12/13/16. I. Liver transplantation for children and adults (initial or retransplantation) - must satisfy the following: A and B
|
|
- Dora Flynn
- 5 years ago
- Views:
Transcription
1 Reference #: MC/T004 Page: 1 of 8 PRODUCT APPLICATION: PreferredOne Administrative Services, Inc. (PAS) ERISA PreferredOne Administrative Services, Inc. (PAS) Non-ERISA PreferredOne Community Health Plan (PCHP) PreferredOne Insurance Company (PIC) Individual PreferredOne Insurance Company (PIC) Large Group PreferredOne Insurance Company (PIC) Small Group Please refer to the member s benefit document for specific information. To the extent there is any inconsistency between this policy and the terms of the member s benefit plan or certificate of coverage, the terms of the member s benefit plan document will govern. Benefits must be available for health care services. Health care services must be ordered by a physician, physician assistant, or nurse practitioner. Health care services must be medically necessary, applicable conservative treatments must have been tried, and the most cost-effective alternative must be requested for coverage consideration. PURPOSE: The intent of this criteria document is to ensure services are medically necessary. GUIDELINES: Medical Necessity Criteria - must satisfy: I and none of II I. Liver transplantation for children and adults (initial or retransplantation) - must satisfy the following: A and B A. Request is for one of the following indications: Cholestatic diseases any of the following: a-d a. Biliary atresia b. Familial cholestatic syndromes c. Primary biliary cirrhosis d. Primary sclerosing cholangitis with development of secondary biliary cirrhosis 2. Hepatocellular disease any of the following: a-e a. Alcoholic cirrhosis b. Chronic active hepatitis with cirrhosis [hepatitis B or C] c. Cryptogenic cirrhosis d. Idiopathic autoimmune hepatitis e. Post-necrotic cirrhosis due to hepatitis B surface antigen negative state 3. Malignancies any of the following: a f a. Primary hepatocellular carcinoma (HCC) must meet all of the following: i v i. Lung metastases must be responsive to chemotherapy; and ii. Member is not a candidate for subtotal liver resection; and iii. Member meets UNOS criteria for tumor size and number; and iv. There is no identifiable extra-hepatic spread of tumor to surrounding lymph nodes, abdominal organs, bone or other sites; and v. Absence of macrovascular involvement.
2 Reference #: MC/T004 Page: 2 of 8 b. Hepatoblastoma must meet all of the following: i-iii i. Member is not a candidate for subtotal liver resection; and ii. Member meets UNOS criteria for tumor size and number; and iii. Absence of identifiable extra-hepatic spread of tumor to surrounding lungs, abdominal organs, bone or other sites. [Note: Spread of hepatoblastoma to veins and lymph nodes does not disqualify a member for coverage of a liver transplant.] c. Epithelioid hemangioendothelioma d. Intra-hepatic cholangiocarcinoma (ie, cholangiocarcinoma confined to the liver) e. Large, unresectable fibrolamellar HCC f. Metastatic neuroendocrine tumor (eg, carcinoid tumors, apudomas, gastrinomas, glucagonomas) must meet all of the following: i-iii i. Presence of severe symptoms; and ii. Metastases restricted to the liver; and iii. Appropriate medical, pharmacologic, or surgical therapy is ineffective, unavailable, or not applicable. 4. Vascular disease any of the following: a or b a. Budd-Chiari syndrome b. Veno-occlusive disease 5. Metabolic disorders and metabolic liver diseases with cirrhosis any of the following: a-e a. Alpha 1-antitrypsin deficiency b. Hemochromatosis c. Inborn errors of metabolism d. Protoporphyria e. Wilson s disease 6. Familial amyloid polyneuropathy 7. Polycystic disease of the liver 8. Porto-pulmonary hypertension (pulmonary hypertension associated with liver disease or portal hypertension) in persons with a mean pulmonary artery pressure (MAP) by catheterization of less than 35mm Hg 9. Toxic reactions (fulminant hepatic failure due to mushroom poisoning, acetaminophen overdose, etc.) 10. Trauma 11. Hepato-pulmonary syndrome must meet all of the following: a-c a. Arterial hypoxemia (PaO2 less than 60mm Hg or AaO2 gradient greater than 20mm Hg in supine or standing position); and b. Chronic liver disease with non-cirrhotic portal hypertension; and c. Intrapulmonary vascular dilation (as indicated by contrast-enhanced echocardiography, technetium-99 macroaggregated albumin perfusion scan, or pulmonary angiography)
