UM Guidelines

	Added:
	This list applies only to Day surgery procedures & does not apply to office procedures, 23-hour admissions, or 1-day admissions.
	Insertion/Replacement/Removal of Tissue Expanders Clinical Indications Presence of scar tissue related to burn/trauma: location, pain, size, photo required. Skin graft necessary post tissue injury/removal. Insertion of implantable contraceptive capsules Clinical Indications Dependent upon individual contract. If contract provides benefits then approve insertion of contraceptive capsules. If contract excludes contraceptive coverage, then deny insertion of contraceptive capsules. Removal with reinsertion, implantable contraceptive capsules Clinical Indications Dependent upon individual contract. If contract provides benefits, then approve the removal and reinsertion of contraceptive capsules. If the contract excludes contraceptive coverage, then deny the removal and reinsertion of contraceptive capsules. Allograft skin, Xenograft skin Allograft: Application of allograft skin (homograft) from a healthy cadaveric donor is applied to a part of the patient’s body to resurface an area damaged by burns, traumatic injury or surgery. Xenograft: Application of a non-human skin graft or biologic wound dressing (e.g., porcine tissue or pigskin) to a part of the recipient’s body following debridement of the burn wound or area of traumatic injury, soft tissue infection and/or tissue necrosis, or surgery. Clinical Indications Secondary or add-on procedure for primary surgery that is medically necessary Appropriateness driven by related diagnosis such as burns, cancers Size of affected area is large (additional 100 square cm.) Application of interdental fixation device for conditions other than fracture or dislocation, includes removal - Refer to BCBST Medical Policy Manual - Modified Condylotomy for Treatment of Temporomandibular Joint (TMJ) Disorders (Hyperlink to BCBST Medical Policy added March 2005*) Clinical Indications Relevant medical records with documentation that application of interdental fixation device was performed in conjunction with an approved orthognathic surgical procedure should be provided. If done with an approved orthognathic surgical procedure, benefits for the fixation are considered incidental to the surgery. If application of interdental fixation procedures are determined to be orthodontic appliances (braces or appliances designed to move teeth; expand or promote bone growth; or to alter an occlusion), it is considered non-covered under medical benefits. These type procedures are determined to be dental benefits or dental procedures. Physical findings Reconstruction of mandibular condyle with bone and cartilage autograft (includes obtaining grafts) e.g., for hemifacial microsomia Clinical Indications The mandible is the lower jawbone. Mandibular rami are areas that protrude at the back of the mandible. The mandibular condyle is the posterior process on the mandibular rami that consists of the superior joint portion, and the condyle neck. Autograft is a graft that is taken from one part of the body and then surgically placed in another site on the same individual. Hemifacial microsomia is significant undergrowth of one side of the face. Diagnostic Procedures (any or all of the following can assist with confirming diagnosis) History Clinical examination Cephalometric radiographs Panoramic and tomographic radiographs Intraoral and facial photographs Dynamic recordings of functional activities Additional radiographs and consultation as needed Linear growth changes (dependent upon individual age) Clinical indications for Surgery or Invasive Treatment Procedure is not merely for cosmetic benefit. History and clinical examination support functional disabilities. Radiographs confirm functional abnormality. Documentation that non-invasive modalities have failed. Reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); partial or complete Dental implants/Osseointegration Procedures are dental and would be evaluated under the dental plan. Interdental wiring, for condition other than fracture Clinical Indications Relevant medical records with documentation of diagnosis prior to interdental wiring (ie, anomalies with surgery involved, restoration of functionality). Documentation should also state that application of interdental fixation device was performed in conjunction with an approved orthognathic surgical procedure. If done with an approved orthognathic surgical procedure, benefits for the wiring are considered incidental to the surgery. If interdental wiring is determined to be an orthodontic appliances (braces or appliances designed to move teeth; expand or promote bone growth; or to alter an occlusion), it is