health outcomes.

Ongoing and Unpublished Clinical Trials Some currently unpublished trials that might influence this policy are listed in Table 3

Thursday, November 8, 2018

CPT code Prolotherapy therapy (proliferative therapy) - 20999


Introduction

Prolotherapy therapy (proliferative therapy) is a method to try to heal joints and connective  tissue. A solution is injected in the area. The solution irritates the tissue, causing inflammation.  This inflammation is supposed to stimulate the body’s natural healing response. These injections  are repeated over time. The hope is to gradually build up new issue in the injured area and  restore strength. Prolotherapy is investigational (unproven). The studies that have been done are  small and don’t show substantial improvement. There’s not enough medical evidence to show if  this technique works.

Note: The Introduction section is for your general knowledge and is not to be  taken as policy coverage criteria . The  rest of the policy uses specific words and concepts familiar to medical professionals. It is intended for  providers. A provider can be a person, such as a doctor, nurse, psychologist, or dentist. A provider also can be a place where medical care is given, like a hospital, clinic, or lab. This policy  informs them about when a  service may be covered 

Coding Code Description

CPT 20999 Unlisted procedure,  musculoskeletal system, general

HCPCS  Description

Prolotherapy  describes a procedure  intended for healing and strengthening ligaments and  tendons by injecting an agent that induces inflammation and stimulates endogenous repair  mechanisms.  Prolotherapy may also be referred to as proliferant injection, prolo, joint  sclerotherapy, regenerative injection therapy, growth factor stimulation injection, or nonsurgical  tendon, ligament, and joint reconstruction M0076 Prolotherapy

Background

The goal of prolotherapy is to promote tissue repair or growth by prompting release of growth  factors, such as cytokines, or by increasing the effectiveness of existing circulating growth  factors due to injection of an irritant solution. The mechanism of action is not well - understood  but may involve local irritation and/or cell lysis. Agents used with prolotherapy have included  zinc sulfate, psyllium seed oil, combinations of dextrose , glycerin , and phenol, or dextrose alone, often combined with a local anesthetic. Polidocanol and  sodium morrhuate, vascular sclerosants,  have also been used to sclerose areas of high intratendinous blood flow associated with  tendinopathies.  Prolotherapy typically involves multiple injections per session conducted over a  series of treatment sessions.

A similar treatment approach involves the injection of autologous platelet - rich plasma, which  contains a high concentration of platelet - derived growth factors.Treatment of musculoskeletal  pain conditions (eg, tendinopathies) with PRP is discussed in a sepa rate policy (see  Related  Policies ).

Summary of Evidence

For  individuals who have musculoskeletal pain (eg, chronic neck, back pain),  osteoarthritic pain,  or  tendinopathies of the upper or lower limbs includes ,the evidence includessmall randomized trials with inconsistent results. Relevant outcomes are symptoms, functional outcomes, and quality of life. The strongest evidence evaluates the use of prolotherapy for the treatment of  osteoarthritis, but the clinical significance of  the  therapeutic  results is  uncertain. The evidence is  insufficient to determine the effects of the technology on health outcomes

Practice Guidelines and Position Statements

American Association of Orthopaedic Medicine


The American Association of Orthopedic Medicine currently has a recommendation posted  online for the use of prolotherapy for back pain. The Association has indicated that “...prolotherapy should be considered a valid treatment option in a selected group of chronic low back pain patients.”Medicare National Coverage The Coverage Issues Manual #35 - 13 states that prolotherapy, joint sclerother apy, and  ligamentous injections with sclerosing agents are not covered, noting that the medical effectiveness of these therapies has not been verified by scientifically controlled studies. In 1999,  on request for reconsideration of coverage of prolotherapy for treatment for chronic low back pain, Medicare retained its noncoverage decision for prolotherapy, citing a lack of scientific  eviden ce on which to base a decision.

Regulatory Status

Sclerosing agents have been approved by the U.S. Food and Drug Administration for use in  treating spider and varicose veins. These sclerosing agents include Asclera® (polidocanol),  Varithena® (an injectable polidocanol foam), Sotradecol® (sodium tetradecyl sulfate), Ethamolin® (ethanolamine oleate), and Scleromate® (sodium morrhuate). These agents are not  currently approved as joint and ligamentous sclerosing agents

Wednesday, October 24, 2018

CPT CODE 0398T, 0071T, 0072T - Magnetic resonance procedure

Introduction

Magnetic resonance - guided  high - intensity ultrasound uses two technologies: magnetic  resonance imaging (MRI) and ultrasound. It is a noninvasive procedure, which means  the skin is  not cut .  MRI uses a magnetic field, radio frequency, and a computer to create detailed images of  organs, tissues, and bones. Ultrasound uses sound waves  at a higher frequency  than a person  can hear.  Ultrasound is usually used to create images of  body  structures to help diagnose  illnesses.  But in this treatment, the ultrasound beams are at a different frequency and are  focused on one area.  Heat is created at the point where the high frequency beams meet , and  the heat ablates ( destroys )  unhealthy tissue . The MRI is used to both guide the location of the  ultrasound beams and  to  monitor treatment. This policy discusses when magnetic resonance - guided high - intensity ultrasound ablation may be considered medically necessary and covered  by the health plan.

Note:
The Introduction section is for your general knowledge and is not to be  taken as policy coverage criteria . The  rest of the policy uses specific words and concepts familiar to medical professionals. It is intended for  providers. A provider can be a person, such as a doctor, nurse, psychologist, or dentist. A provider  also can be a place where medical care is given, like a hospital, clinic, or lab. This policy  informs them about when a  service may be covered.

Documentation Requirements

The patient’s medical records submitted for review for all conditions should document that medical necessity criteria are met. The record should  include the following:
* Documentation that the requested service is for pain control  that has failed  for patient  with bone  metastases, or not a candidate for radiotherapy
OR
* Documentation that patient has essential tremors not responding to medication (such as beta - blockers or anticonvulsants)

Coding Code Description CPT

0398T Magnetic resonance image guided high intensity focused ultrasound (MRgFUS),  stereotactic ablation lesion, intracranial for movement disorder including stereotactic  navigation  and frame placement when performed
0071T Focused ultrasound ablation of uterine leiomyomata, including MR guidance; total  leiomyomata volume of less than 200 cc of tissue
0072T Focused ultrasound ablation of uterine leiomyomata, including MR guidance;  total  leiomyomata volume greater or equal to 200 cc of tissue
53899 Unlisted procedure, urinary system
55899 Unlisted procedure, male genital system
76999 Unlisted ultrasound procedure (eg diagnostic, interventional

Note :  CPT codes, descriptions and  materials are copyrighted by the American Medical Association (AMA). HCPCS  codes, descriptions and materials are copyrighted by Centers for Medicare Services (CMS).

Magnetic resonance - guided high - intensity ultrasound ablation of uterine fibroids is  specifically  identified by the following category III CPT codes:
* 0071T Focused ultrasound ablation of uterine leiomyomata, including MR guidance; total  leiomyomata volume of less than 200 cc of tissue
* 0072T As above, but with total leiomyomata volume great er or equal to 200 cc of tissue.

