CHAPTER 1 Section 3.1, page 5 Section 3.1, page 5

CHANGE 193 6010.57-M NOVEMBER 20, 2017 REMOVE PAGE(S) INSERT PAGE(S) CHAPTER 1 Section 3.1, page 5 Section 3.1, page 5 CHAPTER 4 Section 6.1, pages 1 through 4 Section 6.1, pages 1 through 4 Section 15.1, page 3 Section 15.1, page 3 Section 20.1, pages 1 through 5 Section 20.1, pages 1 through 5 CHAPTER 5 Section 3.1, pages 1 through 5 Section 3.1, pages 1 through 5 CHAPTER 7 Section 18.1, pages 1 through 3 Section 18.1, pages 1 through 3 2

CHANGE 193 6010.57-M NOVEMBER 20, 2017 SUMMARY OF CHANGES CHAPTER 1 1. Section 3.1. This change modernizes the TRICARE benefit by adding TRICARE coverage for Proton Beam Therapy (PBT) for the treatment of Thymoma, a rare disease. EFFECTIVE DATE: 02/16/2016. CHAPTER 4 2. Section 6.1. a. This change modernizes the TRICARE benefit by adding TRICARE coverage for Off-Label use of Autologous Chondrocyte Implantation with a Collagen Derived Cover for the treatment of Patellar Cartilage Lesions. EFFECTIVE DATE: 05/07/2016. b. This change modernizes the TRICARE benefit by adding TRICARE coverage for Matrix-Induced Autologous Chondrocyte Implantation for the Treatment of Cartilage Defects of the Knee. EFFECTIVE DATE: 12/13/2016. 3. Section 15.1. This change modernizes the TRICARE benefit by adding TRICARE coverage for prostate saturation biopsy for the diagnosis of cancer. EFFECTIVE DATE: 04/14/2016. 4. Section 20.1. a. This change modernizes the TRICARE benefit by removing the restriction on billing common procedural codes 63050 and 63051. EFFECTIVE DATE: 09/03/2016. b. This change modernized the TRICARE benefit by removing the exclusion for cerebellar stimulators/pacemakers for the treatment of neurological disorders and allows cost sharing of DBS for the treatment of PD and ET. EFFECTIVE DATE: 02/02/2014. CHAPTER 5 5. Section 3.1. This change modernizes the TRICARE benefit by adding TRICARE coverage for Proton Beam Therapy (PBT) for the treatment of Thymoma, a rare disease. EFFECTIVE DATE: 02/16/2016. CHAPTER 7 6. Section 18.1. This change modernized the TRICARE benefit by removing the restriction on billing common procedural code 97532 for the treatment of cognitive deficits due to acquired brain injury. EFFECTIVE DATE: 09/06/2016. 3

Chapter 1, Section 3.1 Rare Diseases 2.30 Effective February 16, 2016, Proton Beam Therapy (PBT) may be considered for cost-sharing for the treatment of thymoma. 3.0 EXCLUSIONS 3.1 The off-label use of rituximab for the treatment of pediatric linear Immunoglobulin A (IgA) dermatosis is unproven. 3.2 Proton Beam Radiation Therapy (PBRT) for the treatment of juvenile nasal angiofibroma is unproven. 3.3 TRICARE Overseas Program (TOP) beneficiaries are not subject to the requirements of this policy. - END - 5 C-193, November 20, 2017

Surgery Chapter 4 Section 6.1 Musculoskeletal System Issue Date: August 26, 1985 Authority: 32 CFR 199.4(c)(2) and (c)(3) 1.0 CPT 1 PROCEDURE CODES 20005-20551, 20555-22328, 22510-22515, 22532-22856, 22858, 22859, 22861, 22864-27138, 27146-27178, 27181-29861, 29870-29913, 29999 2.0 HCPCS CODES S2118, S2325 3.0 DESCRIPTION The musculoskeletal system pertains to or comprises the skeleton and the muscles. 4.0 POLICY 4.1 Services and supplies required in the diagnosis and treatment of illness or injury involving the musculoskeletal system are covered. U.S. Food and Drug Administration (FDA) approved surgically implanted devices are also covered. 4.2 Autologous cultured chondrocytes on porcine collagen membrane (i.e., Matrix-Induced Autologous Chondrocyte Implantation [MACI]) to treat cartilage defects of the knee is proven. 4.3 Single or multilevel anterior cervical microdiskectomy with allogeneic or autogeneic iliac crest grafting and anterior plating is covered for the treatment of cervical spondylosis. 4.4 Percutaneous vertebroplasty (CPT 1 procedure codes 22510-22512) and balloon kyphoplasty (CPT 1 procedure codes 22513-22515) are covered for the treatment of painful osteolytic lesions and osteoporotic compression fractures refractory to conservative medical treatment. 4.5 Total Ankle Replacement (TAR) (CPT 1 procedure codes 27702 and 27703) surgery is covered if the device is FDA approved and the use is for an FDA approved indication. However, a medical necessity review is required in case of marked varus or valgus deformity. 4.6 Core decompression of the femoral head (hip) for early (precollapse stage I or II) avascular necrosis may be considered for cost-sharing (Healthcare Common Procedure Coding System (HCPCS) code S2325). 1 CPT only 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved. 1 C-193, November 20, 2017

