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August 2012

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Electrical/Neuromuscular Stimulator

Posterior Tibial Nerve Stimulation for Voiding Dysfunction

No coverage will be provided forposterior tibial nerve stimulation for urinary dysfunction, including, but not limited to overactive bladder syndrome, neurogenic bladder, urinary frequency, urgency, incontinence, and retention as this is considered investigational.

Genetic Testing

Basic Coverage Criteria for Genetic Testing

Coverage will be provided for genetic testing of a member when medically necessary.

1. Genetic testing may be considered medically necessary to establish a molecular diagnosis of an inheritable disease in a member when either of the following criteria is met:

a)   The member has a family or personal history which indicates a significant risk for a genetic defect, or

b)   The member demonstrates signs or symptoms of a genetically linked inheritable disease, and

c)   All of the below criteria are met:

  • Following completion of history, physical examination, pedigree analysis, genetic counseling, and conventional diagnostic studies, a definitive diagnosis remains uncertain, and
  • The test is a proven method to identify a genetically linked inheritable disease, and
  • There is sufficient scientific evidence to support that the test results will directly impact the management and treatment decisions of the condition, and
  • The test will result in an improvement of the net health outcome.

2. Genetic testing not meeting the above criteria is considered investigational and not covered.

Genotyping for 9p21 Single Nucleotide Polymorphisms to Predict Risk of Cardiovascular Disease or Aneurysm

No coverage will be provided for the use of 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, peripheral arterial disease, coronary artery calcification) or identification of patients who may be at increased risk for aneurysmal disease (abdominal aortic aneurysms, intracranial aneurysms, polypoidal choroidal vasculopathy).

Plasma Exchange and Apheresis Therapy

Plasma Exchange

Myeloma with acute renal failure and catastrophic antiphospholipid syndrome were previously considered investigational and not covered and will now be medically necessary and covered.

Dense deposit disease with Factor H deficiency and/or elevated C3 nephritis factor was added to the medically necessary conditions and is now covered.

Focal segmental glomerulosclerosis after renal transplant was changed to medically necessary and is covered; and the investigational statement on focal segmental glomerulosclerosis was modified to indicate that it now applies to situations other than after renal transplant.

Hyperviscoscity syndromes with renal failure (other than associated with multiple myeloma or Waldenstrom’s macroglobulinemia) are new investigational indications and not covered.