These CPT codes should not be used with 51702 (insertion of temporary indwelling bladder  catheter, simple) or 77022 (magnetic resonance imaging guidance for, and monitoring of,  visceral tissue ablation). Before the introduc tion of the specific category III CPT codes, the  procedure may have been coded using several codes describing the individual components of  the procedure. CPT codes 0071T - 0072T describe the comprehensive service.

The procedure may be performed in a magnetic resonance imaging suite with an open magnetic  resonance scanner, which might not be available at many institutions. The procedure is  performed in an outpatient setting, with the patient under conscious sedation. There are no specific CPT codes for the use of magnetic resonance - guided high - intensity  ultrasound ablation in metastatic bone cancer. An unlisted code would be used based on the  anatomic location of the metastasis being treated (eg, 23929 for the clavicle) or perhaps an  unlisted radiation oncology code (eg, 77299 or 77499)

Consideration of Age
Magnetic resonance*guided focused ultrasound (MRgFUS) is considered medically necessary for  bone metastases in adult patients, age 18 and older.
This is based on the randomized controlled  trial that studied the use of MRgFUS in  patients with  bone metatsase

Evidence Review Description
An integrated system providing magnetic resonance*guided focused ultrasound (MRgFUS) treatment is proposed as a noninvasive therapy for uterine fibroids and pain palliation of bone  metastases. MRgFUS is also being investigated as a treatment of other benign and malignant  tumors.

Background
Uterine Fibroids

Uterine fibroids are one of the most common conditions affecting women in the reproductive  years. Symptoms of uterine fibroids include menorrhagia, pelvic pressure, or pain.

Treatment
Several approaches currently available to treat symptomatic uterine fibroids include: hysterectomy, abdominal myomectomy, laparoscopic and  hysteroscopic myomectomy,  hormone therapy, uterine artery embolization, and watchful waiting. Hysterectomy and various  myomectomy procedures are considered the  criterion standard treatment.

Metastatic Bone Disease
Metastatic bone disease is one of the most common causes of cancer pain.  Treatment Existing treatments include conservative measures ( eg, massage,  exercise) and pharmacologic  agents ( eg, analgesics, bisphosphonates, corticosteroids). For patients who  do not respond to  these treatments, standard care is external - beam radiotherapy. However, a substantial  proportion of patients have residual pain after radiotherapy, and there is a need for alternative
treatments for these patients.   One option, radiofrequency a blation, is addressed in a  related policy.

Essential Tremors
Essential tremor (ET) is the most common movement disorder, with an estimated prevalence of 5% worldwide. ET most often affects the hands and arms, may affect the head and voice, and rarely includes the face, legs, and trunk. ET is heterogeneous among patients, varying in frequency, amplitude, causes of exacerbation, and association with other neurologic deficits

Treatment
The neuropathology of ET is uncertain, with some evidence suggesting that ET is localized in the  brainstem and cerebellum. If patients with ET experience intermittent or persistent disability due  to the tremors, initial therapy is with  drugs (*-blockersor anticonvulsants). For medicine-refractory patients, surgery (deep brain stimulation or thalamotomy) may be offered, though high rates of adverse events have been observed

Magnetic Resonance*Guided Focused Ultrasound
 
Magnetic resonance - guided focused ultrasound  ( MRgFUS ) is a noninvasive treatment that  combines  2  technologies : focused ultrasound and magnetic resonance imaging (MRI). The  ultrasound  beam penetrates through the soft tissues and, using MRI for guidance and monitoring, the beam can be focused on targeted sites. Ultrasound causes a local increase in temperature in the target tissue, resulting in coagulation necrosis while sparing the surrounding normal structures. Ultrasound waves from each sonication are  directed  at a focal point that has a  maximum focal volume of 20 nm in diameter and 15 nm in height/length. This causes a rapid  rise in temperature (ie , to 65°C - 85°C), which is sufficient to  ablate  tissue at the focal point. In  addition to providing guidance, the associated MRI can provide online thermometric imaging, a  temperature “map” , to confirm the ther apeutic effect of the ablation treatment and allow for real - time adjustment of the treatment parameters

The U.S. Food and Drug Administration (FDA) has approved the ExAblate MRgFUS system (InSightec) for two indications : treatment of uterine fibroids (leiomyomata) and palliation of pain associated with tumors metastatic to bone. The ultrasound equipment is specially designed to be compatible with magnetic resonance magnets and is integrated into standard clinical MRI  units; it also includes a patient table, which  has  a cradle  that houses  the focused  ultrasound transducer in  water or  a  light oil bath. Some models have a detachable cradle; only certain  cradle types can be used for palliation of pain associated with metastatic bone  cancer. For  treating pain associated with bone metastases, the aim of MRgFUS is to destroy nerves in the  bone surface surrounding the tumor. MRgFUS is also being investigated for treatment of other tumors, including breast, prostate,  brain , and desmoid tumors as well as nonspinal osteoid osteoma.(For prostate cancer see Related Policy8.01.61 Focal Treatments for Prostate Cancer)

Summary of Evidence


For individuals who have uterine fibroids who receive MRgFUS, the evidence includes  2  small RCT s , nonrandomized comparative studies, and case series. Relevant outcomes are symptoms,  quality of life, resource utilization, and treatment - related morbidity.  One RCT (N=20)  has  reported some health outcomes, but its primary purpose was to determine the feasibility of a  larger trial. It did not find statistically significant differences in quality of life outcomes between  active and sham treatment groups, but it did find lower fibroid volumes after active treatment.  This trial  did not have an  active comparator , the clinical significance of the primary outcome was  unclear, and there were no follow - up data beyond 1 year.  The second RCT (N=49) is ongoing;  preliminary results at 6 weeks posttreatment, comparing MRgFUS with uterine artery  embolization  have shown that the 2 groups  are comparable in medication use and symptom  improvement following treatments. Patients in the MRgFUS group reported recovering  significantly faster than patients in the
uterine artery embolization  group, as measured by  time  to return to work and time to normal activities. In  a separate  2013 comparative study, outcomes  appeared to be better with uterine artery embolization than with MRgFUS.  Long - term data on  the treatment effects, recurrence rates, and impact on future fertility and pregnancy are lacking .  The evidence is insufficient to determine the effects of the technology on health outcomes.

For individuals  with  metastatic bone cancer who failed or are not candidates for radiotherapy who receive MRgFUS, the evidence includes a sham- controlled randomized trial and several case  series . Relevant outcomes are symptoms, functional outcomes, health status measures, quality  of life, and treatment - related morbidity. The RCT found statistically significant improvements after MRg FUS in a composite outcome comprised of reduction in pain and morphine use, and in  pain reduction as a stand - alone outcome. A substantial proportion of patients in the treatment  group experienced adverse events, but most  events were  transient and not severe.  The case  series reported reductions in pain following MRgFUS treatment, consistent with the RCT.  The  evidence is sufficient to determine that the technology results in a meaningful improvement in  the net health outcome

Tuesday, June 20, 2017

CPT 90801, 90806, 90862 - Psychotherapy codes

CPT Code Description

90801 Interview evaluation

90804 Individual therapy 20 – 30 min

90806 Psychotherapy

90807 Psychotherapy with medical evaluation and management

90862 Pharmacologic management

New and Deleted Procedure Codes

The following psychiatric services procedure codes will be discontinued and replaced as indicated:

Category 2012 Procdure Codes 2013 Procedure Codes

90801                 90791, 90792
90802 90791, 90792
90804, 90816 90832
90806, 90818 90834
90808, 90821 90837

Psychiatric Diagnostic Interview Examination (CPT code 90801):

An E/M service may be substituted for the initial interview procedure, including consultation CPT codes, (CPT codes 99241-99263), provided required elements of the E/M service billed are fulfilled. Consultation services require, in addition to the interview and examination, the provision of a written opinion and/or advice. E/M CPT codes do not include a psychotherapy service.

