August 2024 Form

WPS Medical Policy Updates The Medical Affairs Medical Policy Committee recently approved medical policies that will become effective on the specified dates. Disclaimer: Medical Policies are for informational purposes only and do not constitute medical advice, plan authorization, an explanation of benefits, or a guarantee of payment. Benefit plans vary in coverage and some plans may not provide coverage for all services listed in a policy. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and federal law. Some benefit plans administered by the organization may not utilize Medical Affairs medical policy in all their coverage determinations. Contact Customer Service as listed on the customer ID card for specific plan, benefit, and network status information. Medical policies are based on constantly changing medical science and are reviewed annually and subject to change. The organization uses tools developed by third parties, such as the evidence-based clinical guidelines developed by MCG to assist in administering health benefits. Medical Policies and MCG guidelines are intended to be used in conjunction with the independent professional medical judgment of a qualified health care provider.

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To obtain a referenced MCG guideline specific to your patient’s review, contact Medical Affairs toll-free at 800-333-5003. •
For general medical policy or MCG requests, email medical.policies@wpsic.com. •
If you have specific questions or comments regarding development of policy content, contact the Medical Policy Editor at medical.policies@wpsic.com or 800-333-5003, ext. 06984. •
For questions regarding medical coding related to Medical Policy Committee policies, contact the Code Governance Committee at codegovernance@wpsic.com.

Medical Policy Highlights Back and Neck Pain Procedures-Epidural Injection
Effective June. 1, 2024 Indications of Coverage: ADDED-thoracic ESI’s. Back and Nerve Pain Procedures-Radiofrequency Ablation, Facet and Other Injections Effective June 1, 2024 Indications of Coverage: ADDED-No more than 2 neuroablation sessions on the left side, and 2 neuroablation sessions on the right side, per anatomic spinal region (cervical, thoracic, lumbar) would be deemed medically necessary in a rolling 12-month period. Limitations of Coverage: ADDED-Intradiscal injection of any substance (to include steroid, stem cells, platelet rich plasma [PRP], methylene blue, Via Disc NP anti-TNF-alpha agents such as etanercept) for treatment of chronic pain is considered experimental, investigational, unproven to affect health outcomes.

Back Pain: Sacroiliac and Coccydynia Treatments Effective June 1, 2024 Limitations of Coverage: ADDED-Minimally invasive posterior sacroiliac joint fusion for management of sacroiliac joint pain is experimental, investigational, and unproven to affect health outcomes. Emergency Air/Water Ambulance Services New Effective Nov. 1, 2024 PA is not required for emergency air/water ambulance services. Description: This medical policy addresses emergency ambulance transportation for ill or injured patients via air or water. Air ambulance services are provided by rotary wing (helicopters) or fixed wing (airplanes). Indications of Coverage: Emergency ambulance services are considered medically necessary when the following criteria are met. For air/water ambulance services, ALL of the following criteria must be met:

1. Member has a critical or unstable emergency requiring immediate transport.
2. The transferring hospital or facility or locale does not have adequate facilities to provide the medical services needed by the individual.
3. Transfer is to the closest acute care facility at which the required medical care can be provided. 4. A licensed medical practitioner has ordered the air transport after having evaluated the patient or been consulted telephonically/electronically.
   AND AT LEAST ONE OF THE FOLLOWING:
   i.
   The time to transport by ground would be significantly greater than the time to transport by air (including prep/mobilization time required by the air ambulance team) and that time difference is such that the member’s condition could be jeopardized by this delay. ii. Ground ambulance transport is not feasible, for example, due to remote location or extreme weather or traffic conditions. iii. The member requires capabilities or specialty services during transport that can be provided by the air/ water transport team, but not by the ground transport.
   *Mileage associated with air ambulance service is considered medically necessary up to the distance required for transport to the nearest appropriate facility. Limitations of Coverage: Ambulance services for convenience purposes or personal preference are not medically necessary and not a covered benefit. Transport back to the continental United States (repatriation) or transport to a facility preferred by the member/family, when a geographically closer facility is available to provide the needed services, will be denied as not a covered benefit and/or not medically necessary.
   Mileage in excess of the distance from the trip origin to the nearest appropriate facility is considered not medically necessary.
   Transport beyond the nearest facility equipped to provide the most appropriate care for the member’s condition, as determined by us, will be denied as not medically necessary.

