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May 2011

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Transplant

Allogeneic Pancreas Transplant

Pancreas transplant is considered not medically necessary and not covered in patients with the following conditions:

a) Known current malignancy, including metastatic cancer

b) Recent malignancy with a high incidence of recurrence;

c) Untreated systemic infection making immunosuppression unsafe, including chronic infection; or

d) Other irreversible end-stage disease not attributed to kidney or pancreatic disease.

The following changes have been made to the policy guidelines:

The following guidelines apply:

Absence of significant infection that could be exacerbated by immunosuppressive therapy (e.g., chronic active viral hepatitis B, hepatitis C and human immunodeficiency virus).

Relative contraindications to pancreas transplantation:

a)   History of cancer with a moderate risk of recurrence;

b)   Systemic disease that could be exacerbated by immunosuppression;

c)   Psychosocial conditions or chemical dependence affecting the ability to adhere to therapy.

Durable Medical Equipment

Mechanical insufflation-exsufflation (MI-E) may be considered medically necessary in patients with the following conditions who have an impaired ability to cough, expectorate secretions and require ventilatory assistance: pulmonary disease, neuromuscular disease, spinal cord injury. Other indications for use of MI-E are considered not medically necessary and not covered.

Electrical/Neuromuscular Stimulator

Threshold Electrical Stimulation as a Treatment of Motor Disorders

No coverage will be provided for threshold electrical stimulation as a treatment of motor disorders, including, but not limited to cerebral palsy as this is considered not medically necessary.

Experimental/Investigative Services Ophthalmologic

Epiretinal Radiation Therapy for Age-Related Macular Degeneration

No coverage will be provided for intraocular placement of a radiation source for the treatment of choroidal neovascularization as this is considered investigational.

Experimental/Investigative Services Medicine

Gait Analysis

Comprehensive gait analysis may be considered medically necessary as an aid in surgical planning in patients with gait disorders associated with cerebral palsy; however, it is considered investigational and not covered for all other applications including but not limited to:
a) Surgical planning for conditions other than gait disorders associated with cerebral palsy.

a) Postoperative evaluation of surgical outcomes and rehabilitation planning and/or evaluation for all   conditions.

Endovascular Procedures (Angioplasty and/or Stenting) for Intracranial Arterial Disease (Atherosclerosis and Aneurysms)

Intracranial stent placement may be considered medically necessary as part of the endovascular treatment of intracranial aneurysms for patients when surgical treatment is not appropriate and standard endovascular techniques do not allow for complete isolation of the aneurysm, e.g., wide-neck aneurysm (4 mm or more) or sack-to-neck ratio less than 2:1.

Intracranial stent placement is considered investigational and not covered in the treatment of intracranial aneurysms except as noted above.

Experimental/Investigative Services Surgery

Endovascular Stent Grafts for Thoracic Aortic Aneurysms or Dissections

Endovascular stent grafts may be considered medically necessary for the treatment of descending thoracic aortic aneurysms without dissection using devices approved by the U.S. Food and Drug Administration for their approved specifications.

Endovascular stent grafts are considered investigational and not covered for the treatment of thoracic aortic arch aneurysms, and for the treatment of thoracic aortic dissection.

Hematopoietic Stem-Cell Transplantation

Hematopoietic Stem-Cell Transplantation for Primary Amyloidosis or Waldenstrom’s Macroglobulinemia

Autologous hematopoietic stem-cell transplantation may be considered medically necessary as salvage therapy of chemosensitive Waldenstrom macroglobulinemia.

No coverage will be provided for allogeneic hematopoietic stem-cell transplantation to treat Waldenstrom macroglobulinemia as this is considered investigational.

Hematopoietic Stem-Cell Transplantation for Non-Hodgkin’s Lymphoma

For patients with non-Hodgkin’s lymphoma (NHL) B-cell subtypes considered aggressive (except mantle cell lymphoma), either allogeneic stem-cell transplant (SCT) using a myeloablative conditioning regimen or autologous SCT may be considered medically necessary:

-as salvage therapy for patients who do not achieve a complete remission (CR) after first-line treatment (induction) with a full course of standard-dose chemotherapy;

-to achieve or consolidate a CR for those in a chemosensitive first or subsequent relapse; or 

-to consolidate a first CR in patients with diffuse large B-cell lymphoma, with an age-adjusted International Prognostic Index score that predicts a high- or high-intermediate risk of relapse.

For patients with NHL B-cell subtypes considered indolent, either allogeneic SCT using a myeloablative conditioning regimen or autologous SCT may be considered medically necessary:

-as salvage therapy for patients who do not achieve CR after first-line treatment (induction) with a full course of standard-dose chemotherapy; or

-to achieve or consolidate CR for those in a first or subsequent chemosensitive relapse, whether or not their lymphoma has undergone transformation to a higher grade.

For patients with mantle cell lymphoma:

-Autologous SCT may be considered medically necessary to consolidate a first remission.

-Allogeneic HSCT, myeloablative or reduced-intensity conditioning, may be considered medically necessary as salvage therapy. 

-Autologous HSCT is considered investigational as salvage therapy. 

-Allogeneic HSCT is considered investigational to consolidate a first remission.

Reduced-intensity conditioning allogeneic SCT may be considered medically necessary as a treatment of NHL in patients who meet criteria above for an allogeneic SCT but who do not qualify for a myeloablative allogeneic SCT.

No coverage will be provided for either autologous SCT or allogeneic SCT for the following indications, as they are considered investigational:

-as initial therapy (i.e., without a full course of standard-dose induction chemotherapy) for any NHL;

-to consolidate a first CR for patients with diffuse large B-cell lymphoma and an International Prognostic Index score that predicts a low- or low-intermediate risk of relapse;

-to consolidate a first CR for those with indolent NHL B-cell subtypes; no coverage is provided for tandem transplants to treat patients with any stage, grade, or subtype of NHL as this is considered investigational.

For patients with peripheral T-cell lymphoma:

-Autologous HSCT may be considered medically necessary to consolidate a first complete remission in high-risk peripheral T-cell lymphoma.

-Autologous or allogeneic HSCT (myeloablative or reduced-intensity conditioning) may be considered medically necessary as salvage therapy.

-Allogeneic HSCT is considered investigational and not covered to consolidate a first remission.