Harvard Pilgrim has developed two new medical policies —Surgical Treatment of Idiopathic Scoliosis and Stem Cell Transplantation — to provide guidance on when Harvard Pilgrim considers these treatments medically necessary. Harvard Pilgrim does not require prior authorization for either of these therapies.
Surgical Treatment of Idiopathic Scoliosis
A number of different surgeries are used to treat idiopathic scoliosis (a curvature of the spine greater than 10 degrees whose cause is unknown) when patients exhibit progressive deformity or when bracing or other treatments have failed or are contraindicated. As the Surgical Treatment of Idiopathic Scoliosis Medical Policy details, Harvard Pilgrim considers surgical treatment necessary under the following conditions.
For adults, when all of the following apply to the patient:
- Has a coronal standing Cobb angle of greater than or equal to 45 degrees
- Tried NSAIDS or acetaminophen for at least 3 weeks, unless medically contraindicated
- Engaged in home exercise or physical therapy for 12 weeks or more
- Modified activity for 12 weeks or more
- Continued symptoms or findings after treatment
For infants, children, and adolescents, when all of the following apply:
- The patient has a coronal standing Cobb angle of greater than or equal to 45 degrees.
- Follow up X-rays show a curve progression in a skeletally immature patient.
For patients of all ages, Harvard Pilgrim considers vertebral body stapling experimental and unproven for the treatment of scoliosis because its long-term effectiveness has not been established. For complete information, please refer to the Surgical Treatment of Idiopathic Scoliosis Medical Policy posted on Harvard Pilgrim’s provider website.
Stem Cell Transplantation
Hematopoietic stem cell transplantation is now commonly used to treat patients with hematologic malignancies (tumors that affect the blood, bone marrow, lymph, and lymphatic system), as well as clinical and acquired bone marrow failure, including radiation injury.
Harvard Pilgrim covers non-experimental stem cell transplantation and related procedures that are reasonable and medically necessary for individuals with specific conditions. Covered conditions include:
- Autologous stem cell transplantation: Hodgkin lymphoma, multiple myeloma, non-Hodgkin lymphoma, primary (al) amyloidosis , testicular germ cell tumor, acute promyelocytic leukemia (in second remission) (aml m3), and pediatric cancers.
- Allogeneic stem cell transplantation: acute lymphocytic leukemia (ALL), acute myeloid leukemia (AML), aplastic anemia, chronic lymphocytic leukemia (CLL), chronic myelogenous leukemia (CML), Hodgkin lymphoma, myelodysplastic syndrome , non-Hodgkin lymphoma. Also covered are advanced myeloproliferative neoplasms/disorders (MPD/MPN) including primary myelofibrosis, secondary myelofibrosis (spent phase of P. Vera, ET), and chronic myelomonocytic leukemia (CMML).
For complete information, please see the Stem Cell Transplantation Medical Policy posted on Harvard Pilgrim’s provider website.