Clinical Policy Bulletin: Obsolete and Unreliable Tests and Procedures
Aetna considers the following tests experimental and investigational because the Centers for Medicare & Medicaid Services (CMS) has determined that these diagnostic tests are obsolete or unreliable, have been replaced by more advanced procedures, or they are not recommended by professional specialty societies (e.g., the American College of Cardiology and the American Heart Association):
Prostatotomy for external drainage of prostate abscess
Quinidine for suppressing recurrences of atrial fibrillation
Radiation therapy for acne
Supplemental oxygen for healthy premature baby
This policy includes tests and procedures that have been deemed obsolete by the Centers for Medicare and Medicaid Services, McKesson Corporation ClaimCheck and other authorities. Obsolete tests and procedures are those that are outdated and are no longer standard of care.
Transrectal ultrasound-guided core needle biopsy has replaced incisional biopsy of the prostate for diagnosis of prostate cancer. In the core needle biopsy procedure, a needle is inserted into the wall of the rectum into the prostate gland and a core sample is removed for pathological analysis. Alternatively, the needle may be inserted through the perineum to the prostate gland. Typically, about a dozen cores of the prostate are taken.
Prostate abscesses may occur as a complication of prostatitis. Treatment involves appropriate antibiotics and drainage. Transurethral evacuation or transperineal aspiration have replaced a prostatotomy as the standard method of drainage of a prostatic abscess.
For many years, contrast or chain urethrocystography was used to evaluate the lower urinary tract. This procedure has been replaced by ultrasonography for imaging of the urethrovesical anatomy due to the radiation exposure from contrast or chain urethrocystography and due to the less invasive nature of ultrasonography.
Heart catheterization by left ventricular puncture has been made obsolete by catheterization through the femoral artery or through an upper extremity artery using percutaneous access methods. Right heart catheterization now is commonly performed from the femoral, internal jugular, or subclavian veins.
Cystourethroscopy has replaced cystotomy or cystostomy for cryosurgery or fulguration of bladder lesions. Although cystourethroscopy can be used to deliver radioactive substances to the bladder (intravesical brachytherapy), current evidence-based guidelines do not recommend brachytherapy as an established treatment for bladder cancer.
The standard method of sinus irrigation in sinusitis involves placement of an instrument into the sinus and flushing the sinus with sterile water. This procedure is typically performed with local anesthesia (i.e., novocaine). The Proetz procedure (saline irrigation combined with suctioning) is an older method of sinus irrigation. With the patient in the supine position and the head hyperextended, the nose and nasopharynx are partially filled with a saline solution to which a topical decongestant may be added. Suction is then applied to one nostril while the other is occluded in order to remove the irrigating solution along with the secretions. These steps may be repeated in order to achieve irrigation and drainage of the sinuses. The effectiveness of this procedure in improving clinical outcomes of sinusitis and its advantages over the current standard method of sinus irrigation are not well documented in the peer-reviewed published medical literature.
Kadish and colleagues (2001) noted that cardiointegram (CIG)/omnicardiogram is a technique intended to detect abnormalities in the standard 12-lead electrocardiogram (ECG) that are beyond the standard, routine interpretation in patients at risk of cardiac ischemia. This additional technology consists of a microcomputer that receives output from a standard ECG and transforms it to produce a graphical representation of heart electrophysiological signals. This procedure is mainly used as a substitute for exercise tolerance testing with thallium imaging in patients for whom a resting ECG may be inadequate to identify changes compatible with coronary artery disease. These findings are based on theoretical assumption that poor exercise tolerance is related to electrophysiological signals; but this test does not consider the impact of other symptoms or blood flow. The American College of Cardiology and the American Heart Association do not recommend this test.
