Clinical Policy Bulletins (CPBs) Should the following terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button below labeled “I Accept”. Aetna Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits and do not constitute medical advice. Treating providers are solely responsible for medical advice and treatment of members. Members should discuss any Clinical Policy Bulletin (CPB) related to their coverage or condition with their treating provider. While the Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits.
The Clinical Policy Bulletins (CPBs) express Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. CPT only copyright 2006 American Medical Association. U.S. Disclaimer of Warranties and Liabilities. Post-Herpetic Neuralgia. Background Herpes zoster (HZ) is the consequence of re-activation of the varicella zoster virus that remains latent since primary infection (varicella). The overall incidence of HZ is about 3 per 1000 of the population per year increasing to 10 per 1000 per year by age 80.
Approximately half of persons reaching age 90 years will have had HZ. In approximately 6 %, a second episode of HZ may occur; usually several decades after the first attack. The observation that patients with PHN experience different types of pain (e.g., continuous burning or intense paroxysmal; most often with tactile allodynia) suggests that multiple pathophysiological mechanisms are involved, which may include the peripheral as well as the central nervous systems. Iontophoresis has been suggested to be effective in treating PHN (Ozawa et al, 1999).
In a Cochrane review, Khaliq et al (2007) examined the safety and effectiveness of topical lidocaine in the treatment of PHN. Foot Orthotics. Background The terms used to describe orthotics were very confusing; often, clinicians used different terms to describe even the most basic device. Devices or parts of orthoses were given names that might describe their purpose, the body part to which they were applied, the inventor of the device, or where they were developed. To minimize confusion, a system of standard terminology has been developed. The system uses the first letter of each joint that the orthosis crosses in correct sequence, with the letter "O" for orthosis at the end. Thus, the more common orthoses would be named AFO (ankle-foot orthosis), KAFO (knee-ankle-foot orthosis), and KO (knee orthosis). Foot orthotics may be accommodative or functional. Custom-made orthopedic shoes are shoes fabricated over special modified lasts in accordance with prescriptions and specifications to accommodate gross or greater foot deformities or shortening of a leg at least 1 and 1/2 inches or greater.
External heel modifications: Nerve Conduction Velocity Studies. Background Nerve conduction velocity (NCV) studies are usually carried out to (i) evaluate the integrity of, and (ii) diagnose diseases of, the peripheral nervous system. These studies specifically measure the conduction velocity, latency, amplitude, as well as shape of the response following electrical stimulation of a peripheral nerve through the skin and underlying tissue. Abnormal findings include conduction slowing, conduction blockage, lack of responses, and/or low amplitude responses.
Results of NCV studies can reveal the degree of demyelination and axonal loss in the segment of the nerve examined. Demyelination results in prolongation of conduction time, while axonal loss generally leads to loss of nerve or muscle potential amplitude. Nerve conduction velocity studies are performed by recording and studying the electrical responses from peripheral nerves or the muscle they innervate, following electrical stimulation of the nerve. Appendix Documentation Requirements. Outpatient Medical Self-Care Programs. Policy Aetna considers the following outpatient medical self-care programs medically necessary (subject to applicable plan coverage definitions and limitations; please check benefit plan descriptions for details): Pulmonary rehabilitation for members with chronic pulmonary diseases who meet criteria in CPB 0032 - Pulmonary Rehabilitation. Note on Recognized Programs: Consideration of coverage will be extended to other medically necessary self-care programs (subject to plan coverage definitions and limitations; please check benefit plan descriptions) when: Frequency and Duration: The medically necessary frequency and duration of self-care programs varies depending on the goals and objectives of the program.
Aetna considers participation in a self-care program for a particular illness medically necessary once per lifetime unless an additional episode of illness requires another self-care program (e.g., second heart attack). Note on Non-Covered Programs: Dry Hydrotherapy (Hydromassage, Aquamassage, Water Massage) Background Dry hydrotherapy (also known as hydromassage, aquamassage, water massage) is a self-contained massage device consisting of a table or chair. The individual sits or lies back completely clothed on top of a water-proof barrier that contains interior jets, which rotate and pulsate while releasing streams of pressurized heated water along the body.
The pressure of the water against the body provides the massage. It is intended to relieve pain, increase blood circulation, range of motion (ROM), and decrease the need for other therapies by combining the effects of hydrotherapy, massage therapy, acupressure, thermotherapy, soft tissue manipulation, and trigger point therapy. Aquasoothe/AquaMED (JTL Enterprises, Clearwater, FL) and Massage Time Pro (Sidmar Manufacturing, Inc., Princeton, MN) are dry hydrotherapy systems classified by the Food and Drug Administration (FDA) as class I therapeutic massage devices.
Physical Therapy Services. Background Physical therapy treatment consists of a prescribed program to relieve symptoms, improve function and prevent further disability for individuals disabled by chronic or acute disease or injury. Treatment may include various forms of heat and cold, electrical stimulation, therapeutic exercises, ambulation training and training in functional activities.
Medically necessary physical therapy services must be restorative or for the purpose of designing and teaching a maintenance program for the patient to carry out at home. The services must also relate to a written treatment plan and be of a level of complexity that requires the judgment, knowledge and skills of a physical therapist (or a medical doctor/doctor of osteopathy) to perform and/or supervise the services.
Below is a description and medical necessity criteria for different treatment modalities and therapeutic procedures. Only 1 heat modality would be considered medically necessary during the same treatment session. Selective Nerve Root Blocks. Background Spinal nerve roots, arising from both sides of the spinal cord at each vertebral level, may be compressed or injured as a consequence of herniated discs, stenosis, facet cysts, whiplash, or hyper-extension injuries resulting in pain and inflammation. In the management of patients with low back pain (LBP) and radiculopathy, selective nerve root block (SNRB), also known as selective transforaminal epidural injection, is a procedure used for both diagnostic (to ascertain whether a specific spinal nerve root is the source of pain) and therapeutic (to reduce inflammation around the spinal nerve root, thus reducing or relieving the pain) purposes.
Selective nerve root blocks are usually performed under fluoroscopic guidance; a needle is inserted into the epidural space in the foramen at the suspected spinal level, and medications such as steroids and local anesthetics are then injected into the area bathing the nerve root. Diagnostic SNRB: Therapeutic SNRB: