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November 2011

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Durable Medical Equipment (DME)
Pneumatic Compression Pumps for Treatment of Lymphedema

Single compartment or multichamber lymphedema pumps are considered investigational and not covered in all situations not meeting policy criteria. 

Ultraviolet Light Therapies
Coverage will be provided for ultraviolet light therapy in the home when medically necessary. 

Therapy is limited to Ultraviolet light B (UVB).  Psoralen and Ultraviolet light A (PUVA) is not appropriate for home therapy.

Ultraviolet light therapy in the home may be considered medically necessary in those patients who require long term maintenance therapy and who meet all of the following criteria:

a) The patient must be diagnosed with one of the following conditions:

  • Severe Psoriasis
  • Atopic Dermatitis/Severe Eczema
  • Pruritus of Renal Disease

b) The patient must have a documented positive response to UVB;

c) The patient’s condition must be chronic or recalcitrant in nature requiring long term maintenance therapy exceeding four months;

d) The device must be ordered by a physician;

e) The device must be limited to the most appropriate device which adequately meets the needs of the patient, and is appropriate for the body surface/area being treated;

f) The device must be approved by the Food and Drug Administration and safe for home use.

Ultraviolet light therapy in the home provided for other conditions or not meeting the above criteria is considered not medically necessary and not covered.

Genetic Testing
DNA-Based Testing for Adolescent Idiopathic Scoliosis
No coverage will be provided for DNA-based prognostic testing for adolescent idiopathic scoliosis as this is considered investigational.

Transmyocardial Revascularization
Open transmyocardial laser revascularization is considered not medically necessary and not covered when the policy criteria have not been met.

Wound Care
Tissue-Engineered Skin Substitutes
Coverage will be provided for tissue-engineered skin substitutes when medically necessary.

1.Treatment of chronic, noninfected, full-thickness diabetic lower extremity ulcers using the following tissue-engineered skin substitutes may be considered medically necessary.

  • Apligraf®**
  • Dermagraft®**

2. Treatment of chronic, non-infected, partial or full-thickness lower extremity skin ulcers due to venous insufficiency which have not adequately responded following a one month period of conventional ulcer therapy using the following tissue-engineered skin substitutes may be considered medically necessary.

  • Apligraf®**
  • Oasis™ Wound Matrix***

3. Treatment of dystrophic epidermolysis bullosa using the following tissue-engineered skin substitutes may be considered medically necessary.

  • Dermagraft®****
  • OrCel™ (for the treatment of mitten-hand deformity when standard wound therapy has failed and when provided in accordance with the Humanitarian Device Exemption (HDE) specifications of the FDA)****

4. Treatment of second and third degree burns using the following tissue-engineered skin substitutes may be considered medically necessary.

  • Epicel® (for the treatment of deep dermal or full-thickness burns comprising a total body surface area of greater than or equal to 30% when provided in accordance with the HDE specifications of the FDA)****
  • Integra™**
  • TransCyte™**

5. Breast reconstructive surgery using AlloDerm®* may be considered medically necessary:

  • When there is insufficient tissue expander or implant coverage by the pectoralis major muscle and additional coverage is required,
  • When there is viable but compromised or thin post-mastectomy skin flaps that are at risk of dehiscence or necrosis, or
  • the infra-mammary fold and lateral mammary folds have been undermined during mastectomy and re-establishment of these landmarks is needed.

*Banked Human Tissue
** FDA PMA approved
*** FDA 510(k) cleared
**** FDA-approved under a humanitarian device exemption (HDE)

6. All other uses of allogeneic skin substitutes listed above are considered investigational and not covered.

7. All other skin substitutes not listed above are considered investigational, including, but not limited to:

  • AlloPatch HD™
  • AlloMax™
  • AlloSkin™
  • AlloSkin™ RT
  • ArthroFlex™ (FlexGraft)
  • Avaulta Plus™
  • Biobrane®
  • BioDfence/BioDfactor
  • CellerateRX®
  • Conexa™
  • CorMatrix®
  • CRXa™
  • Cymetra®
  • DermaMatrix Acellular Dermis
  • Durepair Regeneration Matrix®
  • Endoform Dermal Template™
  • ENDURAgen™
  • E-Z Derm™
  • FlexHD® Acellular Hydrated Dermis
  • GammaGraft
  • GraftJacket® Regenerative Tissue Matrix
  • GraftJacket® Xpress, injectable
  • Hyalomatrix® PA
  • Integra™ Flowable Wound Matrix
  • Integra Dermal Regeneration Template
  • MatriStem® Micromatrix
  • MatriStem®Wound Matrix
  • MatriStem® Burn Matrix
  • Matrix HD™
  • MediHoney®
  • Mediskin®
  • MemoDerm™
  • PriMatrix
  • Oasis® Burn Matrix
  • Oasis® Ultra Tri-Layer Matrix
  • Permacol™
  • PriMatrix
  • Repriza™
  • Strattice™ (xenograft)
  • SurgiMend®
  • Talymed®
  • TenoGlide™
  • TheraSkin®Unite™
  • Veritas® Collagen Matrix

Hyperbaric Oxygen (HBO) Therapy
Hyperbaric Oxygen Pressurization (HBO)
No coverage will be provided for systemic hyperbaric oxygenation pressurization in the treatment of the following conditions as this is considered investigational:

  • Acute surgical and traumatic wounds;
  • Chronic arm lymphedema following radiotherapy for cancer;
  • Idiopathic femoral neck necrosis;
  • Radiation-induced injury in the head and neck.

Experimental/Investigative Services Medicine
Percutaneous Intracranial Balloon Angioplasty With or Without Stenting
Intracranial percutaneous transluminal angioplasty with or without stenting is considered investigational and not covered in the treatment of atherosclerotic cerebrovascular disease and subarachnoid hemorrhage-induced intracranial vasospasm.

Experimental/Investigative Services Surgery
Miscellaneous Services
No coverage will be provided for percutaneous tenotomy of the elbow for the treatment of epicondylitis, tennis elbow, or golfer’s elbow as this is considered investigational.

Experimental/Investigative Services Therapy
Baroreflex Stimulation Devices
No coverage will be provided for the use of baroreflex stimulation implanted devices as this is considered investigational.