• New and updated policies effective June 1, 2020

     

    Policy Title – June 1, 2020

    Policy#

    Status

    1

    Orthognathic Surgery

    BSC7.03

    Major Update

    2

    Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions

    7.01.78

    Minor Update

    3

    Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions

    7.01.48

    Minor Update

    4

    Automated Ambulatory Blood Pressure Monitoring for Diagnosis of Hypertension in Patients with Elevated Office Blood Pressure

    1.01.02

    ARCHIVED

    5

    Behavioral Health Treatment for Autism Spectrum Disorders

    BSC3.01

    Minor Update

    6

    Bone Morphogenetic Protein

    7.01.100

    ARCHIVED

    7

    Brachytherapy for Clinically Localized Prostate Cancer Using Permanently Implanted Seeds

    8.01.14

    Admin Update

    8

    Charged-Particle (Proton or Helium Ion) Radiotherapy for Neoplastic Conditions

    BSC8.04

    Admin Update

    9

    Closure Devices for Patent Foramen Ovale and Atrial Septal Defects

    2.02.09

    ARCHIVED

    10

    Computer-Assisted Navigation for Orthopedic Procedure

    7.01.96

    Minor Update

    11

    Cooling Devices Used in the Outpatient Setting

    1.01.26

    ARCHIVED

    12

    Corneal Collagen Cross-Linking

    9.03.28

    Minor Update

    13

    Deep Brain Stimulation

    7.01.63

    ARCHIVED

    14

    Diabetes Prevention Program

    BSC2.11

    Minor Update

    15

    Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome

    2.01.18

    Admin Update

    16

    Discography

    BSC6.01

    ARCHIVED

    17

    Dry Needling of Myofascial Trigger Points

    2.01.100

    ARCHIVED

    18

    Electrical Bone Growth Stimulation of the Appendicular Skeleton

    7.01.07

    ARCHIVED

    19

    Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures

    7.01.85

    ARCHIVED

    20

    Endovascular Procedures for Intracranial Arterial Disease (Atherosclerosis and Aneurysms)

    2.01.54

    Minor Update

    21

    Facet Arthroplasty

    7.01.120

    Minor Update

    22

    Gender Reassignment Surgery

    BSC7.02

    Admin Update

    23

    Genetic Testing for BRCA1 or BRCA2 for Hereditary Breast/Ovarian Cancer Syndrome and Other High-Risk Cancers

    2.04.02

    Admin Update

    24

    Genetic Testing for Cystic Fibrosis

    BSC2.04

    ARCHIVED

    25

    Genetic Testing for Hereditary Hearing Loss

    2.04.87

    ARCHIVED

    26

    Genetic Testing for Limb-Girdle Muscular Dystrophies

    2.04.132

    ARCHIVED

    27

    Genetic Testing for Rett Syndrome

    2.04.81

    ARCHIVED

    28

    Genetic Testing of CADASIL Syndrome

    2.04.75

    ARCHIVED

    29

    High-Dose Rate Temporary Prostate Brachytherapy

    8.01.33

    Admin Update

    30

    Hip Resurfacing

    7.01.80

    Minor Update

    31

    Image-Guided Minimally Invasive Decompression for Spinal Stenosis

    7.01.126

    Minor Update

    32

    Implantation of Intrastromal Corneal Ring Segments

    9.03.14

    Admin Update

    33

    Intensity-Modulated Radiotherapy of the Breast and Lung

    8.01.46

    Admin Update

    34

    Intensity-Modulated Radiotherapy: Abdomen and Pelvis

    8.01.49

    Admin Update

    35

    Intensity-Modulated Radiotherapy: Abdomen and Pelvis

    8.01.49

    Admin Update

    36

    Intensity-Modulated Radiotherapy: Cancer of the Head and Neck or Thyroid

    8.01.48

    Admin Update

    37

    Intensity-Modulated Radiotherapy: Central Nervous System Tumors

    8.01.59

    Admin Update

    38

    Interim Positron Emission Tomography Scanning in Oncology to Detect Early Response During Treatment

    6.01.51

    Admin Update

    39

    Interspinous Fixation (Fusion) Devices

    7.01.138

    ARCHIVED

    40

    Interventions for Progressive Scoliosis

    2.01.83

    ARCHIVED

    41

    Intracavitary Balloon Catheter Brain Brachytherapy for Malignant Gliomas or Metastasis to the Brain