3 Reference #: MC/T004 Page: 3 of 8 B. Selection criteria - must satisfy one of the following: 1 or 2 1. For adolescents, older than 12 years of age, and adults must satisfy one of the following: a or b a. The member has a Model of End-Stage Liver Disease (MELD) score greater than 10; or b. The transplant is approved by the United Network for Organ Sharing (UNOS) Regional Review Board. 2. For children less than or equal to 12 years of age (initial or retransplantation) the transplant is approved by UNOS Regional Review Board. II. Contraindications - none of the following: A- M A. Retransplantation when first transplant rejected due to noncompliance issues (relative) B. Demonstrated noncompliance, which places the organ at risk by not adhering to medical recommendations. C. Active alcohol or substance abuse (absolute). D. Uncontrolled psychiatric disorder that impairs the member s ability to give informed consent and/or be compliant with treatment regimen (absolute). E. Current smoker or history of smoking when the transplant center determines that the member s smoking status will compromise the transplant outcome (absolute). F. Age greater than 65 years (relative) G. Inadequately controlled HIV/AIDS infection, defined as all of the following: CD4 count less than 200 cells/mm3 for more than 6 months 2. HIV-1 RNA (viral load) detectable 3. Not on stable antiviral therapy for more than 3 months 4. Other complications from AIDS, such as opportunistic infection (eg, aspergillus, tuberculosis, coccidioidomycosis, resistant fungal infections) or neoplasms (eg, Kaposi's sarcoma, non-hodgkin's lymphoma). (absolute) H. Presence of local or systemic disease (such as, but not limited to, systemic infection and co-existing medical conditions such as advanced heart or lung disease) likely to limit survival (absolute). I. Presence of any factors likely to limit/hinder: 1. Rehabilitation potential 2. Ability to comply with pre and post-transplant protocol (absolute) J. Inadequately treated malignancies outside of the liver with substantial likelihood of recurrence. K. Portal vein and superior mesenteric vein thrombosis (relative)
4 Reference #: MC/T004 Page: 4 of 8 L. Presence of hepatitis B surface antigen (HBsAG) or hepatitis B e antigen (HbeAg) with fulminant hepatitis which is not responsive to antiviral therapy (such as, but not limited to, lamivudine) (absolute) M. Nonmetastatic hepatocellular carcinoma with one lesion greater than or equal to 5 cm or greater than or equal to three lesions all less than 3 cm. EXCLUSIONS: The following is considered investigative (see Investigative List): Xenotransplantation, solid organ DEFINITIONS: Abuse: A maladaptive pattern of use leading to clinically significant impairment or distress Active alcohol or substance abuse: Absence of formal behavioral/psychological treatment (for abuse) and has not been abstinent from alcohol or other substance/s for at least 3 (three) months prior to transplant. Multivisceral transplant: Includes the stomach, duodenum, pancreas, small intestine, and liver (liver is excluded if recipient liver is normal) Reduced-size liver transplant: A portion of a liver is cut to fit the needs of a small patient (predominantly pediatric patients) and implanted into the recipient. Split-liver transplant: Adult cadaver donor is split into two grafts maintaining its vascular and biliary pedicles and used for two recipients. BACKGROUND: This criteria document is based on expert professional practice guidelines and/or available reliable evidence. The three sources of donor livers are living related donors, living unrelated donors, and cadaver donors, although most come from cadaver donors. Transplanted livers may be whole or partial. Living adult donors may donate a portion of their liver. Guidelines for living donor and cadaver transplants are the same if medical/scientific evidence supports the procedure as standard/acceptable treatment for a specific condition and is not investigative. A designated transplant center/center of excellence may be required by the terms of the member s benefit plan for maximum benefit coverage. There are often many clinical trials and studies associated with transplants (where transplant is considered standard of care). Any component of the transplant that is part of a clinical trial or a study is not eligible for coverage. Refer to benefit plan and medical policy for transplant and re-transplantation benefits, limitations and exclusions, non-coverage explanation of investigational and study generated protocol services, and eligible/non-eligible benefits for the donor.
5 Reference #: MC/T004 Page: 5 of 8 All approved transplants will be reviewed annually for medical necessity and to assess new medical/scientific evidence addressing the therapeutic benefit and safety of the transplant procedure or new contraindications to performing the transplant. All transplant requests require physician review. See Attachment A for documentation required before sending request to physician review.
6 Reference #: MC/T004 Page: 6 of 8 FOR INTERNAL USE ONLY COVERAGE: Prior Authorization: Yes Coverage is subject to the member s contract benefits. CODING: CPT Liver allotransplantation; orthotopic, partial or whole, from cadaver or living donor, any age CPT codes copyright 2016 American Medical Association. All Rights Reserved. CPT is a trademark of the AMA. The AMA assumes no liability for the data contained herein RELATED CRITERIA/POLICIES: Process Manual: UR015 Use of Medical Policy and Criteria Medical Policy: MP/C009 Coverage Determination Guidelines Medical Policy: MP/I001 Investigative Services Medical Policy: MP/T006 PreferredOne Designated Transplant Network Provider REFERENCES: 1. Boudi FB. Pediatric. Medscape Retrieved from 2. Cross TJ, Antoniades CG, Muiesan P et al. Liver transplantation in patients over 60 and 65 years: An evaluation of long-term outcomes and survival. Liver Transpl Oct;13(10): Murray KF, & Carithers RL. AASLD Practice Guidelines: Evaluation of the patient for liver transplantation American Association for the Study of Liver Diseases (AASLD). Hepatology. DOI /hep Centers for Medicare & Medicaid Services. National Coverage Determination (NCD) for Adult Liver Transplantation (260.1) Retrieved from sota&keyword=liver+transplant&keywordlookup=title&keywordsearchtype=and&bc=gaaaabaaaa AAAA%3d%3d& 5. Centers for Medicare & Medicaid Services. National Coverage Determination (NCD) for Pediatric Liver Transplantation (260.2) Retrieved from sota&keyword=liver+transplant&keywordlookup=title&keywordsearchtype=and&bc=gaaaabaaaa AAAA%3d%3d& 6. Dove LM, Brown Jr RS. Patient selection for liver transplantation. In: UpToDate, Travis AC (Ed), UpToDate, Waltham, MA. (Accessed on June 16, 2014.) 7. Martin P, DiMartini A, Feng S, Brown Jr R, Fallon M. Evaluation for liver transplantation in adults: 2013 practice guideline by the American Association for the Study of Liver Diseases and the American Society of Transplantation. Hepatology. 2014;59(3). Retrieved from 8. Squires RH, Ng V, Romer R, et al. Evaluation of the pediatric patient for liver transplantation: 2014 practice guideline by the American Association for the Study of Liver Diseases, American Society of Transplantation and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. Hepatology. 2014;60(1): Retrieved from
7 Reference #: MC/T004 Page: 7 of 8 DOCUMENT HISTORY: Created Date: 07/99 Reviewed Date: 11/27/07, re-adopted 07/10/12, 07/09/13, 06/16/14, 06/16/15, 06/16/16, 11/15/16 Revised Date: 11/16/04, 11/15/05, 11/28/06, 07/10/12, 08/06/13, 08/14/15, 08/16/16, 11/15/16
8 Reference #: MC/T004 Page: 8 of 8 Attachment A Required documentation must have all of the following before sending to physician review: A - E A. Letter of medical necessity outlining the member s medical and treatment history and rationale for the proposed transplant. B. Formal transplant evaluation including, but not limited to, cardiac, pulmonary, and renal function. C. Recent relevant imaging reports. D. Recent relevant laboratory studies. E. Current psychosocial studies documented by a formal psychological or psychosocial evaluation.
