Health Evidence Review Commission's Value-based Benefits Subcommittee

Recommendations

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VIII. Coverage guidances – Cat Livingston 11:30 AM A. Skin substitutes for chronic skin ulcers (EGBS) B. Metabolic and bariatric surgery (HTAS) IX. Public comment 12:55 PM X. Adjournment – Susan Williams 1:00 PM Health Evidence Review Commission (503) 373-1985
Value-based Benefits Subcommittee Recommendations Summary For Presentation to: Health Evidence Review Commission on January 14, 2016 For specific coding recommendations and guideline wording, please see the text of the 1-14-2016 VbBS minutes. RECOMMENDED CODE MOVEMENT (effective with the next set of interim modifications, no later than 10/1/16, unless otherwise indicated) Move the diagnosis code for Barrett’s esophagus without dysplasia from an uncovered line to a covered line with a guideline change allowing long term proton pump inhibitor therapy Move the diagnosis codes for Barrett’s esophagus with dysplasia from an uncovered line to the covered esophageal cancer line, a line title was changed to reflect this inclusion Move the eosinophilic esophagitis diagnosis code from one covered line to another Move several conditions of the mouth with no treatment from a covered line to an uncovered line Add procedure codes for acupuncture and chiropractic/osteopathic manipulation to the scoliosis line (implemented along with delayed changes related to conditions of the back and spine) Move the procedure code for placement of artificial discs from the scoliosis line to the covered back surgery line Delete the procedure codes for epidural steroid injections from the back conditions line and add to the Services Recommended For Non-Coverage Table Delete the procedure codes for maintenance of intrathecal pumps from the back condition lines Add procedure codes for proton beam therapy to nine lines for pediatric malignancies and remove from one benign tumor line Various straightforward coding changes ITEMS CONSIDERED BUT NO RECOMMENDATIONS FOR CHANGES MADE A guideline on smoking cessation prior to elective surgical procedures was discussed in detail and staff was directed to complete more research and bring the topic back in March RECOMMENDED GUIDELINE CHANGES (effective with the next set of interim modifications, no later than 10/1/16, unless otherwise indicated) Edit the wording of the guideline regarding disease of the lips to clarify the included ICD- 10 codes Edit the surgical back guideline to remove the requirement for 6 months of conservative therapy prior to a patient being eligible for surgery on the uncovered back surgery line; add epidural steroid injections to the list of uncovered procedures (implemented along with delayed changes related to conditions of the back and spine) Edit the guideline for advanced imaging for low back conditions to specify that repeat imaging is only covered for significant changes in a patient’s condition, and to return to Value-based Benefits Subcommittee Summary Recommendations, 1/14/2016
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Page 3: AGENDA VALUE-BASED BENEFITS SUBCOMM
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Page 13 and 14: Recommended Actions: 1) Add CPT 225
Page 15 and 16: 6) Modify DIAGNOSTIC GUIDELINE D4,
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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
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Page 29 and 30: Straightforward Issues—March, 201
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Page 33 and 34: Vitamin A Deficiencies Issue: sever
Page 35 and 36: 2018 Biennial Review Merging Select
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Page 39 and 40: 296 ADRENAL OR CUTANEOUS HEMORRHAGE
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T h e n e w e ngl a nd j o u r na l
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Endovascular Management of Intracra
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Balloon Dilation of Intracranial Va
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Balloon Dilation of Intracranial Va
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Downloaded from http://jnis.bmj.com
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Neurocrit Care (2011) 15:336-341 DO
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Endovascular stent insertion for in
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Authors’ conclusions At present t
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Breast/Chest Surgery Requirements f
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add laser hair removal due to the n
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Based on your interpretation of the
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Issue 6: A patient has contacted th
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Mammoplasty (CPT 19316, 19324-19325
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HERC staff recommendations: 1) Modi
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Mammoplasty (CPT 19316, 19324-19325
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Gender-affirming Vaginoplasty Danie
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Also, being severely overweight inc
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most of the surgery was in this are
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Letters of Support for Gender-affir
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or one letter with two signatures i
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is known as a transwoman; and the i
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• liposuction • mastopexy • n
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58573 Laparoscopy, surgical, with t
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21127 Augmentation, mandibular body
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Such operating subsidiaries include
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Gender Reassignment Surgery D. Age
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Gender Reassignment Surgery number
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Gender Reassignment Surgery 15775 P
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Gender Reassignment Surgery June 30
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Acupuncture for Tobacco Cessation Q
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Evidence: 1) White 2014 i , Cochran
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especially acupuncture combined wit
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HERC staff summary Four meta-analys
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Acupuncture and related interventio
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Main results We included 38 studies
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The American Journal of Chinese Med
