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July 2012

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Electrical/Neuromuscular Stimulator

Sacral Nerve Neuromodulation/Stimulation

For urinary incontinence and non-obstructive retention, a trial period of sacral nerve neuromodulation with either percutaneous nerve stimulation or a temporarily implanted lead may be considered medically necessaryand coveredin patients who meet all of the following criteria:

a)   There is a diagnosis of at least one of the following:

  • Urge incontinence
  • Urgency-frequency
  • Non-obstructive urinary retention

b)   There is documented failure or intolerance to at least two conventional therapies (e.g., behavioral training such as bladder training, prompted voiding, or pelvic muscle exercise training, pharmacologic treatment for at least a sufficient duration to fully assess its efficacy, and/or surgical corrective therapy);

c)   Incontinence is not related to a neurologic condition.

Permanent implantation of a sacral nerve neuromodulation device may be considered medically necessary in patients who meet all of the following criteria:

a)   All of the above criteria a) - c) are met, and

b)   A trial stimulation period demonstrates at least 50% improvement in symptoms over a period of at least 2 weeks.

Sleep Disorder Services

Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome

A nasal expiratory positive airway pressure (EPAP) device (e.g., PROVENT Sleep Apnea Therapy) is considered investigational and not covered.

Genetic Testing

Genetic Testing for Alpha-1 Antitrypsin Deficiency

Coverage will be provided for genetic testing for alpha-1 antitrypsin deficiency when medically necessary.

1.   Genetic testing for alpha-1 antitrypsin deficiency may be considered medically necessarywhen both of the following conditions are met:

a)   Patient is suspected of having alpha-1 antitrypsin deficiency because of clinical factors and/or because the patient may be at high risk of having alpha-1 antitrypsin deficiency due to a first-degree relative (parent, child or sibling) with AAT deficiency; AND

NOTE:  The following clinical factors should prompt suspicion by physicians that their patient may be more likely to have AAT deficiency:

  • Early-onset emphysema (age of 45 years or less)
  • Emphysema in the absence of a recognized risk factor (smoking, occupational dust exposure, etc.)
  • Emphysema with prominent basilar hyperlucency
  • Otherwise unexplained liver disease
  • Necrotizing panniculitis
  • Anti-proteinase 3-positive vasculitis (C-ANCA [anti-neutrophil cytoplasmic antibody]-positive vasculitis)
  • Bronchiectasis without evident etiology

b)   Patient has a serum alpha-1 antitrypsin level in the range of severe deficiency (a level of less than 11 uM is generally considered to be associated with an increased risk of clinical disease, but this cut-off may vary according to the specific test used).

2.   Genetic testing for alpha-1 antitrypsin deficiency is considered investigationalin all other situations.

Genetic Testing for Hemochromatosis

Genetic testing for HFE gene mutations may be considered medically necessaryand covered in a patient with abnormal serum iron indices (specifically elevated transferrin saturation and elevated serum ferritin concentration) indicating iron overload.

Genetic testing for HFE gene mutations may be considered medically necessary and covered in individuals with a family history of hemochromatosis in a first-degree relative (parent, child or sibling).

Genetic testing for hereditary hemochromatosis in screening of the general population is considered investigational and not covered.

Photodynamic Therapy

Photodynamic Therapy for Choroidal Neovascularization

Photodynamic therapy is considered investigational and not covered when used in combination with one or more of the anti-vascular endothelial growth factor therapies (anti-VEGF), i.e., pegatanib (Macugen®), ranibizumab (Lucentis®), bevacizumab (Avastin®), aflibercept (Eylea™) as a treatment of CNV associated with age-related macular degeneration, pathologic myopia, presumed ocular histoplasmosis, or for other ophthalmologic disorders, including CNV secondary to central serous chorioretinopathy.

Experimental/Investigative Services Ophthalmologic

Intravitreal Corticosteroid Implants

A fluocinolone acetonide intravitreal implant approved by the U.S. Food and Drug Administration (i.e., Retisert®) may be considered medically necessary for the treatment of chronic noninfectious intermediate, posterior or panuveitis.

A dexamethasone intravitreal implant approved by the U.S. Food and Drug Administration (i.e., Ozurdex™) may be considered medically necessary for the treatment of:

a)   Non-infectious ocular inflammation, or uveitis, affecting the intermediate or posterior segment of the eye, OR

b)   Macular edema following branch or central retinal vein occlusion.

Ablation Services

Endoscopic Radiofrequency Ablation or Cryoablation for Barrett’s Esophagus;

Radiofrequency Ablation of the Esophagus

Radiofrequency ablation may be considered medically necessaryand coveredfor treatment of Barrett’s esophagus with low-grade dysplasia when the diagnosis of low-grade dysplasia is confirmed by two pathologists prior to radiofrequency ablation.

Hematopoietic Stem-Cell Transplantation (HSCT)

Hematopoietic Stem-Cell Transplantation for Solid Tumors of Childhood

Tandem autologous hematopoietic stem-cell transplantation may be considered medically necessaryand covered for high-risk neuroblastoma.

No coverage will be provided for tandem autologous hematopoietic stem-cell transplantation for the treatment of all other types of pediatric solid tumors except high-risk neuroblastoma, as noted above, as this is considered investigational.