Ablation Procedures for Peripheral Neuromas, 7.01.147Minimally invasive ablation procedures such as radiofrequency ablation or cryoablation are considered investigational for the treatment of peripheral neuromas.
Alcohol Injections for Treatment of Peripheral Neuromas, 2.01.97Alcohol injections are considered investigational for the treatment of peripheral neuromas (eg, Morton’s neuroma).
Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting, 2.02.24This policy was previously archived and is being reinstated. Cardiac hemodynamic monitoring for the management of heart failure in the ambulatory care and outpatient setting using arterial pressure during the Valsalva maneuver, implantable direct pressure monitoring of the pulmonary artery, inert gas rebreathing, or thoracic bioimpedance is considered investigational.
CT Angiography (CTA) Chest
CT Abdomen/CT Pelvis/CT Abdomen & Pelvis
Orthognathic Surgery, 9.02.501This policy is revised as follows:
Orthoptic and Vision Therapy, Visual Perceptual Training, Vision Restoration Therapy, and Neurovisual Rehabilitation, 9.03.508This policy replaces policy 9.03.03. These services are considered investigational:
Treatment of Hyperhidrosis, 8.01.519Iontophoresis and radiofrequency ablation are considered investigational for all categories. Botulinum toxin is considered investigational for plantar, craniofacial, and secondary gustatory hyperhidrosis.
Ablative Procedures of Peripheral Nerves to Treat Pain, 7.01.565This replaces policy 7.01.154. Ablative procedures of peripheral nerves to treat pain for all indications are considered investigational for the following treatments: cooled radiofrequency ablation, cryoneuroloysis (cryoablation, cryotherapy, cryoanalgesia), or radiofrequency ablation.
Gene Expression Profiling for Cutaneous Melanoma, 12.04.146Gene expression testing is considered investigational in the evaluation of patients with suspicious pigmented lesions, patients with melanocytic lesions with indeterminate histopathologic features, and patients with cutaneous melanoma.Note: Effective January 4, 2019, the services originally described in this policy are reviewed by AIM Specialty Health®.
Three‐Dimensional Printed Orthopedic Implants, 7.01.161Three-dimensional printed implants are considered medically necessary for custom implants for patients with bone or joint deformity. They are considered investigational for standard and patient-matched implants.
Closure Devices for Patent Foramen Ovale and Atrial Septal Defects, 2.02.09The policy is modified to state that the percutaneous transcatheter closure of a patent foramen ovale using Amplatzer PFO Occluder may be considered medically necessary to reduce the risk of recurrent ischemic stroke if patient meets all of the specified criteria.
Cranial Electrotherapy Stimulation and Auricular Electrostimulation, 8.01.58Electrical stimulation of the ear (also known as auricular neurostimulation) for opioid withdrawal is considered investigational.
Drug Testing in Pain Management and Substance Use Disorder Treatment Settings, 2.04.513This policy is revised as follows:
Electrical Stimulation Devices, 1.01.507The policy is modified to state that pulsed electrical stimulation and pulsed electromagnetic therapy are considered investigational for any indication including but not limited to the treatment of osteoarthritis, rheumatoid arthritis, neuropathic pain (diabetic peripheral neuropathy), post‐operative or non‐postoperative pain, or wounds.
Transcatheter Pulmonary Valve Implantation, 7.01.131The policy is revised to state that transcatheter pulmonary valve implantation is considered medically necessary for patients with congenital heart disease and current right ventricular outflow tract obstruction or regurgitation when specified indications are met.
Wearable Cardioverter Defibrillators as a Bridge to Implantable Cardioverter-Defibrillator Placement, 2.02.506The policy statements are edited for clarity. These indications are added as investigational: post coronary artery bypass graft (CABG) surgery patients, high-risk patients awaiting heart transplant, patients with newly diagnosed nonischemic cardiomyopathy, and women with peripartum cardiomyopathy.
Intravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric Disorders, 5.01.586This replaces policy 5.01.16. The policy is expanded to include the statement that intravenous infusion of ketamine for psychiatric symptoms or disorders is considered investigational.
Palynziq™ (pegvaliase-pqpz), 5.01.585Palynziq™ (pegvaliasepqpz) may be considered medically necessary to treat phenylketonuria (PKU) in adults when criteria are met.
Drugs for Rare Diseases, 5.01.576
The policy is revised to add criteria for Crysvita® (burosemab).
Exondys 51® (eteplirsen), 5.01.570
This policy is updated to reflect recently published long-term follow up from the clinical study.
Migraine and Cluster Headache Medications, 5.01.503
The policy is updated and simplified, and it consolidates previous updates. CGRP inhibitors are added to the discussion of prophylaxis.
Monoclonal Antibodies for the Treatment of Lymphomas, 2.03.502
The policy is revised to update the indications for Adcetris® (brentuximab vedotin).
A deleted policy is one whose number is no longer used but the content is either moved into another policy or replaced with a new policy and number.
Intravenous Anesthetics for the Treatment of Chronic Pain, 5.01.16 (replaced with 5.01.586)
Radiofrequency Ablations of Peripheral Nerves to treat Pain, 7.01.154 (replaced with 7.01.565)
Ablative Procedures of Peripheral Nerves to Treat Pain, 7.01.565
Now reviewed for investigative
0441T - Ablation, percutaneous, cryoablation, includes imaging guidance; lower extremity distal/peripheral nerve
Expanded Molecular Panel Testing of Cancers to Identify Targeted Therapies, 12.04.115
Now requires prior authorization; currently reviewed for investigative
81455 - Targeted genomic sequence analysis panel, solid organ or hematolymphoid neoplasm, DNA analysis, and RNA analysis when performed, 51 or greater genes (eg, ALK, BRAF, CDKN2A, CEBPA, DNMT3A, EGFR, ERBB2, EZH2, FLT3, IDH1, IDH2, JAK2, KIT, KRAS, MLL, NPM1, NRAS, MET, NOTCH1, PDGFRA, PDGFRB, PGR, PIK3CA, PTEN, RET), interrogation for sequence variants and copy number variants or rearrangements, if performed
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