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Medical Policy: 10.01.14
Original Effective Date: April 2009
Reviewed: September 2011
Revised:
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
A humanitarian use device (HUD) is a device that is intended to benefit patients by treating or diagnosing a disease or condition that affects fewer than 4,000 individuals in the United States per year. A device manufacturer’s research and development costs could exceed its market returns for diseases or conditions affecting small patient populations.
In 1996, the Food and Drug Administration (FDA) issued a regulation to carry out provisions of the Safe Medical Devices Act of 1990 regarding HUDs. The regulation requires the submission of a humanitarian device exemption (HDE) application which is similar to a premarket approval (PMA) application, but is exempt from the effectiveness requirements of a PMA. An HDE application is not required to contain the results of scientifically valid clinical investigations demonstrating that the device is effective for its intended purpose. The application must contain sufficient information for the FDA to determine that the devise does not pose an unreasonable or significant risk of illness or injury and that the probable benefit to health outweighs the risk of injury or illness from its use, taking into account the probable risks and benefits of currently available devices or alternative forms of treatment. An approved HDE authorizes the marketing of a HUD; however, an HUD may only be used after institutional review board (IRB) approval has been obtained for the use of the device for the FDA-approved indication. The healthcare provider is responsible for obtaining IRB approval before using the HUD to treat or diagnose patients.
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Prior Approval:
Not applicable
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Policy:
Devices that have been designated by the FDA as HUDs may be subject to individual review unless stated otherwise in a Wellmark medical policy. HUDs may be subject to individual review because they are exempt from effectiveness data and scientifically-validated clinical evidence required by the FDA to gain approval.
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Procedure Codes and Billing Guidelines:
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To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9-CM diagnostic codes.
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Selected References:
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U.S. Department of Health and Human Services. Food and Drug Administration. Center for Devices and Radiological Health. Guidance for Industry and FDA Staff: Humanitarian Device Exemption (HDE) Regulation: Questions and Answers. July 18, 2006. Available at: http://www.fda.gov/cdrh/ode/guidance/1381.pdf.
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Samuel FE Jr. Safe Medical Devices Act of 1990. Health Aff (Millwood), 1991
Spring; 10(1):192-5.
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Policy History:
Date Reason Action
June 2010 Interim review Prior approval removed
August 2010 Annual review Policy renewed
September 2011 Annual review Policy renewed
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark 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 Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.
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