B. Interactive Psychiatric Diagnostic Interview Examination (CPT code 90802):

CPT codes 90802, 90810-90815, 90823-90829 and 90857 may also be covered for any psychiatric disorder as specified in the “ICD-9-CM codes that Support Medical Necessity”
section for adults who also have one of the conditions as specified in the Local Coverage Determination. Both the primary psychiatric diagnosis and secondary communication disorder must be submitted on the claim.

Understanding the Diagnosis and Treatment of Depression

In an effort to identify ways that we may help to improve Member anti-depression medication compliance, a research study was designed and conducted by TideWatch Partners, LLC to examine the diagnosis and treatment of depression. The study gathered insights from providers, primary care physicians (PCP) and behavioral health specialists, specifically psychiatrists, about
their experience treating patients who have been diagnosed with depression.

The objectives of this study were to:

• Gain an understanding of the depression diagnosing process, including diagnostic tools and methods, and treatment plan development

• Identify barriers to Member compliance with anti-depression medications

• Assess ways that Oxford might help Members overcome these barriers Analysis of the survey showed that, among other issues, clarifying and educating providers about referrals specific to depression might help eliminate some of the perceived barriers. The following list is a summary of information that will assist you when referring Oxford Members for behavioral healthcare.

• All inpatient behavioral health services require precertification

• Outpatient behavioral health services require precertification or a PCP referral when provided to all Members, excluding Members of New Jersey small group and Individual plans

• Services provided to Members of New Jersey small group gated plans and New Jersey Individual gated plans require a referral only

• Services provided to Members of New Jersey small group non-gated plans and New Jersey Individual non-gated plans do not require a referral or precertification

• Members may obtain referrals for outpatient behavioral health services through their PCP or by calling Provider Services at 800-666-1353

Please note: Members who obtain a referral from the Behavioral Health Department do not need to go to their PCP.

• Medication management may be authorized once a month or 12 times in one year for Members who are stabilized on medication; however, if more sessions are required to stabilize a patient, providers may request additional sessions by calling the Behavioral Health Department at 800- 201-6991

• A list of participating specialists (including psychiatrists, social workers and nurse practitioners) is available through the Doctor Search tool on www.oxfordhealth.com or by calling Provider Services at 800-666-1353 



Monday, June 12, 2017

CPT 19380, 19328, 19330 - Breast repair reconstruction

CPT Code Description

19328 Removal of intact mammary implant

19330 Removal of mammary implant material

19355 Correction of inverted nipples

19370 Open periprosthetic capsulotomy, breast

19371 Periprosthetic capsulectomy, breast

19380 Revision of reconstructed breast


COVERAGE RATIONALE

Indications for Coverage

If the member's condition meets the Women's Health and Cancer Rights (WHCRA) criteria, please refer to the policy titled Breast Reconstruction Post Mastectomy.

Criteria for a Coverage Determination as Reconstructive and Medically Necessary:

Removal of breast implants with capsulectomy/capsulotomy for symptomatic capsular contracture is considered reconstructive and medically necessary when the following criteria are met:

** Baker grade III or IV capsular contracture; Baker Grading System for Capsular Contracture

o Grade I - breast is soft without palpable thickening

o Grade II - breast is a little firm but no visible changes in appearance

o Grade III - breast is firm and has visible distortion in shape

o Grade IV - breast is hard and has severe distortion or malposition in shape; pain/discomfort may be associated with this level of capsule contracture (ASPS, 2005)

** Limited movement leading to an inability to perform tasks that involve reaching or abduction. Examples include retrieving something from overhead, combing one's hair, reaching out or above to grab something to stabilize oneself.

Removal of a deflated saline breast implant shell is considered cosmetic and is not medically necessary unless the implants were done post-mastectomy. Refer to the policy titled Breast Reconstruction Post Mastectomy.

Correction of inverted nipples is considered reconstructive and medically necessary when one of the following criteria are met:

** Member meets the Women's Health and Cancer Rights Act (WHCRA) criteria (refer to the policy titled Breast Reconstruction Post Mastectomy for details); or

** Documented history of chronic nipple discharge, bleeding, scabbing or ductal infection. Note: If the correction of congenital inverted nipples may be covered based on the state mandates or member specific benefit plan document. See Congenital Anomaly definition below.


Revision of a reconstructed (CPT Code 19380) breast is considered reconstructive and medically necessary when the original reconstruction was done for mastectomy or other covered health service.

Refer to the Applicable Codes section below for a list of codes that meet the criteria for a reconstructed breast. Breast reconstruction done for Poland Syndrome (see definition below) is reconstructive. Although no functional impairment may exist for the breast reconstruction for Poland Syndrome, this has been deemed reconstructive surgery.

Removal of a ruptured silicone gel breast implant is covered regardless of the indication for the initial implant placement.


Additional Information

Tissue protruding at the end of a scar ("dog ear"/standing cone), painful scars or donor site scar revisions must be reviewed to determine if the procedure meets reconstructive guidelines.


Coverage Limitations and Exclusions

Some states require benefit coverage for services that Oxford considers cosmetic procedures, such as repair of external congenital anomalies in the absence of a functional impairment. Please refer to member specific benefit plan document.



** Cosmetic breast procedures are excluded from coverage. Examples include but are not limited to:

o Replacement of an existing breast implant if the earlier breast implant was performed as a cosmetic procedure . (Replacement of an existing breast implant is considered reconstructive if the initial breast implant followed mastectomy. Refer to the Breast Reconstruction Post Mastectomy policy.)

o Breast reduction surgery that is determined to be a cosmetic procedure. This exclusion does not apply to breast reduction surgery which we determine is requested to treat a physiologic functional impairment or to coverage required by the Women's Health and Cancer Right's Act.

o Breast surgery only for the purpose of creating symmetrical breasts except when post mastectomy.

o Breast prosthetics or replacement following a cosmetic breast augmentation.

** Revision of a prior reconstructed breast due to normal aging does not meet the definition of a covered reconstructive health service.



DEFINITIONS

Congenital Anomaly: A physical developmental defect that is present at the time of birth, and that is identified within the first twelve months of birth. Functional/Physical Impairment: A physical/functional or physiological impairment causes deviation from the normal function of a tissue or organ. This results in a significantly limited, impaired, or delayed capacity to move, coordinate actions, or perform physical activities and is exhibited by difficulties in one or more of the following areas: physical and motor tasks; independent movement; performing basic life functions.

Poland Syndrome: A rare, nonfamilial anomalad of unknown cause. The components of the syndrome include absence of the pectoralis major muscle, absence or hypoplasia of the pectoralis minor muscle, absence of costal cartilages, hypoplasia of breast and subcutaneous tissue (including the nipple complex), and a variety of hand anomalies. The most common chest wall reconstructive procedure in Poland’s is rotation of the latissimus dorsi muscle to reconstruct the anterior chest wall deficiency and anterior axillary fold.

