Treatment &Diagnosis:
Ablative FractionalLaser (AFL) treatment including Carbon Dioxide Laser and Erbium:Yttrium-Aluminum Garnet Laser for symptomatic scars resulting fromburns and other trauma
Effective Date:
February 24,2021.
Termination Date:
February 23,2026.
Preauthorization:
Not required.
Coverage Guidelines:
AFL (CPT 0479Tand 0480T) for the treatment of symptomatic burns and scars is coveredfor one or more of the following symptoms: itch, burn, pain, tightness,ulcerations or physical functional impairment.
Examples of physicalfunctional impairment include, but are not limited to: decreasedrange of motion with use of associated body part; problems withcommunication, respiration, eating, swallowing; visual impairments;skin integrity; distortion of nearby body parts; or obstructionof an orifice.
EXCLUSIONS:
•AFLtreatments for social, emotional and psychological impairment orpotential impairments are excluded.
•AFLtreatments performed solely for cosmetic purpose is excluded unlessotherwise covered under Chapter 4, Section 2.1.
TED Special ProcessingCode: AT
Reimbursem*nt:
The contractorshall reimburse CPT codes 0479T/0480T for professional servicesat rates equivalent to the CPT codes 17280/17286. The contractorshall update the reimbursem*nt rates for CPT codes 0479T/0480T eachtime TRICARE updates the CHAMPUS Maximum Allowable Charge (CMAC)rates for CPT codes 17280/17286.
Treatment & Diagnosis:
Digital Breast Tomosynthesis(DBT) for Breast Cancer Screening
Effective Date:
January 1, 2020.
Termination Date:
December 31, 2024.
Preauthorization:
Not required.
Coverage Guidelines:
Digital Breast Tomosynthesis(DBT), also known as three-dimensional mammography, for breast cancerscreening (Current Procedural Terminology (CPT) procedure codes77063 and 77067) may be covered annually instead of the conventionaltwo-dimensional screening mammography.
For all women beginning atage 40. Covered annually beginning at age 30 for women who havea 15% or greater lifetime risk of breast cancer (according to riskassessment tools based on family history such as the Gail model,the Claus model, and the Tyrer-Cuzick model), or who have any ofthe following risk factors:
•History of breast cancer, DuctalCarcinoma In Situ (DCIS), Lobular Carcinoma In Situ (LCIS), Atypical DuctalHyperplasia (ADH), or Atypical Lobular Hyperplasia (ALH);
•Extremely dense breasts whenviewed by mammogram;
•Known BRCA1 or BRCA2 gene mutation;
•First-degree relative (parent,child, sibling) with a BRCA1 or BRCA2 gene mutation, and have not hadgenetic testing themselves;
•Radiation therapy to the chestbetween the ages of 10 and 30 years; or
•History of Li-Fraumeni, Cowden,or Bannayan-Riley-Ruvalcaba syndrome, or a first-degree relative witha history of one of these syndromes.
The contractor shall coverDBT under the provisional coverage policy as a primary preventivebreast cancer screening otherwise covered under 32 CFR 199.4(e)(28). Thus, the contractorshall not charge copayments or cost-shares associated with thisservice. The contractor shall not charge TRICARE Select enrolleesa cost-share when the enrollee receives this service from networkor non-network providers. The contractor shall not require TRICAREPrime enrollees to have a referral or authorization when the enrolleereceives this service from any network provider within their regionof enrollment. If a TRICARE Prime clinical preventive service isnot available from a network provider (e.g., a network provideris not available within prescribed access parameters), the contractorshall allow an enrollee to receive the service from a non-networkprovider with a referral from the Primary Care Manager (PCM). Ifa TRICARE Prime enrollee uses a non-network provider without firstobtaining a referral from the PCM, the contractor shall apply thePoint of Service (POS) option for payment.
TED Special Processing Code:DB
Treatment & Diagnosis:
Platelet Rich Plasma Injectionsfor the treatment of Musculoskeletal Conditions
Effective Date:
October 1, 2019.
Termination Date:
September 30, 2024.
Preauthorization:
Not required.
Coverage Guidelines:
Platelet Rich Plasma (PRP)injections (CPT 0232T) is covered when the following criteria aremet:
•Patient is diagnosed with mildto moderate chronic osteoarthritis of the knee; AND
•Conservativetreatment such as physical therapy, diet and exercise, has beenunsuccessful after three months or is contraindicated; AND
•Radiographicevidence of osteoarthritis.
OR
•Patient is diagnosed with lateralepicondylitis; AND
•Evidenceof diagnosis on physical exam.
•Radiographicexam not required.
•Conservativetreatment such as physical and occupational therapy has been unsuccessfulafter three months or is contraindicated.
TED Special Processing Code:MC
Note:PRP shall be prepared and storedin accordance with U.S. Food and Drug Administration (FDA) regulationtitled “Additional Standards for Human Blood and Blood Products”found in 21 CFR, Section 640.34(D) Processing.
Treatment & Diagnosis:
Open, Arthroscopic and CombinedHip; Surgical for the treatment of Femoroacetabular Impingement (FAI)
Effective Date:
January 1, 2016.
Termination Date:
December 31, 2018.
Preauthorization:
Required.
Coverage Guidelines:
Open, arthroscopic and combinedhip surgery is covered when the following criteria are met:
•Moderateto severe and persistent activity limiting hip pain that is worsenedby flexion activities.
•Physicalexamination consistent with the diagnosis of FAI with at least onepositive test required:
•Positive impingement sign (painwhen bringing the knee up towards the chest and then rotating itinward towards the opposite shoulder); or
•Flexion Abduction ExternalRotation (FABER) provocation test (the test is positive if it elicits similarpain as complained by the patient or the range of motion of thehip is significantly decreased compared to the contra lateral hip);or
•Posterior inferior impingementtest (the test is positive if it elicits similar pain as complainedby the patient).
•Failureto improve with greater than three months of conservative treatment(e.g., physical therapy, activity modification, non-steroidal anti-inflammatorymedications, intra-articular injection, etc.). Requests shall includewhat conservative treatments were used and how long; and
•Radiographicevidence of FAI:
•CAM:
1. Pistol-grip deformity (characterizedon radiographs by flattening of the usually concave surface of thelateral aspect of the femoral head due to an abnormal extensionof the more horizontally oriented femoral epiphysis); or
2. Alpha angle greater than50 degrees (measurement of an abnormal alpha angle from an obliqueaxial image along the femoral neck); or
•Pincer:
1. Coxa profunda (floor ofthe fossa acetabuli touching or overlapping the ilioischial line medially);or
2. Acetabular retroversion(the alignment of the mouth of the acetabulum does not face the normalanterolateral direction, but inclines more posterolaterally); or
3. Os acetabuli (an ossiclelocated at the acetabular rim); or
4. Protrusio acetabuli (ananteroposterior radiograph of the pelvis that demonstrates a center-edgeangle greater than 40 degrees and medicalization of the medial wallof the acetabulum past the ilioischial line); and
Absence of advanced arthritis(i.e., Tönnis Grade 2 [small cysts, moderate joint space narrowing, moderateloss of head sphericity] or Tönnis Grade 3 [large cysts, severejoint space narrowing, severe deformity of the head]).
Inclusion criteria must bedocumented.