9 PreferredOne Community Health Plan Nondiscrimination Notice PreferredOne Community Health Plan ( PCHP ) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. PCHP does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. PCHP: Provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages If you need these services, contact a Grievance Specialist. If you believe that PCHP has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Grievance Specialist PreferredOne Community Health Plan PO Box Minneapolis, MN Phone: (TTY: ) Fax: customerservice@preferredone.com You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, a Grievance Specialist is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C , (TDD) Complaint forms are available at Language Assistance Services NDR PCHP LV (10/16)
10 PreferredOne Insurance Company Nondiscrimination Notice PreferredOne Insurance Company ( PIC ) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. PIC does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. PIC: Provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages If you need these services, contact a Grievance Specialist. If you believe that PIC has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Grievance Specialist PreferredOne Insurance Company PO Box Minneapolis, MN Phone: (TTY: ) Fax: customerservice@preferredone.com You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, a Grievance Specialist is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C , (TDD) Complaint forms are available at Language Assistance Services NDR PIC LV (10/16)
12/12/17. I. Liver transplantation for children and adults (initial or retransplantation) - must satisfy the following: A and B
Reference #: MC/T004 Page: 1 of 8 PRODUCT APPLICATION: PreferredOne Administrative Services, Inc. (PAS) ERISA PreferredOne Administrative Services, Inc. (PAS) Non-ERISA PreferredOne Community Health Plan
More informationDepartment of Origin: Integrated Healthcare Services. Approved by: Chief Medical Officer Department(s) Affected: Date approved: 01/10/17
Reference #: MP/D005 Page: 1 of 3 PRODUCT APPLICATION: PreferredOne Administrative Services, Inc. (PAS) ERISA PreferredOne Administrative Services, Inc. (PAS) Non-ERISA PreferredOne Community Health Plan
More information03/13/18. A. Symptoms lasting for greater than or equal to 12 months that have resulted to significant impairment in activities of daily living; and
Reference #: MC/I008 Page: 1 of 5 PRODUCT APPLICATION: PreferredOne Administrative Services, Inc. (PAS) ERISA PreferredOne Administrative Services, Inc. (PAS) Non-ERISA PreferredOne Community Health Plan
More information01/26/17. Replaces Effective Policy Dated: Autism Spectrum Disorders in Children: Assessment 01/19/16 and Evaluation Reference #: MP/A005 Page 1 of 4
Reference #: MP/A005 Page 1 of 4 PRODUCT APPLICATION: PreferredOne Administrative Services, Inc. (PAS) ERISA PreferredOne Administrative Services, Inc. (PAS) Non-ERISA PreferredOne Community Health Plan
More informationPURPOSE: The intent of this policy is to provide guidelines for coverage of dental procedures under the medical benefit.
Integrated Reference #: MP/D009 Page 1 of 4 PRODUCT APPLICATION: PreferredOne Community Health Plan (PCHP) PreferredOne Administrative Services, Inc. (PAS) ERISA PreferredOne Administrative Services, Inc.
More information01/10/17. Replaces Effective Policy Dated: Amino Acid Based Elemental Formula (AABF) 09/28/15 Reference #: MP/A003 Page: 1 of 3
Reference #: MP/A003 Page: 1 of 3 PRODUCT APPLICATION: PreferredOne Administrative Services, Inc. (PAS) ERISA PreferredOne Administrative Services, Inc. (PAS) Non-ERISA PreferredOne Community Health Plan
More informationApproved by: Integrated Health Quality Management Subcommittee Effective Date: Department of Origin: Integrated Healthcare Services.
Reference #: MC/M020 Page 1 of 5 PRODUCT APPLICATION: PreferredOne Administrative Services, Inc. (PAS) ERISA PreferredOne Administrative Services, Inc. (PAS) Non-ERISA PreferredOne Community Health Plan
More information09/12/17. I. Electrical Bone Growth Stimulator (invasive, semi-invasive, or non-invasive) any of the following: A-C
Reference #: MC/F021 Page: 1 of 4 PRODUCT APPLICATION: PreferredOne Administrative Services, Inc. (PAS) ERISA PreferredOne Administrative Services, Inc. (PAS) Non-ERISA PreferredOne Community Health Plan
More information03/14/17. II. Initial early intensive-level behavioral and developmental therapy must have both of the following: A and B
Reference #: MC/M024 Page 1 of 6 PRODUCT APPLICATION: PreferredOne Administrative Services, Inc. (PAS) ERISA PreferredOne Administrative Services, Inc. (PAS) Non-ERISA PreferredOne Community Health Plan
More informationFYI ONLY Generic Name. Generics available. zoledronic acid N/A
Criteria Document: Reference #: PC/A011 Page 1 of 5 PRODUCT APPLICATION: PreferredOne Administrative Services, Inc. (PAS) ERISA PreferredOne Administrative Services, Inc. (PAS) Non-ERISA PreferredOne Community
