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December 2011

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Transplant
Liver Transplant

Liver transplantation is considered investigational and not covered in the following patients:

- Patients with an extrahepatic malignancy including cholangiocarcinoma

- Patients with neuroendocrine tumors metastatic to the liver

Liver transplantation is considered not medically necessaryand not coveredin the following patients:

- Patients with hepatocellular carcinoma that has extended beyond the liver

- Patients with ongoing alcohol and/or drug abuse. (Evidence for abstinence may vary among liver transplant programs, but generally a minimum of 3 months is required.)

Total Artificial Hearts and Implantable Ventricular Assist Devices
Percutaneous ventricular assist devices (pVADs) (such as the TandemHeart™ and Impella® Recover LP 2.5 Percutaneous Cardiac Support System) are considered investigational and not covered for all indications.

Electrical Bone Growth Stimulation
Ultrasound Accelerated Fracture Healing Device

Low-intensity ultrasound treatment may be considered medically necessaryand coveredas a treatment of delayed union of bones, excluding the skull and vertebra.

No coverage will be provided for other applications of low intensity ultrasound treatment including, but not limited to, treatment of congenital pseudoarthroses, open fractures, or stress fractures since these applications are considered investigational.

Electrical Bone Growth Stimulation of the Appendicular Skeleton
No coverage will be provided for applications of electrical bone growth stimulation that are consideredinvestigational including, but not limited to, immediate post-surgical treatment after appendicular skeletal surgery, or for the treatment of fresh fractures or delayed union.

Endometrial Ablation
Endometrial ablation is considered investigational and not covered for all other indications except for those women with menorrhagia who are not candidates for, or who are unresponsive to, hormone therapy and would otherwise be considered candidates for hysterectomy.

Genetic Testing
NOTCH3
Genotyping for Diagnosis of CADASIL

No coverage will be provided for NOTCH3 testing for the diagnosis of CADASIL (Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy)as this is considered investigational.

Hyperbaric Oxygen (HBO) Therapy
Hyperbaric Oxygen Pressurization

Systemic hyperbaric oxygen pressurization may be considered medically necessary for the recommended timeframes (when indicated) in the treatment of the following conditions:

Compromised skin grafts or flaps;

a)   The current standard includes twice daily treatments until the graft or flap appears viable and then once per day until completely healed.

b)   Benefit should be seen by twenty treatments; if not, continuation of therapy should be reviewed.

Necrotizing soft-tissue infections;

a)   Ten HBO treatments.

Experimental/Investigative Services Pathology/Laboratory
Identification of Microorganisms Using Nucleic Acid Probes

Identification of microorganisms using nucleic acid probes is medically necessary and covered for the detection of influenza, clostridium difficile and trichomonas vaginalis, but it is considered investigational and not covered for mycoplasma pnuemoniae.

Experimental/Investigative Services Ophthalmologic
Viscocanalostomy and Canaloplasty

No coverage will be provided for viscocanalostomy as this is considered investigational.

Retinal Telescreening for Diabetic Retinopathy
Coverage will be provided for retinal telescreening when medically necessary.

-Retinal telescreening with digital imaging and manual grading of images may be considered medically necessaryand coveredas a screening technique for the detection of diabetic retinopathy.

-Retinal telescreening is considered investigationaland not coveredfor all other indications, including the monitoring and management of disease in individuals diagnosed with diabetic retinopathy.

Experimental/Investigative Services Medicine
Quantitative Sensory Testing

No coverage will be provided for quantitative sensory testing including, but not limited to, current perception threshold testing, pressure-specified sensory device testing, vibration perception threshold testing, and thermal threshold testing, as this is considered investigational.

Experimental/Investigative Services Surgery
Auricular Electrostimulation

No coverage will be provided for electrical stimulation of auricular acupuncture points as this is considered investigational.

Dynamic Spine Stabilization
No coverage will be provided for dynamic spine stabilization for the treatment of degenerative spine disorders, either as an adjunct to spinal fusion surgery, or an alternative to fusion as this is considered investigational.  (The Dynesys® Dynamic Stabilization System by Zimmer, Inc. is an example of such a device.)

Bariatric Surgery
The surgical procedures which may be considered medically necessary have been outlined and now include the sleeve gastrectomy.

Hypertension has been added to the Patient Selection Criteria as a clinically significant obesity-related disease.