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CLINICAL RESEARCH STUDY Alternative
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Current guideline note: GUIDELINE N
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. Patient has a wound classified as
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National Coverage Determination (NC
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National Coverage Determination (NC
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Section 7.0 New Discussion Items
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From Dr. Ruscher I am a Pediatric S
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Evidence—pectus excavatum 1) de O
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d. Exercise capacity or other patie
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Other policies 1) NICE 2009 a. Curr
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spurt. (Goretsky, 2004) Requests fo
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HERC staff recommendations: 1) Keep
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Disposition of submitted literature
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Data collection and analysis Two re
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Cardiac Function Before and After S
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European Journal of Cardio-thoracic
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The American Journal of Surgery (20
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Normalized cardiopulmonary exercise
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Journal of Pediatric Surgery (2005)
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REVIEW C URRENT OPINION Pectus cari
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Journal of Pediatric Surgery 50 (20
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Placement of pectus bar for pectus
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CIGNA covers surgical repair of pec
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optimal age for surgical repair is
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Professional Societies/Organization
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http://www.plasticsurgery.org/medic
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36. Liu SL, Li L, Cheng W, Hou WY,
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Pectus Excavatum and Poland's Syndr
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growth and subsequently require sur
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650 Bae et al controversial, but do
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652 Bae et al capacity of adults wh
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Telemedicine for Retinopathy of Pre
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impact on stroke recurrence (Afzal
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hypertrophic cardiomyopathy, and ar
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Downloaded from http://heart.bmj.co
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Cardiac Event Monitors file://dhs.s
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Cigna Medical Coverage Policy Subje
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• long-term continuous 48- to 21-
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Literature Review Continuous 24- to
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(46/56) of the patients were receiv
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presymptom memory loop recorders (a
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Covered when medically necessary to
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patient selected events transmitted
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19. Joshi AK, Kowey PR, Prystowsky
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46. U.S. Food and Drug Administrati
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Electric Tumor Treatment Fields for
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10) Industry sponsored trial Major
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d. Essential Health Benefit (EHB) d
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h. Wisconsin - up to 35 units of PT
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Appendix A Diagnoses which appear o
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t. 99468-99480 NICU/PICU 2) Service
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In any event, the proposed quantita
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March 2, 2016 Via Email: Darren.d.c
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Mr. Darren Coffman Director, Health
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Section 8.0 Coverage Guidances
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Background - Skin Ulcers • Common
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Background - Skin Substitutes • S
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Background - Skin Substitutes • T
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Key Questions 1. What is comparativ
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Evidence Sources • Medline search
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Evidence Summary Evidence shows mod
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Public Comment • Submitted by Sol
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Late breaking studies • Late brea
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Prerequisites • Based on combinat
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RATIONALE FOR GUIDANCE DEVELOPMENT
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Coverage question: Should Apligraf
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Dermagraft® Coverage question: Sho
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OASIS® Wound Matrix Coverage quest
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Coverage question: Should EpiFix®
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Coverage question: Should Graftjack
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TheraSkin® Coverage question: Shou
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tissue and replace the wound with f
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Products derived from human donor t
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o Multilayered compression therapy
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Table 3. Summary of Included Random
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The prescribing information contain
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Important Outcome: Adverse Effects
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Critical Outcome: Quality of Life N
