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August 2014

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Fecal Microbiota Transplantation
Coverage will be provided for fecal microbiota transplantation when medically necessary.

Fecal microbiota transplantation may be considered medically necessaryfor treatment of patients with recurrent Clostridium difficile infection under the following conditions: (See Guidelines)

  • There have been at least 3 episodes of recurrent infection; AND
  • Episodes are refractory to appropriate antibiotic regimens, including at least 1 regimen of pulsed vancomycin.

Fecal microbiota transplantation is considered investigationaland not coveredin all other situations

Transplant
Islet Transplantation
Coverage will be provided for islet transplantation when medically necessary.

  1. Autologous pancreas islet transplantation may be considered medically necessary as an adjunct to a total or near total pancreatectomy in patients with chronic pancreatitis.
  2. Allogeneic islet transplantation is considered investigational for the treatment of type 1 diabetes.
  3. Islet transplantation is considered investigationaland not coveredin all other situations.

Surgically Implanted Hearing Devices
Cochlear Implant.
Cochlear implantation with a hybrid cochlear implant/hearing aid device that includes the hearing aid integrated into the external sound processor of the cochlear implant, including but not limited to the Nucleus® Hybrid™ L24 Cochlear Implant System, is considered investigational and not covered.

Sleep Disorder Services
Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome
No coverage will be provided for implantable hypoglossal nerve stimulators as they are considered investigationalfor all indications, including but not limited to the treatment of OSA.

Experimental/Investigative Services Pathology/Laboratory
PathFinderTG® Molecular Testing
No coverage will be provided for molecular testing using the PathFinder TG® system for all indications including the evaluation of pancreatic cyst fluid, suspected or known gliomas, and Barrett esophagus as this is considered investigational.

Experimental/Investigative Services Radiology
Scintimammography and Gamma Imaging of the Breast and Axilla
No coverage will be provided for preoperative or intraoperative sentinel lymph node detection using handheld or mounted mobile gamma cameras as this is considered investigational.

Tumor Markers
Coverage will be provided for measurement of urinary bladder cancer tumor markers when medically necessary.

  1. Measurement of the urinary bladder cancer tumor marker UroVysion® may be considered medically necessary as an adjunct in the diagnosis and management of bladder cancer in asymptomatic individuals with a negative cystoscopy and/or imaging study.
  2. Measurement of all other urinary bladder cancer tumor markers is considered investigational as an adjunct in the diagnosis of, monitoring, and/or screening for bladder cancer.

Genetic Testing for Mental Health Conditions
Genetic testing for mutations associated with mental health disorders is considered investigational and not covered in all situations.

Genetic testing panels for mental health disorders, including but not limited to the Genecept Assay, STA2R test, the GeneSight Psychotropic panel, and the Proove Narcotic Risk assay, are considered investigational and not covered for all indications.

Genetic Testing of Mitochondrial Disorders
Coverage will be provided for genetic testing to confirm the diagnosis of a mitochondrial disorder when medically necessary.

Genetic testing to confirm the diagnosis of a mitochondrial disorder may be considered medically necessaryas an alternative to muscle biopsy under the following conditions:

  • Clinical signs and symptoms are consistent with a specific mitochondrial disorder, but the diagnosis cannot be made with certainty by clinical and/or biochemical evaluation; AND
  • Genetic testing is restricted to the specific mutations that have been documented to be pathogenic for the particular mitochondrial disorder being considered

Genetic testing of at-risk female relatives may be considered medically necessaryas part of a preconceputal evaluation under the following conditions:

  • There is a defined mitochondrial disorder in the family of sufficient severity to cause impairment of quality of life or functional status; AND
  • A mutation that is known to be pathogenic for that specific mitochondrial disorder has been identified in the index case.

Genetic testing for mitochondrial disorders using expanded panel testing is considered investigational and not covered.

Genetic testing for mitochondrial disorders is considered investigationaland not coveredin all other situations when the criteria for medical necessity are not met.

Genetic Testing for Li-Fraumeni Syndrome
Coverage will be provided for genetic testing for TP53 mutations when medically necessary.
Genetic testing for TP53 mutations may be considered medically necessaryto confirm a diagnosis of Li- Fraumeni syndrome under the following conditions:

  • In a patient who meets either the classic or the Chompret clinical diagnostic criteria for Li- Fraumeni syndrome, or
  • In women with early-onset breast cancer (age of diagnosis ≤35 years).

Genetic testing for a TP53 mutation may be considered medically necessary in an at-risk relative of a proband with a known TP53 mutation.

Genetic testing for a germline TP53 mutation is considered not medically necessary and not covered for all other indications.

Gene Expression Profiling for Uveal Melanoma
No coverage will be provided for gene expression profiling for uveal melanoma as it is considered investigational.