Chapter 4, Section 6.1 Musculoskeletal System 4.7 Single-level, cervical Total Disc Replacement (ctdr) (CPT 2 procedure code 22856) and twolevel ctdr (CPT 2 procedure code 22858) using an FDA approved cervical artificial intervertebral disc for the treatment of cervical DDD, intractable radiculopathy, and/or myelopathy is covered if the disc is used in accordance with its FDA labeled indications. 4.8 High Energy Extracorporeal Shock Wave Therapy (HE ESWT) for the treatment of plantar fasciitis is covered when all of the following conditions are met: Patients have chronic plantar fasciitis of at least six months duration; Patients have undergone and failed six months of appropriate conservative therapy; and HE ESWT is defined as Energy Flux Density (EFD) greater than 0.12 millijoules per square millimeter (mj/mm2). 4.9 Meniscal allograft transplant of the knee is covered. 4.10 Hip resurfacing (CPT 2 procedure codes 27125 and 27130, and HCPCS S2118) with an FDA approved device is proven for the treatment of Degenerative Joint Disease (DJD) of the hip in patients who are less than 65 years old and who meet all of the following criteria: Have chronic, persistent pain and/or disability; Are otherwise healthy and active; Have normal proximal femoral bone geometry and bone quality; and Would otherwise receive a conventional Total Hip Replacement (THR), but are likely to outlive a conventional THR implant system s expected life. 4.11 Minimally Invasive Surgery (CPT 2 procedure code 27279) for treatment of sacroiliac joint pain is proven. 4.12 Autologous Chondrocyte Implantation (ACI), with Carticel, for the repair of patellar cartilage lesions is proven. 5.0 EXCLUSIONS 5.1 Ligament replacement with absorbable copolymer carbon fiber scaffold is unproven. 5.2 Prolotherapy, joint sclerotherapy and ligamentous injections with sclerosing agents (HCPCS procedure code M0076) are unproven. 5.3 Trigger point injection (CPT 2 procedure codes 20552 and 20553) for migraine headaches. 2 CPT only 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved. 2 C-193, November 20, 2017

Chapter 4, Section 6.1 Musculoskeletal System 5.4 Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection), three or more levels (CPT 3 procedure code 0375T) is unproven. 5.5 Removal of total disc arthroplasty (artificial disc), anterior approach, cervical, each additional interspace (CPT 3 procedure code 0095T) is unproven. Also, see Section 1.1. 5.6 Lumbar total disc arthroplasty (lumbar artificial intervertebral disc revision including replacement, lumbar total disc replacement) for degenerative disc disease is unproven (CPT 3 procedure codes 22857, 22862, 0163T, 0164T, and 0165T). 5.7 Low Energy (LE) or radial ESWT for the treatment of plantar fasciitis is unproven. Any form of ESWT for the treatment of lateral epicondylitis is unproven. 5.8 XSTOP Interspinous Process Decompression System (CPT 3 procedure codes 0171T and 0172T, HCPCS code C1821) for the treatment of neurogenic intermittent claudication secondary to lumbar spinal stenosis is unproven. 5.9 Femoroacetabular Impingement (FAI) open surgery, surgical dislocation (CPT 3 procedure codes 27140 and 27179), for the treatment of hip impingement syndrome or labral tear is unproven. 5.10 Hip arthroscopy with debridement of articular cartilage (CPT 3 procedure code 29862) for the treatment of FAI is unproven. 5.11 Hip arthroscopy with femoroplasty (CPT 3 procedure code 29914) treatment of FAI; cam lesion is unproven. 5.12 Hip arthroscopy with acetabuloplasty (CPT 3 procedure code 29915) treatment of FAI; pincer lesion is unproven. 5.13 Hip arthroscopy with labral repair (CPT 3 procedure code 29916) for treatment of FAI syndrome is unproven. 5.14 Osteochondral allograft of the humeral head with meniscal transplant and glenoid microfracture in the treatment of shoulder pain and instability is unproven. 5.15 Thermal Intradiscal Procedures (TIPs) (CPT 3 procedure codes 22526, 22527, 62287, and Healthcare Common Procedure Coding System (HCPCS) code S2348) are unproven. TIPs are also known as: Intradiscal Electrothermal Annuloplasty (IEA), Intradiscal Electrothermal Therapy (IDET), Intradiscal Thermal Annuloplasty (IDTA), Percutaneous Intradiscal Radiofrequency Thermocoagulation (PIRFT), Coblation Percutaneous Disc Decompression, Nucleoplasty (also known as Percutaneous Radiofrequency (RF) Thermomodulation or Percutaneous Plasma Diskectomy), Radiofrequency Annuloplasty (RA), Intradiscal Biacuplasty (IDB), Percutaneous (or Plasma) Disc Decompression (PDD), Targeted Disc Decompression (TDD), Cervical Intradiscal RF Lesioning. 3 CPT only 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved. 3 C-180, February 17, 2017