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infection, and response to usual ca
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leeding surface wounds, abrasions,
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group developed an infection in ano
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illuminate the comparative effectiv
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Other considerations Expert input a
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leg ulcers, but do not provide reco
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pe=All&PolicyType=Final&s=All&KeyWo
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Coverage guidance is prepared by th
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Low: The subcommittee’s confidenc
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Indication No. of Studies Study Des
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Indication Adverse Effects No. of S
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Adverse Effects DFU 1 RCT High Unkn
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Abbreviations: DFU - diabetic foot
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OASIS® versus Dermagraft® Indicat
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substitute,” or “bioengineered
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APPENDIX D. APPLICABLE CODES CODES
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Q4146 Q4147 Q4148 Q4149 Q4150 Q4151
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APPENDIX E: FREQUENCY OF APPLICATIO
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CG-Skin substitutes for diabetic fo
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Public Comments HERC Coverage Guida
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HERC Coverage Guidance - Skin Subst
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Bariatric Surgery Draft Coverage Gu
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Background - Obesity • Obesity is
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Background - Treatments • Structu
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Background - Surgery Vertical sleev
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Background - Surgery • Biliopancr
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Background - Surgery 2011 2012 2013
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Key Questions 1. Should coverage be
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Evidence Strengths and Limitations
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Evidence Review - Adults • WA HTA
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Evidence Review - Adults • Chang
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Evidence Review - Adults • Kwok (
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Evidence Summary - Adults • Baria
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Evidence Summary - Adults • Harms
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Evidence Summary - Reoperation •
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Evidence Review - Children • Gene
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Evidence Review - Children • Blac
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Evidence Summary - Children • Bar
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HEALTH EVIDENCE REVIEW COMMISSION (
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GRADE‐INFORMED FRAMEWORK The HERC
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Coverage question: Should bariatric
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Coverage question: Should bariatric
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EVIDENCE OVERVIEW Clinical backgrou
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These procedures can be performed l
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Critical outcomes selected for incl
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Systematic Review (Quality) Total N
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Kwok (2014) Kwok et al. (2014) is a
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ias were included. The average base
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Thirteen of the included studies (a
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Mahawar, Graham, Carr, Jennings, Sc
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primary). Quantitative cumulative o
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Thomas (2012) Thomas & Agarwal (201
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EVIDENCE SUMMARY Despite the existe
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Bariatric surgery for children is a
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POLICY LANDSCAPE SOURCES Quality me
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Non‐Covered Procedures Aetna, Cig
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Black, J. A., White, B., Viner, R.
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Fitch, A., Fox, C., Bauerly, K., Gr
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APPENDIX A. METHODS Scope Statement
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United States Preventive Services T
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Low: The subcommittee’s confidenc
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Quality Assessment (Confidence in E
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APPENDIX D. MORTALITY BENEFIT OUTCO
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Johnson (2013) Retrospective cohort
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APPENDIX E. BARIATRIC SURGERY COVER
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Table E2. Bariatric Surgery Coverag
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Table E3. Pre‐Surgical Requiremen
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(BPD/DS) for individuals with a BMI
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Table E5. Repeat Surgery Coverage P
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Distal gastric bypass (long limb ga
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45.51 Isolation of segment of small
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APPENDIX G. OUTCOMES BY BASELINE ME
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APPENDIX H. COST‐EFFECTIVENESS ES
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GUIDELINE NOTE 8, BARIATRIC SURGERY
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Bariatric/Metabolic Surgery for Obe
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Bariatric/Metabolic Surgery for Obe
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Bariatric/metabolic surgery for obe
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Health Evidence Review Commission's Value-based Benefits Subcommittee

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