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December 2010

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Hematopoietic Stem-Cell Transplantation for Autoimmune Diseases

Autologous or allogeneic hematopoietic stem cell transplantation is considered investigational and not covered as a treatment of autoimmune disease including, but not limited to, multiple sclerosis (MS), juvenile idiopathic and rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and systemic sclerosis/scleroderma, and Type I diabetes mellitus.


Allogeneic Hematopoietic Stem-Cell Transplantation for Genetic Diseases and Acquired Anemias

The following medically necessary indications were added to the policy:


Allogeneic hematopoietic stem cell transplantation is considered medically necessary for selected patients with the following disorders:


a) Hemoglobinopathies

- Sickle cell anemia for children or young adults with either a history of prior stroke or at increased risk of stroke or end-organ damage.

- Homozygous beta-thalassemia (i.e., thalassemia major).


b) Bone marrow failure syndromes

-Hereditary (including Fanconi anemia, dyskeratosis congenita, Shwachman-Diamond, Diamond-Blackfan) or acquired (e.g., secondary to drug or toxin exposure) forms.


c) Primary immunodeficiencies

- Absent or defective T-cell function (e.g., severe combined immunodeficiency, Wiskott-Aldrich syndrome, X-linked lymphoproliferative syndrome).

- Absent or defective natural killer function (e.g. Chediak-Higashi syndrome).

- Absent or defective neutrophil function (e.g. Kostmann syndrome, chronic granulomatous disease, leukocyte adhesion defect).


d) Inherited metabolic disease

- Lysosomal and peroxisomal storage disorders except Hunter, Sanfilippo, and Morquio syndromes.


e) Genetic disorders affecting skeletal tissue

- Infantile malignant osteopetrosis (Albers-Schonberg disease or marble bone disease).


Endometrial Ablation

The policy was modified to state that coverage shall be provided for intrauterine ablation or resection of the endometrium, after other pathologic etiologies for menorrhagia have been ruled out, for the following indications, such as, but not limited to:

- For women with menorrhagia that is unresponsive to medical management, hormonal therapy and/or dilation and curettage; and


- The menorrhagia shall be of a degree of severity and persistence that the failure of prior treatment shall be such that the Member would otherwise be a candidate for hysterectomy.


Scanning Computerized Ophthalmic Diagnostic Imaging

Scanning computerized ophthalmic diagnostic imaging is used for early detection of glaucoma damage to the nerve fiber layer or optic nerve of the eye. Conditions which are not indications for the use of scanning computerized ophthalmic diagnostic imaging will require clinical review. 


The following statement was added to the policy in order to clarify denying coverage for conditions other than Glaucoma and Retinal disorders: Coverage will not be provided for scanning computerized ophthalmic diagnostic imaging for conditions not meeting the clinical indications as they are considered not medically necessary.


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


Experimental/Investigative Services OB/GYN

Fetal Fibronectin Enzyme Immunoassay

The use of FFN assays may be considered medically necessary for use in women with singleton or twin gestations, with intact membranes, cervical dilation <3 cm, and who are experiencing symptoms suggestive of preterm labor between 24 and <35 weeks’ gestation. This population represents women who are most likely to be hospitalized and treated in an attempt to prevent preterm birth.


Experimental/Investigative Services Miscellaneous

Implantation of Intrastromal Corneal Ring Segments

Implantation of intrastromal corneal ring segments is considered investigational and not covered for all other conditions except the following:


(1) When used as a treatment of myopia, intrastromal corneal ring segments are considered not medically necessary.


(2) When used for the treatment of keratoconus, intrastromal corneal ring segments may be considered medically necessary in patients 21 years of age or older who meet the following criteria:


-the patient has experienced a progressive deterioration in their vision, such that they can no longer achieve adequate function vision with contact lenses or spectacles; and


-corneal transplantation is the only alternative to improve their function vision; and


- The patient has a clear central cornea with a corneal thickness of 450 microns or greater at the proposed incision site.


Experimental/Investigative Services Medicine



Dermatoscopy, using either direct inspection, digitization of images, or computer-assisted analysis, as a technique to evaluate or serially monitor pigmented skin lesions is considered investigational and is not covered.


Dermatoscopy as a technique to define peripheral margins of basal cell carcinomas is considered investigational and is not covered.



Experimental/Investigative Services Surgery

Percutaneous Axial Anterior Lumbar Fusion


Percutaneous axial anterior lumbar fusion is considered investigational and is not covered.