Health Evidence Review Commission's Value-based Benefits Subcommittee

Recommendations

Info

Section 4.0 Biennial <strong>Review</strong>
2018 Biennial <strong>Review</strong> Merging Selected Neonatal Lines Issue: There are multiple lines on the Prioritized List which related to the birth of an infant or to newborn medical conditions. Many of these lines contain basically the same treatment CPT codes—hospitalization codes, NICU codes, and pediatric intensive care codes. Each also contains diagnosis codes for possibly serious newborn conditions which might require nursery or NICU care. These lines are generally all in the highest priority area of the Prioritized List. These lines were reviewed by the ICD-10 neonatology reviewers, who made few suggestions for change. However, HERC staff feel that many of these lines should be merged together due to very similar diagnoses, having only one or a few diagnoses, or having diagnoses that are equally important to treat compared to another line. The following 26 lines contain newborn conditions. Lines for conditions which require specific surgical interventions, such as congenital heart disease or cleft palate, are not included in this list and are not recommended by staff for merging at this time. 2 BIRTH OF INFANT—contains ICD-10 codes for newborns affected by various maternal conditions/infections/exposures, multiple gestation, possible birth defects, observation for suspected conditions in newborns, infants with serious infections such as sepsis, as well as normal newborns with no suspected conditions 11 RESPIRATORY CONDITIONS OF FETUS AND NEWBORN—contains ECMO codes 15 CONGENITAL INFECTIOUS DISEASES—contains diagnoses that might be used for an extended period 16 CONGENITAL SYPHILIS— contains diagnoses that might be used for an extended period 17 VERY LOW BIRTH WEIGHT (UNDER 1500 GRAMS)—contains ICD-10 codes for premature infants, as well as a subset of brain injury and bleeding codes (intraventricular hemorrhage and hypoxic ischemic encephalopathy). 18 NEONATAL MYASTHENIA GRAVIS 19 FEEDING PROBLEMS IN NEWBORNS 21 SYNDROME OF "INFANT OF A DIABETIC MOTHER" AND NEONATAL HYPOGLYCEMIA 22 OMPHALITIS OF THE NEWBORN AND NEONATAL INFECTIVE MASTITIS 23 LOW BIRTH WEIGHT (1500-2500 GRAMS)—contains ICD-10 codes for premature infants, mostly overlapping with line 17 27 INTRACRANIAL HEMORRHAGES; CEREBRAL CONVULSIONS, DEPRESSION, COMA, AND OTHER ABNORMAL CERERAL SIGNS OF THE NEWBORN 31 DRUG WITHDRAWAL SYNDROME IN NEWBORN 34 SEVERE BIRTH TRAUMA FOR BABY—contains mostly intracranial hemorrhage diagnoses, which are missing from line 27 35 NEONATAL THYROTOXICOSIS 36 HEMATOLOGICAL DISORDERS OF FETUS AND NEWBORN 43 DISORDERS RELATING TO LONG GESTATION AND HIGH BIRTHWEIGHT—contain ICD-10 codes for large for gestational age and post-term infants
Page 1 and 2: Health Evidence Review Commission's
Page 3 and 4: AGENDA VALUE-BASED BENEFITS SUBCOMM
Page 5 and 6: Value-based Benefits Subcommittee R
Page 7 and 8: VALUE-BASED BENEFITS SUBCOMMITTEE C
Page 9 and 10: ‣ Topic: Barrett’s esophagus Di
Page 11 and 12: 7) Remove M42.1 (Adult osteochondro
Page 13 and 14: Recommended Actions: 1) Add CPT 225
Page 15 and 16: 6) Modify DIAGNOSTIC GUIDELINE D4,
Page 17 and 18: tumor, benign brain and malignant b
Page 19 and 20: Appendix A Revised Guideline Notes
Page 21 and 22: Appendix A Revised Guideline Notes
Page 23 and 24: Appendix B New Guideline Notes GUID
Page 25 and 26: Section 2.0 Staff Report
Page 27 and 28: 12) Removed G0458 (Low dose rate (l
Page 29 and 30: Straightforward Issues—March, 201
Page 31 and 32: Straightforward Issues—March, 201
Page 33: Vitamin A Deficiencies Issue: sever
Page 37 and 38: have similar prioritization (i.e. a
Page 39 and 40: 296 ADRENAL OR CUTANEOUS HEMORRHAGE
Page 41 and 42: Section 5.0 Previously Discussed It
Page 43 and 44: HERC staff recommendations: 1) Add
Page 45 and 46: 5D showed no difference in any of t
Page 47 and 48: . The usefulness of emergent angiop
Page 49 and 50: Endovascular stent insertion for in
Page 55 and 56: T h e n e w e ngl a nd j o u r na l
Page 57 and 58: Endovascular Management of Intracra
Page 59 and 60: Balloon Dilation of Intracranial Va
Page 61 and 62: Balloon Dilation of Intracranial Va
Page 63 and 64: Downloaded from http://jnis.bmj.com
Page 65 and 66: Neurocrit Care (2011) 15:336-341 DO
Page 73 and 74: Authors’ conclusions At present t
Page 75 and 76: Breast/Chest Surgery Requirements f
Page 77 and 78: add laser hair removal due to the n
Page 79 and 80: Based on your interpretation of the
Page 81 and 82: Issue 6: A patient has contacted th
Page 83 and 84: Mammoplasty (CPT 19316, 19324-19325
Page 85 and 86:
HERC staff recommendations: 1) Modi
Page 87 and 88:
Mammoplasty (CPT 19316, 19324-19325
Page 89 and 90:
Gender-affirming Vaginoplasty Danie
Page 91 and 92:
Also, being severely overweight inc
Page 93 and 94:
most of the surgery was in this are
Page 95:
Letters of Support for Gender-affir
Page 98 and 99:
or one letter with two signatures i
Page 100 and 101:
is known as a transwoman; and the i
Page 102 and 103:
• liposuction • mastopexy • n
Page 104 and 105:
58573 Laparoscopy, surgical, with t
Page 106 and 107:
21127 Augmentation, mandibular body
Page 108 and 109:
Such operating subsidiaries include
Page 110 and 111:
Gender Reassignment Surgery D. Age
Page 112 and 113:
Gender Reassignment Surgery number
Page 114 and 115:
Gender Reassignment Surgery 15775 P
Page 116 and 117:
Gender Reassignment Surgery June 30
Page 118 and 119:
Acupuncture for Tobacco Cessation Q
Page 120 and 121:
Evidence: 1) White 2014 i , Cochran
Page 122 and 123:
especially acupuncture combined wit
Page 124 and 125:
HERC staff summary Four meta-analys
Page 126 and 127:
Acupuncture and related interventio
Page 128 and 129:
Main results We included 38 studies
Page 130 and 131:
The American Journal of Chinese Med
Page 132 and 133:
CLINICAL RESEARCH STUDY Alternative
Page 134 and 135:
Current guideline note: GUIDELINE N
Page 136 and 137:
. Patient has a wound classified as
Page 138 and 139:
National Coverage Determination (NC
Page 140 and 141:
National Coverage Determination (NC
Page 142 and 143:
Section 7.0 New Discussion Items
Page 144 and 145:
From Dr. Ruscher I am a Pediatric S
Page 146 and 147:
Evidence—pectus excavatum 1) de O
Page 148 and 149:
d. Exercise capacity or other patie
Page 150 and 151:
Other policies 1) NICE 2009 a. Curr
Page 152 and 153:
spurt. (Goretsky, 2004) Requests fo
Page 154 and 155:
HERC staff recommendations: 1) Keep
Page 156 and 157:
Disposition of submitted literature
Page 158 and 159:
Data collection and analysis Two re
Page 160 and 161:
Cardiac Function Before and After S
Page 162 and 163:
European Journal of Cardio-thoracic
Page 164 and 165:
The American Journal of Surgery (20
Page 166:
Normalized cardiopulmonary exercise
Page 169 and 170:
Journal of Pediatric Surgery (2005)
Page 172 and 173:
REVIEW C URRENT OPINION Pectus cari
Page 174 and 175:
Journal of Pediatric Surgery 50 (20
Page 176 and 177:
Placement of pectus bar for pectus
Page 178 and 179:
Page 180 and 181:
Page 182 and 183:
CIGNA covers surgical repair of pec
Page 184 and 185:
optimal age for surgical repair is
Page 186 and 187:
Professional Societies/Organization
Page 188 and 189:
http://www.plasticsurgery.org/medic
Page 190 and 191:
36. Liu SL, Li L, Cheng W, Hou WY,