Glaucoma Surgical Treatments (Micro-bypass Stents, Filtration Devices, and Shunts) Effective July 1, 2024 Indications of Coverage: ADDED-Insertion of iStent Infinite or XEN gel stent does not require a concurrent cataract surgery. It is deemed medically necessary when ALL of the following are met:

1. Usage and number of stents are in accordance with FDA approved indications.
2. In an individual age 18 years or older.
3. Diagnosis of primary open-angle glaucoma, pseudo-exfoliative glaucoma or pigmentary glaucoma.
4. Failure, intolerance or contraindication to a trial of maximal medical therapy.
5. Failure or contraindication to at least one of the standard surgical techniques (laser trabeculoplasty or trabeculectomy). Limitations of Coverage: ADDED-Optical coherence tomography-guided laser trabeculotomy for treatment of glaucoma is considered experimental, investigational, unproven to affect health outcomes. MRI (Magnetic Resonance Imaging) of Upper and Lower Extremities Effective July 1, 2024 Indications of Coverage: ADDED-Osteoarthritis (OA)-When there are persisting pain/symptoms with failure of four-week trial of conservative therapy** (PT/Chiro, and/or provider directed HEP) within the past 6 months, OR worsening of symptoms during conservative treatment AND at least ONE of the following are met: a. Known or suspected OA at earlier stages of the disease and x-ray is non-diagnostic. b. Clinical need for assessing pathology in other structures of the joint not visualized by radiography, such as effusions, synovium, menisci, and ligaments.
   c. Strong clinical suspicion is documented for pathologies other than OA that can be a cause of symptoms. Neuropsychological Testing Effective June 1, 2024 Indications of Coverage: ADDED-Complicated Attention-deficit/hyperactivity disorder (ADHD) when ALL of the following are present: i.
   Specific neurocognitive behavioral deficits related to ADHD that need to be evaluated; and ii. Testing has been recommended by a physician and is related or secondary to a known or suspected organic/medical condition resulting from brain injury or disease process, including one or more of the following: a. Concussion or traumatic brain injury b. History of CNS (central nervous system) infection c. Intractable seizure disorder d. Cancer treatment effects e. Genetic disorders f. Inborn errors of metabolism g. History of stroke, hypoxic-ischemic encephalopathy, or intracranial vascular malformation

Skin and Soft Tissue Substitutes
Effective June. 1, 2024 Indications of Coverage: ADDED-All skin substitute products must be used in accordance with FDA approved labeling. ADDED-Kumar Class I. Temporary, impervious dressing materials

1. Bilayered, amnio-derived skin substitutes: Allograft related skin or soft tissue substitutes including EpiFix or Grafix (Grafix PL, GrafixPRIME, and Grafix PL PRIME [Non-injectable]). A. EpiFix or Grafix (Grafix PL, GrafixPRIME, and Grafix PL PRIME [Non-injectable]) are medically necessary for diabetic ulcers, venous stasis ulcers, burns or traumatic wounds, surgical postoperative wounds, and other acute or chronic wounds, when ALL of the following are met: a. No wound infection b. No measurable signs of healing with at least four weeks of conventional therapy (that is, no
   decrease in size or depth of the targeted wound, or no decrease in the degree of exudate
   or necrotic tissue) Note: EpiFix or Grafix are limited to one application per week for up to 12 weeks.

2. Bilayered, amnion and chorion derived skin substitutes: AmnioBand Membrane or Guardian are

   medically necessary for the treatment of diabetic foot ulcers when ALL of the following are met: A. Conventional wound care to continue during treatment along with continued clinical glycemic management B. Diabetes mellitus (type 1 or type 2) C. Full-thickness ulcer and no exposed tendon, muscle, capsule, or bone D. Ulcer history duration greater than four weeks. E. No measurable signs of healing with at least four weeks of conventional therapy (that is, no decrease in size or depth of the targeted wound, or no decrease in the degree of exudate or necrotic tissue). F. No wound infection Kumar Class II, dermal skin substitutes

3. Diabetic and Venous stasis ulcers: Apligraf (Graftskin) is considered medically necessary when ALL
   of the following are met: A. Adequate circulation to affected extremity as documented by physical exam and/or doppler ultrasound exam, such as palpable pulses or ankle-brachial index >0.7. B. Conventional wound care to continue during treatment, along with continued clinical glycemic management (if patient is diabetic) C. Full-thickness ulcer and no exposed tendon, muscle, capsule, or bone. D. Ulcer history duration greater than four weeks E. No measurable signs of healing with at least four weeks of conventional therapy (that is, no decrease in size or depth of the targeted wound, or no decrease in the degree of exudate or necrotic tissue). F. No wound infection.

