Medical Policy: 10.01.14 

Original Effective Date: April 2009 

Reviewed: June 2021 

Revised: June 2021 

 

Notice:

This policy contains information which is clinical in nature. The policy is not medical advice. The information in this policy is used by Wellmark to make determinations whether medical treatment is covered under the terms of a Wellmark member's health benefit plan. Physicians and other health care providers are responsible for medical advice and treatment. If you have specific health care needs, you should consult an appropriate health care professional. If you would like to request an accessible version of this document, please contact customer service at 800-524-9242.

 

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 medical device intended to benefit patients by treatment or diagnosis of a disease or condition that affects fewer than 8,000 individuals in the United States per year. The United States Food and Drug Administration (FDA) evaluates humanitarian use devices (HUDs) through the Humanitarian Device Exemption (HDE) process. A device that is granted an HDE indicates that the device is approved for marketing, but the approval is based on evidence of safety and probable benefit rather than the higher standard of reasonable assurance and effectiveness.

 

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. It creates an alternative pathway for getting market approval for medical devices that may help people with rare diseases or conditions. Because clinical investigation demonstrating a HUD's efficacy is not feasible (given the low prevalence of the disease in the population), an FDA-approved HDE grants manufacturers an exemption from the usual premarket approval process and allows marketing of the device only for the FDA-labeled HDE indication(s). Under FDA requirements, a HUD may only be used after institutional review board (IRB) approval has been obtained for the use of the device in accordance with the FDA-labeled indication(s) under the HDE.

 

Prior Approval:

Not applicable

 

Policy:

Humanitarian use device (HUD) by the United States Food and Drug Administration (FDA) may be considered medically necessary when ALL of the following criteria are met:

  • The device is being utilized in accordance with the Humanitarian Device Exemption (HDE) labeled indication(s) approved by the FDA; and
  • Humanitarian use device (HUD) will only be covered in facilities that have an institutional review board (IRB) to oversee the clinical application of such device; and
  • The IRB must approve the application of the device to ensure that it will be used in accordance with the FDA-labeled indication(s); and
  • Documentation of the IRB approval is provided to ensure compliance with the FDA-labeled indication(s).

 

A comprehensive list of devices and their respective FDA-labeled HDE indication(s) is available at: http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfHDE/HDEInformation.cfm

 

Humanitarian use device (HUD) requested for off-label uses (i.e., outside of their FDA-labeled Humanitarian Device Exemption (HDE) indication[s]) are considered investigational and, therefore, not covered because their safety and/or effectiveness cannot be established by review of the available published peer reviewed literature.

 

Procedure Codes and Billing Guidelines:

To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or diagnosis codes.

  • Coding is variable depending on the device being requested.

 

Selected References:

  • 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.
  • Samuel FE Jr. Safe Medical Devices Act of 1990. Health Aff (Millwood), 1991 Spring; 10(1):192-5.
  • U.S. Department of Health and Human Services. Food and Drug Administration Medical Devices, Products and Medical Procedures, Devices Approvals and Clearance, Humanitarian Device Approvals and Exemption.
  • U.S. Department of Health and Human Services. Food and Drug Administration Medical Devices HDE Approvals, Listing of CDRH Humanitarian Device Exemptions
  • U.S. Department of Health and Human Services Food and Drug Administration Medical Devices Regulation and Guidance, Humanitarian Device Exemption
  • U.S. Department of Health and Human Services Food and Drug Administration Guidance for Industry and Food and Drug Administration Staff Humanitarian Use Device (HUD) Designations

 

Policy History:

  • June 2021 - Annual Review, Policy Revised
  • June 2020 - Annual Review, Policy Renewed
  • June 2019 - Annual Review, Policy Renewed
  • June 2018 - Annual Review, Policy Renewed
  • June 2017 - Annual Review, Policy Renewed
  • June 2016 - Annual Review, Policy Renewed
  • July 2015 - Annual Review, Policy Renewed
  • August 2014 - Annual Review, Policy Revised
  • August 2013 - Annual Review, Policy Renewed
  • September 2012 - Annual Review, Policy Revised
  • September 2011 - Annual Review, Policy Renewed
  • August 2010 - Annual Review, Policy Renewed
  • June 2010 - Interim Review, Prior Approval Removed

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.

 

*CPT® is a registered trademark of the American Medical Association.