Note: Poland Syndrome does not include tuberous breasts or developmental breast asymmetry.

Sickness: physical illness, disease or Pregnancy. The term Sickness as used in this Certificate does not include mental illness or substance abuse, regardless of the cause or origin of the mental illness or substance abuse)

Wednesday, May 24, 2017

CPT code 44970, 44960, 44950

CPT Code Description Appendectomy Code Family

44950 Appendectomy

44955 Appendectomy; when done for indicated purpose at time of other major procedure (not as separate procedure) (List separately in addition to code for primary procedure)

44960 Appendectomy; for ruptured appendix with abscess or generalized peritonitis

44970 Laparoscopy, surgical, appendectomy When any single or multiple physician or other health care professional reports a code from the Once in a Lifetime Procedures list, that code or any code from the same Code Family will be reimbursed only once during a patient’s lifetime. In the appendectomy example, a single code from the Appendectomy Code Family will be reimbursed only once during a patient’s lifetime, because each person has only one appendix and can have only one appendectomy during his or her lifetime.

REIMBURSEMENT GUIDELINES

Oxford will reimburse certain procedures only once during a patient’s lifetime. Once in a Lifetime Procedures are not limited to a single CPT code, but may be represented by Code Families, which are a group of CPT codes that describe the same or similar type of service. Under this policy, Oxford provides reimbursement for only one procedure from a designated Code Family during a patient’s lifetime.

For example, there are four separate appendectomy CPT codes that can be used, based upon the particular circumstance, to report the removal of the appendix. The four codes, listed below, make up the Code Family that describes the removal of an appendix.



Modifiers

There may be situations that require the code(s) for a Once in a Lifetime Procedure to be submitted more than once during a patient’s lifetime. In such cases, more than one Once in a Lifetime Procedure, whether the same code or a different code from the same Code Family will be considered separately for reimbursement if reported with one of the following modifiers:

Modifier Description

53 Discontinued procedure

55 Postoperative management only

56 Preoperative management only

58 Staged or related procedure or service by the same physician

For additional information related to the percentage of the allowable fee to be paid when one of these modifiers is appended to a claim for a subsequent procedure, please refer to the Discontinued Procedure policy, Split Surgical Package policy and/or Global Days policy.


DEFINITIONS

Code Family: A group of CPT codes that describe the same or similar type of service.

Once in a Lifetime Procedure: A procedure that can be performed by a physician(s) or other health care professional(s) only once in a patient’s lifetime.


QUESTIONS AND ANSWERS


Q: Would there ever be an instance where a CPT code for a Once in a Lifetime Procedure may be reported more than once?

A: Yes, there are instances where a CPT code for a Once in a Lifetime Procedure may be reported more than once. Modifiers may be used to indicate a procedure or service has been altered in some way, but not changed in its actual code description. For example, by definition, modifier 53 (Discontinued Procedure) is to be used when a procedure is terminated for unforeseeable circumstances. Per coding guidelines, the procedure code would be initially reported with modifier 53 appended to the CPT code to indicate the discontinued procedure and then at a later time, the CPT code would be submitted again when (if) the procedure took place in its entirety.



2 Q: How is a Once in a Lifetime Procedure reimbursed when reported by two different physicians on different dates of service?

A: When any physician or other health care professional reports a code from the Once in a Lifetime Procedures policy list on multiple dates of service excluding the same date of service, the code will be reimbursed only once. Oxford follows a "first in, first out" claim payment methodology in determining which claim will be considered for reimbursement when duplicate claims are received.

3 Q: What if two different physicians each report the same procedure on the same date of service for the same patient from the Once in a Lifetime Procedures list? 

A: The Once in a Lifetime procedure codes are subject to duplicate billing when reported by the same or different providers.



Wednesday, May 10, 2017

CPT 30400, 30410, 30420 & 30465 - Rhinoplasty procedures

CPT Code Description

Rhinoplasty

30400 Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip

30410 Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip

30420 Rhinoplasty, primary; including major septal repair

30430 Rhinoplasty, secondary; minor revision (small amount of nasal tip work)

30435 Rhinoplasty, secondary; intermediate revision (bony work with osteotomies)

30450 Rhinoplasty, secondary; major revision (nasal tip work and osteotomies)

30460 Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columnar lengthening; tip only

30462 Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columnar lengthening; tip, septum, osteotomies Repair of Vestibular Stenosis

30465 Repair of nasal vestibular stenosis (e.g., spreader grafting, lateral nasal wall reconstruction)

Rhinophyma

30120 Excision or surgical planing of skin of nose for rhinophyma Lysis Intranasal Synechia

30560 Lysis intranasal synechia Septal Dermatoplasty

30620 Septal or other intranasal dermatoplasty (does not include obtaining graft)


RHINOPLASTY AND OTHER NASAL SURGERIES


INSTRUCTIONS FOR USE

This Clinical Policy provides assistance in interpreting Oxford benefit plans. Unless otherwise stated, Oxford policies do not apply to Medicare Advantage members. Oxford reserves the right, in its sole discretion, to modify its policies as necessary. This Clinical Policy is provided for informational purposes. It does not constitute medical advice. The term Oxford includes Oxford Health Plans, LLC and all of its subsidiaries as appropriate for these policies.

When deciding coverage, the member specific benefit plan document must be referenced. The terms of the member specific benefit plan document [e.g., Certificate of Coverage (COC), Schedule of Benefits (SOB), and/or Summary Plan Description (SPD)] may differ greatly from the standard benefit plan upon which this Clinical Policy is based. In the event of a conflict, the member specific benefit plan document supersedes this Clinical Policy. All reviewers must first identify member eligibility, any federal or state regulatory requirements, and the member specific benefit plan coverage prior to use of this Clinical Policy. Other Policies may apply.

UnitedHealthcare may also use tools developed by third parties, such as the MCG™ Care Guidelines, to assist us in administering health benefits. The MCG™ Care Guidelines are intended to be used in connection with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice. 



CONDITIONS OF COVERAGE

Applicable Lines of Business/ Products This policy applies to Oxford Commercial plan membership.

Benefit Type General benefits package

Referral Required

(Does not apply to non-gatekeeper products)

No

Authorization Required

(Precertification always required for inpatient admission) Yes

Precertification with Medical Director Review Required Yes1 Applicable Site(s) of Service

(If site of service is not listed, Medical Director review is required)

Outpatient, Office

Special Considerations 1Precertification with review by a Medical Director or their designee may be required.

BENEFIT CONSIDERATIONS

Before using this policy, please check the member specific benefit plan document and any federal or state mandates, if 
applicable.



Essential Health Benefits for Individual and Small Group

For plan years beginning on or after January 1, 2014, the Affordable Care Act of 2010 (ACA) requires fully insured non-grandfathered individual and small group plans (inside and outside of Exchanges) to provide coverage for ten categories of Essential Health Benefits (“EHBs”). Large group plans (both self-funded and fully insured), and small group ASO plans, are not subject to the requirement to offer coverage for EHBs. However, if such plans choose to provide coverage for benefits which are deemed EHBs, the ACA requires all dollar limits on those benefits to be removed on all Grandfathered and Non-Grandfathered plans. The determination of which benefits constitute EHBs is made on a state by state basis. As such, when using this policy, it is important to refer to the member specific benefit plan document to determine benefit coverage.