More information06/13/17. A. Completed a comprehensive diabetes education program within the past two years; and
Reference #: MC/L011 Page 1 of 4 PRODUCT APPLICATION: PreferredOne Community Health Plan (PCHP) PreferredOne Administrative Services, Inc. (PAS) ERISA PreferredOne Administrative Services, Inc. (PAS) Non-ERISA
More informationDate approved: 04/18/18. Approved by: Pharmacy and Therapeutics Quality Management Subcommittee Effective Date: Department of Origin: Pharmacy
Integrated Healthcare Services and Criteria Document: Reference #: PC/V001 Page: 1 of 9 PRODUCT APPLICATION: PreferredOne Administrative Services, Inc. (PAS) ERISA PreferredOne Administrative Services,
More informationClinical Policy: Pediatric Liver Transplant
Clinical Policy: Reference Number: CP.MP.120 Last Review Date: 04/18 Coding Implications Revision Log See Important Reminder at the end of this policy for important regulatory and legal information. Description
More informationB. To assess an individual when clinical evaluation suggests use of non-prescribed medications or illegal substances; or
Integrated Reference #: MP/D010 Page: 1 of 7 PRODUCT APPLICATION: PreferredOne Community Health Plan (PCHP) PreferredOne Administrative Services, Inc. (PAS) ERISA PreferredOne Administrative Services,
More informationCorporate Medical Policy Liver Transplant
Corporate Medical Policy Liver Transplant File Name: Origination: Last CAP Review: Next CAP Review: Last Review: liver_transplant 12/1995 5/2017 5/2018 5/2017 Description of Procedure or Service Liver
More informationPANCREATIC ISLET TRANSPLANT
PANCREATIC ISLET TRANSPLANT Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices
More informationHEALTH SERVICES POLICY & PROCEDURE MANUAL
PAGE 1 of 6 PURPOSE To establish basic understanding of indications and contraindications for transplantation of various organs. POLICY The N.C. Department of Correction, Division of Prisons, Health Services
More informationSOMATULINE DEPOT (lanreotide acetate)
SOMATULINE DEPOT (lanreotide acetate) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical
More informationRADIOFREQUENCY ABLATION OF PRIMARY OR METASTATIC LIVER TUMORS
Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs are dependent upon
More informationCorporate Medical Policy Liver Transplant and Combined Liver-Kidney Transplant
Corporate Medical Policy Liver Transplant and Combined Liver-Kidney Transplant File Name: Origination: Last CAP Review: Next CAP Review: Last Review: liver_transplant_and_combined_liver_kidney_transplant
More informationTransplant Hepatology
Transplant Hepatology Certification Examination Blueprint Purpose of the exam The exam is designed to evaluate the knowledge, diagnostic reasoning, and clinical judgment skills expected of the certified
More informationRADIOFREQUENCY ABLATION OF MISCELLANEOUS SOLID TUMORS EXCLUDING LIVER TUMORS
EXCLUDING LIVER TUMORS Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs
More informationCorporate Medical Policy
Corporate Medical Policy Small Bowel, Small Bowel with Liver, or Multivisceral Transplant File Name: Origination: Last CAP Review: Next CAP Last Review: small_bowel_liver_and_multivisceral_transplant 2/1996
More informationIMMUNE CELL FUNCTION ASSAY
IMMUNE CELL FUNCTION ASSAY Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and
More informationHEMATOPOIETIC CELL TRANSPLANTATION FOR EPITHELIAL OVARIAN CARCINOMA
CARCINOMA Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs are dependent
More informationENDOBRONCHIAL ULTRASOUND FOR DIAGNOSIS AND STAGING OF LUNG CANCER
CANCER Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs are dependent
More informationSanta Clara Family Health Plan Cal MediConnect Plan (Medicare-Medicaid Plan) 2017 Drug List
Upcoming Changes to Santa Clara Family Health Plan Cal MediConnect Plan (Medicare-Medicaid Plan) 2017 Drug List Updated 8/1/2017 Santa Clara Family Health Plan (SCFHP) Cal MediConnect Plan (Medicare-Medicaid
More information2018 Preventive Schedule
2018 Preventive Schedule Medicare-Covered Services PLAN YOUR CARE: KNOW WHAT YOU NEED AND WHEN TO GET IT Preventive or routine care helps us stay well or finds problems early, when they are easier to treat.
More informationINTRAPERITONEAL CHEMOTHERAPY, CYTOREDUCTION
INTRAPERITONEAL CHEMOTHERAPY, CYTOREDUCTION Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures,
More informationTusculum College. Benefit Summary. $25 Copay. $25 Copay. after Deductible. 20% after Deductible 20% after Deductible
Benefit Plan Features: Annual Deductible Benefit Summary Your Cost In-Network Individual/Family $750/$1500 Annual Out-of-Pocket Maximum Individual/Family $3500/$7000 4th Quarter Carry-over Covered Services
More informationGENETIC TESTING FOR PREDICTING RISK OF NONFAMILIAL BREAST CANCER
Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs are dependent upon
More informationApproval of a drug under this criteria document does not ensure full coverage of the drug.
