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October 2012

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Stereotactic Radiosurgery and Charged-Particle Radiation Therapy
Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy

SRS using a gamma or LINAC unit may be considered medically necessary and coveredfor the following indications:

a)   Arteriovenous malformations;

b)   Acoustic neuromas;

c)   Pituitary adenomas;

d)   Non-resectable, residual or recurrent menigiomas;

e)   Craniopharyngiomas;

f)    Glomus jugulare tumors;

g)   Solitary or multiple brain metastases in patients having good performance status and no active systemic disease (defined as extracranial disease that is stable or in remission);

h)   Primary malignancies of the CNS (Central Nervous System) including but not limited to high grade gliomas (initial treatment or treatment of recurrence); and

i)    Trigeminal neuralgia refractory to medical management.

When SRS is performed using fractionation for the medically necessary indications described above, it is considered medically necessary and covered.

Investigational (non-covered) applications of SRS include, but are not limited to, the treatment of seizures and functional disorders other than trigeminal neuralgia, including chronic pain.

SBRT may be considered medically necessaryfor the following indications:

a)   Patients with stage T1 or T2a non-small cell lung cancer (not larger than 5cm) showing no nodal or distant disease and who are not candidates for surgical resection;

b)   Spinal or vertebral body tumors (metastatic or primary) in patients who have received prior radiation therapy;

c)   Spinal or vertebral metastases that are radioresistant (e.g., renal cell carcinoma, melanoma and sarcoma).

When SBRT is performed using fractionation for the medically necessary indications described above, it is considered medically necessary and covered.

SBRT is considered investigationaland not coveredfor primary and metastatic tumors of the liver, pancreas, kidney, adrenal glands and prostate.

Brachytherapy
Brachytherapy for Clinically Localized Prostate Cancer Using Permanently Implanted Seeds

No coverage will be provided for focal or subtotal prostate brachytherapy as this is considered investigational in the treatment of prostate cancer.

Genetic Testing
Genetic Testing for FMR 1 Mutations (including Fragile X Syndrome)

Coverage will be provided for genetic testing for FMR 1 mutations when medically necessary.

1.Genetic testing for FMR 1 mutations may be considered medically necessaryfor the following patient populations:

a)   Individuals of either sex with mental retardation, developmental delay, or autism spectrum disorder,

b)   Individuals seeking reproductive counseling who have a family history of fragile X syndrome or a family history of undiagnosed mental retardation,

c)   Prenatal testing of fetuses of known carrier mothers,

d)   Affected individuals or their relatives who have had a positive cytogenetic fragile X test result, and who are seeking further counseling related to the risk of carrier status among themselves or their relatives.

2. Genetic testing for FMR 1 mutations is considered not medically necessary for all other patient populations.

Genetic Testing for Rett Syndrome

Coverage will be provided for genetic testing for Rett Syndrome when medically necessary.

1. Mutation testing for Rett syndrome may be considered medically necessary to confirm a diagnosis of Rett syndrome in a female child with developmental delay and signs/symptoms of Rett syndrome, but when there is uncertainty in the clinical diagnosis.

2. All other indications for mutation testing for Rett syndrome, including prenatal screening and testing of family members, are considered investigational and not covered.

Experimental/Investigative Services Pathology/Laboratory
PreDx™ Diabetes Risk Profile

No coverage will be provided for the measurement of serum biomarkers associated with Type 2 diabetes to determine relative risk of developing diabetes as this is considered investigational.

Experimental/Investigative Services Surgery
Biometric Bone Void Filler

No coverage will be provided for biometric bone void fillers (e.g., Integra, Allomatrix, Opteform, Trinity Evolution, Vitoss, Wellgraft PE II) when administered during arthroscopic knee surgery as this is considered investigational.

Tumor Marker
Urinary Tumor Markers for Bladder Cancer

No coverage will be provided for the use of urinary tumor markers in the diagnosis of, monitoring, and/or screening for bladder cancer, as this is considered investigational.

Not Medically Necessary
Miscellaneous Services

No coverage will be provided for Rhinomanometry as it is considered not medically necessary.

Myoelectric Prosthesis for the Upper Limb
Myoelectric Prosthesis for the Upper Limb

No coverage will be provided for a prosthesis with individually powered digits, including but not limited to a partial hand prosthesis as this is considered investigational.

Ablation Services
Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate, or Dermatologic Tumors

Cryosurgical ablation is considered investigational and not covered as a treatment of benign or malignant tumors of the breast, lung, pancreatic cancer and renal cell carcinomas in patients who are surgical candidates, or other solid tumors outside the liver and prostate.

Intensity-Modulated Radiation Therapy (IMRT)
Intensity-Modulated Radiation Therapy (IMRT): Cancer of the Head and Neck or Thyroid

Intensity-modulated radiation therapy (IMRT) as a technique to deliver radiation therapy may be considered medically necessaryand coveredfor the treatment of thyroid cancers in close proximity to organs at risk (esophagus, salivary glands, and spinal cord) and 3-D CRT planning is not able to meet dose volume constraints for normal tissue tolerance.

Intensity-Modulated Radiation Therapy (IMRT): Central Nervous System Tumors
Intensity-modulated radiation therapy (IMRT) as a technique to deliver radiation therapy may be considered medically necessary and covered for the treatment of tumors of the central nervous system when the tumor is in close proximity to organs at risk (brain stem, spinal cord, cochlea and eye structures including optic nerve and chiasm, lens and retina) and 3-D CRT planning is not able to meet dose volume constraints for normal tissue tolerance.

Intensity-Modulated Radiation Therapy (IMRT): Breast and Lung
Intensity modulated radiation therapy (IMRT) of the chest wall is considered investigational and not covered as a technique of postmastectomy irradiation.