    8.01.45

    Admin Update

    42

    Intraoperative Neurophysiologic Monitoring

    7.01.58

    Minor Update

    43

    KIF6 Genotyping for Predicting Cardiovascular Risk and/or Effectiveness of Statin Therapy

    2.04.67

    ARCHIVED

    44

    Knee Arthroplasty for Adults

    BSC7.10

    Minor Update

    45

    Laboratory and Genetic Testing for Use of 5-Fluorouracil in Patients With Cancer

    2.04.68

    Minor Update

    46

    Lower Limb Prostheses

    BSC1.01

    Minor Update

    47

    Measurement of Serum Antibodies to Monoclonal Antibodies

    2.04.84

    Admin Update

    48

    Microprocessor Controlled Prostheses for the Lower Limb

    1.04.05

    Minor Update

    49

    Miscellaneous (Noncardiac, Nononcologic) Applications of Fluorine 18 Fluorodeoxyglucose Positron Emission Tomography

    6.01.06

    Admin Update

    50

    Nerve Graft with Radical Prostatectomy

    7.01.81

    ARCHIVED

    51

    Neuropsychological Testing

    BSC2.06

    Minor Update

    52

    Occipital Nerve Stimulation

    7.01.125

    ARCHIVED

    53

    Outpatient Pulmonary Rehabilitation

    8.03.05

    ARCHIVED

    54

    Patient-Specific Instrumentation (e.g., Cutting Guides) for Joint Arthroplasty

    7.01.144

    Minor Update

    55

    Percutaneous Balloon Kyphoplasty, Radiofrequency Kyphoplasty, and Mechanical Vertebral Augmentation

    6.01.38

    ARCHIVED

    56

    Percutaneous Vertebroplasty and Sacroplasty

    6.01.25

    Minor Update

    57

    Peripheral Subcutaneous Field Stimulation

    7.01.139

    ARCHIVED

    58

    Power Wheelchairs and Power Operated Vehicles for Permanent Use

    BSC1.02

    Minor Update

    59

    Radioembolization for Primary and Metastatic Tumors of the Liver

    8.01.43

    Admin Update

    60

    Responsive Neurostimulation for the Treatment of Refractory Focal Epilepsy

    7.01.143

    ARCHIVED

    61

    Sacral Nerve Neuromodulation/Stimulation

    7.01.69

    ARCHIVED

    62

    Speech Therapy

    BSC8.02

    Minor Update

    63

    Spinal Cord and Dorsal Root Ganglion Stimulation

    7.01.25

    ARCHIVED

    64

    Subtalar Arthroereisis

    7.01.104

    Minor Update

    65

    Surgical Treatment of Femoroacetabular Impingement

    7.01.118

    Minor Update

    66

    Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders

    2.01.50

    Admin Update

    67

    Vertebral Axial Decompression

    8.03.09

    Minor Update

    68

    Vertical Expandable Prosthetic Titanium Rib

    7.01.110

    ARCHIVED

    69

    Virtual Colonoscopy/Computed Tomography Colonography

    6.01.32

    Admin Update

    70

    Wearable Cardioverter Defibrillators

    2.02.15

    Admin Update

    71

    Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders

    2.04.102

    Admin Update

  • New and updated policies effective May 1, 2020

     

    Policy Title – May 1, 2020

    Policy#

    Status

    1

    Balloon Dilation of the Eustachian Tube

    7.01.158

    Major Update

    2

    Dermatologic Applications of Photodynamic Therapy

    2.01.44

    Major Update

    3

    Gender Reassignment Surgery

    BSC7.02

    Major Update

    4

    Hysterectomy Surgery for Benign Conditions

    BSC7.09

    Major Update

    5

    Panniculectomy, Abdominoplasty, and Surgical Management of Diastasis Recti

    BSC7.04

    Major Update

    6

    Surgical Treatment of Gynecomastia

    BSC7.13

    Major Update

    7

    Total Hip Arthroplasty for Adults

    BSC7.11

    Major Update

    8

    Amniotic Membrane and Amniotic Fluid

    7.01.149

    Minor Update

    9

    Autologous Platelet-Derived Growth Factors for Wound Healing and Other NonOrthopedic Conditions