Criteria Document: Reference #: PC/A011 Page 1 of 8 PRODUCT APPLICATION: PreferredOne Administrative Services, Inc. (PAS) ERISA PreferredOne Administrative Services, Inc. (PAS) Non-ERISA PreferredOne Community
More informationMEDICAL COVERAGE GUIDELINES ORIGINAL EFFECTIVE DATE: 10/04/17 SECTION: DRUGS LAST REVIEW DATE: LAST CRITERIA REVISION DATE: ARCHIVE DATE:
BAVENCIO (avelumab) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs
More information06/12/18. [Note: When orthognathic surgery is not a covered benefit, it is non-covered for any diagnosis, including sleep apnea.]
Reference #: MC/B002 Page: 1 of 5 PRODUCT APPLICATION: PreferredOne Community Health Plan (PCHP) PreferredOne Administrative Services, Inc. (PAS) ERISA PreferredOne Administrative Services, Inc. (PAS)
More informationGENETIC TESTING FOR TAMOXIFEN TREATMENT
GENETIC TESTING FOR TAMOXIFEN TREATMENT Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical
More informationINTRACAVITARY BALLOON BRACHYTHERAPY FOR MALIGNANT AND METASTATIC BRAIN TUMORS
METASTATIC BRAIN TUMORS Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and
More informationLiver Transplantation Evaluation: Objectives
Liver Transplantation Evaluation: Essential Work-Up Curtis K. Argo, MD, MS VGS/ACG Regional Postgraduate Course Williamsburg, VA September 13, 2015 Objectives Discuss determining readiness for transplantation
More informationMOLECULAR TESTING IN THE MANAGEMENT OF PULMONARY NODULES
MOLECULAR TESTING IN THE MANAGEMENT OF PULMONARY NODULES Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services,
More informationALPHA1-PROTEINASE INHIBITORS
ALPHA1-PROTEINASE INHIBITORS Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices
More information03/13/18. PURPOSE: The intent of this criteria document is to ensure services are medically necessary.
Reference #: MC/C007 Page 1 of 5 PRODUCT APPLICATION: PreferredOne Community Health Plan (PCHP) PreferredOne Administrative Services, Inc. (PAS) ERISA PreferredOne Administrative Services, Inc. (PAS) Non-ERISA
More informationDRUG TESTING IN PAIN MANAGEMENT AND SUBSTANCE USE DISORDER(S) TREATMENT
TREATMENT Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs are dependent
More informationTusculum College. Benefit Summary Option/Quote: 2. 30% after Deductible. $35 Copay. 30% after Deductible
Benefit Plan Features: Annual Deductible Effective Date: 4/1/2018 Network: S Benefit Summary Option/Quote: 2 Your Cost In-Network Individual/Family $1250/$2500 Annual Out-of-Pocket Maximum Tusculum College
More informationNon-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document.
HYDROXYPROGESTERONE THERAPY Makena (hydroxyprogesterone caproate injection) Hydroxyprogesterone caproate compound Hydroxyprogesterone caproate injection with benzyl benzoate and the preservative benzyl
More informationORAL IMPLANT PROCEDURES
ORAL IMPLANT PROCEDURES Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and
More informationOntario s Adult Referral and Listing Criteria for Liver Transplantation
Ontario s Adult Referral and Listing Criteria for Liver Transplantation Version 3.0 Trillium Gift of Life Network Ontario s Adult Referral & Listing Criteria for Liver Transplantation PATIENT REFERRAL
More informationHEMATOPOIETIC CELL TRANSPLANTATION FOR HODGKIN LYMPHOMA
HEMATOPOIETIC CELL TRANSPLANTATION FOR HODGKIN LYMPHOMA Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services,
More informationHEMATOPOIETIC CELL TRANSPLANTATION FOR PRIMARY AMYLOIDOSIS
Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs are dependent upon
More informationCalendar Year Deductible Annual Benefit Maximum. ADA Code Covered Services Member pays. n/a Office visit $5 per visit
Blue Shield of California Dental HMO Plan Dental HMO Basic Benefit summary Effective January 1, 2018 THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE
More informationCorporate Medical Policy
Corporate Medical Policy Pancreas Transplant File Name: Origination: Last CAP Review: Next CAP Review: Last Review: pancreas_transplant 1/2000 5/2017 5/2018 8/2017 Description of Procedure or Service Transplantation
More informationLARTRUVO (olaratumab)
LARTRUVO (olaratumab) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs
More informationCIMZIA (certolizumab pegol)
CIMZIA (certolizumab pegol) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices
More informationGENETIC TESTING FOR KRAS, NRAS AND BRAF VARIANT ANALYSIS IN METASTATIC COLORECTAL CANCER
METASTATIC COLORECTAL CANCER Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices
More informationMYLOTARG (gemtuzumab ozogamicin)
MYLOTARG (gemtuzumab ozogamicin) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices
More informationSolid Organ Transplants
MEDICAL POLICY 7.03.509 Solid Organ Transplants BCBSA Ref. Policies: 7.03.01, 7.03.02, 7.03.06, 7.03.07 7.03.08 & 7.03.09 Effective Date: Nov. 1, 2018 RELATED MEDICAL POLICIES: Last Revised: Oct. 26, 2018
More informationPERJETA (pertuzumab) FOR TREATMENT OF MALIGNANCIES
PERJETA (pertuzumab) FOR TREATMENT OF MALIGNANCIES Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures,
More informationNon-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document.