Chapter 4, Section 6.1 Musculoskeletal System 5.16 Spinal manipulation under anesthesia (CPT 4 procedure codes 00640 and 22505) for the treatment of back pain is unproven. 5.17 Minimally Invasive Lumbar Decompression (mild ) for the treatment of Degenerative Disc Disease (DDD) and/or spinal stenosis is unproven. 5.18 Athletic pubalgia surgery is unproven. 6.0 EFFECTIVE DATES 6.1 February 6, 2006, for percutaneous vertebroplasty and balloon kyphoplasty. 6.2 May 1, 2008, for TAR. 6.3 May 1, 2008, for core decompression of the femoral head. 6.4 December 24, 2012, for single-level, ctdr using an FDA approved cervical artificial intervertebral disc. 6.5 December 2, 2013, for HE ESWT for plantar fasciitis. 6.6 May 1, 2015, for meniscal allograft transplant of the knee. 6.7 May 21, 2014, for hip resurfacing for treatment of DJD of the hip. 6.8 July 27, 2015, for two-level ctdr using an FDA approved cervical artificial intervertebral disc. 6.9 August 23, 2016, Minimally Invasive Surgery (CPT 4 procedure code 27279) for the treatment of sacroiliac joint pain is proven. 6.10 May 7, 2016, for ACI surgery, with Carticel, for the repair of patellar cartilage lesions. 6.11 December 13, 2016, for autologous cultured chondrocytes on porcine collagen membrane. - END - 4 CPT only 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved. 4 C-193, November 20, 2017

Chapter 4, Section 15.1 Male Genital System 3.10 Effective April 14, 2016, prostate saturation biopsy for men at risk for prostate cancer, with one previous negative biopsy, with abnormal Digital Rectal Exams (DRE), with elevated or rising Prostate-Specific Antigen (PSA) levels and/or abnormal findings on previous biopsies (CPT 3 procedure code 55706) is covered. 4.0 EXCLUSIONS 4.1 Penile implants and related services when performed for psychological impotence, sex gender change surgery, or such other conditions as gender dysphoria. 4.2 Testicular prosthesis and related services when performed for sex gender change surgery or such other conditions as gender dysphoria. 4.3 Therapy for sexual dysfunctions or inadequacies (see Chapter 7, Section 1.1). 4.4 Arterial revascularization for distal lesions and venous leakage when treatment is for organic impotency. 4.5 All services and supplies directly and indirectly related to surgical treatment (i.e., sex gender change), except when performed to correct ambiguous genitalia, which is documented to have been present at birth (CPT 3 procedure codes 55970 and 55980). 4.6 Reversal of surgical sterilization (CPT 3 procedure codes 54900, 54901, and 55400), except as stated in paragraph 3.9. 4.7 Cryosurgery for prostate metastases M or N is unproven. 4.8 Electroejaculation (CPT 3 procedure code 55870). 4.9 Prophylactics (condoms). 4.10 Over-The-Counter (OTC) spemicidal products. 4.11 Penile Vibratory Stimulation (PVS) devices, such as Ferticare Personal 2 medical vibrator. - END - 3 CPT only 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved. 3 C-193, November 20, 2017

Surgery Chapter 4 Section 20.1 Nervous System Issue Date: August 29, 1985 Authority: 32 CFR 199.4(c)(2) and (c)(3) 1.0 CPT 1 PROCEDURE CODES 61000-61626, 61680-62264, 62268-62284, 62290-63048, 63050, 63051, 63055-64484, 64505-64595, 64600-64650, 64680-64999, 95961, 95962, 95970-95975, 95978, 95979 2.0 POLICY 2.1 Services and supplies required in the diagnosis and treatment of illness or injury involving the nervous system are covered. 2.2 Therapeutic embolization (CPT 1 procedure code 61624) may be covered for the following indications. The list of indications is not all inclusive. Other indications are covered when documented by reliable evidence as safe, effective and comparable or superior to standard care (proven). Cerebral Arteriovenous Malformations (AVMs). Vein of Galen Aneurysm. Inoperable or High-Risk Intracranial Aneurysms. Dural Arteriovenous Fistulas. Meningioma. Pulmonary Arteriovenous Malformations (PAVMs). 2.3 Implantation of depth electrodes is covered. Implantation of a U.S. Food and Drug Administration (FDA) approved vagus nerve stimulator, and battery replacement, may be covered for the following indications: As adjunctive therapy in reducing the frequency of seizures in adults and adolescents over 12 years of age, which are refractory to anti-epileptic medication. As therapy for children 12 years of age or younger who have a diagnosis of medically refractory Lennox-Gastaut Syndrome (LGS) (a rare disease). Effective July 27, 2012, as adjunctive therapy in reducing the frequency of seizures that are refractory to anti-epileptic medications in beneficiaries under the age of 12. 1 CPT only 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved. 1 C-193, November 20, 2017

