Endothelial keratoplasty (Descemet’s stripping endothelial keratoplasty or Descemet’s stripping automated endothelial keratoplasty) may be considered medically necessary and covered for the treatment of endothelial dysfunction, including but not limited to Fuch’s endothelial dystrophy, aphakic, and pseudophakic bullous keratopathy, and failure or rejection of a previous corneal transplant.
Positron Emission Tomography (PET)
Miscellaneous Applications of Positron Emission Tomography (PET)
No coverage will be provided for PET scanning for vasculitis as this is considered investigational.
BRAF Mutation Analysis in Metastatic Colorectal
No coverage will be provided for BRAF mutation analysis to predict nonresponse to anti-EGFR monoclonal antibodies cetuximab and panitumumab in the treatment of metastatic colorectal cancer as this is considered investigational.
Cryosurgical Ablation and Radiofrequency Ablation
Catheter Ablation for Cardiac Arrhythmias
Coverage is provided for catheter ablation for cardiac arrhythmias when medically necessary.
1. Catheter ablation may be considered medically necessary for the treatment of supraventricular tachyarrhythmias, as follows:
a) Treatment of paroxysmal supraventricular tachycardia due to AV nodal re-entry tachycardia
b) Treatment of paroxysmal supraventricular tachycardia due to accessory pathways
c) Treatment of atrial flutter
d) Treatment of focal atrial tachycardia
2. Catheter ablation using radiofrequency energy may be considered medically necessary for the treatment of chronic, recurrent, ventricular tachycardia that is refractory to implantable cardioverter-defibrillator treatment and antiarrhythmic medications, and for which an identifiable arrhythmogenic focus can be identified.
3. Catheter ablation for cardiac arrhythmias not meeting above criteria is considered not medically necessary and not covered.
Contrast Enhanced Cardiac Computed Tomography Angiography (CTA) for Coronary Artery Evaluation
Coverage for CTA will be provided when medically necessary. No coverage will be provided for CTA's which do not meet policy criteria as this is considered investigational. In addition, no coverage will be provided for CTA's when patients present with policy contraindications as this is considered not medically necessary.
The following procedures are considered experimental/investigative and members are responsible for any charges for treatment for:
Experimental/Investigative Services Pathology/Laboratory
Microarray-Based Gene Expression Testing for Cancers of Unknown Primary
In June 2010, the “Pathwork® Tissue of Origin Test Kit-FFPE” (Pathwork Diagnostics) was cleared for marketing by the FDA through the 510(k) process. The 2010 clearance is an expanded application which allows the test to be run on a patient’s formalin-fixed, paraffin-embedded (FFPE) tumor.
Since there is no new data published on the clinical impact of this testing, the investigational policy statement remains unchanged, but revised as follows to include its expanded application:
Gene expression profiling using the Pathwork® tissue of origin test or the Pathwork® Tissue of Origin test kit-FFPE to evaluate the site of origin of a tumor of unknown primary and to distinguish a primary from a metastatic tumor is considered investigational and not covered.
Experimental/Investigative Services Medicine
Computerized 2-lead Resting Electrocardiogram Analysis for the Diagnosis of Coronary Artery Disease
Computerized 2-lead resting electrocardiogram analysis (e.g.,multifunction cardiogram) for diagnosing coronary artery disease is considered investigational and not covered.
Dynamic posturography tests a patient’s balance control in situations intended to isolate factors that affect balance in everyday experiences. Dynamic posturography is considered investigational and not covered.
Experimental/Investigative Services Surgery
Endobronchial valves are considered investigational and not covered as a treatment of prolonged air leaks and/or as a treatment for patients with COPD or emphysema.