ERYTHROPOIESIS-STIMULATING AGENTS (ESAs) Epoetin alfa (Epogen, Procrit ) Darbepoetin alfa (Aranesp ) Methoxy polyethylene glycol (PEG) epoetin-beta (Mircera ) Non-Discrimination Statement and Multi-Language
More informationExperience in 1,000 Liver Transplants Under Cyclosporine-Steroid Therapy: A Survival Report
Experience in 1,000 Liver Transplants Under Cyclosporine-Steroid Therapy: A Survival Report S. watsuki. T.E. Starzl, S. Todo, R.D. Gordon, C.O. Esquivel, A.G. Tzakis, L. Makowka, J.W. Marsh, B. Koneru,
More informationHEMATOPOIETIC CELL TRANSPLANTATION FOR SOLID TUMORS OF CHILDHOOD
CHILDHOOD Non-Discrimination Statement Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices drugs are dependent upon
More informationCONTINUOUS OR INTERMITTENT GLUCOSE MONITORING IN INTERSTITIAL FLUID
FLUID Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs are dependent
More informationSmile SM Value 50/1500/No Ortho/MAC
Blue Shield of California Dental PPO Plan Smile SM Value 50/1500/No Ortho/MAC Benefit summary Effective January 1, 2018 THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A
More informationMEDICAL POLICY SUBJECT: LIVER TRANSPLANTATION
MEDICAL POLICY SUBJECT: LIVER TRANSPLANTATION CATEGORY: Transplant EFFECTIVE DATE: 07/02/99 PAGE: 1 OF: 10 If a product excludes coverage for a service, it is not covered, and medical policy criteria do
More informationOriginal Policy Date
MP 7.03.02 Small Bowel/Liver and Multivisceral Transplant Medical Policy Section Surgery Issue 12/2013 Original Policy Date 12/2013 Last Review Status/Date Reviewed with literature search/12/2013 Return
More informationINTRAVITREAL IMPLANTS
INTRAVITREAL IMPLANTS Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs
More informationCARDIOVASCULAR RISK PANELS
CARDIOVASCULAR RISK PANELS Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and
More informationALPHA-FETOPROTEIN-L3 FOR DETECTION OF HEPATOCELLULAR CANCER
Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs are dependent upon
More informationCalendar Year Deductible Annual Benefit Maximum. ADA Code Covered Services Member pays
An independent member of the Blue Shield Association A50861-SG (1/19) Dental HMO Plan Dental HMO Standard Benefit summary Effective January 1, 2019 THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE
More informationCorporate Medical Policy
Corporate Medical Policy File Name: Origination: Last CAP Review: Next CAP Review: Last Review: renal_kidney_transplantation 4/1980 4/2017 4/2018 4/2017 Description of Procedure or Service A kidney transplant,
More informationMULTIMARKER SERUM TESTING RELATED TO OVARIAN CANCER
MULTIMARKER SERUM TESTING RELATED TO OVARIAN CANCER Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures,
More informationPROTEOMIC TESTING FOR SYSTEMIC THERAPY IN NON-SMALL-CELL LUNG CANCER
CANCER Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs are dependent
More informationSTELARA (ustekinumab)
STELARA (ustekinumab) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs
More informationPERCUTANEOUS BALLOON KYPHOPLASTY, RADIOFREQUENCY KYPHOPLASTY, AND MECHANICAL VERTEBRAL AUGMENTATION
KYPHOPLASTY, AND MECHANICAL VERTEBRAL AUGMENTATION Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures,
More informationENTYVIO (vedolizumab)
ENTYVIO (vedolizumab) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs
More informationINTRAOPERATIVE RADIATION THERAPY
INTRAOPERATIVE RADIATION THERAPY Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices
More informationDEEP BRAIN STIMULATION
DEEP BRAIN STIMULATION Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs
More informationSmile SM Deluxe Gold 50/1500/Ortho/U85
Blue Shield of California Dental PPO Plan Smile SM Deluxe Gold 50/1500/Ortho/U85 Benefit summary Effective January 1, 2017 THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS
More informationRelated Policies None
Medical Policy MP 7.03.06 BCBSA Ref. Policy: 7.03.06 Last Review: 08/20/2018 Effective Date: 08/20/2018 Section: Surgery Related Policies None DISCLAIMER Our medical policies are designed for informational
More informationGATTEX (teduglutide [rdna origin])
GATTEX (teduglutide [rdna origin]) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices
More informationKYMRIAH (tisagenlecleucel)
KYMRIAH (tisagenlecleucel) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and
More informationRELISTOR (methylnaltrexone bromide) INJECTION FOR SUBCUTANEOUS USE
RELISTOR (methylnaltrexone bromide) INJECTION FOR SUBCUTANEOUS USE Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for
More informationPediatric Dental and Vision
Individual & Family Plans (IFP) and Small Business Group (SBG) Health Net of California, Inc. (Health Net) Pediatric Dental and Vision Andre Hamil Health Net When you purchase a Health Net PureCare HSP
More informationBRINEURA (cerliponase alfa)
BRINEURA (cerliponase alfa) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices
More informationAPOKYN (apomorphine hydrochloride)
APOKYN (apomorphine hydrochloride) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices
More informationOverall Goals and Objectives for Transplant Hepatology EPAs:
Overall Goals and Objectives for Transplant Hepatology EPAs: 1. DIAGNOSTIC LIST During the one-year Advanced Pediatric Transplant Hepatology Program, fellows are expected to develop comprehensive skills
More informationLIMB COMPRESSION DEVICES FOR VENOUS THROMBOEMBOLISM PROPHYLAXIS
PROPHYLAXIS Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs are dependent
More informationNEGATIVE PRESSURE WOUND THERAPY
NEGATIVE PRESSURE WOUND THERAPY Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices
More information2017 Preventive Schedule
2017 Preventive Schedule PLAN YOUR CARE: KNOW WHAT YOU NEED AND WHEN TO GET IT Preventive or routine care helps us stay well or finds problems early, when they are easier to treat. The preventive guidelines
More informationTYMLOS (abaloparatide)
TYMLOS (abaloparatide) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs
More informationOriginal Effective Date: Guidance Number: MCG-114 Revision Date(s): 8/23/12, 1/9/13
Subject: Liver Transplantation Adult & Pediatric Original Effective Date: Guidance Number: MCG-114 Revision Date(s): 8/23/12, 1/9/13 8/23/12 Medical Coverage Guidance Approval Date: 1/9/2013 PREFACE This
More informationClinical Policy: Heart-Lung Transplant Reference Number: CP.MP.132
Clinical Policy: Reference Number: CP.MP.132 Effective Date: 06/17 Last Review Date: 06/17 Coding Implications Revision Log See Important Reminder at the end of this policy for important regulatory and
More informationRelated Policies: None
Medical Policy MP 7.03.06 Original Policy Date: December 1995 Last Review: 09/28/2017 Effective Date: 11/15/2017 Section: Surgery End Date: Related Policies: None Disclaimer Our medical policies are designed
More informationMEDICAL POLICY SUBJECT: KIDNEY TRANSPLANT
MEDICAL POLICY SUBJECT: KIDNEY TRANSPLANT PAGE: 1 OF: 6 If a product excludes coverage for a service, it is not covered, and medical policy criteria do not apply. If a commercial product, including an
More informationSmile SM Plus 50/1500/Ortho/MAC
Dental PPO Plan Smile SM Plus 50/1500/Ortho/MAC Benefit summary Effective January 1, 2019 THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF
More informationTYSABRI FOR CROHN S DISEASE
TYSABRI FOR CROHN S DISEASE Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices
More informationBLINCYTO (blinatumomab)
BLINCYTO (blinatumomab) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and
More informationNon-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document.
XOLAIR (omalizumab) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs
More informationHEMATOPOIETIC CELL TRANSPLANTATION FOR CHRONIC MYELOID LEUKEMIA
LEUKEMIA Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs are dependent
More informationVYXEOS (daunorubicin and cytarabine)
VYXEOS (daunorubicin and cytarabine) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical
More informationNon-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document.
NUCALA (mepolizumab) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs
More informationBALLOON OSTIAL DILATION FOR TREATMENT OF CHRONIC SINUSITIS
BALLOON OSTIAL DILATION FOR TREATMENT OF CHRONIC SINUSITIS Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services,
More information