Page 192 and 193:
Pectus Excavatum and Poland's Syndr
Page 194 and 195:
Page 196 and 197:
Page 198 and 199:
Page 200 and 201:
Page 202 and 203:
Page 204 and 205:
growth and subsequently require sur
Page 206 and 207:
650 Bae et al controversial, but do
Page 208 and 209:
652 Bae et al capacity of adults wh
Page 210:
Telemedicine for Retinopathy of Pre
Page 214 and 215:
impact on stroke recurrence (Afzal
Page 216 and 217:
hypertrophic cardiomyopathy, and ar
Page 218 and 219:
Downloaded from http://heart.bmj.co
Page 220 and 221:
Cardiac Event Monitors file://dhs.s
Page 222 and 223:
Page 224 and 225:
Page 226 and 227:
Page 228 and 229:
Page 230 and 231:
Page 232 and 233:
Page 234 and 235:
Page 236 and 237:
Page 238 and 239:
Page 240 and 241:
Cigna Medical Coverage Policy Subje
Page 242 and 243:
• long-term continuous 48- to 21-
Page 244 and 245:
Literature Review Continuous 24- to
Page 246 and 247:
(46/56) of the patients were receiv
Page 248 and 249:
presymptom memory loop recorders (a
Page 250 and 251:
Covered when medically necessary to
Page 252 and 253:
patient selected events transmitted
Page 254 and 255:
19. Joshi AK, Kowey PR, Prystowsky
Page 256 and 257:
46. U.S. Food and Drug Administrati
Page 258 and 259:
Electric Tumor Treatment Fields for
Page 260 and 261:
10) Industry sponsored trial Major
Page 262 and 263:
d. Essential Health Benefit (EHB) d
Page 264 and 265:
h. Wisconsin - up to 35 units of PT
Page 266 and 267:
Appendix A Diagnoses which appear o
Page 268 and 269:
t. 99468-99480 NICU/PICU 2) Service
Page 270 and 271:
In any event, the proposed quantita
Page 272 and 273:
March 2, 2016 Via Email: Darren.d.c
Page 274 and 275:
Mr. Darren Coffman Director, Health
Page 276 and 277:
Section 8.0 Coverage Guidances
Page 278 and 279:
Background - Skin Ulcers • Common
Page 280 and 281:
Background - Skin Substitutes • S
Page 282 and 283:
Background - Skin Substitutes • T
Page 284 and 285:
Key Questions 1. What is comparativ
Page 286 and 287:
Evidence Sources • Medline search
Page 288 and 289:
Evidence Summary Evidence shows mod
Page 290 and 291:
Public Comment • Submitted by Sol
Page 292 and 293:
Late breaking studies • Late brea
Page 294 and 295:
Prerequisites • Based on combinat
Page 296 and 297:
RATIONALE FOR GUIDANCE DEVELOPMENT
Page 298 and 299:
Coverage question: Should Apligraf
Page 300 and 301:
Dermagraft® Coverage question: Sho
Page 302 and 303:
OASIS® Wound Matrix Coverage quest
Page 304 and 305:
Coverage question: Should EpiFix®
Page 306 and 307:
Coverage question: Should Graftjack
Page 308 and 309:
TheraSkin® Coverage question: Shou
Page 310 and 311:
tissue and replace the wound with f
Page 312 and 313:
Products derived from human donor t
Page 314 and 315:
o Multilayered compression therapy
Page 316 and 317:
Table 3. Summary of Included Random
Page 318 and 319:
The prescribing information contain
Page 320 and 321:
Important Outcome: Adverse Effects
Page 322 and 323:
Critical Outcome: Quality of Life N
Page 324 and 325:
infection, and response to usual ca
Page 326 and 327:
leeding surface wounds, abrasions,
Page 328 and 329:
group developed an infection in ano
Page 330 and 331:
illuminate the comparative effectiv
Page 332 and 333:
Other considerations Expert input a
Page 334 and 335:
leg ulcers, but do not provide reco
Page 336 and 337:
pe=All&PolicyType=Final&s=All&KeyWo
Page 338 and 339:
Coverage guidance is prepared by th
Page 340 and 341:
Low: The subcommittee’s confidenc
Page 342 and 343:
Indication No. of Studies Study Des
Page 344 and 345:
Indication Adverse Effects No. of S
Page 346 and 347:
Adverse Effects DFU 1 RCT High Unkn
Page 348 and 349:
Abbreviations: DFU - diabetic foot
