Updates to Medical Policies and Clinical UM Guidelines Effective January 15, 2012

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1 Updates t Medical Plicies and Clinical UM Guidelines Effective January 15, 2012 UniCare is pleased t prvide yu with ur updated and new medical plicies and clinical UM guidelines. The majr new new plicies and changes are summarized belw. Additinal changes are included in Attachment A at the end f this dcument. Please refer t the specific plicy fr cding, language, and ratinale updates and changes that are nt summarized in this ntice. New Medical Plicies Effective January 15, 2012 DME Electric Tumr Treatment Field (TTF): This plicy addresses electrical fields knwn as tumr treatment fields (TTF), which are created by lw intensity, alternating intermediate frequency electric currents delivered t the malignant tumr site by insulated electrdes placed n skin surface f the tumr site. As a result f the unique shape and electrical characteristics f dividing tumr cells, TTF expsure may damage the dividing cells thrugh anti micrtubule mechanisms and culd stp tumr grwth while sparing nrmal tissue. The use f devices t generate electric tumr treating fields (TTF) as a treatment fr malignant tumrs is cnsidered investigatinal and nt medically necessary RAD Digital Breast Tmsynthesis: This plicy addresses digital breast tmsynthesis (DBT) (three dimensinal [3 D] mammgraphy), which is being investigated as an adjunct and alternative t x ray mammgraphy fr the screening and diagnsis f breast cancer. DBT cmbines the use f tmgraphy and 3 D recnstructin with breast imaging t imprve the visibility f breast lesins. Digital breast tmsynthesis is cnsidered investigatinal and nt medically necessary fr all indicatins SURG Sacral Nerve Stimulatin (SNS) and Percutaneus Tibial Nerve Stimulatin (PTNS) fr Urinary and Fecal Incntinence; Urinary Retentin: This plicy addresses sacral nerve stimulatin (SNS) and percutaneus tibial nerve stimulatin (PTNS) in thse with chrnic, refractry urinary and fecal incntinence as well as urinary retentin. Outlines medically necessary, and investigatinal and nt medically necessary indicatins fr sacral nerve stimulatin (SNS) fr urinary incntinence and retentin, and fecal incntinence Lists investigatinal and nt medically necessary indicatins fr percutaneus tibial nerve stimulatin (PTNS) Mved infrmatin and criteria n sacral nerve stimulatin fr urinary indicatins and PTNS frm SURG t this new plicy Sacral nerve stimulatin and PTNS fr fecal incntinence nw addressed n this plicy SURG Radifrequency and Pulsed Radifrequency Ablatin f Trigger Pint Pain: This plicy addresses the treatment f trigger pint pain with radifrequency (RF) r pulsed radifrequency (PRF) ablatin. Radifrequency (RF) and pulsed radifrequency (PRF) ablatin treatment f trigger pints are cnsidered investigatinal and nt medically necessary Cverage and administrative services are prvided by UniCare Life & Health Insurance Cmpany, a separately incrprated and capitalized subsidiary f WellPint, Inc. Registered mark f WellPint, Inc WellPint, Inc.