COVERAGE RATIONALE

Some states require benefit coverage for services that Oxford considers cosmetic procedures, such as repair of external congenital anomalies in the absence of a functional impairment. Please refer to member specific benefit plan document.

Indications for Coverage

Rhinoplasty-Primary (CPT 30410, 30420)

Rhinoplasty-primary is considered reconstructive and medically necessary when all of the following criteria are present:

** Prolonged, persistent obstructed nasal breathing due to nasal bone and septal deviation that are the primary causes of an anatomic mechanical nasal airway obstruction, and

** The nasal airway obstruction cannot be corrected by septoplasty alone as documented in the medical record, and 

** Photos clearly document the nasal bone/septal deviation as the primary cause of an anatomic mechanical nasal airway obstruction and are consistent with the clinical exam, and

** The proposed procedure is designed to correct the anatomic mechanical nasal airway obstruction and relieve the nasal airway 
obstruction by centralizing the nasal bony pyramid (30410) and also straightening the septum (30420), and

** One of the following is present:

o Nasal fracture with nasal bone displacement severe enough to cause nasal airway obstruction, or

o Residual large cutaneous defect following resection of a malignancy or nasal trauma, and

** Nasal airway obstruction is causing significant symptoms (e.g., chronic rhinosinusitis, difficulty breathing), and

** Obstructive symptoms persist despite conservative management for 4 weeks or greater, which includes, where appropriate, nasal steroids or immunotherapy. 


Rhinoplasty-Tip (CPT 30400)

Rhinoplasty-tip is primarily cosmetic. However, it is considered reconstructive and medically necessary when all of the following criteria are present:

** Prolonged, persistent obstructed nasal breathing due to tip drop that is the primary cause of an anatomic mechanical nasal airway obstruction (this code is usually cosmetic), and

** Photos clearly document tip drop as the primary cause of an anatomic mechanical nasal airway obstruction and are consistent with the clinical exam (acute columellar-labial angle), and

** The proposed procedure is designed to correct the anatomic mechanical nasal airway obstruction and relieve the nasal airway obstruction by lifting the nasal tip, and

** Nasal airway obstruction is causing significant symptoms (e.g., chronic rhinosinusitis, difficulty breathing), and 

** Obstructive symptoms persist despite conservative management for 4 weeks or greater, which includes, where appropriate, nasal steroids or immunotherapy.

Rhinoplasty-Secondary (CPT 30430, 30435, 30450)

Rhinoplasty-secondary is primarily cosmetic. However, it is considered reconstructive and medically necessary when all of the following criteria are present:

** Required as treatment of a complication/residual deformity from primary surgery performed to address a functional impairment when a documented functional impairment persists due to the complication/deformity (these codes are usually cosmetic), and

** Photos clearly document the secondary deformity/complication as the primary cause of an anatomic mechanical nasal airway obstruction and are consistent with the clinical exam, and

** The proposed procedure is designed to correct the anatomic mechanical nasal airway obstruction and relieve the nasal airway obstruction by correcting the deformity or treating the complication. (These codes are usually cosmetic), and

** Nasal airway obstruction is causing significant symptoms (e.g., chronic rhinosinusitis, difficulty breathing), and 

** Obstructive symptoms persist despite conservative management for 4 weeks or greater, which includes, where appropriate, nasal steroids or immunotherapy.


DEFINITIONS

When applicable, please refer to the member specific benefit plan document for definitions. 

Congenital Anomaly: A physical developmental defect that is present at the time of birth, and that is identified within the first twelve months of birth.

External Nasal Valve, NARES: Lateral Crus (wing) of the lower lateral (alar) cartilage. 

Functional/Physical Impairment: A physical/functional or physiological impairment causes deviation from the normal function of a tissue or organ. This results in a significantly limited, impaired, or delayed capacity to move, coordinate actions, or perform physical activities and is exhibited by difficulties in one or more of the following areas: physical and motor tasks; independent movement; performing basic life function. Mechanical Nasal Airway Obstruction: Trouble breathing through the nose (not snoring) due to a bony or cartilaginous deformity.

Prolonged, Persistent Nasal Airway Obstruction: Trouble breathing through the nose (not snoring) that has not responded to six weeks of medical management such as nasal steroids, antihistamines, and decongestants.

Elimination of rhinitis medicamentosa as a cause for airway obstruction.

Reconstructive Surgery: Defined by the American Society of Plastic Surgeons, 'is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance. Rhinitis Medicamentosa (RM): A condition of rebound nasal congestion brought on by extended use of topical decongestants (e.g., oxymetazoline, phenylephrine, xylometazoline, and naphazoline nasal sprays) and certain oral medications (e.g., sympathomimetic amines and various 2-imidazolines) that constrict blood vessels in the lining of the nose.

Septal Dermatoplasty: The physician removes diseased intranasal mucosa and replaces it with a separately reportable split thickness graft. The surgery is performed on one nasal side. A lateral rhinotomy is made to expose the intranasal mucosa. The diseased mucosal tissue is excised from the septum, nasal floor, and anterior aspect of the inferior turbinate. A split thickness graft is sutured to the recipient bed, covering the exposed cartilage and submucosal surfaces. Gauze packing and splints are placed in the grafted nasal cavity.

Synechia: An adhesion of parts, typically the nasal side wall to the septum. 

Tuesday, March 21, 2017

CPT g0180 - Care plan oversight services



Care Plan Oversight Services


Care Plan Oversight (CPO) is physician supervision of patients under either the home health or hospice benefit where the patient requires complex or multi-disciplinary care requiring ongoing physician involvement. Medicare does not pay for care plan oversight services for nursing facility or skilled nursing facility patients.

Separate payment is allowed for the services involved in physician certification/re-certification and development of a plan of care for Medicare covered home health services.

Submit HCPCS code G0179 for re-certification after a patient has received services for at least 60 days (or one certification period). HCPCS code G0179 may be reported only once every 60 days, except in the rare situation when the patient starts a new episode before 60 days elapses and requires a new plan of care to start a new episode.

Submit HCPCS code G0180 when the patient has not received Medicare covered home health services for at least 60 days. The initial certification (HCPCS code G0180) cannot be filed on the same date of service as the supervision service HCPCS codes (G0181 or G0182).
HCPCS Codes

G0179: MD re-certification HHA PT

G0180: MD certification HHA patient

G0181: Home health care supervision

G0182: Hospice care supervision

How to submit a claim

Submit CPT codes 99201-99263 and 99281-99357 only when there has been a face-to-face meeting/encounter

HHA / Hospice Provider Number: The requirement to include the HHA or Hospice provider number on a care plan oversight claim for HCPCS codes G0181 and G0182 is waived until further notice, and as a result, claims submitted with the number will be rejected.

Dates of service: for HCPCS codes G0181 and G0182, submit the first and last date during which documented care planning services were actually provided during the calendar month.

