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June 2014

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Electrical/Neuromuscular Stimulator
Vagus Nerve Stimulation
No coverage will be provided for vagus nerve stimulation 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:

  1. Treatment of other conditions, including but not limited to heart failure, fibromyalgia, depression, essential tremor, headaches, obesity, tinnitus and traumatic brain injury.
  2. Non-implantable vagus nerve stimulation devices for all indications.
  3. All other indications not identified above as medically necessary.

Outpatient Therapies
Cognitive Rehabilitation
Cognitive rehabilitation (as a distinct and definable component of the rehabilitation process) is considered investigational for applications, including, but not limited to stroke, post-encephalitic or post-encephalopathy patients, autism spectrum disorders, seizure disorders, and the aging population, including Alzheimer’s patients.

Molecular Panel Testing of Cancers to Identify Targeted Therapies
No coverage will be provided for the use of expanded cancer mutation panels for selecting targeting cancer treatment as this is considered investigational.

Genetic Testing, Including Chromosomal Microarray Analysis and Next-Generation Sequencing Panels, for the Evaluation of Patients with Developmental Delay/Intellectual Disability or Autism Spectrum Disorder
Panel testing using next-generation sequencing is considered investigationaland not coveredin all cases of suspected genetic abnormality in children with developmental delay/intellectual disability or autism spectrum disorder.

BCR-ABL1 Testing in Chronic Myelogenous Leukemia and Acute Lymphoblastic Leukemia
BCR/ABL1 testing for messenger RNA transcript levels by quantitative real-time reverse transcription-polymerase chain reaction (RT-PCR) at baseline prior to initiation of treatment and at appropriate intervals during therapy is considered medically necessaryand coveredfor monitoring of Philadelphia chromosome-positive acute lymphoblastic leukemia treatment response and remission.

Evaluation of ABL kinase domain point mutations to evaluate patients for tyrosine kinase inhibitor resistance is considered medically necessaryand coveredwhen there is inadequate initial response to treatment or any sign of loss of response.

Evaluation of ABL kinase domain point mutations is considered investigationaland not coveredfor monitoring in advance of signs of treatment failure or disease progression.

Laboratory and Genetic Testing for Use of 5-Fluorouracil in Patients With Cancer
No coverage will be provided for TheraGuide® testing for genetic mutations in dipyrimidine dehydrogenase (DPYD) or thymidylate synthase (TYMS) to guide 5-FU dosing and/or treatment choice in patients with cancer as this is considered investigational.