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June 2010

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Cochlear Implant
Coverage will be provided for unilateral or bilateral implantation of an FDA approved cochlear implant device in patients age 12 months and older with bilateral severe to profound pre or post lingual (sensorineural) hearing loss defined as a hearing threshold of pure-tone average of 70 decibels (dB) hearing loss or greater at 500 HZ (hertz), 100 HZ, and 2000 HZ, and have shown limited or no benefit from hearing aids.

Contrast Enhanced Cardiac Computed Tomography Angiography (CTA) for Coronary Artery Evaluation
The policy is being revised to clarify the criteria for approval of CTA to align with current medical standards from the American College of Cardiology & American College of Radiology.

The following procedures are considered experimental/investigational and members are responsible for any charges for treatment for:
Genetic Testing
Multi-gene Expression Assay for Predicting Recurrence in Colon Cancer
No coverage will be provided for the 12-gene expression test (Oncotype DX® colon cancer test) as this is considered investigational; including use for predicting the likelihood of disease recurrence for stage II colon cancer patients following surgery.

Experimental/Investigational Services Medicine
Closure Devices for Patent Foramen Ovale and Atrial Septal Defects
Closure of patent foramen ovale using a transcatheter approach is considered investigational and not covered since there are currently no transcatheter devices with FDA approval or clearance for closure of patent foramen ovale. 

Experimental/Investigational Services OB/GYN
First-Trimester Detection of Down Syndrome Using Fetal Ultrasound Markers Combined with Maternal Serum Assessment
The scope of this policy was expanded to include an additional fetal ultrasound marker, fetal nasal bone assessment, and the following language was added to the policy: First-trimester screening for detection of Down syndrome incorporating fetal nasal bone assessment translucency is considered investigational and is not covered.

Experimental/Investigational Services Medicine
Bioimpedance Devices for Detection of Lymphedema
Devices using bioimpedance (bioelectrical impedance spectroscopy) for use in the diagnosis, surveillance, or treatment of patients with lymphedema; including use in subclinical secondary lymphedema are considered investigational and are not covered.

Experimental/Investigational Services Surgery
Image-Guided Minimally Invasive Lumbar Decompression for Spinal Stenosis

Image-guided minimally invasive lumbar decompression (IG-mild) is a new percutaneous decompressive procedure performed solely under fluoroscopic guidance (without endoscopic or microscopic visualization of the work area).  No evidence is available at this time to evaluate the efficacy of this procedure; it is considered investigational and is not covered.

Experimental/Investigational Services Therapy
Extracorporeal Photopheresis as Treatment for and Prevention of Organ Rejection after Solid Organ Transplant
Extracorporeal Photopheresis (ECP) in all other situations related to treatment or prevention of rejection in solid organ transplantation EXCEPT to treat cardiac allograft rejection that is either recurrent or that is refractory to standard immunosuppressive drug treatment is considered investigational and is not covered.

Osteoarticular Transfer System (OATS)/Autologous Chondrocyte Transplant (ACT)
Autologous Chondrocyte Implantation and Other Cell-based Treatments of Focal Articular Cartilage Lesions
No coverage will be provided for treatment of focal articular cartilage lesions with autologous minced cartilage since this is considered investigational.

No coverage will be provided for coverage for treatment of focal articular cartilage lesions with allogeneic minced cartilage or cartilage cells since this is considered investigational.