Kumar Class II, Single layer durable skin substitutes

1. Dermal skin substitutes: A. Dermagraft or Allopatch is considered medically necessary for diabetic ulcers when ALL of the
   following are met: a. Adequate circulation to affected extremity as documented by physical exam and/or doppler ultrasound exam, such as palpable pulses or ankle-brachial index >0.7. b. Conventional wound care to continue during treatment, along with continued clinical glycemic management c. Diabetes mellitus (type 1 or type 2) d. Full-thickness ulcer and no exposed tendon, muscle, capsule, or bone e. Ulcer history duration greater than six weeks f.
   No measurable signs of healing with at least four weeks of conventional therapy (that is, no decrease in size or depth of the targeted wound, or no decrease in the degree of exudate or necrotic tissue). g. No wound infection Kumar Class III-Composite
2. Skin graft, autografts-Epicel may be considered medically necessary for deep dermal or full thickness burns comprising a total body surface area of greater than or equal to 30%.
3. Tissue-engineered skin substitutes; including Biobrane may be considered medically necessary for the management of superficial partial thickness burn wounds.
4. Transcyte is considered medically necessary for full and partial thickness burn wounds when the wound is too large for autograft or prior to autograft placement. AlloDerm and AlloDerm-RTM are considered medically necessary for any of the following:
5. Breast reconstruction surgery, provided the surgery is not cosmetic.
6. Surgical repair of complex abdominal wall wounds.
7. For ear drug augmentation (tympanoplasty), repair of skull base defect, and temporal bone lining. Limitations of Coverage: ADDED-ArthroFLEX for all indications, to include musculoskeletal procedures and anterior cruciate reconstruction. ADDED-Acellular dermal matrix (ADM) products derived from allograft human skin such as, MemoDerm (Stryker), InteguPly (PuraGraft), Dermaspan (Biomet Orthopedics), SimpliDerm (Elutia) for musculoskeletal procedures. ADDED-Omeza Collagen Matrix (Omeza), Phoenix Wound Matrix (RenovoDerm), Impax Dual Layer Amniotic Graft (Legacy Medical Consultants) (amniotic membrane product), carePatch (Extremity Care) for Treatment of wounds. ADDED-Skin substitutes for treatment of acute wounds.

Spinal Manipulation Treatments and Chiropractic Services Effective Nov.. 1, 2024 Indications of Coverage:
Re-evaluation of the treatment plan: ADDED-Must be performed every 4 weeks for visit frequency for 2-3 visits per week, or every 8 visits for a treatment plan of 1 time a week, whichever applies to the specific member. Exacerbations, flare-ups or recurrence, ADDED-For each and every reported exacerbation or flare- up, there must be a documented complete, revised physical exam as well as a revision of the treatment plan, or else the continued treatments will be deemed not medically necessary. ADDED-Transcutaneous electrical nerve stimulation (TENS) is considered medically necessary for ANY of the following: a. Dysmenorrhea and BOTH i. and ii. Are met: i. No response to treatment with NSAIDs or hormone therapy (e.g., oral contraceptives) ii. Other causes of dysmenorrhea, such as endometriosis, etc. have been ruled out b. Knee osteoarthritis when ALL of the following are met: i. Surgical procedure (e.g., arthroplasty) is not indicated as patient is considered a high surgical risk ii. Disabling knee pain or stiffness iii. 6 or more weeks of treatment with medication (e.g., acetaminophen, NSAIDs) when there is inadequate response c. Postoperative pain when ANY of the following is met: i. Conventional pain control techniques fail to adequately
reduce pain ii. Unacceptable medication-related adverse events iii. Need to reduce opioid dosage Limitations of Coverage: ADDED-Repeat imaging is considered not medically necessary, unless there is documentation of unexpected lack of progress from treatments or worsening of symptoms despite treatments. ADDED-A treatment plan of once per month or treatments provided on an as needed basis, are not consistent with evidence-based guidelines and standards for acute treatment of conditions and are deemed maintenance care, and thus, not covered. ADDED-As per the Office of Inspector General, in a Medicare population, when chiropractic care extends beyond 24 treatments in a year, the likelihood is approximately 100% that those services are medically unnecessary, and more likely to be maintenance in nature at higher service volumes. Thus, any services exceeding 24 sessions in a rolling 12-month period are deemed not medically necessary, and likely maintenance.

Tumor Treating Fields (Alternating Electric Field Therapy)
Effective July. 1, 2024 Indications of Coverage-If Indications of Coverage (in letters A. and B. above) are met, the tumor treating fields device may be approved for-changed 6 months to 3 months. Continued use will require review by the Health Plan’s Medical Director every-changed 6 months to 3 months. ADDED-Continuation of tumor treating fields therapy beyond the initial 3 months is considered medically necessary when ALL of the following criteria are met:

1. Magnetic resonance (MRI) scan has been performed within 2 months prior to request and documents none of the following: a. Tumor growth of greater than 25%; OR b. Appearance of one or more new tumors in the brain (felt radiologically or based on biopsy to be glioblastoma); AND
2. KPS score of at least 60; AND

3. Documentation that the individual has been using the device at least 18 hours daily in the most recent
   30-day trial. Reminder All genetic, genomic, pharmacogenetic, pharmacogenomic, molecular genetic, mRNA, DNA, chromosome, telomere, single nucleotide polymorphism (SNP), gene sequencing, gene expression profiles, and gene- related panels, tests, and analyses require prior authorization BEFORE the testing is completed. Determination of genetic panel coverage is based on assessment of the test’s analytical and clinical validity, the clinical utility of the test, and evidence demonstrating a positive impact of the test panel on the care of individuals with, or at risk for, the conditions being tested. The Medical Policy Committee (MPC) considers multi-gene test panels experimental, investigational, and unproven to affect health outcomes unless otherwise determined during prior authorization review. The complete library of our medical policies and the quarterly Medical Policy Update reports can be found online at wpshealth.com. No password required! ©2024 Wisconsin Physicians Service Insurance Corporation. All rights reserved. JO25974

       
   
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