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February 2014

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Transplant
Heart/Lung Transplant
Heart/lung retransplantation after a failed primary heart/lung transplant may be considered medically necessaryand would be coveredin patients who meet criteria for heart/lung transplantation.

Heart/lung transplantation is considered investigational in all other situations and not covered.

Heart Transplant
Heart retransplantation after a failed primary heart transplant may be considered medically necessaryand would be coveredin patients who meet criteria for heart transplantation.

Heart transplantation is considered investigationalin all other situations and not covered.

Genetic Testing
Genetic Testing for Macular Degeneration
No coverage will be provided for genetic testing for macular degeneration as this is considered investigational.

Carrier Testing for Genetic Diseases
Coverage will be provided for carrier testing when medically necessary.

Carrier testing for genetic diseases is considered medically necessaryand is coveredwhen one of the following criteria is met:

  • The individuals have a previously affected child with the genetic disease OR
  • One or both individuals have a first- or second-degree relative who is affected OR
  • One or both individuals have a first-degree relative with an affected offspring OR
  • One individual is known to be a carrier OR
  • One or both individuals are members of a population known to have a carrier rate that exceeds a threshold considered appropriate for testing for a particular condition

AND all of the following criteria are met:

  • The natural history of the disease is well understood and there is a reasonable likelihood that the disease is one with high morbidity in the homozygous or compound heterozygous state.
  • Alternative biochemical or other clinical tests to definitively diagnose carrier status are not available, or, if available, provide an indeterminate result or are individually less efficacious than genetic testing.
  • The genetic test has adequate sensitivity and specificity to guide clinical decision making and residual risk is understood. An association of the marker with the disorder has been established.

Expanded carrier screening panels are considered to be not medically necessary and not covered.

Fetal RHD Genotyping Using Maternal Plasma
No coverage will be provided for fetal RHD genotyping using maternal plasma as this is considered investigational.

Genetic Testing for Epilepsy
No coverage will be provided for genetic testing for epilepsy as this is considered investigational.

Genecept Assay
No coverage will be provided for the Genecept™ panel assay is considered investigationalfor all indications.

Microarray-based Gene Expression Analysis for Prostate Cancer Management
No coverage will be provided for microarray-based gene expression analysis to guide management of prostate cancer as this is considered investigationalin all situations.

Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes
Genetic testing for BRAF V600E or MLH1 promoter methylation may be considered medically necessaryand would be coveredto exclude a diagnosis of Lynch syndrome when MLH1 protein is not expressed in a colorectal cancer on immunohistochemical (IHC) analysis.

No coverage will be provided for genetic testing for all other gene mutations for Lynch syndrome or colorectal cancer is considered investigational.

Experimental/Investigative Services Pathology/Laboratory
Cardiovascular Risk Panels
No coverage will be provided for cardiovascular risk panels, consisting of multiple individual biomarkers intended to assess cardiac risk (other than simple lipid panels, i.e., Total cholesterol, LDL cholesterol, HDL cholesterol, and Triglycerides), as they are considered investigational.

Experimental/Investigative Services Surgery
Implantable Sinus Stents for Postoperative Use Following Endoscopic Sinus Surgery
No coverage will be provided for the use of implantable sinus stents/spacers for postoperative treatment following endoscopic sinus surgery as this is considered investigational.