Gu et al (2005) stated that mechanical fragility of red blood cells (RBCs) is a critical variable for the hemolysis testing of many important clinical devices, such as pumps, valves, and cannulae, and gas exchange devices. Unfortunately, no standardized test for RBC mechanical fragility is currently well accepted. Although many test devices have been proposed for the study of mechanical fragility of RBCs, no one has ever shown that their results have any relevance to a blood pump. Thus, the fundamental objective of this study was to determine if one or more test devices could be validated as calibrators to document the fragility of the test blood used for any particular test blood. These investigators compared 5 mechanical fragility test systems to each other and to a Biopump, with respect to hemolysis. All 5 devices seem to measure the same parameter; the hemo-resistometer most closely matched the pump test results, but the stainless steel bead test may be the most practical for routine calibration purposes.
The Canadian Agency for Drugs and Technologies in Health's report on "Re-assessment of health technologies: Obsolescence and waste" (Joshi et al, 2009) noted that the National Library of Medicine listed examples of health care technologies that were found “to be ineffective or harmful after being widely diffused". Some of these obsolete technolgies include the following (not an all-inclusive list):
Colectomy to treat epilepsy
Diethylstilbestrol to improve pregnancy outcomes
Gastric bubble for morbid obesity
Gastric freezing for peptic ulcer disease
Mammary artery ligation for coronary artery disease
Optic nerve decompression surgery for non-arteritic anterior ischemic optic neuropathy
Quinidine for suppressing recurrences of atrial fibrillation
Radiation therapy for acne
Supplemental oxygen for healthy premature baby.
CPT Codes / HCPCS Codes / ICD-9 Codes
CPT codes not covered for indications listed in the CPB:
Displacement therapy (Proetz type)
Cystotomy or cystostomy; with fulguration and/or insertion of radioactive material
with cryosurgical destruction of intravesical lesion
Injection procedure and placement of chain for contrast and/or chain urethrocystography
Cystourethroscopy with insertion of radioactive substance, with or without biopsy or fulguration
Biopsy, prostate; incisional, any approach
Prostatotomy, external drainage of prostatic abscess, any approach; simple
Adrenocorticotropic hormone (ACTH) [animal tests]
Glutamate dehydrogenase [serum]
Coagulation time; Lee and White [calcium saturation clotting time]
activated [calcium saturation clotting time]
other methods [calcium saturation clotting time]
Mechanical fragility, RBC
Counterimmunoelectrophoresis, each antigen [amylase]
HCPCS codes not covered for indications listed in the CPB:
Henry JB. Clinical Diagnosis and Management by Laboratory Methods. 19th ed. Philadelphia, PA: W.B. Saunders Co.; 1996.
Klaassen CD, Amdur MO, Doull J. Casarett and Doull's Toxicology: The Basic Science of Poisons. 3rd ed. New York, NY: Macmillan Publishing Co.; 1986.
Xact Medicare Services. Procedures of questionable current usefulness (POQCU) - pathology and laboratory. Medicare Medical Policy Bulletin. No. G-33. Camp Hill, PA: Xact; May 27, 1996. Available at: http://www.xact.org/policy/g33.html. Accessed March 27, 2000.
Kadish AH, Buxton AE, Kennedy HL, et al; ACC/AHA clinical competence statement on electrocardiography and ambulatory electrocardiography: A report of the American College of Cardiology/American Heart Association/American College of Physicians-American Society of Internal Medicine Task Force on Clinical Competence (ACC/AHA Committee to Develop a Clinical Competence Statement on Electrocardiography and Ambulatory Electrocardiography). J Am Coll Cardiol. 2001;38(7):2091-2100.
Gu L, Smith WA, Chatzimavroudis GP. Mechanical fragility calibration of red blood cells. ASAIO J. 2005;51(3):194-201.
Centers for Medicare & Medicaid Services (CMS). NCD for cardiointegram (CIG) as an alternative to stress test or thallium stress test. CMS Manual System. Pub. 100-3. Medicare National Coverage, Chapter 1, Part 1, Section 20.27 Baltimore, MD: CMS; last modified April 23, 2009.
Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.