Medical Policy Update

Revised Medical Policies

Medical Policy IV.82 Targeted Biopsy of the Prostate and Prostate Screening

Effective Date: 11/01/2022
Preauthorization Required: Yes

1. MRI Prostate for screening may be considered scientifically validated in patients who meet the following criteria: 
   1. Patient has had prior TRUS biopsy AND
   2. Age 40-74 years old with a PSA >3 and/or abnormal digital rectal exam OR
   3. Age 75 years of age or older with a PSA ≥4 and/or abnormal digital rectal exam 
2. MRI Prostate for screening is considered investigational when the above criteria are not met as its clinical effectiveness has not been established 
3. Repeat MRI Prostate for screening may be considered scientifically validated in patients who meet ALL the following:
   1. It has been at least 6 months since the last prostate MRI AND
   2. PSA remains elevated AND/OR
   3. Abnormal digital rectal exam (DRE)
4. Repeat MRI Prostate for screening is considered investigational for all other indications as its clinical effectiveness has not been established.

Medical Policy III.105 Procedures to Treat Dysmenorrhea and Uterine Fibroids

Effective Date: 08/17/2022
Preauthorization Required: Yes

1. Laparoscopic or transcervical radiofrequency ablation (RFA) as a treatment of symptomatic uterine fibroids may be considered medically necessary in women 18 years and older when ALL the following conditions are met: 
   1. Evidence of uterine fibroids via ultrasound that are less than 10 cm in diameter for laparoscopic RFA (with Acessa) or 7 cm for transcervical RFA (with Sonata); AND 
   2. Patient desires a uterine-sparing treatment approach or is ineligible for hysterectomy or other uterine-sparing alternatives to RFA (e.g., laparoscopic myomectomy, uterine artery embolization [UAE]) (see Policy Guidelines*); AND 
   3. Patient has experienced at least 1 of the following symptoms that are a direct result of the fibroid(s): 
      1. Menorrhagia or other abnormal uterine bleeding that interferes with daily activities or causes anemia (see Policy Guidelines*); OR 
      2. Pelvic pain or pressure; OR 
      3. Urinary symptoms (e.g., urinary frequency, urgency) related to bulk compression of the bladder; OR 
      4. Gastrointestinal symptoms related to bulk compression of the bowel (e.g., constipation, bloating); OR 
      5. Dyspareunia (painful or difficult sexual relations). 
2. Other laparoscopic, transcervical, or percutaneous techniques for myolysis of uterine fibroids, including use of laser or bipolar needles, cryomyolysis, and magnetic resonance imaging-guided laser ablation, are considered investigational. 
3. Open and laparoscopic uterine nerve ablation and presacral neurectomy for dysmenorrhea are considered investigational.  

Medical Policy III.218 Spinal Cord and Dorsal Ganglion Root Stimulator

Effective Date: 09/07/2022
Preauthorization Required: Yes

1. Patient is 18 years of age or older AND
2. Patient has refractory pain or burning in area AND
3. Patient has two of the following:
   1. numbness
   2. sensory loss 
   3. paresthesia 

AND

4. Patient has tried and failed all of the following:
   1. sympathetic block AND
   2. home exercise, occupational therapy, or physical therapy for 6 months or more AND
   3. antidepressant or antiepileptic drugs for 4 weeks or more 

AND

5. Patient does NOT have any of the following:
   1. untreated or uncontrolled psychiatric disorder 
   2. drug or alcohol misuse (patient must be alcohol free for at least 4 weeks)
   3. active immunosuppression 
   4. bleeding disorder
   5. systemic or localized infection at operative site
   6. cardiac pacemaker, implantable cardioverter or other neurostimulator
   7. pregnant