LIST OF ADVANCED TREATMENTS COVERABLE UNDER MEDICAL BENEFITS ADVANCE TREATMENT COVERABLE CONDITIONS 1 Cryoablation Primary therapy alternative to surgery for individuals with localized disease or as a salvage therapy for recurrent cancer following failure of radiation therapy Prostate Cancer with localized disease (T1 or T2 - Organ confined) as a primary therapy alternative to surgery or irradiation Prostate Cancer with (locally advanced) or as salvage therapy for recurrent cancer following failure of radiation therapy Malignant Endobronchial Obstruction High risk individual for surgical intervention with Renal Cell Carcinoma, up to 4-cm in size Drug resistant or intolerance Atrial fibrillation, with evidence of a localized site(s) of origin Low-risk superficial Basal Cell Carcinoma or Squamous Cell Carcinoma in situ (Bowen disease), where surgery or radiation is contraindicated or impractical Soft Tissue Sarcoma of the extremities or the trunk in symptomatic persons with disseminated metastases 2 Combined and Personalized Immunotherapy (CIC): Nivolumab (Opdiva) are man-made monoclonal antibodies versions of immune system proteins designed to bind to specific targets in the body and causes immune response that destroys cancer cells Bladder cancer Recurrence post cystectomy, or for metastatic disease Classical Hodgkin lymphoma Colorectal cancer, small bowel adenocarcinoma, appendicle carcinoma, and anal adenocarcinoma Head and neck cancer Hepatocellular carcinoma Kidney cancer Malignant pleural mesothelioma Melanoma Metastatic squamous cell anal carcinoma
Non-small cell lung cancer (adenocarcinoma with mixed type) Primary carcinoma of the urethra Small cell lung cancer Upper gastrointestinal tract tumors Urothelial carcinoma of the prostate 3 Combined and Personalized Immunotherapy (CIC): Pembrolizumab (Keytruda) are Immune checkpoint inhibitors drugs that remove obstacles from the immune system Urothelial carcinoma (Transitional cell carcinoma) Bladder cancer Primary carcinoma of the urethra Upper gastrointestinal tract tumors Urothelial carcinoma of the prostate Colorectal cancer Small bowel adenocarcinoma Appendiceal carcinoma 4 Combined and Personalized Immunotherapy (CIC): Cancer Vaccine Therapy known as Tumor-associated antigenic peptidebased vaccines for treatment of cancers Adult metastatic castrate-resistant Prostate cancer
5 Proton Beam Radiotherapy (PBRT) Proton beam radiation therapy (PBRT) is a type of external beam radiation therapy (EBRT) that utilizes protons (positively charged subatomic particles) that are precisely targeted to a specific tissue mass Chordomas or chondrosarcomas arising at the base of the skull or cervical spine without distant metastases; or Malignancies in children (21 years of age and younger); or Uveal melanomas confined to the globe (i.e. not distant metastases) (the uvea is comprised of the iris, ciliary body, and choroid [the vascular middle coat of the eye]) 6 Neutron Beam Radiation Therapy (NBRT) Neutron beam radiation therapy (NBRT) is a specialized type of EBRT that uses high energy neutrons (neutral charged subatomic particles) targeted toward tissue masses that are characterized by lower tumor oxygen levels and a slower cell cycle as neutrons require less oxygen and are less dependent on the cell s position in the cell division cycle Inoperable tumor; or Locally advanced tumor especially in persons with gross residual disease; or unresectable tumor
7 Stem Cells for Hematopoietic Cell Transplant Bone marrow harvested from compatible donors to obtain the stem cells or bone marrow name as allogeneic bone marrow or peripheral stem cell transplant Hodgkin's disease Non-Hodgkin's lymphoma (NHL) High risk stage II to stage III neuroblastoma & stage IV neuroblastoma primary recurrent or refractory disease (Primary refractory is defined as a tumor that does not achieve a complete remission after initial standard-dose chemotherapy. Relapse is defined as a tumor recurrence after a prior complete remission) Person with chemosensitive neuroblastoma who has relapsed after an autologous hematopoietic cell transplant Person who has relapsed or progressive chemotherapy sensitive Ewing's sarcoma family of tumors that is not widely metastatic Person with primitive neuroectodermal tumors (PNET) including medulloblastoma and pineoblastoma Person with ependymoma who are ineligible for radiotherapy Person with extraocular retinoblastoma Persons with progressive or relapsed chemosensitive Wilm's tumor 8 Deep-Brain Stimulation (DBS) Unilateral or bilateral deep brain stimulators (e.g. stimulation of the ventral intermediate thalamic nucleus, globus pallidus, and subthalamic nucleus) criteria with Durable Medical Equipment (DME) For treatment of intractable tremors as a consequence of Parkinson's disease with appropriate assessment of the independency in his/her daily life to meet the medical necessity
