Molecular Testing in the Management of Pulmonary Nodules, 12.04.142 Plasma-based proteomic testing (Xpresys® Lung) in patients with pulmonary nodules detected radiographically is investigational. Gene expression profiling (Percepta® Bronchial
Genomic Classifier) on bronchial brushings in patients with indeterminate bronchoscopy results is investigational. Note: Effective January 4, 2019 the services originally described in this policy are reviewed by AIM Specialty Health®.
Sphenopalatine Ganglion Block for Headache, 7.01.159 Sphenopalatine ganglion blocks are investigational for all indications. Read the full policy.
Amniotic Membrane and Amniotic Fluid, 7.01.149 The policy statement was revised to include a medically necessary statement for sutured human amniotic membrane grafts for specific eye indications. Human amniotic membrane without suture is investigational
for eye indications. Read the full policy.
Cardiac Rehabilitation in the Outpatient Setting, 8.03.08 The policy statement was revised to include a statement that intensive cardiac rehabilitation with the Ornish Program for Reversing Heart Disease and the Pritikin Program are not medically
necessary. Read the full policy.
Genetic Testing for Mitochondrial Disorders, 12.04.117 The policy statements were revised as follows: Genetic testing is no longer restricted to a set of specific mutations documented for a particular mitochondrial disorder. The medical necessity
statement was revised to remove “female” for carrier testing of at-risk relatives. Note: Effective January 4, 2019 the services originally described in this policy are reviewed by AIM Specialty Health®.
Genetic Testing for Rett Syndrome, 12.04.81 The policy statement for genetic testing to diagnosis Rett syndrome in a child was revised to remove the word “female.” A medically necessary policy statement was added for targeted genetic testing
to determine carrier status of a mother or sister of a person with Rett syndrome. All other genetic testing for Rett syndrome is investigational. Note: Effective January 4, 2019 the services originally described in this policy are reviewed by AIM Specialty Health®.
Hematopoietic Cell Transplantation for Solid Tumors of Childhood, 8.01.511 The policy statement was revised as follows: Hematopoietic cell transplantation (HCT) for metastatic retinoblastoma is medically necessary. HCT for retinoblastoma without
metastases is investigational. HCT for late stage Wilms tumor is investigational. Tandem autologous HCT for high-risk or relapsed neuroblastoma is medically necessary. Read the full policy.
Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Conditions, 1.01.15 The policy was clarified to state that use of high-frequency chest wall compression devices and intrapulmonary percussive devices are considered
not medically necessary rather than investigational for chronic lung conditions such as obstructive pulmonary disease or respiratory conditions associated with neuromuscular disorders. Read the full policy.
Percutaneous Vertebroplasty and Sacroplasty, 6.01.25 The policy statement was revised to include a medically necessary statement for vertebroplasty in vertebral fractures less than 6 weeks old when the fracture leads to hospitalization or
prevents walking. Read the full policy.
An archived policy is no longer active and is not used for reviews.
Prostatic Urethral Lift, 7.01.151 (This service will now be covered.)
Effective August 1, 2017
Amniotic Membrane and Amniotic Fluid, 7.01.149 Reviewed for medical necessity; prior authorization required
Q4131 - EpiFix, per square centimeter
Q4132 - Grafix core, per square centimeter
Q4133 - Grafix prime, per square centimeter
Q4145 - EpiFix, injectable, 1 mg
Q4154 - Biovance, per square centimeter
Clinical Trials, 10.01.518 Reviewed for medical necessity; prior authorization required
S9990 - Services provided as part of a Phase II clinical trial
S9991 - Services provided as part of a Phase III clinical trial
Bronchial Thermoplasty, 7.01.127 Prior authorization is required (currently reviewed for investigative)
31660 - Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial thermoplasty, 1 lobe
31661 - Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial thermoplasty, 2 or more lobes
Genetic Testing for Mental Health Conditions, 12.04.515 Reviewed for investigative; requires prior authorization
0015U - Drug metabolism (adverse drug reactions), DNA, 22 drug metabolism and transporter genes, real-time PCR, blood or buccal swab, genotype and metabolizer status for therapeutic decision support
JAK2 and MPL Mutation Analysis in Myeloproliferative Neoplasms, 12.04.60 Reviewed for medical necessity; prior authorization required
0017U - Oncology (hematolymphoid neoplasia), JAK2 mutation, DNA, PCR amplification of exons 12-14 and sequence analysis, blood or bone marrow, report of JAK2 mutation not detected or detected
Quantitative Assay for Measurement of HER2 Total Protein Expression and HER2 Dimers, 12.04.76 Reviewed for investigative; requires prior authorization
0009U - Oncology (breast cancer), ERBB2 (HER2) copy number by FISH, tumor cells from formalin fixed paraffin embedded tissue isolated using image-based dielectrophoresis (DEP) sorting, reported as ERBB2 gene amplified or non-amplified
Amniotic Membrane and Amniotic Fluid, 7.01.149 Revised from investigative review; now reviewed for medical necessity and requires prior authorization
Q4137 - AmnioExcel or BioDExCel, per sq cm
Q4139 - AmnioMatrix or BioDMatrix, injectable, 1 cc.
Q4148 - Neox 1k, per sq cm
Q4151 - AmnioBand or Guardian, per sq cm
Q4155 - NeoxFlo or ClarixFlo, 1 mg
Q4156 - Neox 100, per sq cm
Q4162 - AmnioPro Flow, BioSkin Flow, BioRenew Flow, WoundEx Flow, Amniogen-A, Amniogen-C, 0.5 cc
Q4163 - AmnioPro, BioSkin, BioRenew, WoundEx, Amniogen-45, Amniogen-200, per sq cm
Q4168 - AmnioBand, 1 mg
Lipid Apheresis, 8.02.04 Revised from medical necessity review; now reviewed as investigative
0342T - Therapeutic apheresis with selective HDL delipidation and plasma reinfusion
Bioengineered Skin and Soft Tissue Substitutes, 7.01.113 Removed from investigative review
Q4104 - Integra Bilayer Matrix Wound Dressing (BMWD), per square centimeter
Q4108 - Integra Matrix, per square centimeter
Prostatic Urethral Lift, 7.01.151 Removed from investigative review; now covered as medically necessary
52441 - Cystourethroscopy, with insertion of permanent adjustable transprostatic implant; single implant
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