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August 2013

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Transplant
Kidney Transplant
Kidney retransplant after a failed primary kidney transplant may be considered medically necessary and covered.

Genetic Testing
Genetic Testing for Lactase Insufficiency
No coverage will be provided for the use of targeted mutation analysis of -13910 C>T for the prediction of lactase insufficiency as this is considered investigational.

Foot Care Services
Laser Treatment of Onychomycosis
No coverage will be provided for laser treatment of onychomycosis as this is considered investigational.

Experimental/Investigative Services
No coverage will be provided for all services and procedures identified by a CPT Category III code, unless specific policy language exists extending coverage for a particular Category III code, as these codes represent emerging technology that may not be FDA approved, or proven to be safe and effective based upon peer review or scientific literature, or have not been performed by many health care professionals across the country, as these are considered investigational.

Experimental/Investigative Services Surgery
No coverage will be provided for the use of an interlaminar stabilization device following decompressive surgery as this is considered investigational.

Hematopoietic Stem-Cell Transplantation (HSCT)
Hematopoietic Stem-Cell Transplantation for Acute Lymphoblastic Leukemia
Allogeneic HSCT is considered medically necessary and coveredto treat relapsing ALL after a prior autologous HSCT in adults and children.