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July 2013

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Genetic Testing
Molecular Markers in Fine Needle Aspirates of the Thyroid

No coverage will be provided for the use of a gene expression classifier [miRInform™ (Asuragen) and Veracyte® (Afirma)] in fine-needle aspirates of the thyroid that are cytologically considered to be indeterminate, atypical or suspicious for malignancy, as this is considered investigational.

Experimental/Investigative Services Surgery
Diagnosis and Treatment of Sacroiliac Joint Pain

No coverage will be provided for the use of fusion/stabilization of the sacroiliac joint for the treatment of back pain presumed to originate from the SI joint as it is considered investigational, including but not limited to percutaneous and minimally invasive techniques.

Percutaneous Kyphoplasty, Vertebroplasty and Sacroplasty
Percutaneous Balloon Kyphoplasty and Mechanical Vertebral Augmentation

No coverage will be provided for percutaneous mechanical vertebral augmentation using any other device, including but not limited to Kiva® VCF Treatment System, as this is considered investigational.

Cardiac Rhythm Devices
Biventricular Pacemakers (Cardiac Resynchronization Therapy) for the Treatment of Heart Failure

No coverage will be provided for triple-site (triventricular) CRT, using an additional pacing lead, as this is considered investigational.

Hematopoietic Stem-Cell Transplantation (HSCT)
Orthopedic Applications of Stem-Cell Therapy

No coverage will be provided for allograft bone products containing viable stem cells, including but not limited to demineralized bone matrix (DBM) with stem cells, as this is considered investigationalfor all orthopedic applications.