Do not submit the first and last calendar date of the month unless services were provided on those dates)
Submit the claim after the end of the month in which the service is performed

Report care planning only once per calendar month

Report only one month's services per line item

Dates of service: for HCPCS codes G0179 and G0180, submit the date physician signed the certification or re-certification

Documentation

Claims for care plan oversight services will be denied when review of the beneficiary claims history fails to identify a covered physician service requiring a face-to-face encounter by the same physician during the six months preceding the provision of the first care plan oversight service
Medical records for these service must indicate:
The physician spent 30 minutes or more for countable care planning activities
The specific service furnished, including the date and length of time

Monday, March 20, 2017

cpt 66821 - YAG capusulotomy surgery

CPT/HCPCS Codes

Group 1 Codes:

66821 After cataract laser surgery

Coverage Indications, Limitations, and/or Medical Necessity

Indications

YAG laser capsulotomies (YAG) are performed in cases of opacification of the posterior capsule, generally no less than 90 days following cataract extraction. YAG performed less than 90 days following cataract extraction should meet both the indications and limitations of this LCD. The percentage of patients having this procedure varies greatly among ophthalmologists. Diagnosis of functional visual impairment due to capsular opacification is based on clinical judgment regarding one or more of the following:

Visual loss and/or symptom of glare (visual acuity 20/30 or worse under Snellen conditions, using contrast sensitivity, or simulated glare testing);
Symptoms of decreased contrast;
Amount of posterior capsular opacification; or
Other possible causes of decreased vision following cataract surgery.

Limitations 

This procedure will not be covered within three months post cataract surgery unless justified by one of the following indications:

Posterior capsular plaque/opacity which cannot be safely removed during primary phacoemulsification cataract procedure
Capsular block during which cataract remnants and fluid become trapped within the lens capsule and addressed with YAG laser posterior capsulotomy
Contraction of the posterior capsule with displacement of the intraocular lens



Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
N/A

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

N/A


ICD-10 Codes that Support Medical Necessity

ICD-10 CODE DESCRIPTION

H26.491 - H26.493 - Opens in a new window Other secondary cataract, right eye - Other secondary cataract, bilateral
T85.21XA Breakdown (mechanical) of intraocular lens, initial encounter
T85.29XA Other mechanical complication of intraocular lens, initial encounter

Friday, March 10, 2017

CPT 19318, 77059 - Surgery, Breast reduction mammplasty, MRI procedure


CPT/HCPCS Codes



11920 Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.0 sq cm or less
11921 Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.1 to 20.0 sq cm
11922 Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; each additional 20.0 sq cm (List separately in addition to code for primary procedure)
11970 Replacement of tissue expander with permanent prosthesis
11971 Removal of tissue expander(s) without insertion of prosthesis
19316 Mastopexy
19318 Reduction Mammoplasty (see Section B for other indications)
19324 Mammaplasty, augmentation; without prosthetic implant
19325 Mammaplasty, augmentation; with prosthetic implant
19340 Immediate insertion of breast prosthesis following mastopexy, mastectomy  or in reconstruction
19342 Delayed insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction
19350 Nipple/areola reconstruction
19357 Breast reconstruction, immediate or delayed, with tissue expander, including subsequent expansion
19361 Breast reconstruction with latissimus dorsi flap, with or without prosthetic implant
19364 Breast reconstruction with free flap
19366 Breast reconstruction with other technique
19367 Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), single pedicle, including closure of donor site;
19368 Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), single pedicle, including closure of donor site; with microvascular anastomosis (supercharging)
19369 Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), double pedicle, including closure of donor site
19370 Open periprosthetic capsulotomy, breast
19371 Periprosthetic capsulectomy, breast
19380 Revision of reconstructed breast
19396 Preparation of moulage for custom breast implant (not covered for Priority Health Medicaid)
Coverage Indications, Limitations, and/or Medical Necessity

Background:

Reduction mammaplasty is the surgical removal of a substantial portion of the breast, including the skin and underlying glandular tissue, until a clinically normal size is obtained.

Reduction mammaplasty is performed to reduce the size of the breast/breasts and:

help ameliorate symptoms caused by hypertrophy or

to reduce the size of a contralateral breast to bring it into symmetry with a breast reconstructed after cancer surgery.

Indications:

Reduction mammaplasty is considered medically necessary:

When the patient has significant symptoms that have interfered with normal daily activities despite conservative management for at least 6 months, including at least one of the following criteria:

History of back and/or shoulder pain which adversely affects activities of daily living (ADLs) unrelieved by, e.g.: conservative analgesia (e.g., such as NSAID, compresses, massage, etc.), supportive measures (e.g., such as garments, back brace, etc.), physical therapy, correction of obesity.

History of significant arthritic changes in the cervical or upper thoracic spine, optimally managed with medication and/or significant restriction of activity (e.g.: signs and symptoms of ulnar paresthesias evidenced by nerve conduction studies, cervicalgia, torticollis, or acquired kyphosis).

Signs and symptoms of: intertrigonous maceration and/or infection of the inframammary skin (e.g., hyperpigmentation, bleeding, chronic moisture, and evidence of skin breakdown refractory to dermatologic measures), or shoulder grooving with skin irritation (e.g., areas of excoriation and breakdown) by appropriate supporting garment.

AND:

The amount of breast tissue removed (by pathology report) is at least 400 grams per breast.


When the patient’s normal breast is reduced to achieve symmetry with a breast reconstructed after cancer surgery.

Limitations

Cosmetic surgery to reshape the breasts and surrounding tissue to improve appearance is not a Medicare benefit. The use of such CPT codes as 12034 and 12035, 14001, 15830, 15836, 15839, 15876 through 15879, and 19350 associated with reshaping will be considered part of (bundled into) the primary reduction mammaplasty procedure.

Indications of coverage must be met.




Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
999x Not Applicable

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

N/A



Breast Implant Removal
1. Removal of breast implants that were placed for reconstruction after mastectomy, injury, congenital asymmetry, or augmentation mammoplasty is a covered benefit for the following indications:

a. Implants with recurrent infection
b. Extruded implants
c. Baker Class IV Contracture, associated with severe pain, or
d. Breast cancer, new or recurrent (mastectomy and lumpectomy can be done with an implant in place, however, if a breast malignancy is discovered and the surgeon has requested coverage for removal, it is appropriate to provide coverage).
e. Implant rupture
2. Replacement/reinsertion of a breast implant is a covered benefit only if the original placement surgery would have been a covered benefit (e.g. if original prosthesis was placed due to cancer surgery, replacement of the prosthesis is a covered benefit; if original surgical indication was cosmetic augmentation, replacement of the prosthesis is not a covered benefit).
3. Removal of breast implants for the following conditions has been determined to not be medically necessary, and therefore, not a covered benefit:
a. Breast malposition/asymmetry
b. Baker Class II or III Contracture*
c. Patient anxiety related to the possibility of developing systemic disease, or anxiety related to the influence of breast implants on a current "autoimmune disease". It has not been proven that individuals with breast implants are at an increased risk of developing a systemic disease, or that the implants influence the current status of the systemic disease.
4. Pain is frequently cited an indication for removal. The requesting physician should supply clinical information related to the degree of contracture (Baker classification*), or describe the etiology of the pain.

