Errata to the 7/1/2016 Prioritized List 1) On 6/29/2017, the following corrections were made: a. Website addresses were corrected for the new Oregon Health Authority Web site in all guideline notes referencing a Coverage Guidance. In addition, a web address in the Multisector Interventions section on Tobacco Use was updated. b. M67.0 (Short Achilles tendon (acquired)) was moved to line 297 NEUROLOGICAL DYSFUNCTION IN POSTURE AND MOVEMENT CAUSED BY CHRONIC CONDITIONS from line 382 DYSFUNCTION RESULTING IN LOSS OF ABILITY TO MAXIMIZE LEVEL OF INDEPENDENCE IN SELF- DIRECTED CARE CAUSED BY CHRONIC CONDITIONS THAT CAUSE NEUROLOGICAL DYSFUNCTION c. Psoriasis corrections: i. Add psoriasis, parapsoriasis and similar ICD-10 codes to line 544 MILD PSORIASIS; DERMATOPHYTOSIS: SCALP, HAND, BODY, DEEP-SEATED 1. L40.0 Psoriasis vulgaris 2. L40.1 Generalized pustular psoriasis 3. L40.2 Acrodermatitis continua 4. L40.3 Pustulosis palmaris et plantaris 5. L40.4 Guttate psoriasis 6. L40.8 Other psoriasis 7. L40.9 Psoriasis, unspecified 8. L41.0 Pityriasis lichenoides et varioliformis acuta ii. Add psoriatic arthropathy ICD-10 codes to line 50 RHEUMATOID ARTHRITIS AND OTHER INFLAMMATORY POLYARTHROPATHIES) and remove from line SEVERE INFLAMMATORY SKIN DISEASE 1. L40.51 Distal interphalangeal psoriatic arthropathy 2. L40.52 Psoriatic arthritis mutilans 3. L40.53 Psoriatic spondylitis 4. L40.54 Psoriatic juvenile arthropathy 5. L40.59 Other psoriatic arthropathy d. Add line 544 to Guideline Note 21 SEVERE INFLAMMATORY SKIN DISEASE, and append “See Guideline Note 57 for the definition of mild psoriasis included on line 544.” e. Add line 430 to Guideline Note 57 MILD PSORIASIS and append “See Guideline Note 21 for the definition of moderate/severe psoriasis included on line 430.” f. Remove dermatophytosis other than that specified in title of line 493 DERMATOPHYTOSIS OF NAIL, GROIN, AND FOOT AND OTHER DERMATOMYCOSIS, which already appear on line 544 MILD PSORIASIS; DERMATOPHYTOSIS: SCALP, HAND, BODY, DEEP-SEATED i. B35.0 Tinea barbae and tinea capitis ii. B35.2 Tinea manuum iii. B35.4 Tinea corporis iv. B35.5 Tinea imbricate g. Remove B35.8 (Other dermatophytosis, including disseminated), unspecified) from line 544 MILD PSORIASIS; DERMATOPHYTOSIS: SCALP, HAND, BODY, DEEP-SEATED, which already appears on line 493 DERMATOPHYTOSIS OF NAIL, GROIN, AND FOOT AND OTHER DERMATOMYCOSIS Updated 8/18/2016 h. Remove B35.9 (Dermatophytosis, unspecified) from line 493 DERMATOPHYTOSIS OF NAIL, GROIN, AND FOOT AND OTHER DERMATOMYCOSIS and add to line 544 MILD PSORIASIS; DERMATOPHYTOSIS: SCALP, HAND, BODY, DEEP-SEATED i. Change title of line 544 to MILD PSORIASIS; DERMATOPHYTOSIS: SCALP, HAND, BODY, DEEP-SEATED 2) On April 26, 2017, the following corrections were made: a) ICD-10-CM codes were removed from line 382 DYSFUNCTION RESULTING IN LOSS OF ABILITY TO MAXIMIZE LEVEL OF INDEPENDENCE IN SELF- DIRECTED CARE CAUSED BY CHRONIC CONDITIONS THAT CAUSE NEUROLOGICAL DYSFUNCTION and added to line 297 NEUROLOGICAL DYSFUNCTION IN POSTURE AND MOVEMENT CAUSED BY CHRONIC CONDITIONS a) M24.52 Contracture, elbow b) M24.53 Contracture, wrist c) M24.55 Contracture, hip d) M24.56 Contracture, knee e) M24.571-M24.576 Contracture, ankle and foot b) Guideline Note 49, Wearable Cardiac Defibrillators was edited as shown below: Wearable cardiac defibrillators (WCDs; CPT 93745, HCPCS E0617, K0606-K0609) are included on these lines for patients at high risk for sudden cardiac death who meet the medical necessity criteria for an implantable cardioverter defibrillator (ICD) as defined by the CMS 2005 National Coverage Determination but are unable to have an ICD implanted due to medical condition (e.g. ICD explanted due to infection with waiting period before ICD reinsertion or current medical condition contraindicates surgery). WCDs are not included on these lines for use during the waiting period for ICD implantation after myocardial infarction, coronary bypass surgery, or coronary artery stenting. c) The following ICD-10 diagnoses codes for rectal and anal abscesses were removed from line 51 DEEP ABSCESSES, INCLUDING APPENDICITIS AND PERIORBITAL ABSCESS and added to line 210 SUPERFICIAL ABSCESSES AND CELLULITIS: f) K61.0 Anal abscess g) K61.1 Rectal abscess h) K61.2 Anorectal abscess i) K61.3 Ischiorectal abscess j) K61.4 Intrasphincteric abscess d) Guideline Note 127 Gender Dysphoria was corrected (only the excerpt below was edited) a. Mammoplasty (CPT 19316, 19324-19325, 19340, 19342, 19350, 19357-19380) is only included on this line when 12 continuous months of hormonal (estrogen) therapy has failed to result in breast tissue growth of Tanner Stage 5 on the puberty scale OR there is any contraindication to, intolerance of or patient refusal