Chapter 4, Section 20.1 Nervous System 2.4 Spinal cord and deep brain stimulation are covered in the treatment of chronic intractable pain. Coverage includes: 2.4.1 The accessories necessary for the effective functioning of the covered device. 2.4.2 Repair, adjustment, replacement and removal of the covered device and associated surgical costs. 2.5 The Guglielmi Detachable Coil (GDC) may be cost-shared for embolizing unruptured intracranial aneurysms that, because of their morphology, their location, or the patient s general medical condition, are considered by the treating neurosurgical team to be: 2.5.1 Very high risk for management by traditional operative techniques; or 2.5.2 Inoperable; or 2.5.3 For embolizing other vascular malformation such as AVMs and arteriovenous fistulae of the neurovasculature, to include arterial and venous embolizations in the peripheral vasculature. 2.6 Thoracic epidural steroid injections for the treatment of pain due to symptomatic thoracic disc herniations may be considered for cost-sharing when a patient meets all of the following criteria: Pain is radicular; and Pain is unresponsive to conservative treatment. 2.7 Non-pulsed Radiofrequency (RF) denervation (CPT 2 procedure codes 64633-64636) for the treatment of chronic cervical and lumbar facet pain is covered when the following criteria are met: 2.7.1 No prior spinal fusion surgery in the vertebral level being treated, and 2.7.2 Low back (lumbosacral) or neck (cervical) pain, suggestive of facet joint origin as evidenced by absence of nerve root compression as documented in the medical record on history, physical and radiographic evaluations; and the pain is not radicular, and 2.7.3 Pain has failed to respond to three months of conservative management which may consist of therapies such as nonsteroidal anti-inflammatory medications, acetaminophen, manipulation, physical therapy, and a home exercise program, and 2.7.4 A trial of controlled diagnostic medial branch blocks under fluoroscopic guidance has resulted in at least a 50% reduction in pain; and 2.7.5 If there has been a prior successful RF denervation, a minimum time of six months has elapsed since prior RF treatment (per side, per anatomical level of the spine). 2 CPT only 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved. 2 C-162, June 14, 2016

Chapter 4, Section 20.1 Nervous System 2.8 Endoscopic laminotomy (CPT 3 procedure code 63030) is covered for the treatment of lumbar spinal stenosis. The endoscopic spinal system used in the procedure must be FDA approved. 2.9 Sacral Nerve Stimulation (SNS) for the treatment of chronic fecal incontinence is covered for patients who have failed or are not candidates for more conservative treatment, and who have a weak but structurally intact anal sphincter refractory to conservative measures. See Section 14.1 for coverage policy for the urinary system and the Sacral Nerve Root Stimulation (SNS). 2.10 Intracranial angioplasty (CPT 3 procedure code 61630) may be covered when medically necessary and appropriate. 2.11 Deep Brain Stimulation (DBS) for the treatment of Parkinson s Disease (PD) and Essential Tremor (ET) is proven when using an FDA approved device, according to FDA indications. 2.12 Cervical laminoplasty 2/> segments and cervical laminoplasty with graft/plate (CPT 3 procedure codes 63050 and 63051) are proven safe and effective. 3.0 EXCLUSIONS 3.1 N-butyl-2-cyanoacrylate (Histacryl Bleu ), iodinated poppy seed oils (e.g., Ethiodol ), and absorbable gelatin sponges are not FDA approved. 3.2 Transcutaneous, percutaneous, functional dorsal column electrical stimulation in the treatment of multiple sclerosis or other motor function disorders is unproven. 3.3 Deep brain neurostimulation in the treatment of insomnia, depression, anxiety, and substance abuse is unproven. 3.4 Psychosurgery is not in accordance with accepted professional medical standards and is not covered. 3.5 Endovascular GDC treatment of wide-necked aneurysms and rupture is unproven. 3.6 Dorsal Root Entry Zone (DREZ) thermocoagulation or microcoagulation neurosurgical procedure is unproven. 3.7 Extraoperative electrocortiography for stimulation and recording in order to determine electrical thresholds of neurons as an indicator of seizure focus is unproven. 3.8 Neuromuscular Electrical Stimulation (NMES) for the treatment of denervated muscles is unproven. 3.9 Stereotactic cingulotomy is unproven. 3.10 Laminoplasty, cervical with decompression of the spinal cord, two or more vertebral segments with reconstruction of the posterior bony elements (CPT 3 procedure codes 63050 and 63051). 3 CPT only 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved. 3 C-193, November 20, 2017