* Various systems have been used to classify breast contractures, but the most commonly used is the Baker classification. Four grades are described as follows:
Grade I Augmented breast feels soft as a normal breast
Grade II Augmented breast is less soft and implant can be palpated, but is not visible
Grade III Augmented breast is firm, palpable and the implant (or distortion) is visible
Grade IV Augmented breast is hard, painful, cold, tender and distorted

Reduction Mammoplasty

Unilateral and bilateral reduction mammoplasty is a covered benefit according to InterQual criteria.

For augmentation mammoplasty for asymmetry that is not cancer related see
C. Breast Reconstruction and Revision below. Limitations and Exclusions:
a. Mastopexy procedures (e.g. breast ptosis) are not a covered benefit. These procedures are considered to be cosmetic in nature and not performed to relieve pain due to macromastia.
b. Reduction mammoplasty for cosmetic purposes (to improve  appearance) is not a covered benefit.

Breast Reconstruction and Revision

This section applies to reconstruction and revision for breast cancer. It would also apply to women at high risk of breast cancer who require prophylactic mastectomy.

Initial reconstruction can occur immediately after a mastectomy or be delayed until a patient undergoes radiation or chemotherapy or determines whether she wants breast reconstruction. Some women will opt for immediate breast reconstruction after mastectomy, while some may prefer delayed reconstruction. While some reconstructions can be completed in a single procedure, other techniques may require two or more surgical procedures for completion of the reconstructive process.

Further clarification of coverage for breast reconstruction and revision is outlined below.

1. Coverage for the breast affected by cancer, as well as for the breast(s) removed prophylactically (including bilateral prophylactic mastectomies).

The following are covered benefits:
a. Treatment for complications of breast reconstruction including cellulitis, other infections, and lymphedema.
b. Revisions required by surgical complications including infection, hematoma or seroma, or skin or flap necrosis.
c. Capsulotomies/capsulectomies for pain or contractures (see II. A. Breast Implant Removal above) for coverage criteria.
d. Prosthesis removal for pain, contractures, rupture, leakage or infection. (see II. A. Breast Implant Removal above) for coverage criteria.
e. Scar revisions are only covered if one of the following apply:
i. The scar resulted from a serious complication such as infection or wound dehiscence from surgery or post-op period
ii. The scar revision is an integral (not incidental) part of another covered procedure

Breast Reconstruction and Revision

This section applies to reconstruction and revision for breast cancer. It would also apply to women at high risk of breast cancer who require prophylactic mastectomy.

Initial reconstruction can occur immediately after a mastectomy or be delayed until a patient undergoes radiation or chemotherapy or determines whether she wants breast reconstruction. Some women will opt for immediate breast reconstruction after mastectomy, while some may prefer delayed reconstruction. While some reconstructions can be completed in a single procedure, other techniques may  require two or more surgical procedures for completion of the reconstructive process. Further clarification of coverage for breast reconstruction and revision is outlined below.

1. Coverage for the breast affected by cancer, as well as for the breast(s) removed prophylactically (including bilateral prophylactic mastectomies).

The following are covered benefits:
a. Treatment for complications of breast reconstruction including cellulitis, other infections, and lymphedema.
b. Revisions required by surgical complications including infection, hematoma or seroma, or skin or flap necrosis.
c. Capsulotomies/capsulectomies for pain or contractures (see II. A. Breast Implant Removal above) for coverage criteria.
d. Prosthesis removal for pain, contractures, rupture, leakage or infection. (see II. A. Breast Implant Removal above) for coverage criteria.
e. Scar revisions are only covered if one of the following apply:
i. The scar resulted from a serious complication such as infection or wound dehiscence from surgery or post-op period
ii. The scar revision is an integral (not incidental) part of another covered procedure

Breast reconstruction surgery is also a covered benefit when incidental to disease and/or injury if:
a. a functional impairment is established and surgery is intended to correct the functional impairment OR
b. breast reconstructive surgery is performed to correct asymmetry of a breast when surgery has been performed on the other breast incidental to disease or injury.

Prior Authorization Requirements for Medicaid members (all of the following are required). The following documentation should be provided by the requesting physician:
a. Patient’s age
b. Physical description of the enlarged breast including symmetry, mass, induration and size
c. Medical history assessing the differential diagnosis including chronic diseases and medications
d. Previous work-up including mammogram and fine needle aspirate, where appropriate for evaluation of unilateral gynecomastia or masses.
e. High-quality original photographs for evaluation of the gynecomastia grade.

Digital Breast Tomosynthesis (DBT)

a. A screening DBT is considered medically necessary for individuals that have dense breasts.
b. A diagnostic DBT is considered medically necessary for individuals that have abnormal mammogram findings that require further imaging

Breast Reconstruction and Revision

Breast reconstruction surgery includes those surgical procedures which are intended to restore the normal appearance of the breast. This restoration occurs after surgery, accidental injury, or trauma.

Mastectomy for cancer is the most common reason women seek breast reconstruction, but other conditions such as severe post radiation changes or congenital deformities are other reasons that a woman may seek breast reconstruction.

Techniques of reconstruction include: tissue expansion, flap reconstruction, nipple areola reconstruction with subsequent implantation of a breast prosthesis. The tissue expander is a balloon-like device which is surgically placed under the chest tissue to create a breast-shaped space for the breast implant. Flap reconstruction allows for reconstruction using the patient’s own tissues. Donor flap sites include the back, lower abdomen, buttocks, or lateral hip region. For a latissumus flap the latissimus dorsimuscle is used. This muscle is frequently used for reconstruction surgery due to its large size and versatility. For a TRAM flap (transverse rectus abdominus musculocutaneous flap) excess abdominal tissue is tunneled under the skin from the lower abdomen to the chest and used to replace the breast tissue. For a free flap, tissue from other body sites (such as buttock or lateral thigh region) is transferred to the chest.

Although breast reconstruction is a cosmetic procedure, there are both Federal and Michigan state laws requiring health plans to cover breast reconstruction in certain defined circumstances. The federal and state requirements differ. 

Pathological gynecomastia is associated with both androgen deficiency and estrogen excess. Both causes may be due to medications, diseases related to endocrinologic abnormalities, tumors, chronic disease, chromosomal abnormalities, familial disorders, and other miscellaneous conditions. While there is  always a concern when a mass is present, breast cancer accounts for only 0.2 percent of all malignancies in male patients. A suspicious mass or lesion requires biopsy.

Gynecomastia Scale adapted from the McKinney and Simon, Hoffman and Kohn scales:

Grade I Small breast enlargement with localized button of tissue that is concentrated around the areola.

Grade II Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest.

Grade III Moderate breast enlargement exceeding areola boundaries with edges that are distinct from the chest with skin redundancy present. Grade IV Marked breast enlargement with skin redundancy and feminization of the breast

Screening Mammography and Breast MRI
Screening Mammography
Screening mammography involves radiographic (X-ray) examination of the breast

performed at regular intervals, usually every 1 to 2 years, to detect breast cancer before it displays signs or symptoms. The goals of screening mammography for average risk  women without any symptoms are to reduce breast cancer morbidity and mortality (illness and death). This can be accomplished by the accurate detection of the disease before it has metastasized (spread from the breast to another part of the body), when treatment can be less aggressive, and when the likelihood of long-term remission (decrease in symptoms) or cure is the highest.