2 SURG Ablatin f Sft Tissue Using Irreversible Electrpratin (IRE): This plicy addresses use f the Nanknife Oncbinic System fr sft tissue ablatin, which is classified by the U.S. Fd and Drug Administratin (FDA) as a Class II electrsurgical cutting and cagulatin device. Ablatin f sft tissue using irreversible electrpratin (IRE) is cnsidered investigatinal and nt medically necessary fr all indicatins Revised Medical Plicies and Adpted Clinical UM Guidelines Effective January 15, 2012 DRUG Belimumab (Benlysta ): This plicy addresses the use f belimumab fr the treatment f individuals age 18 r lder with active, antibdy psitive systemic lupus erythematsus (SLE), and fr ther indicatins. Remved SLE clinical manifestatins requirement and list frm medically necessary criteria Added psychsis and seizures as examples f active central nervus system lupus in medically necessary criteria Clarified sterid requirement in medically necessary criteria Remved "females wh are pregnant r nursing" as cntraindicatin Clarified investigatinal and nt medically necessary cntraindicatin addressing sterid dses TRANS Mechanical Circulatry Assist Devices (Ventricular Assist Devices, Percutaneus Ventricular Assist Devices and Artificial Hearts): This plicy addresses ventricular assist devices, percutaneus ventricular assist devices and artificial hearts. Title revised, previusly titled: Mechanical Circulatry Assist Devices (Ventricular Assist Devices and Artificial Hearts) Expanded scpe f plicy Added the use f percutaneus ventricular assist devices (e.g., TandemHeart System, Impella Recver LP 2.5 Percutaneus Cardiac Supprt System, and Impella Recver LP 5.0 Percutaneus Cardiac Supprt System) as investigatinal and nt medically necessary CG DRUG 13 Hepatitis B Interfern Antiviral Therapy: This guideline addresses the treatment f chrnic hepatitis B infectin with FDA apprved injectable agents Interfern alfa 2b and Peginterfern alfa 2a. Added cmpensated liver disease t medically necessary clinical indicatins as a required criteria Clarified nt medically necessary statement and added uncntrlled depressin t the list f cntraindicatins WellPint Medical Plicies and Clinical UM Guidelines are develped by ur Medical Plicy and Technlgy Assessment Cmmittee. The Cmmittee, which includes WellPint medical directrs and representatives frm practicing physician grups, meets quarterly t review current scientific data and clinical develpments. Medical Plicies and Clinical UM Guidelines are subject t the apprval f the Physician Relatins Cmmittee. All cverage written r administered by UniCare excludes frm cverage services r supplies that are investigatinal and/r nt medically necessary. A member s claim may nt be eligible fr payment if it was determined nt t meet medical necessity criteria set frth in WellPint s Medical Plicies. Review prcedures have been refined t facilitate claim investigatin. Cverage and administrative services are prvided by UniCare Life & Health Insurance Cmpany, a separately incrprated and capitalized subsidiary f WellPint, Inc. Registered mark f WellPint, Inc WellPint, Inc.

3 Yu can access the cmplete list f WellPint Medical Plicies and Clinical UM Guidelines frm > Prviders > WellPint Medical Plicies > adapted clinical UM guidelines. Attachment A The revised medical plicies listed belw will becme effective fr services rendered n r after January 15, Medical Plicy Number SURG Medical Plicy Title Endvascular/Endluminal Repair f Artic Aneurysms, Artiliac Disease, Artic Dissectin and Artic Transectin Medical Plicy Changes Updated system edits t match plicy psitin statement and cding sectin fr the fllwing cdes: Endvascular repair f descending thracic arta; invlving cverage f left subclavian artery rigin, initial endprsthesis plus descending thracic artic extensin(s), if required, t level f celiac artery rigin Endvascular repair f descending thracic arta; nt invlving cverage f left subclavian artery rigin, initial endprsthesis plus descending thracic artic extensin(s), if required, t level f celiac artery rigin Placement f prximal extensin prsthesis fr endvascular repair f descending thracic arta; initial extensin Placement f prximal extensin prsthesis fr endvascular repair f descending thracic arta; each additinal prximal extensin (list separately in additin t cde fr primary prcedure) Placement f distal extensin prsthesis(s) delayed after endvascular repair f descending thracic arta Open subclavian t cartid artery transpsitin perfrmed in cnjunctin with endvascular repair f descending thracic arta, by neck incisin, unilateral Bypass graft, with ther than vein, transcervical retrpharyngeal cartid cartid, perfrmed in cnjunctin with endvascular repair f descending thracic arta, by neck incisin Endvascular repair f infrarenal abdminal artic aneurysm r dissectin; using art artic tube prsthesis Endvascular repair f infrarenal abdminal artic aneurysm r dissectin; using mdular bifurcated prsthesis (1 dcking limb) Endvascular repair f infrarenal abdminal artic aneurysm r dissectin; using mdular bifurcated prsthesis (2 dcking limbs) Endvascular repair f infrarenal abdminal artic aneurysm r dissectin; using unibdy bifurcated prsthesis Endvascular repair f infrarenal abdminal artic aneurysm r dissectin; using art uniiliac r art unifemral prsthesis Cverage and administrative services are prvided by UniCare Life & Health Insurance Cmpany, a separately incrprated and capitalized subsidiary f WellPint, Inc. Registered mark f WellPint, Inc WellPint, Inc.