Chapter 4, Section 20.1 Nervous System 3.11 Transcatheter placement of intravascular stent(s) intracranial (e.g., atherosclerotic or venous sinus stenosis) including angioplasty, if performed (CPT 3 procedure code 61635) is unproven. See Chapter 1, Section 3.1 for coverage policy regarding treatment of pseudotumor cerebri. 3.12 Balloon dilation of intracranial vasospasm, initial vessel (CPT 4 procedure code 61640) each additional vessel in same family (CPT 4 procedure code 61641) or different vascular family (CPT 4 procedure code 61642) is unproven. 3.13 Endoscopic thoracic sympathectomy. 3.14 Trigger point injection for migraine headaches. 3.15 Sphenopalatine ganglion block (CPT 4 procedure code 64505) for the treatment of chronic migraine headaches and neck pain is unproven. 3.16 RF denervation (CPT 4 procedure codes 64633, 64634) for the treatment of thoracic facet pain is unproven. Pulsed Radiofrequency Ablation (RFA) for spinal pain is unproven. 3.17 Implantation of Occipital Nerve Stimulator for the treatment of chronic intractable migraine headache is unproven. 3.18 Cryoablation of Occipital Nerve (CPT 4 procedure code 64640) for the treatment of chronic intractable headache is unproven. 3.19 Spinal cord and deep brain neurostimulation in the treatment of chronic intractable headache or migraine pain is unproven. 3.20 Thermal Intradiscal Procedures (TIPs) (CPT 4 procedure codes 22526, 22527, 62287, and Healthcare Common Procedure Coding System (HCPCS) code S2348) are unproven. TIPs are also known as: Intradiscal Electrothermal Annuloplasty (IEA), Intradiscal Electrothermal Therapy (IDET), Intradiscal Thermal Annuloplasty (IDTA), Percutaneous Intradiscal Radiofrequency Thermocoagulation (PIRFT), Coblation Percutaneous Disc Decompression, Nucleoplasty (also known as Percutaneous RF thermomodulation or Percutaneous Plasma Diskectomy), Radiofrequency Annuloplasty (RA), Intradiscal Biacuplasty (IDB), Percutaneous (or Plasma) Disc Decompression (PDD), Targeted Disc Decompression (TDD), Cervical Intradiscal RF Lesioning. 3.21 Laser ablation of paravertebral facet joint nerves (CPT 4 procedure codes 64622 and 64623) is unproven. (This applies only to laser ablation and should not be applied to RFA.) 3.22 Minimally Invasive Lumbar Decompression (mild ) for the treatment of Degenerative Disc Disease (DDD) and/or spinal stenosis is unproven. 4.0 EFFECTIVE DATES 4.1 January 1, 1989, for PAVM. 4.2 April 1, 1994, for therapeutic embolization for treatment of meningioma. 4 CPT only 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved. 4 C-193, November 20, 2017

4.3 July 14, 1997, for GDC. TRICARE Policy Manual 6010.57-M, February 1, 2008 Chapter 4, Section 20.1 Nervous System 4.4 The date of FDA approval of the embolization device for all other embolization procedures. 4.5 June 1, 2004, for Magnetoencephalography. 4.6 June 10, 2008, for thoracic epidural steroid injections. 4.7 January 1, 2009, for non-pulsed RF denervation for the treatment of chronic cervical and lumbar facet pain. 4.8 January 1, 2009, for endoscopic laminotomy for the treatment of lumbar spinal stenosis. 4.9 October 1, 2011, for vagus nerve stimulator for treatment of LGS in children 12 years of age or younger. 4.10 March 14, 2011, for SNS for the treatment of chronic fecal incontinence in patients who have failed or are not candidates for more conservative treatment, and who have a weak but structurally intact anal sphincter refractory to conservative measures. 4.11 August 9, 2012, for intracranial angioplasty. 4.12 February 2, 2014, for DBS for the treatment of PD and ET. - END - 5 C-193, November 20, 2017

Radiology Chapter 5 Section 3.1 Radiation Oncology Issue Date: March 27, 1991 Authority: 32 CFR 199.4(b)(2), (b)(2)(x), (c)(2)(viii), and (g)(15) 1.0 CPT 1 PROCEDURE CODES 37243, 61793, 61795, 77261-77421, 77427-77799, 0073T 2.0 HCPCS PROCEDURE CODES G0339, G0340 3.0 DESCRIPTION 3.1 Radiation therapy is also known as radiotherapy, radiation treatment, x-ray therapy, cobalt therapy, and proton beam therapy. The primary purpose of radiation therapy is to eliminate or shrink localized cancers (as opposed to cancers that have spread to distant parts of the body). 3.2 Stereotactic radiosurgery/radiotherapy is a method of delivering ionizing radiation to small intracranial targets. Stereotactic radiosurgery entails delivering a high dose in a single session. Stereotactic radiotherapy entails fractionating the dose over a number of treatments. 3.2.1 There are three main variations of stereotactic radiosurgery/radiotherapy: gamma beam or gamma knife, linear accelerator (linac), and charged particle beam (proton or helium ion). The three radiation delivery devices differ technically in several ways: source of radiation, size and shape of the radiation field, and range of radiation dosages. 3.2.2 The radiosurgical/radiotherapy procedure is preceded by a process of localizing the target, which can be performed with one or more of the following techniques: skull x-ray, cerebral angiography, Computerized Tomography (CT), or Magnetic Resonance Imaging (MRI). 4.0 POLICY 4.1 Radiation therapy (fast neutron, hyperfractionated, and radioactive chromic phosphate synoviorthesis) is covered for those indications documented by reliable evidence as safe, effective and comparable or superior to standard care (proven). For coverage on brachytherapy/radiation therapy, see Section 3.2. 1 CPT only 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved. 1 C-157, February 16, 2016

