Independence has reviewed the following services as part of the policy maintenance process. Based on the available peer-reviewed literature and medical society guidelines, these previously eligible services have been determined to be not medically necessary or experimental/investigational. The changes in coverage positions will become effective as outlined below.

Changes effective November 1, 2016

Changes to the following policy will be posted in the Active Notifications section of the Medical Policy Portal:

• Medical Policy #05.00.61e: Cervical Traction for In-home Use

The following coverage change will be reflected:

• HCPCS E0849, E0855, E0860: Cervical traction using a mechanical or pneumatic device in the home setting will be considered not medically necessary. Cervical traction has been performed to relieve muscle spasms in the neck and shoulders and to relieve the pain of pinched nerves in the neck. It may be administered by various techniques ranging from supine mechanical motorized or pneumatic traction.

The following coverage changes will be communicated in the News & Announcements section of the Medical Policy Portal:

• CPT^® 82172: Measurement of apolipoprotein particles will be considered experimental/investigational as an adjunct to LDL cholesterol in the risk assessment and management of cardiovascular disease. Numerous lipid and non-lipid biomarkers have been proposed as potential risk markers for cardiovascular disease. These biomarkers include apolipoproteins B, AI, and E.
• CPT 86357: Quantification of natural killer (NK) cells will be considered experimental/investigational for all indications. The purported indications for quantification of NK cells include, but are not limited to, biomarkers of Lyme disease progression, recurrent pregnancy loss, adoptive immunotherapy and cellular therapy, and chronic fatigue syndrome.
• CPT 86677: Antibody testing for Helicobacter pylori will be considered experimental/investigational for all indications. Antibody testing may be performed to determine the presence of Helicobacter pylori (H. pylori), a common cause of intestinal disease and suspected as a cause of ulcerated stomach tissue. This test may be performed by enzyme-linked immunosorbent assay or chemiluminescence assay. Carbon isotope (13C or 14C) urea breath testing or stool antigen testing for H. pylori are clinically valid test options. The stool antigen test is cleared by the U.S. Food and Drug Administration (FDA) for use in the initial diagnosis, therapeutic monitoring, and eradication confirmation in adults and children. The urea breath tests are cleared by the FDA for the initial diagnosis and eradication confirmation in adults.

For additional information on these changes, please review the following news articles:

Commercial:

• Measurement of Apolipoprotein Particles (i.e., apolipoprotein B, apolipoprotein AI, apolipoprotein E)
• Quantification of Natural Killer (NK) Cells
• Antibody Testing for Helicobacter pylori (H. pylori)

Medicare Advantage:

• Quantification of Natural Killer (NK) Cells
• Antibody Testing for Helicobacter pylori (H. pylori)

Changes effective January 1, 2017

Changes to the following policies will be posted in the Active Notifications section of the Medical Policy Portal:

• Commercial: #12.01.01ai: Experimental/Investigational Services
• Medicare Advantage: #MA00.005h: Experimental/Investigational Services

These policies are being updated to reflect that the following services will be considered experimental/investigational as of January 1, 2017:

• HCPCS A9584: Iodine I-123 ioflupane is a radiopharmaceutical agent used during dopamine transported single-photon emission computed tomography. It is intended to assist in the evaluation of adults with suspected Parkinsonian syndromes and has been proposed to differentiate between clinically uncertain Parkinsonian syndromes and essential tremor.
• CPT 0159T: The use of computer-aided evaluation (CAE) in the interpretation of contrast-enhanced magnetic resonance imaging of the breast has been proposed as a mechanism to assist radiologists in the interpretation of breast MRIs.
• CPT 62291: Cervical and thoracic provocative discography may be used to determine whether a disc is painful on injection. It is an invasive procedure that involves the injection of radiopaque contrasting materials (1 to 3 mL) into the intervertebral disc, followed by computed tomography to examine the disc abnormality.
• CPT 77605: Deep hyperthermia generated by an external source, alone or in combination with radiation therapy, can be administered using local and whole body techniques. Local hyperthermia entails elevating the temperature of superficial or subcutaneous tumors while sparing surrounding normal tissue using either external or interstitial modalities. Whole body hyperthermia requires the individual to be placed under either general anesthesia or deep sedation.

Changes to the following policies will be posted in the Active Notifications section of the Medical Policy Portal:

• Commercial: #11.14.24a: Manipulation Under Anesthesia
• Medicare Advantage: #MA11.091a: Manipulation Under Anesthesia

These policies are being updated to reflect that the following service will be considered experimental/investigational as of January 1, 2017:

• CPT 27275: Manipulation under anesthesia (MUA) for disorders of the hip is a non-invasive treatment used to treat acute and chronic conditions, including muscular or spinal pain. Under anesthesia, spastic muscles are believed to relax and diminish pain sensations, which theoretically may permit joint manipulation through a full range of motion.

Visit the Medical Policy Portal to learn more about these medical policy updates. Select Accept and Go to Medical Policy Online, then select Commercial or Medicare Advantage under News and Announcements and/or Active Notifications to review the complete communication.

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