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January 2013

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Durable Medical Equipment (DME)
Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers

Two-phase multi-chamber lymphedema pumps (e.g., Flexitouch and the Lympha Press Optimal®) are covered for treatment of lymphedema.

Lymphedema pumps are considered investigational and not covered for the treatment of venous ulcers.

Electrical/Neuromuscular Stimulator
Gastric Electrical Stimulation

No coverage will be provided for gastric electrical stimulation for the treatment of gastroparesis of diabetic, idiopathic or post-surgical etiology it is considered investigational

Genetic Testing
BRAF Gene Mutation Testing To Select Melanoma Patients for BRAF Inhibitor Targeted Therapy

Testing for the BRAFV600 mutation in tumor tissue of patients with stage IIIC or IV melanoma may be considered medically necessary and covered for select patients for treatment with FDA-approved BRAF inhibitors.  (Currently only vemurafenib has FDA approval for treatment of advanced melanoma).

Experimental/Investigative Services Pathology/Laboratory
Bone Turnover Markers for Diagnosis and Management of Osteoporosis and Diseases Associated with High Bone Turnover

No coverage will be provided for measurement of bone turnover markers in the management of patients with conditions associated with high rates of bone turnover, including but not limited to Paget’s disease, primary hyperparathyroidism and renal osteodystrophy as this is considered investigational.

Nerve Fiber Density Testing
No coverage will be provided for the measurement of sweat gland nerve fiber density as this is investigational.

Experimental/Investigative Services Ophthalmologic
Aqueous Shunts and Stents for Glaucoma

No coverage will be provided for the use of a micro-stent as this is considered investigational.

Experimental/Investigative Services Surgery
Facet Joint Denervation

Chemodenervation for facet joint pain is considered investigational and not covered for the treatment of chronic spinal/back pain and has been added to the other investigational indications (pulsed radiofrequency denervation, laser denervation, and cryodenervation).

Experimental/Investigative Services Therapy
Inhaled Nitric Oxide

Inhaled nitric oxide is investigational and not covered when used in premature neonates born at less than or equal to 34 weeks of gestation and adults and children with acute hypoxemic respiratory failure.

Ablation Services
Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors

Radiofrequency ablation is considered investigationaland not coveredas a technique for ablation of thyroid tumors.

Cardiac Rhythm Devices
Wearable Cardioverter-Defibrillators as a Bridge to Implantable Cardioverter-Defibrillator Placement

Use of wearable cardioverter-defibrillators for the prevention of sudden cardiac death is considered medically necessary and covered as interim treatment for those who:

  1. Meet the criteria for an implantable cardioverter-defibrillator; and
  2. Have a temporary contraindication to receiving an ICD, such as a systemic infection, at the current time; and
  3. Have been scheduled for an ICD placement or who had an ICD removed and have been rescheduled for placement of another ICD once the contraindication is treated.