Chapter 5, Section 3.1 Radiation Oncology 4.2 Gamma knife radiosurgery/radiotherapy is covered for the following indications. This list of indications is not all inclusive. Other indications are covered when documented by reliable evidence as safe, effective, and comparable or superior to standard care (proven). Arteriovenous Malformations (AVMs). Benign brain tumors. Acoustic neuromas (vestibular Schwannomas). Pituitary adenomas. Craniopharyngiomas. Other tumors of the skull base. Pineal region tumors. Metastatic brain tumors. High grade gliomas (glioblastoma multiforme, anaplastic astrocytomas). 4.3 Linear accelerator radiosurgery/radiotherapy is covered for the following indications. This list of indications is not all inclusive. Other indications are covered when documented by reliable evidence as safe, effective, and comparable or superior to standard care (proven). AVMs. Acoustic neuromas (vestibular Schwannomas). Metastatic brain tumors. 4.4 Proton beam radiosurgery/radiotherapy is covered for the following indications. This list of indications is not all inclusive. Other indications are covered when documented by reliable evidence as safe, effective, and comparable or superior to standard care (proven). AVMs. Cushing s disease or acromegaly caused by pituitary microadenomas. As postoperative therapy in patients who have undergone biopsy or partial resection of the chordoma or low grade (I or II) chondrosarcoma of the basisphenoid region (skullbase chordoma or chondrosarcoma) or cervical spine. As primary therapy for patients with uveal melanoma, with no evidence of metastasis or extrascleral extension, and with tumors up to 22 mm in largest diameter and 14 mm in height. Prostate cancer. Meningioma. Low grade glioma (astrocytoma, grade I-II). Glioblastoma multiforme. Soft tissue sarcoma (liposarcoma). Hodgkin s disease when conventional radiotherapy is contraindicated. Acoustic neuromas. As post-operative therapy for sacral chordoma under the rare disease policy as described in Chapter 1, Section 3.1. Thymoma 4.5 Helium ion beam radiosurgery/radiotherapy is covered for the following indications. This list of indications is not all inclusive. Other indications are covered when documented by reliable evidence as safe, effective, and comparable or superior to standard care (proven). 2 C-193, November 20, 2017

Chapter 5, Section 3.1 Radiation Oncology 4.5.1 As primary therapy for patients with melanoma of the uveal tract, with no evidence of metastasis or extrascleral extension, and with tumors up to 24 mm in largest diameter and 14 mm in height. 4.5.2 As postoperative therapy in patients who have undergone biopsy or partial resection of the chordoma or low grade (I or II) chondrosarcoma of the basisphenoid region (skull-base chordoma or chondrosarcoma) or cervical spine. 4.6 Extracranial stereotactic radiosurgery/radiotherapy including image-guided robotic linear accelerator-based stereotactic body radiotherapy (SBRT) (CPT 2 procedure codes 77435, 77373 and HCPCS codes G0339, G0340) and all related medically necessary services and supplies (CPT 2 procedure code 55876) are covered for the following indications. Primary and metastatic lung carcinoma. Prostate cancer. 4.7 Frameless stereotaxy (neuronavigation) is covered for the following indications. This list of indications is not all inclusive. Other indications are covered when documented by reliable evidence as safe, effective, and comparable or superior to standard care (proven). Localization, surgical planning and guidance for intracranial tumors, skull base tumors, metastatic brain tumors, AVMs, cavernomas, chordomas, and pituitary adenomas. Biopsy guidance. Cerebrospinal fluid shunt placement. Surgery for intractable epilepsy. Spinal surgery. 4.8 The frameless stereotaxy device must be U.S. Food and Drug Administration (FDA) approved. The following devices are FDA approved: StealthStation System, The Operating Arm, ISG Viewing Wand, MKM System, and Philips Easyguide. Other systems which are FDA approved are also covered. 4.9 High energy neutron radiation treatment (CPT 2 procedure codes 77422 and 77423) is covered for adenoid cystic carcinoma for the following indications: Unresectable, inoperable or recurrent tumors. Locally advanced disease. In situations where surgical extirpation would cause considerable morbidity. 4.10 The off-label use of Selective Internal Radiation Therapy (SIRT), also known as radioembolization, with yttrium-90 microspheres (resin or glass) for the treatment of unresectable liver tumors from metastatic breast cancer is safe, effective, and in accordance with nationally accepted standards of practice in the medical community. 5.0 EXCLUSIONS 5.1 Helium ion beam radiosurgery/radiotherapy for AVMs and ependymoma is unproven. 2 CPT only 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved. 3 C-157, February 16, 2016