of hormonal therapy. e) Guideline note 62, Negative Pressure Wound Therapy was edited as shown below: Negative pressure wound therapy (CPT 97605-97608, HCPCS G0456, G0457) is included on these lines only for patients who: • Have wounds that are refractory to or have failed standard therapies; • Are not suitable candidates for surgical wound closure; or, Updated 6/8/2016 • Are at high risk for delayed or non-healing wounds due to factors such as compromised blood flow, diabetic complications, wounds with high risk of fecal contamination, extremely exudative wounds, and similar situations. f) Ancillary Guideline A1, Nerve Blocks was edited as shown below: The Health Evidence Review Commission intends that single injection and continuous nerve blocks (CPT 64400-64450, 64461-64463, 64505-64530) should be covered services if they are required for successful completion of perioperative pain control for, or post- operative recovery from a covered operative procedure when the diagnosis requiring the operative procedure is also covered. Additionally, nerve blocks, are covered services for patients hospitalized with trauma, cancer, or intractable pain conditions, if the underlying condition is a covered diagnosis. g) Guideline Note 42, CHEMODENERVATION FOR CHRONIC MIGRAINE was edited as shown below: Chemodenervation for treatment of chronic migraine (CPT 64615) is included on this line for prophylactic treatment of adults who meet all of the following criteria: A) have chronic migraine defined as headaches on at least 15 days per month of which at least 8 days are with migraine B) has not responded to or have contraindications to at least three prior pharmacological prophylaxis therapies (beta-blocker, calcium channel blocker, anticonvulsant or tricyclic antidepressant) C) treatment is administered in consultation with a neurologist or headache specialist. Treatment is limited to two injections given 3 months apart. Additional treatment requires documented positive response to therapy. Positive response to therapy is defined as a reduction of at least 6 7 headache days per month compared to baseline headache frequency. 3) On November 7, 2016, the following corrections were made: a. The following codes were added to line 88 DIABETES MELLITUS WITH END STAGE RENAL DISEASE Treatment SIMULTANEOUS PANCREAS/KIDNEY (SPK) TRANSPLANT, PANCREAS AFTER KIDNEY (PAK) TRANSPLANT i. E10.21 Type 1 diabetes mellitus with diabetic nephropathy ii. E10.22 Type 1 diabetes mellitus with diabetic chronic kidney disease iii. E10.29 Type 1 diabetes mellitus with other diabetic kidney complication b. Condition descriptions for lines 325 and 589 were corrected i. Line 325 OBESITY (ADULT BMI ≥ 30, CHILDHOOD BMI ≥ 95th PERCENTILE) AND OVERWEIGHT IN ADULTS (BMI >25) WITH CARDIOVASCULAR RISK FACTORS ii. Line 589 OBESITY (ADULT BMI ≥ 30, CHILDHOOD BMI ≥ 95th PERCENTILE) AND OVERWEIGHT IN ADULTS (BMI >25) WITH CARDIOVASCULAR RISK FACTORS 1. On August 18, 2016 the following corrections were posted a. Remove M43.6 Torticollis from line 407 CONDITIONS OF THE BACK AND SPINE b. Move ICD-10-CM E51.2 Wernicke's encephalopathy from line 205 to line 206 CHRONIC ORGANIC MENTAL DISORDERS INCLUDING DEMENTIAS. Updated 6/8/2016 c. Add ICD-10-CM Q06.8 Other specified congenital malformations of spinal cord to line 351 CONDITIONS OF THE BACK AND SPINE WITH URGENT SURGICAL INDICATIONS. d. Remove CPT 63200 Laminectomy, with release of tethered spinal cord, lumbar from line 366 SCOLIOSIS. 2. On July 12, 2016 the following corrections were posted a. Add ICD-10-CM codes S32.002A, S32.012A, S32.022A, S32.032A, S32.042A and S32.052A (Unstable burst fractures of the vertebrae) to line 154 CERVICAL VERTEBRAL DISLOCATIONS/FRACTURES, OPEN OR CLOSED; O THER VERTEBRAL DISLOCATIONS/FRACTURES, OPEN OR UNSTABLE; SPINAL CORD INJURIES WITH OR WITHOUT EVIDENCE OF VERTEBRAL INJURY b. Remove S32.002A, S32.002D,S32.002G,S32.012A,S32.012D,S32.012G,S32.022A, S32.022D,S32.022G,S32.032A,S32.032D,S32.032G,S32.042A, S32.042D,S32.042G,S32.052A, S32.052D and S32.052G (Unstable burst fractures of the vertebrae) from line 482 CLOSED DISLOCATIONS/FRACTURES OF NON-CERVICAL VERTEBRAL COLUMN WITHOUT NEUROLOGIC INJURY OR STRUCTURAL INSTABILITY c. Modify GN136 removing reference to unstable burst fracture. d. Modify GN 97, removing ICD-10-CM codes S43.60 and S43.62 (Sprains of sternoclavicular joint). e. Move ICD-10-CM codes M76.20-M76.22 (iliac crest spur) from line 381 DISRUPTIONS OF THE LIGAMENTS AND TENDONS OF THE ARMS AND LEGS, EXCLUDING THE KNEE, RESULTING IN SIGNIFICANT INJURY/IMPAIRMENT and add to line 361 RHEUMATOID ARTHRITIS, OSTEOARTHRITIS, OSTEOCHONDRITIS DISSECANS, AND ASEPTIC NECROSIS OF BONE f. Add a reference to M76.2 (iliac crest spur) to GN 114. Updated 6/8/2016 .