4 Medical Plicy Number SURG (cntinued) Medical Plicy Title Endvascular/Endluminal Repair f Artic Aneurysms, Artiliac Disease, Artic Dissectin and Artic Transectin (cntinued) Medical Plicy Changes Transcatheter placement f wireless physilgic sensr in aneurysmal sac during endvascular repair, including radilgical supervisin and interpretatin, instrument calibratin, and cllectin f pressure data (list separately in additin t cde fr primary prcedure) Endvascular placement f iliac artery cclusin device (list separately in additin t cde fr primary prcedure) Open femral artery expsure fr delivery f endvascular prsthesis, by grin incisin, unilateral Placement f femral femral prsthetic graft during endvascular artic aneurysm repair (list separately in additin t cde fr primary prcedure) Open iliac artery expsure fr delivery f endvascular prsthesis r iliac cclusin during endvascular therapy, by abdminal r retrperitneal incisin, unilateral Placement f prximal r distal extensin prsthesis fr endvascular repair f infrarenal abdminal artic r iliac aneurysm, false aneurysm, r dissectin; initial vessel Placement f prximal r distal extensin prsthesis fr endvascular repair f infrarenal abdminal artic r iliac aneurysm, false aneurysm, r dissectin; each additinal vessel (list separately in additin t cde fr primary prcedure) Endvascular repair f infrarenal abdminal artic aneurysm r dissectin, radilgical supervisin and interpretatin Placement f prximal r distal extensin prsthesis fr endvascular repair f infrarenal artic r iliac artery aneurysm, pseudaneurysm, r dissectin, radilgical supervisin and interpretatin Endvascular repair f descending thracic arta; invlving cverage f left subclavian artery rigin, initial endprsthesis plus descending thracic artic extensin(s), if required, t level f celiac artery rigin, radilgical supervisin and interpretatin Endvascular repair f descending thracic arta; nt invlving cverage f left subclavian artery rigin, initial endprsthesis plus descending thracic artic extensin(s), if required, t level f celiac artery rigin, radilgical supervisin and interpretatin Placement f prximal extensin prsthesis fr endvascular repair f descending thracic arta; radilgical supervisin and interpretatin Cverage and administrative services are prvided by UniCare Life & Health Insurance Cmpany, a separately incrprated and capitalized subsidiary f WellPint, Inc. Registered mark f WellPint, Inc WellPint, Inc.

5 SURG (cntinued) SURG Endvascular/Endluminal Repair f Artic Aneurysms, Artiliac Disease, Artic Dissectin and Artic Transectin (cntinued) Steretactic Radisurgery (SRS) and Steretactic Bdy Raditherapy (SBRT) Placement f distal extensin prsthesis(s) (delayed) after endvascular repair f descending thracic arta, as needed, t level f celiac rigin, radilgical supervisin and interpretatin Nninvasive physilgic study f implanted wireless pressure sensr in aneurysmal sac fllwing endvascular repair, cmplete study including recrding, analysis f pressure and wavefrm tracings, interpretatin and reprt Updated system edits t match plicy psitin statement and cding sectin fr the fllwing cdes: Radiatin treatment delivery, steretactic radisurgery (SRS), cmplete curse f treatment f cranial lesin(s) cnsisting f 1 sessin; multi surce Cbalt 60 based Radiatin treatment delivery, steretactic radisurgery (SRS), cmplete curse f treatment f cranial lesin(s) cnsisting f 1 sessin; linear acceleratr based Steretactic bdy radiatin therapy, treatment delivery, per fractin t 1 r mre lesins, including image guidance, entire curse nt t exceed 5 fractins G0173 Linear acceleratr based steretactic radisurgery, cmplete curse f therapy in ne sessin G0251 Linear acceleratr based steretactic radisurgery, delivery including cllimatr changes and custm plugging, fractinated treatment, all lesins, per sessin, maximum 5 sessins per curse f treatment G0339 Image guided rbtic linear acceleratr based steretactic radisurgery, cmplete curse f therapy in ne sessin, r first sessin f fractinated treatment G0340 Image guided rbtic linear acceleratr based steretactic radisurgery, delivery including cllimatr changes and custm plugging, fractinated treatment, all lesins, per sessin, secnd thrugh fifth sessins, maximum 5 sessins per curse f treatment Cverage and administrative services are prvided by UniCare Life & Health Insurance Cmpany, a separately incrprated and capitalized subsidiary f WellPint, Inc. Registered mark f WellPint, Inc WellPint, Inc.

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