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October 2013

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Transplant
Small Bowel/Liver and Multivisceral Transplant
A small bowel/liver transplant or multivisceral retransplant may be considered medically necessaryafter a failed primary small bowel/liver transplant or multivisceral transplant. Coverage is provided.

Electrical/Neuromuscular Stimulator
Deep Brain Stimulation
No coverage will be provided for deep brain stimulation for the following indications as they are considered investigational and, therefore, not covered because the safety and effectiveness of these services cannot be established by review of the available published peer-reviewed literature:

  • Treatment of other psychiatric or neurologic disorders including, but not limited to Tourette’s syndrome, depression, obsessive compulsive disorders, anorexia nervosa, alcohol addiction, chronic pain, and epilepsy.

Surgically Implanted Hearing Devices
Cochlear Implant
Cochlear implantation as a treatment for patients with unilateral hearing loss with or without tinnitus is considered investigational and is not covered.

Genetic Testing
Genetic Testing for Statin-Induced Myopathy
No coverage will be provided for genetic testing for the presence of variants in the SLCO1B1 gene for the purpose of identifying patients at risk of statin-induced myopathy as this is considered not medically necessary.

Genetic Testing for the Diagnosis of Inherited Peripheral Neuropathies
No coverage will be provided for genetic testing for the diagnosis of inherited peripheral neuropathies to confirm a clinical diagnosis, or for all other indications as this is considered investigational.

Genetic Cancer Susceptibility Panels Using Next Generation Sequencing
No coverage will be provided for genetic cancer susceptibility panels using next generation sequencing (i.e., BreastNext, OvaNext, ColoNext, and CancerNext) as these are considered investigational.

Microarray-Based Gene Expression Profile Testing for Multiple Myeloma Risk Stratification
No coverage will be provided for microarray-based gene expression profile testing (i.e., MyPRS™/MyPRS Plus™ GEP70 test from Signal Genetics LLC, Little Rock, AR) for multiple myeloma as it is considered investigationalfor all indications.

Experimental/Investigative Services Radiology
Myocardial Sympathetic Innervation Imaging in Patients with Heart Failure
No coverage will be provided for myocardial sympathetic innervation imaging with 123Iodine meta-iodobenzylguanidine (MIBG) as this is considered investigationalfor patients with heart failure (i.e. AdreView™).

Ablation Services
Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate, or Dermatologic Tumors
No coverage will be provided for cryosurgical ablation for the following indications as they are considered investigational:

  1. As a treatment of renal cell carcinomas in patients who are surgical candidates.
  2. As a treatment of benign or malignant tumors of the breast, lung, pancreas and other solid tumors or metastases outside the liver and prostate.