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December 2012

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Transplant
Total Artificial Hearts and Implantable Ventricular Assist Devices

Total artificial hearts with FDA-approved devices may be considered medically necessary and covered as a bridge to heart transplantation for patients with biventricular failure who have no other reasonable medical or surgical treatment options, who are ineligible for other univentricular or biventricular support devices, and are currently listed as heart transplantation candidates or are undergoing evaluation to determine candidacy for heart transplantation, and not expected to survive until a donor heart can be obtained.

Electrical Bone Growth Stimulation
Ultrasound Accelerated Fracture Healing Device

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

Electrical Bone Growth Stimulation of the Appendicular Skeleton
BCNEPA will not provide coverage 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, delayed union, or failed arthrodesis.

Genetic Testing
Cytochrome p450 Genotyping

CYP450 genotyping for the purpose of aiding in the choice of clopidogrel versus alternative anti-platelet agents, or in decisions on the optimal dosing for clopidogrel, may be considered medically necessary and covered.

CYP450 genotyping for the purpose of aiding in the choice of drug or dose to increase efficacy and/or avoid toxicity for all other drugs is considered investigational and not covered, aside from determinations in the separate applications noted below (see R, S, T).  This includes, but is not limited to, CYP450 genotyping for the following applications:

  • Selection and dosing of selective norepinephrine reuptake inhibitors
  • Selection and dosing of tricyclic antidepressants

Genetic Testing for Inherited Thrombophilia
BCNEPA will not provide coverage for genetic testing for inherited thrombophilia, including testing for factor V Leiden mutations, prothrombin gene mutations, and mutations in the MTHFR gene, as this is considered investigational.

Genetic Testing for Cystic Fibrosis
BCNEPA will provide coverage for genetic testing of the CFTR gene for cystic Fibrosis (CF) using the American College of Medical Genetics (ACMG) recommended mutation core panel (ACMG-23) when medically necessary.

1. Genetic carrier testing for CF may be considered medically necessary and covered for any of the following indications:

a) Couples seeking prenatal care; or

b) Couples who are planning a pregnancy; or

c)  Persons with a family history of CF; or

d)  Persons with a first degree relative identified as a CF carrier; or

e)  Reproductive partners of persons with CF.

2. Genetic testing for the diagnosis of CF may be considered medically necessary and covered for any of the following indications

a)  An individual who has one or more characteristic phenotypic features of CF, but negative/equivocal sweat chloride values; or

b)  An infant who has a meconium ileus or other symptoms indicative of CF, but who is too young to produce adequate volumes of sweat; or

c)  A male with congenital absence of the vas deferens (CAVD).

3.   Genetic testing for prenatal (fetus) diagnosisof CF may be considered medically necessary and covered for any of the following indications:

a)  A fetus when both parents have an combination of a diagnosis of CF, or is a known carrier of a CFTR mutation, or has a family history of CF; or

b)  A fetus when both parents are CFTR mutation carriers and an echogenic bowel is identified on ultrasound.

4.   Genetic testing for CF is considered not medically necessary and not covered for any of the following indications:

a)   Carrier screening in the general population; or

b)   Persons who have previously been tested; or

c)   Routine genetic screening for CF in newborns; or

d)   CFTR gene sequence analysis or extended mutation panels (i.e., beyond the ACMG-23 standard mutation panel).

Transcatheter Embolization
Occlusion of Uterine Arteries Using Transcatheter Embolization

One repeat transcatheter embolization of uterine arteries to treat persistent symptoms of uterine fibroids after an initial uterine artery embolization may be considered medically necessary and covered.

Experimental/Investigative Services Medicine
Optical Diagnostic Devices for Evaluating Skin Lesions Suspected of Malignancy

BCNEPA will not provide coverage for dermatoscopy or optical diagnostic devices using the following techniques as this is considered investigational:

  1. Dermatoscopy, using either direct inspection, digitization of images, or computer-assisted analysis, as a technique to evaluate or serially monitor pigmented skin lesions;
  2. Computer-based optical imaging devices e.g., multispectral digital skin lesion analysis, as a technique to evaluate or serially monitor pigmented skin lesions (MelaFind).
  3. Dermatoscopy and computer-based optical imaging devicesfor defining peripheral margins of skin lesions suspected of malignancy prior to surgical excision.

Experimental/Investigative Services Surgery
Interspinous Fixation (Fusion) Devices

BCNEPA will not provide coverage for interspinous fixation (fusion) devices for any indication, including but not limited to use in combination with interbody fusion, or alone for decompression in patients with spinal stenosis as this is considered investigational.

Ablation Services
Diagnosis and Treatment of Sacroiliac Joint Pain

BCNEPA will not provide coverage for radiofrequency ablation of the sacroiliac joint as this is considered investigational.

Cardiac Rhythm Devices
Implantable Cardioverter Defibrillator (ICD)

The use of a subcutaneous ICD is considered investigationaland not coveredfor all indications in adult and pediatric patients.

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

The use of direct and amplified nucleic acid probes to identify microorganisms which are part of a respiratory virus panel may be considered medically necessary and covered in the diagnosis of respiratory tract infections.

The use of nucleic acid probes for the purpose of quantification of microorganisms which are part of a respiratory virus panel is considered investigational and not covered in the diagnosis of respiratory tract infections.