Chapter 5, Section 3.1 Radiation Oncology 5.2 Intra-Operative Radiation Therapy (IORT) is unproven. 5.3 High energy neutron radiation treatment delivery, single treatment area using a single port or parallel-opposed ports with no blocks or simple blocking (CPT 3 procedure code 77422) is unproven (except for treatment of adenoid cystic carcinoma, see paragraph 4.9). 5.4 High energy neutron radiation treatment delivery, single treatment area using a single port or parallel-opposed ports with no blocks or simple blocking one or more isocenter(s) with coplanar or non-coplanar geometry with blocking and/or wedge, and/or compensator(s) (CPT 3 procedure code 77423) is unproven (except for treatment of adenoid cystic carcinoma, see paragraph 4.9). 5.5 Proton Beam Therapy (PBT) radiosurgery/radiotherapy for the treatment of inoperable nonsmall cell lung cancer is unproven. 6.0 EFFECTIVE DATES 6.1 February 26, 1986, for proton beam radiosurgery/radiotherapy for AVMs. 6.2 March 1, 1988, for proton beam radiosurgery/radiotherapy for patients with Cushing s disease or acromegaly caused by pituitary microadenoma. 6.3 October 6, 1988, for gamma beam (gamma knife) radiosurgery/radiotherapy for treatment of AVM, benign brain tumors, acoustic neuromas, pituitary adenomas, craniopharyngiomas, other tumors of the posterior fossa and pineal region tumors. 6.4 January 1, 1990, for proton beam radiosurgery/radiotherapy for soft tissue sarcoma (liposarcoma). 6.5 June 18, 1990, for proton beam radiosurgery/radiotherapy for chordomas or chondrosarcomas. 6.6 January 1, 1994, for gamma beam (gamma knife) and linear accelerator radiosurgery/ radiotherapy for metastatic brain tumors. 6.7 January 1, 1996, for proton beam radiosurgery/radiotherapy for uveal melanoma. 6.8 January 1, 1996, for helium ion beam radiosurgery/radiotherapy for uveal melanoma and chordomas or chondrosarcomas. 6.9 April 1, 1996, for linear accelerator radiosurgery/radiotherapy for AVMs and acoustic neuromas. 6.10 April 26, 1996, for proton beam radiosurgery/radiotherapy for prostate cancer. 6.11 October 1, 1997, for gamma knife radiosurgery/radiotherapy for high grade gliomas (glioblastoma multiforme, anaplastic astrocytomas). 3 CPT only 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved. 4 C-193, November 20, 2017

Chapter 5, Section 3.1 Radiation Oncology 6.12 January 1, 1998, for extracranial stereotactic radiosurgery/radiotherapy for lung carcinoma. 6.13 The date of FDA approval for frameless stereotaxy. 6.14 October 24, 2014, for image-guided robotic linear accelerator-based stereotactic body radiation therapy (SBRT) and all related medically necessary services and supplies for the treatment of prostate cancer. 6.15 July 4, 2014, for the off-label use of SIRT, also known as radioembolization, with yttrium-90 microspheres (resin or glass) for the treatment of unresectable liver tumors from metastatic breast cancer. 6.16 February 16, 2016, for Proton Beam Therapy (PBT) for treatment of thymoma. - END - 5 C-193, November 20, 2017

Medicine Chapter 7 Section 18.1 Rehabilitation - General Issue Date: June 5, 1995 Authority: 32 CFR 199.4(a)(1), (e)(24), and 10 USC 1077(a)(17) 1.0 DESCRIPTION Rehabilitation is the reduction of an acquired loss of ability to perform an activity in the manner, or within the range considered normal, for a human being. 2.0 POLICY 2.1 Section 704 of the National Defense Authorization Act for Fiscal Year 2002 (NDAA FY 2002), PL 107-107, states the Department may provide any rehabilitative therapy to improve, restore, or maintain function, or to minimize or prevent deterioration of function, of a patient when prescribed by a physician. Any therapy for the purpose of improving restoring, maintaining, or preventing deterioration of function, must be medically necessary and appropriate medical care. The rehabilitation therapy must be rendered by an authorized provider, necessary to the establishment of a safe and effective maintenance program in connection with a specific medical condition, provided at a skilled level and must not be custodial care or otherwise excluded from coverage (e.g., exercise or able to be provided at a non-skilled level). 2.2 Services which have been demonstrated to be capable of reliably confirming the severity of impaired function attributable to a physical impairment may be cost-shared when medically necessary and appropriate. 2.3 Services or items which have been demonstrated to be usually capable of reducing or arresting the severity of impaired function attributable to a physical impairment may be costshared when medically necessary and appropriate. 2.4 Otherwise covered services that incidentally address cognitive deficits as factors involved with the restoration of lost neuromuscular functions are covered. 2.5 Otherwise covered services such as diagnostic or assessment tests and examinations that are prescribed specifically and uniquely to measure the severity of cognitive impairment are covered. 2.6 The following therapies and services rendered by an employee of an authorized institutional provider may be cost-shared when part of a comprehensive rehabilitation treatment plan: Physical therapy. Rehabilitation counseling. Mental health services. 1 C-91, July 8, 2013

