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May 2014

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Experimental/Investigative Services Ophthalmologic
Intraocular Radiation Therapy for Age-Related Macular Degeneration

No coverage will be provided for stereotactic radiation therapy for the treatment of choroidal neovascularization as this is considered investigational.

Epidermal Growth Factor Receptor (EGFR) Mutation Analysis for Patients with Non-Small Cell Lung Cancer (NSCLC)
Epidermal Growth Factor Receptor (EGFR) Mutation Analysis for Patients with Non-Small Cell Lung Cancer (NSCLC)

Coverage will be provided for analysis of the Epidermal Growth Factor Receptor (EGFR) gene mutation for patients with Non-Small Cell Lung Cancer (NSCLC) when medically necessary.

Except as noted below, analysis of 2 types of somatic mutation within the EGFR gene – small deletions in exon 19 and a point mutation in exon 21 (L858R) – may be considered medically necessaryto predict treatment response to erlotinib or afatinib in patients with advanced lung adenocarcinoma or in whom an adenocarcinoma component cannot be excluded.

Analysis of 2 types of somatic mutation within the EGFR gene – small deletions in exon 19 and a point mutation in exon 21 (L858R) – is considered investigationaland not covered for patients with advanced NSCLC of squamous cell-type.

Analysis for other mutations within exons 18-24, or other applications related to NSCLC, is considered investigational and not covered.

Antigen Leukocyte Antibody Testing (ALCAT)
Antigen Leukocyte Antibody Testing

No coverage will be provided for the Antigen Leukocyte Antibody Test (ALCAT) as it is considered not medically necessaryfor all indications.