9 Nerve Block A nerve block is a form of regional anesthesia. Peripheral nerve blocks (PNBs) entail the injection of corticosteroids, local anesthetics, neurolytic agents and/or sclerosing agents into or near peripheral nerves or nerve ganglion resulting in the temporary interruption of conduction of impulses in peripheral nerves or nerve trunks (somatic and sympathetic nerves). Peripheral nerve blocks attempt to block pain signals and in theory provide prolonged relief from pain Femoral nerve blocks for acute post-operative pain after knee replacement surgery Intercostal nerve blocks for acute intercostal pain, and for chronic intercostal neuritis as part of a comprehensive pain management program Peripheral nerve blocks (continuous or single-injection) for the treatment of (i) acute pain, and (ii) For chronic pain only as part of an active component of a comprehensive pain management program Peripheral nerve blocks for the treatment of chronic pain post-herniorrhaphy to avoid more aggressive treatments (e.g. surgery) 10 Back Pain (Invasive procedures) Procedures that used to treat chronic pain that an individual especially at neck and back bone that limit daily activities and has lasted more than 3 months despite appropriate conservative treatment (including, but not limited to rest, systemic medications, and/or physical therapy) Facet joint injections (intra-articular and medial branch blocks) in persons with severe chronic neck and back pain. A set of facet joint injections (intra-articular or medial branch blocks) means up to 6 such injections per sitting, and this can be repeated once at the same levels and side, no sooner than one week after the initial set of injections Trigger point injections of corticosteroids and/or local anesthetics for treating members with chronic neck or back pain or myofascial pain syndrome Sacroiliac joint injections are considered medically necessary to relieve pain associated with lower lumbosacral disturbances. Interlaminar epidural injections of corticosteroid preparations (e.g. Depo-Medrol), with or without added anesthetic agents Chymopapain chemonucleolysis is considered medically necessary for the treatment of sciatica due to a herniated disc with the following criteria met: A. Person has leg pain worse than low back pain; and B. Person has radicular symptoms reproduced by sciatic stretch tests; and C. Person has only a single-level herniated disc with nerve root impingement at clinically suspected level demonstrated by MRI, CT, or myelography; and
D. Person has objective neurologic deficit (e.g. diminished deep tendon reflex, motor weakness, or hyperalgesia in dermatomal distribution); and E. Person with pain not relieved by at least 6 weeks of conservative treatments Percutaneous lumbar discectomy, manual or automated Non-pulsed radiofrequency facet denervation with intractable cervical or back pain with or without sciatica 11 Brachytherapy Also known as interstitial radiation, intracavitary radiation, internal radiation therapy) Breast cancer Esophageal cancer Eye tumors Genitourinary cancers other than bladder cancer (including penile cancer, prostate cancer, urethral cancer) Gynecologic cancer (cervical, endometrial, vaginal or vulvar) Head and neck cancers (including buccal mucosa cancer, lip cancer, mouth cancer, nasopharyngeal cancer, salivary gland cancer, soft palate cancer, tonsillar fossa/pillar cancer) Respiratory and digestive tract cancers (including lung cancer for palliation of obstructive symptoms due to intraluminal tumor), pelvic recurrence of colorectal cancer, pleural mesotheliomas, rectal (anal cancer) Skin cancer, where surgical resection and photon or electron beam techniques are contraindicated Soft tissue sarcomas Stenotic obstruction post lung transplantation refractory to other treatments such as balloon dilation, laser debridement, or stent placement Note: 1. This list is not exhaustive and is subject to revision by Prudential Assurance Malaysia Berhad, from time to time. 2. The above advanced treatments are covered by Prudential Assurance Malaysia Berhad for the above stated health conditions ONLY. In the event, the above advanced treatment is sought for any conditions other than above, as advised by your Attending Doctor, please seek confirmation on the coverage. 3. The above treatment will be covered under the medical plan subject to terms & conditions as specified in the policy contract. For more enquiries, please email: customer.mys@prudential.com.my