Chapter 7, Section 18.1 Rehabilitation - General Speech pathology services. Occupational therapy. 2.7 The specialized knowledge of a skilled provider may be required to establish a maintenance program intended to prevent or minimize deterioration caused by a medical condition. Establishing such a program is a skilled service. The initial evaluation of the patient s needs, the designing by a skilled provider of a maintenance program which is appropriate to the capacity and tolerance of the patient, the instruction of the patient or family members in carrying out the program and infrequent evaluations may be required. 2.8 While a patient is under a restorative rehabilitative therapy program, the skilled provider should reevaluate his/her condition when necessary and adjust any exercise program that the patient is expected to carry out himself/herself or with the aid of family members to maintain the function being restored. Consequently, by the time it is determined that no further restoration is possible, i.e., by the end of the last restorative session, the provider will have already designed the maintenance program required and instructed the patient or family member in the carrying out of the program. Therefore, where a maintenance program is not established until after the restorative rehabilitative therapy has been completed, it would not be considered medically necessary and appropriate medical care and would be excluded from coverage. 2.9 Once a patient has reached the point where no further significant practical improvement can be expected, the skills of an authorized provider will not be required in the carrying out of an activity/exercise program required to maintain function at the level to which it has been restored. The services of a skilled provider in designing a maintenance program will be covered, carrying out the program is not considered skilled care, medically necessary or appropriate medical care consequently such services are not covered. 2.10 Services that are palliative in nature are not considered medically necessary and appropriate medical care and are not covered. These services generally do not require physician judgement and skill for safety and effectiveness. 2.11 Cognitive Rehabilitation Therapy (CRT) (CPT 1 procedure code 97532) for the treatment of cognitive deficits due to Acquired Brain Injury (ABI) (Traumatic Brain Injury [TBI] or stroke) is proven and may be covered on an outpatient basis when the following requirements are met: Therapy provided by an authorized individual TRICARE provider. A documented cognitive impairment with related compromised functional status exists. (See paragraph 2.1 medically necessary and appropriate.) The individual is willing and able to actively participate in the treatment plan. (See paragraph 2.1, must not be custodial care.) For mild TBI and stroke, a short term trial of CRT which focuses on time-limited, measurable goals related to reducing activity limitations and improving activity participation may be undertaken to assess whether the patient would benefit from strategy training and memory compensation techniques. A goal-based, functional re- 1 CPT only 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved. 2 C-193, November 20, 2017

Chapter 7, Section 18.1 Rehabilitation - General assessment to document treatment response shall be completed and submitted no later than one month after treatment for any further authorization of care. (See paragraph 2.8. the skilled provider should reevaluate his/her condition when necessary.) 3.0 EXCLUSIONS 3.1 Community and work integration training, such as listed in CPT 2 procedure code 97537 is excluded. 3.2 Vocational rehabilitation. Educational services intended to provide a beneficiary with the knowledge and skills required for the performance of a specific occupation, vocation, or job. 3.3 Coma stimulation. Activities of external stimulation intended to arouse a beneficiary from a coma. 3.4 Programs. Standard bundles of services (programs) as an all-inclusive priced unit or services. Note: Services rendered during such a program encounter must be itemized and each reviewed to determine if rendered by an authorized individual professional provider, if it is a covered benefit, and whether it is medically necessary and appropriate. 3.5 Sensory integration therapy (CPT 2 procedure code 97533) which may be considered a component of cognitive rehabilitation is unproven. 3.6 Self-administered computer-based CRT is unproven. 3.7 The use of a Monochromatic Infrared Energy (MIRE) device for treatment of diabetic peripheral neuropathy is unproven. 3.8 Services provided to address disorders or conditions (e.g., speech, language, or communication) resulting from occupational or educational deficits. 3.9 Low Level Laser Therapy (LLLT) (also known as low level light therapy or cold laser therapy) for treatment of soft tissue injuries, pain or inflammation is unproven. 4.0 EFFECTIVE DATE Effective September 6, 2016 for CRT for the treatment of cognitive deficits due to ABI. - END - 2 CPT only 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved. 3 C-193, November 20, 2017