considered non-covered under medical benefits. These type procedures are determined to be dental benefits or dental procedures. Excision of lesion of meniscus or capsule (e.g., cyst, ganglion), knee Clinical Indications Relevant medical records with documentation of pain in knee joint accentuated by activity. Documentation of symptoms such as catching, popping, snapping, and giving way should be provided if present. Documentation of the results from a MRI or a surgical arthroscopy of knee should be provided showing the presence of the lesion. Documentation demonstrating failure of conservative treatment measures (i.e.: steroid injections, anti-inflammatory medications) must be provided. Hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint Clinical Indications Failure of nonsurgical treatment including but not limited to drug therapy such as pain medication, anti-inflammatories and others, orthotics, rest etc. with persistent pain Pain interferes with activities of daily living (i.e. walking, working etc.) Bronchoscopy, with brushing or protected brushing; with bronchial alveolar lavage with placement of catheter(s) for intracavitary radioelement application Clinical Indications Diagnostic indicators: Endobronchial signs and symptoms (may be necessary in obtaining specimen) Chronic cough Hemoptysis Atelectasis Obstructive pneumonia Lung cancer and/or suspected lung cancer established by x-ray For tissue diagnosis For staging For early diagnosis Burns Suspect injury to bronchial tree Therapeutic indications: Removal of a foreign body Lung Abscess Possibly to rule out; or For drainage Tracheal Stenosis For dilation Respiratory Toilette Excessive secretions with inability to clear Laparoscopy, surgical; with retroperitoneal lymph node sampling (biopsy), single or multiple; abdomen, peritoneum, and omentum with biopsy (single or multiple); with aspiration of cavity or cyst (single or multiple); with removal of leiomyomata, subserosal (single or multiple); with enterolysis. Clinical Indications Relevant medical records with documentation of: Patient history and physical examination. Previous treatments and/or procedures that have been performed, if applicable. Documentation supporting the physician is unable to obtain samples or provide necessary medical intervention without surgery. Laparoscopic retroperitoneal lymph node dissection is appropriate, but not limited to, patients with stage I nonseminomatous testis cancer that have a low likelihood of metastatic disease. Coverage of outpatient procedures is dependent on the individual contract. Excision/Resection of Lip Clinical Indications Cancerous lesion involving lip Burn/injury to lip: photo required. Non-cancerous lesion involving lip: photo required. Congenital malformation of lip: photo required. Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without D & C. Clinical Indications Relevant medical records with documentation of: Patient history/complaints of related symptomology (e.g., abdominal pain, abnormal menstruation, pelvic pressure, urinary frequency not of infective etiology, sciatic or hip pain not due to injury or other disease process, acquired dysmenorrhea in the 35-40 age group) Pelvic exam findings-may or may not be abnormal Previous treatments/surgical procedures, if applicable (e.g., hormonal therapy, previous D&C, previous hysteroscopy) Previous diagnostic procedures performed, if applicable (e.g., pelvic exam, hysteroscopy, ultrasound) Coverage of outpatient surgical procedures is dependent on the individual contract. Hysteroscopy, surgical; with lysis of intrauterine adhesions (any method) Clinical Indications Relevant medical records with documentation of: Patient history/complaints, (e.g., pain, infertility, abnormal menstruation) Physical exam findings (e.g., pelvic exam) Previous treatments, if applicable (e.g., previous D & C, hysteroscopy) Previous diagnostic procedures performed. if applicable (e.g., biopsy, ultrasound) Coverage of outpatient surgical procedures is dependent on the individual contract. Cerclage of uterine cervix; Endometrial sampling (biopsy) with or without endocervical sampling (biopsy), without cervical dilation, any method - Refer to BCBST Medical Policy Manual - Cervical Cerclage (Hyperlink to BCBST Medical Policy added March 2005*) Clinical Indications Relevant medical records with documentation of the diagnosis. Appropriateness determined by diagnosis (i.e., abnormal uterine bleeding, infertility, endometrial hyperplasia or cancer) Endometrial biopsy should not be performed routinely for confirmation of ovulation because accurate, less invasive tests are available. Coverage of these procedures when used for infertility treatment is dependent on individual contracts.