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June, 2011

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Cochlear Implantation
Cochlear Implant
Unilateral or bilateral cochlear implantation of a U.S. Food and Drug Administration (FDA) approved cochlear implant device may be considered medically necessary 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 dB (decibels) hearing loss or greater at 500 HZ (hertz), 1000 HZ, and 2000 HZ, and have shown limited or no benefit from hearing aids. Cochlear implantation when above criteria are not met is considered not medically necessary and is not covered.

Prophylactic Surgeries
Prophylactic Mastectomy
Prophylactic surgeries may be considered medically necessary in patients with documentation of specific risk factors. Additional risk factors have been identified for prophylactic oophorectomy and prophylactic mastectomy.  Prophylactic surgery for patients without documentation of specific risk factors is considered not medically necessary and not covered.

Transcatheter Embolization
Radioembolization for Primary and Metastatic Tumors of the Liver
Radioembolization or SIRT may be considered medically necessary for the following indications:

a)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.

b)In primary hepatocellular carcinoma as a bridge to liver transplantation.

c)To treat hepatic metastases from neuroendocrine tumors (carcinoid and noncarcinoid) with diffuse and symptomatic disease when systemic therapy has failed to control symptoms.

Radioembolization may be considered medically necessary to treat unresectable hepatic metastases from colorectal carcinoma that are both progressive and diffuse, in patients with liver-dominant disease who are refractory to chemotherapy or are not candidates for chemotherapy.

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

Experimental/Investigative Services OB/GYN
Fetal Surgery for Prenatally Diagnosed Malformations
In utero repair of myelomeningocele may be considered medically necessary under the following conditions:

•The fetus is at less than 26 weeks’ gestation; and
•Myelomeningocele is present with an upper boundary located between T1 and S1 with evidence of hindbrain herniation.

In utero repair of myelomeningocele is considered investigational and not covered in the following situations:
  
•Fetal anomaly unrelated to myelomeningocele; OR
•Severe kyphosis; OR
•Risk of preterm birth (e.g., short cervix or previous preterm birth); OR
•Maternal body mass index of 35 or more.

Other applications of fetal surgery are investigational and not covered, including but not limited to, temporary tracheal occlusion as a treatment of congenital diaphragmatic hernia or treatment of congenital heart defects.

Experimental/Investigative Services Pathology/Laboratory
Laboratory Testing to Allow Area Under the Curve (AUC) Targeted 5-Fluorouracil (5-FU) Dosing for Patients Administered 5-FU for Cancer
No coverage will be provided for OnDose™ testing or other types of assays for determining 5-fluorouracil area under the curve in order to adjust 5-FU dose for colorectal cancer patients or other cancer patients as this is considered investigational.

Experimental/Investigative Services Radiology
Digital Breast Tomosynthesis
No coverage will be provided for Digital breast tomosynthesis in the screening or diagnosis of breast cancer as this is considered investigational.

Chondral Defects of the Knee
Meniscal Allografts and Collagen Meniscus Implants
Meniscal allograft transplantation may be considered medically necessary in patients who have had a prior meniscectomy and have symptoms related to the affected side, when all of the following criteria are met:

a)Adult patients should be too young to be considered an appropriate candidate for total knee arthroplasty or other reconstructive knee surgery (e.g., younger than 55 years

b)Disabling knee pain with activity that is refractory to conservative treatment

c)Absence or near absence (more than 50%) of the meniscus, established by imaging or prior surgery

d)Documented minimal to absent diffuse degenerative changes in the surrounding articular cartilage (e.g. Outerbridge grade II or less, < 50% joint space narrowing)

e)Normal knee biomechanics, or alignment and stability achieved concurrently with meniscal transplantation

Meniscal allograft transplantation may be considered medically necessary when performed in combination, either concurrently or sequentially, with autologous chondrocyte implantation, osteochondral allografting or osteochondral autografting for focal articular cartilage lesions.

Microprocessor-Controlled Prostheses for the Lower Limb
Microprocessor-Controlled Prostheses for the Lower Limb
A microprocessor-controlled knee may be considered medically necessary in amputees who meet all of the following requirements:

a)Demonstrated need for long distance ambulation at variable rates (use of the limb in the home or for basic community ambulation is not sufficient to justify provision of the computerized limb over standard limb applications); OR demonstrated patient need for regular ambulation on uneven terrain or for regular use on stairs (use of the limb for limited stair climbing in the home or employment environment is not sufficient evidence for prescription of this device over standard prosthetic application); AND

b)Physical ability, including adequate cardiovascular and pulmonary reserve, for ambulation at faster than normal walking speed; and

c)Adequate cognitive ability to master use and care requirements for the technology.

A microprocessor-controlled knee is considered not medically necessary and not covered in individuals who do not meet these criteria.

Cryosurgical Ablation and Radiofrequency Ablation (RFA)
Catheter Ablation of the Pulmonary Veins as Treatment for Atrial Fibrillation
 
Transcatheter radiofrequency ablation of arrhythmogenic foci in the pulmonary veins may be considered medically necessary as a treatment for either of the following indications which have failed to respond to adequate trials of antiarrhythmic medications:

•Symptomatic paroxysmal or symptomatic persistent atrial fibrillation; or

•As an alternative to atrioventricular nodal ablation and pacemaker insertion in patients with class II or III congestive heart failure and symptomatic atrial fibrillation.

Repeat radiofrequency ablations may be considered medically necessary in patients with recurrence of atrial fibrillation and/or development of atrial flutter following the initial procedure.

Transcatheter ablation of arrhythmogenic foci in the pulmonary veins is considered investigational and not covered as a treatment for all indications except for specific cases of atrial fibrillation as noted above.

Transcatheter cryoablation of arrhythmogenic foci in the pulmonary veins as a treatment for atrial fibrillation is considered investigational and not covered.

Hematopoietic Stem-Cell Transplantation
Hematopoietic Stem-Cell Transplantation for Multiple Myeloma

Tandem autologous-autologous hematopoietic stem-cell transplantation may be considered medically necessary to treat multiple myeloma in patients who fail to achieve at least a near-complete or very good partial response after the first transplant in the tandem sequence.

Intensity-Modulated Radiation Therapy
-Intensity Modulated Radiation Therapy (IMRT) of the Breast and Lung
-Intensity Modulated Radiation Therapy (IMRT) of the Prostate
-Intensity Modulated Radiation Therapy (IMRT): Cancer of the Head and Neck or Thyroid
-Intensity Modulated Radiation Therapy (IMRT): Abdomen and Pelvis

This new policy effective May 1, 2011 which addresses an advanced technology utilizing three-dimensional conformal radiation therapy for delivering precise radiation doses to tumors with the potential to maximally spare adjacent normal tissue.

Coverage for IMRT is dependent on specific policy criteria, therefore, all requests for this service or claims submitted for the provision of this service will be subjected to the clinical review process.