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April 2014

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Transplant
Isolated Small Bowel Transplant
A small bowel retransplant may be considered medically necessaryand coveredafter a failed primary small bowel transplant.

Lung and Lobar Lung Transplant
Lung or lobar lung retransplantation after a failed lung or lobar lung transplant may be considered medically necessary and coveredin patients who meet criteria for lung transplantation.

Lung or lobar lung transplantation is considered investigational in all other situations and not covered.

Liver Transplant
Liver transplantation may be considered medically necessaryand coveredin patients with polycystic disease of the liver who have massive hepatomegaly causing obstruction or functional impairment.

Liver transplantation may be considered medically necessary and coveredin pediatric patients with non-metastatic hepatoblastoma.

Liver transplantation is considered investigational in all other situations not described above and not covered.

Electrical Bone Growth Stimulator
Ultrasound Accelerated Fracture Healing Device
No coverage will be provided for other applications of low intensity ultrasound treatment including, but not limited to treatment of congenital pseudarthroses, open fractures, fresh surgically-treated closed fractures, stress fractures, arthrodesis or failed arthrodesis, since these applications are considered investigational.

Cardiac Rhythm Devices
Wearable Cardioverter-Defibrillators
No coverage will be provided for the use of wearable cardioverter-defibrillators for the prevention of sudden cardiac death for the following indications as they are considered investigational and, therefore, not covered because the safety and effectiveness of these services cannot be established by review of the available published peer-reviewed literature: high-risk patients awaiting heart transplant.

Genetic Testing for Cardiac Ion Channelopathies
Coverage will be provided for genetic testing for cardiac ion channelopathies when medically necessary.

Genetic testing in patients with suspected congenital long QT syndrome may be considered medically necessaryand coveredfor the following indications:

Individuals who do not meet the clinical criteria for LQTS (i.e., those with a Schwartz score less than 4), but who have:

  • a close relative (i.e., first-, second-, or third-degree relative) with a known LQTS mutation; or
  • a close relative diagnosed with LQTS by clinical means whose genetic status is unavailable; or
  • signs and/or symptoms indicating a moderate-to-high pretest probability* of LQTS.

* Determining the pretest probability of LQTS is not standardized. An example of a patient with a moderate-to-high pretest probability of LQTS is a patient with a Schwartz score of 2–3.

Genetic testing for LQTS to determine prognosis and/or direct therapy in patients with known LQTS is considered investigational and not covered.

Genetic testing for CPVT may be considered medically necessaryfor patients who do not meet the clinical criteria for CPVT but who have:

  • a close relative (i.e. first-, second-, or third-degree relative) with a known CPVT mutation; or
  • a close relative diagnosed with CPVT by clinical means whose genetic status is unavailable; or
  • signs and/or symptoms indicating a moderate-to-high pretest probability of CPVT.

Genetic testing for Brugada syndrome is considered investigational and not covered.

Genetic testing for short QT syndrome is considered investigational and not covered.

Analysis of MGMT Promoter Methylation in Malignant Gliomas
No coverage will be provided for MGMT promoter methylation testing for prognostic value or as a predictive biomarker for response to treatment with alkylating agents as this is considered investigational.

Genetic Testing for Dilated Cardiomyopathy
No coverage will be provided for genetic testing for dilated cardiomyopathy as this is considered investigational in all situations.

Bio-Engineered Skin and Soft Tissue Substitutes
Breast reconstructive surgery using allogeneic acellular dermal matrix products* (i.e., AlloDerm®, AlloMax™, DermaMatrix™, FlexHD®, GraftJacket®) may be considered medically necessary and covered:

  • when there is insufficient tissue expander or implant coverage by the pectoralis major muscle and additional coverage is required,
  • when there is viable but compromised or thin post-mastectomy skin flaps that are at risk of dehiscence or necrosis, or
  • the infra-mammary fold and lateral mammary folds have been undermined during mastectomy and re-establishment of these landmarks is needed.

Due to insufficient evidence, the following products have been added to the list of investigational skin and soft tissue substitutes and are not covered:

  • ACell® UBM Hydated Wound Dressing
  • ACell® UBM Lyophilized Wound Dressing
  • Aongen™ Collagen Matrix
  • Atlas Wound Matrix
  • Avagen Wound Dressing
  • Collagen Sponge (Innocoll)
  • Collagen Wound Drssing (Oasis Research)
  • Collaguard®
  • CollaSorb™
  • CollaWound™
  • Collexa®
  • Collieva®
  • Coreleader Colla-Pad
  • Dermadapt™ Wound Dressing
  • DressSkin
  • Excellagen
  • FortaDerm™ Wound Dressing
  • HA Absorbent Wound Dressing
  • Helicoll
  • Hyalomatrix® (Laserskin®)
  • Jaloskin®
  • Matrix Collagen Wound Dressing
  • Primatrix™ Dermal Repair Scaffold
  • Puros® Dermis
  • Repliform®
  • Stimulen™ Collagen
  • Suprathel®
  • TheraForm™ Standard/Sheet
  • Unite® Biomatrix

Navigated Transcranial Magnetic Stimulation (nTMS)
No coverage will be provided for Navigated transcranial magnetic stimulation as it is considered investigational for all purposes, including but not limited to the preoperative evaluation of patients being considered for brain surgery, when localization of eloquent areas of the brain (e.g., controlling verbal or motor function) is an important consideration in surgical planning.