Page 350 and 351:
OASIS® versus Dermagraft® Indicat
Page 352 and 353:
substitute,” or “bioengineered
Page 354 and 355:
APPENDIX D. APPLICABLE CODES CODES
Page 356 and 357:
Q4146 Q4147 Q4148 Q4149 Q4150 Q4151
Page 358 and 359:
APPENDIX E: FREQUENCY OF APPLICATIO
Page 360 and 361:
CG-Skin substitutes for diabetic fo
Page 362 and 363:
Page 364 and 365:
Page 366 and 367:
Public Comments HERC Coverage Guida
Page 368 and 369:
HERC Coverage Guidance - Skin Subst
Page 370 and 371:
Page 372 and 373:
Page 374 and 375:
Bariatric Surgery Draft Coverage Gu
Page 376 and 377:
Background - Obesity • Obesity is
Page 378 and 379:
Background - Treatments • Structu
Page 380 and 381:
Background - Surgery Vertical sleev
Page 382 and 383:
Background - Surgery • Biliopancr
Page 384 and 385:
Background - Surgery 2011 2012 2013
Page 386 and 387:
Key Questions 1. Should coverage be
Page 388 and 389:
Evidence Strengths and Limitations
Page 390 and 391:
Evidence Review - Adults • WA HTA
Page 392 and 393:
Evidence Review - Adults • Chang
Page 394 and 395:
Evidence Review - Adults • Kwok (
Page 396 and 397:
Evidence Summary - Adults • Baria
Page 398 and 399:
Evidence Summary - Adults • Harms
Page 400 and 401:
Evidence Summary - Reoperation •
Page 402 and 403:
Evidence Review - Children • Gene
Page 404 and 405:
Evidence Review - Children • Blac
Page 406 and 407:
Evidence Summary - Children • Bar
Page 408 and 409:
HEALTH EVIDENCE REVIEW COMMISSION (
Page 410 and 411:
GRADE‐INFORMED FRAMEWORK The HERC
Page 412 and 413:
Coverage question: Should bariatric
Page 414 and 415:
Coverage question: Should bariatric
Page 416 and 417:
EVIDENCE OVERVIEW Clinical backgrou
Page 418 and 419:
These procedures can be performed l
Page 420 and 421:
Critical outcomes selected for incl
Page 422 and 423:
Systematic Review (Quality) Total N
Page 424 and 425:
Kwok (2014) Kwok et al. (2014) is a
Page 426 and 427:
ias were included. The average base
Page 428 and 429:
Thirteen of the included studies (a
Page 430 and 431:
Mahawar, Graham, Carr, Jennings, Sc
Page 432 and 433:
primary). Quantitative cumulative o
Page 434 and 435:
Thomas (2012) Thomas & Agarwal (201
Page 436 and 437:
EVIDENCE SUMMARY Despite the existe
Page 438 and 439:
Bariatric surgery for children is a
Page 440 and 441:
POLICY LANDSCAPE SOURCES Quality me
Page 442 and 443:
Non‐Covered Procedures Aetna, Cig
Page 444 and 445:
Black, J. A., White, B., Viner, R.
Page 446 and 447:
Fitch, A., Fox, C., Bauerly, K., Gr
Page 448 and 449:
APPENDIX A. METHODS Scope Statement
Page 450 and 451:
United States Preventive Services T
Page 452 and 453:
Low: The subcommittee’s confidenc
Page 454 and 455:
Quality Assessment (Confidence in E
Page 456 and 457:
APPENDIX D. MORTALITY BENEFIT OUTCO
Page 458 and 459:
Johnson (2013) Retrospective cohort
Page 460 and 461:
APPENDIX E. BARIATRIC SURGERY COVER
Page 462 and 463:
Table E2. Bariatric Surgery Coverag
Page 464 and 465:
Table E3. Pre‐Surgical Requiremen
Page 466 and 467:
(BPD/DS) for individuals with a BMI
Page 468 and 469:
Table E5. Repeat Surgery Coverage P
Page 470 and 471:
Distal gastric bypass (long limb ga
Page 472 and 473:
45.51 Isolation of segment of small
Page 474 and 475:
APPENDIX G. OUTCOMES BY BASELINE ME
Page 476 and 477:
APPENDIX H. COST‐EFFECTIVENESS ES
Page 478 and 479:
GUIDELINE NOTE 8, BARIATRIC SURGERY
Page 480 and 481:
Bariatric/Metabolic Surgery for Obe
Page 482 and 483:
Bariatric/Metabolic Surgery for Obe
Page 484 and 485:
Bariatric/metabolic surgery for obe
Page 486 and 487:
Page 488 and 489:
show all

Health Evidence Review Commission's Value-based Benefits Subcommittee

Create successful ePaper yourself

Delete template?

Save as template?