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August 2011

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Medical Policy Changes Effective 8/1/11


Kidney Transplant

Kidney transplantation is considered not medically necessaryin patients with the following absolute contraindications:

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 disease.

The following guidelines apply:
Relative contraindications to kidney 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; or

d) Lack of adequate cardiopulmonary reserve.

HIV-positive patients who meet the following criteria, as stated in the 2001 guidelines of the American Society of Transplantation, could be considered candidates for kidney transplantation:

a) CD4 count >200 cells per cubic millimeter for >6 months

b) HIV-1 RNA undetectable

c) On stable anti-retroviral therapy >3 months

d) No other complications from AIDS (e.g., opportunistic infection, including aspergillus, tuberculosis, coccidiosis mycosis, resistant fungal infections, Kaposi’s sarcoma, or other neoplasm), and

e) Meeting all other criteria for transplantation.

Durable Medical Equipment (DME)

Pneumatic Compression Devices

The following investigational indications were added to existing policy, and associated coding will now require clinical review:

-Segmental pneumatic compression pumps and appliances are considered investigational and not covered for the treatment of lymphedema of the chest or trunk.

-Pneumatic compression pumps are considered investigational and not covered when used for the treatment of arterial insufficiency.

Genetic Testing

Genetic Testing for Lipoprotein(a) Variant(s) as a Decision Aid for Aspirin Treatment

No coverage is provided for the use of genetic testing for the rs3798220 allele (LPA-Aspirin Check®) as this is considered investigationalin patients who are being considered for treatment with aspirin to reduce risk of cardiovascular events.

Genotyping for 9p21 Genetic Polymorphisms to Predict Cardiovascular Disease Risk

No coverage is provided for genotyping for 9p21 single nucleotide polymorphisms as this is considered investigational, including use to identify patients who may be at increased risk of cardiovascular disease or its manifestations (e.g., MI, ischemic stroke) or those who may be at increased risk of abdominal aortic aneurysm or intracranial aneurysm.

Experimental/Investigative Services Ophthalmologic

Aqueous Shunts and Devices for Glaucoma

Canaloplasty may be considered medically necessaryas a method to reduce intraocular pressure in patients with glaucoma under the following conditions:

a) Medical therapy has failed to adequately control intraocular pressure, AND

b) The patient is not a candidate for any other intraocular pressure lowering procedure (e.g. trabeculectomy or glaucoma drainage implant).

Canaloplasty is considered investigational and not covered under all other conditions, including angle closure glaucoma.

Bariatric Surgery

A sleeve gastrectomy is an alternative approach to bariatric surgery for morbid obesity resulting in a stomach remnant shaped like a tube or sleeve. This procedure is relatively simple to perform, and can be done as an open or laparoscopic procedure. Some surgeons have proposed the sleeve gastrectomy as the first in a two-stage procedure for very high-risk patients.

Once considered investigational, it is now medically necessary in the treatment of morbid obesity that has not responded to conservative measures.

Hematopoietic Stem-Cell Transplantation

Stem-cell Therapy for Peripheral Arterial Disease

No coverage is provided for treatment of peripheral arterial disease, including critical limb ischemia, with injection or infusion of cells concentrated from bone marrow aspirate as this is considered investigational.