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November 2010

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Hyperbaric Oxygen (HBO) Therapy

Hyperbaric Oxygen Pressurization (HBO)

Chronic refractory osteomyelitis is considered medically necessary for patients who respond to initial treatment with antibiotics, surgical debridement and HBO; therapy should be continued for approximately 4-6 weeks. Review is indicated after 30-40 sessions.


Transcatheter Embolization

Radioembolization for Primary and Metastatic Tumors of the Liver

Coverage is provided for radioembolization, also referred to as selective internal radiation therapy or SIRT, when medically necessary.


Radioembolization or SIRT may be considered medically necessary for the following indications:


- To treat primary hepatocellular carcinoma that is unresectable and limited to the liver.

·         Radioembolization is used for unresectable HCC that is > 3cm.

·         Radioembolization should be reserved for patients with adequate functional status (ECOG 0-2), adequate liver function and reserve, Child Pugh score A or B, and liver-dominant metastases.


- In primary hepatocellular carcinoma as a bridge to liver



-To treat hepatic metastases from neuroendocrine tumors

(carcinoid and noncarcinoid) with diffuse and symptomatic

disease when systemic therapy has failed to control



Radioembolization is considered investigational to treat unresectable hepatic metastases from colorectal carcinoma and is not covered.


Radioembolization is considered investigational and not covered for all other hepatic metastases except for metastatic neuroendocrine tumors as noted above.


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


Genetic Testing

Array Comparative Genomic Hybridization (aCGH) for the Genetic Evaluation of Patients with Developmental Delay/Mental Retardation or Autism Spectrum Disorder

No coverage is provided for genetic testing for Array CGH (targeted or whole-genome) in the evaluation of children with cognitive developmental delay/mental retardation or autism spectrum disorder as this is considered investigational.


No coverage is provided for prenatal genetic testing for Array CGH as this is considered investigational.


Experimental/Investigative Services Pathology/Laboratory

Bone Turnover Markers for Diagnosis and Management of Osteoporosis

Measurement of bone turnover markers (collagen cross-links) in the diagnosis and management of osteoporosis is considered investigational and is not covered.

Experimental/Investigative Services Surgery

Bone Morphogenetic Protein

Bone morphogenetic protein (rh-BMP-2 or rh-BMP-7) is considered investigational for indications including, but not limited to, posterior or transforaminal interbody spinal fusion.

Experimental/Investigative Services Therapy

Radioimmunotherapy in the Treatment of Non- Hodgkin Lymphoma

The use of tositumomab (Bexxar®) or ibritumomab tiuxetan (Zevalin®) as part of a preparatory regimen prior to hematopoietic stem-cell is considered investigational and is not covered.


Tumor  Markers

Serum Biomarker Human Epididymis Protein 4 (HE4)

No coverage will be provided for the HE4 (Human epididymis protein 4) enzyme immunometric assay for the quantitative determination of HE4 in human serum as this is considered investigational for all indications including:

  • Diagnosing malignant disease in women with signs or symptoms possibly suggestive of ovarian cancer.
  • Monitoring disease progression or recurrence in women diagnosed with epithelial ovarian cancer.
  • Screening asymptomatic women for ovarian cancer.

Cryosurgical Ablation and Radiofrequency Ablation

Catheter Ablation of the Pulmonary Veins as Treatment for Atrial Fibrillation (AF)

Transcatheter cryoablation of the pulmonary veins as a treatment for AF is considered investigational and is not covered.