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February 2010

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Genetic Testing
Genetic Testing for Inherited Susceptibility to Colon Cancer Including Microsatellite Instability: the requirement for a positive family history is no longer required for testing the index patient who has colorectal cancer to determine if they have Lynch Syndrome.

Clarification is added to the coverage for Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer. Added statements address testing of multiple ipsilateral primary tumors and the timing of Oncotype DX testing (within six months following diagnosis).  Use of this testing in those with node-positive breast cancer is still considered investigational and is not covered.

Brachytherapy
Endobronchial Brachytherapy used as palliative treatment for severe hemoptysis and in recurrent tumors may be considered medically necessary.

Endometrial Ablation
The following contraindication for intrauterine ablation or resection of the endometrium has been added: patient with any anatomic or pathologic condition in which weakness of the myometrium could exist, such as history of previous classical cesarean sections or transmural myomectomy.

Uterine Artery Embolization (UAE)
The following contraindications for UAE have been added: presence of an IUD (can be removed prior to procedure); or presence of gynecological malignancies.

Therapy
Intraoperative radiation therapy may be considered medically necessary in selected cases of rectal cancer.

Surgery

  • Periureteral Bulking Agents as a treatment of Vesicoureteral Reflux (VUR) may be considered medically necessary for reflux grades II-IV when medical therapy has failed and surgical intervention for VUR is indicated.
  • Transanal Endoscopic Microsurgery (TEMS) may be considered medically necessary for removal of rectal adenomas and selected T1 rectal cancers.
  • Hematopoietic Stem Cell Transplantation for CNS Embryonal Tumors and Ependymoma:
    autologous consolidation therapy in patients with previously untreated embryonal tumors showing complete or partial response to, or stable disease after, induction therapy may be considered medically necessary. 
  • Hematopoietic Stem Cell Transplantation for Hodgkin Lymphoma: tandem autologous stem cell transplantation (SCT) and reduced-intensity conditioning (RIC) allogeneic SCT may be considered medically necessary in specific situations.

Miscellaneous
Ophthalmologic Techniques for Evaluating Glaucoma: the policy is revised to indicate that specific techniques may be considered medically necessary in the care of patients with glaucoma.  The policy statement will clarify that the techniques can be used in the diagnosis and evaluation of patients who are glaucoma-suspects in addition to those with a diagnosis of glaucoma.

The following procedures are considered experimental/investigational and members are responsible for any charges for treatment for:

Brachytherapy
Endobronchial Brachytherapy used in asymptomatic recurrent disease is considered investigational and is not covered.

Functional Neuromuscular Electrical Stimulation
New applications were added related to use in hand and foot function; these are considered investigational and are not covered. 

Medicine
No coverage is provided for the use of biventricular pacemakers in patients with mild (class I and II) heart failure.  Patients should be treated with a stable and maximal pharmacological regimen prior to implant. 

Surgery

  • No coverage is provided for saturation biopsy for diagnosis and staging of prostate cancer. 
  • No coverage is provided for Bilateral auditory brain stem implantation (ABI) and penetrating electrode auditory brainstem implant.
  • No coverage is provided for collagen meniscus implants.
  • Hematopoietic Stem Cell Transplantation for Hodgkin Lymphoma: no coverage is provided for second autologous stem-cell transplantation for relapsed lymphoma after a prior autologous hematopoietic stem-cell transplant; this is considered investigational.

OATS/ACT

  • No coverage is provided for matrix-induced Autologous Chondrocyte Implantation (MACI);
    this is considered investigational.

Wound Care
Recombinant and Autologous Platelet-Derived Growth Factors as a Treatment of Wound Healing and Other Conditions: use of platelet-rich plasma as an adjunct to surgical procedures is not covered.