According to the State of Michigan Insurance Code, breast cancer screening is defined as mammography using a standard 2-view per breast, low-dose radiographic examination of the breasts, and using equipment designed and dedicated specifically for mammography, in order to detect unsuspected breast cancer.

The Insurance Code goes on to define breast cancer diagnostic services as procedures intended to aid in the diagnosis of breast cancer, delivered on an inpatient or outpatient basis, including but not limited to mammogram, mammography, surgical breast biopsy, and pathologic examination and interpretation.

Breast MRI

Women with inherited mutations of the BRCA1 or BRCA2 gene have the highest risk of breast cancer. They make up 5 to 10 percent of women with breast cancer and are also at increased risk for ovarian cancer. The cumulative risk of breast cancer in women with BRCA1 mutations is 3.2 percent by the age of 30 years, 19.1 percent by the age of 40, 50.8 percent by the age of 50, 54.2 percent by the age of 60, and 85.0 percent by the age of 70; the cumulative lifetime risk for carriers of BRCA1 or BRCA2 mutations is 50 to 85 percent.

Screening mammography detects less than half of the breast cancers in mutation carriers, perhaps owing to young age, dense breasts, or pathological features of the tumor. Cancers in mutation carriers grow rapidly; half of them appear in the intervalbetween annual mammograms. The median size of such "interval cancers" is 1.7 cm,  and half have spread to axillary lymph nodes by the time they are detected. It has been suggested that supplementing mammography with other imaging techniques, shorter screening intervals, or both may be valuable in mutation carriers. Liberman, L. “Breast Cancer Screening with MRI—What are the Data for Patients at High Risk?” New England Journal of Medicine, 351; 5, July 29, 2004, pp. 497-500.

D07.30 Carcinoma in situ of unspecified female genital organs
Z40.01 Encounter for prophylactic removal of breast
Z42.1 Encounter for breast reconstruction following mastectomy
Z42.8 Encounter for other plastic and reconstructive surgery
following medical procedure or healed injury\
Z85.3 Personal history of malignant neoplasm of breast
Z90.10 – Z90.13 Acquired absence of breast and nipples
Z98.82 Breast implant status
N64.89 Other specified disorders of breast
T85.44xA - T85.44xS Capsular contracture of breast implant,
N65.0 Deformity of reconstructed breast
N65.1 Disproportion of reconstructed breast
T85.41xA - T84.49xS Mechanical complication of breast prosthesis and implant
T85.79xA - T85.79xS Infection and inflammatory reaction due to other internal prosthetic devices, implants and grafts
T85.828A-T85.828S Fibrosis due to other internal prosthetic devices, implants and grafts
T85.848A-T85.848S Pain due to other internal prosthetic devices, implants and grafts
T85.898A-T85.898S Other specified complication of other internal prosthetic devices, implants and grafts


Indications for Coverage

Breast reconstruction is covered for Members who have a Mastectomy with or without a diagnosis of cancer. Mastectomy includes partial (lumpectomy, tylectomy, quadrantectomy, and segmentectomy), simple, and radical.

This benefit does not include aspirations, biopsy (open or core), excision of cysts, fibroadenomas or other benign or malignant tumors, aberrant breast tissue, duct lesions, nipple or areolar lesions, or treatment of gynecomastia.

There is not a time frame in which the Member is required to have the reconstruction done post Mastectomy under the Women’s Health and Cancer Rights Act of 1998.

In accordance with Federal and State mandates, the following services are covered:
* Reconstruction of the breast on which the Mastectomy was performed
* Surgery and reconstruction of the other breast to produce a symmetrical appearance, including nipple tattooing
* Prosthesis (Implanted and/or external)
* Treatment of physical complications of Mastectomy, including lymphedema Various surgical techniques are used for breast reconstruction, including but not limited to:
* Insertion of FDA approved breast implants and tissue expanders
* Breast Implants and tissue expanders post Mastectomy with or without skin substitutes, approved by the FDA, including but not limited to: Alloderm, Allomax or FlexHD are a covered benefit
* Transverse Rectus Abdominus Myocutaneous Flap (TRAM)
* Latissimus Dorsi Flap (LD)
* Deep Inferior Epigastric Perforator (DIEP) Flap
* Gluteal Flap (GAP free flap)


Breast MRI

* Breast MRI is usually bilateral (CPT®77059) or can be unilateral (CPT®77058) in some after mastectomy, per physician request.

* MRI guided breast biopsy (CPT®19085) includes the imaging component. Additional lesions should be billed using CPT®19086.

* MRI Breast can be repeated at least 6 months after an MRI directed breast biopsy to document successful lesion sampling if histology is benign and nonspecific, equivocal or uncertain.

Breast MRI - Practice Notes

Although breast MRI has superior sensitivity in identifying new unknown malignancies, it carries a significant false positive risk when compared to mammogram and ultrasound. Incidental lesions are seen on 15% of breast MRI’s and increase with younger age The percentage of incidental lesions that turn out to be malignant varies from 3% to 20% depending on the individual population. Cancer is identified by breast MRI in only 0.7% of those with “inconclusive mammographic lesions

Breast Reconstruction

* CTA or MRA of the body part from which the free tissue transfer flap is being taken, can be performed for breast reconstruction preoperative planning.2,3
o For example, CTA (CPT®74175 and CPT®72191) or MRA (CPT®74185 and CPT®72198) of the abdomen and pelvis for Deep Inferior Epigastric Perforators (DIEP) flap
* There is currently insufficient evidence-based data to support the need for routine advanced imaging for TRAM flaps or other flaps performed on a vascular pedicle

 CAD for Breast MRI

* The use of CAD with breast MRI is currently considered investigational, experimental, and/or unproven.
o 3D rendering codes (CPT®76376 or CPT®76377) should not be used in conjunction with code 0159T

Breast MRI is NOT Indicated

* Breast MRI should not be used to determine biopsy recommendations for suspicious or indeterminate lesion(s) that can be readily biopsied, either using imaging guidance or physical exam, such as palpable masses and microcalcifications.

* MRI should not be used for routine surveillance in individuals with history of breast cancer, unless there are physical exam, imaging findings, recurrent, or residual disease at the mastectomy site

Breast MRI Indications

* Breast MRI is indicated for breast augmentation, breast implants (saline or silicone), breast reconstruction, free injection, and capsular contracture to:
o Evaluate or confirm breast implant rupture when mammography or ultrasound is uninterpretable6
* If leakage is detected on MRI or any other modality, the implant(s) should be removed and no further surveillance MRI of the affected breast(s) is indicated.
* Surveillance for silent/asymptomatic rupture of silicone implants is considered investigational.
* Cigna does not cover surveillance MRI for breast implants if they were placed as part of purely cosmetic surgery.
* Annual breast MRI is indicated for high risk histologies:
o Atypical ductal hyperplasia (AD); Atypical lobular hyperplasia (ALH); Lobular carcinoma in situ (LCIS)
* Equivocal or Occult Findings
o Radiologist Report Recommendation for Breast MRI and one of the following:
* Inconclusive or conflicting findings on mammography or ultrasound of a lesion that is not a palpable mass
o A probably benign lesion on MRI (MRI BI-RADSTM 3) should undergo repeat MRI in 6 months.

Most read cpt modifiers