Technology assessment committee

The Technology Assessment Committee meets regularly to review medical technology. The following details recent committee decisions. These policies apply to all places of service, all providers, and all lines of business, unless otherwise noted.

Subject	Stretta Procedure for Management of Gastroesophageal Reflux Disease
Reason for Review	Provider request to review procedure coverage
Summary	Non-covered; Experimental/Investigational

Subject	Intensity Modulated Radiation Therapy (IMRT)
Reason for Review	New technology review
Summary	IMRT is covered when reasonable and necessary, when a more intense treatment of a tumor is required but radiation to adjacent healthy tissue needs to be limited.

Subject	Human Papillomavirus (HPV) Testing
Reason for Review	Review test coverage
Summary	Indications HPV DNA testing is considered medically necessary for assessment of women with atypical squamous cells of undetermined significance (ASCUS). The use of a combination Pap smear and HPV DNA screening is considered medically necessary for screening women aged 30 years and older. If this combination is used, it is not considered medically necessary to re-screen women who receive negative results on both tests more frequently than every 3 years. If both tests are negative, then re-screening of HPV with Pap should only be in 3 years. This does not affect the members’ coverage for annual Pap smears. If HPV positive only, then re-screen in 1 year for Pap only.
Limitations	HPV testing is not indicated in women under 30 years of age or in women with a definitive interpretation of cervical cancer. Testing should be stopped in women over 70 years old. Testing is not of value post hysterectomy for a benign condition. Cervicography or speculoscopy are considered experimental and investigational for the screening or diagnosis of cervical cancer. Similarly video colpography is considered experimental at this time.

Pharmacy Issues
Subject	Vivatrol
Reason for Review	Align pharmacy and medical policy coverage.
Summary	Effective 6/1/07 Non-covered (medical benefit). Deny claims for JCODE J2315.

Subject	Orencia
Reason for Review	Align pharmacy and medical policy prior authorization criteria.
Summary	Effective 6/1/07 (medical benefit).Require J0129 to deny without prior authorization.

Subject	Rituxan
Reason for Review	Align pharmacy benefit and medical benefit prior authorization criteria.
Summary	Effective 6/1/07 (medical benefit). Require J9310 to deny without prior authorization. Note: Oncologists/Hematologists Exempt - No prior authorization required.

Subject	Tysabri
Reason for Review	Align pharmacy benefit and medical benefit prior authorization criteria.
Summary	Effective 6/1/07 (medical benefit). Require Q4079 to deny without prior authorization. Commercial and Medicare only.