    2.01.16

    Minor Update

    10

    Bariatric Surgery

    7.01.47

    Minor Update

    11

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

    2.02.10

    Admin Update

    12

    Cardiac Applications of Positron Emission Tomography Scanning

    6.01.20

    Admin Update

    13

    Cardiac Rehabilitation in the Outpatient Setting

    8.03.08

    ARCHIVED

    14

    Charged-Particle (Proton or Helium Ion) Radiotherapy for Neoplastic Conditions

    BSC8.04

    Minor Update

    15

    Chelation Therapy for Off-Label Uses

    8.01.02

    Minor Update

    16

    Cleft Palate - Dental Related Services

    BSC2.01

    Minor Update

    17

    Cochlear Implant

    7.01.05

    Minor Update

    18

    Cognitive Rehabilitation

    8.03.10

    ARCHIVED

    19

    Continuous Passive Motion in the Home Setting

    1.01.10

    Minor Update

    20

    Corneal Topography/Computer-Assisted Corneal Topography/Photokeratoscopy

    9.03.05

    ARCHIVED

    21

    Cranial Electrotherapy Stimulation and Auricular Electrostimulation

    8.01.58

    Minor Update

    22

    Dental Anesthesia

    BSC2.02

    Minor Update

    23

    Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome

    2.01.18

    Admin Update

    24

    Dynamic Posturography

    2.01.02

    Minor Update

    25

    Electrical and Electromagnetic Stimulation for the Treatment of Arthritis

    1.01.27

    Minor Update

    26

    Endothelial Keratoplasty

    9.03.22

    Minor Update

    27

    Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions

    2.01.40

    Admin Update

    28

    Eyelid Thermal Pulsation for the Treatment of Dry Eye Syndrome

    9.03.29

    Minor Update

    29

    Functional Endoscopic Sinus Surgery for Chronic Rhinosinusitis

    7.01.155

    ARCHIVED

    30

    Gastric Electrical Stimulation

    7.01.73

    Minor Update

    31

    Gene Expression Profiling for Uveal Melanoma

    2.04.120

    ARCHIVED

    32

    Gene Expression Testing in the Evaluation of Patients with Stable Ischemic Heart Disease

    2.04.72

    Minor Update

    33

    Gene Expression-Based Assays for Cancers of Unknown Primary

    2.04.54

    Minor Update

    34

    Genetic Testing for CHARGE Syndrome

    2.04.106

    ARCHIVED

    35

    Genetic Testing for Duchenne and Becker Muscular Dystrophy

    2.04.86

    ARCHIVED

    36

    Genetic Testing for Epilepsy

    2.04.109

    ARCHIVED

    37

    Genetic Testing for Facioscapulohumeral Muscular Dystrophy

    2.04.105

    ARCHIVED

    38

    Genetic Testing for Familial Cutaneous Malignant Melanoma

    2.04.44

    Minor Update

    39

    Genetic Testing for FMR1 Variants (Including Fragile X Syndrome)

    2.04.83

    ARCHIVED

    40

    Genetic Testing for Hereditary Pancreatitis

    2.04.99

    ARCHIVED

    41

    Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes

    2.04.08

    Admin Update

    42

    Genetic Testing for Macular Degeneration

    2.04.103

    Minor Update

    43

    Genetic Testing for Marfan Syndrome, Thoracic Aortic Aneurysms and Dissections, and Related Disorders

    2.04.129

    ARCHIVED

    44

    Genetic Testing for Neurofibromatosis

    2.04.137

    ARCHIVED

    45

    Genetic Testing for Predisposition to Inherited Hypertrophic Cardiomyopathy

    2.02.28

    Minor Update

    46

    Genetic Testing for PTEN Hamartoma Tumor Syndrome

    2.04.88

    ARCHIVED

    47

    Genetic Testing for the Diagnosis of Inherited Peripheral Neuropathies

    2.04.89

    ARCHIVED

    48

    Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer

    8.01.23

    ARCHIVED

    49

    Hematopoietic Cell Transplantation for Hodgkin Lymphoma

    8.01.29

    Minor Update

    50

    Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors in Adults

    8.01.24

    ARCHIVED

    51

    Hippotherapy

    8.03.12

    Minor Update

    52

    Hyperbaric Oxygen Therapy

    2.01.04

    Admin Update

    53

    Implantable Bone-Conduction and Bone-Anchored Hearing Aids

    7.01.03

    Minor Update

    54

    Implantable Cardioverter Defibrillators

    7.01.44

    Admin Update

    55

    Implantable Infusion Pump for Pain and Spasticity

    7.01.41

    ARCHIVED

    56

    Implantation of Intrastromal Corneal Ring Segments

    9.03.14

    Minor Update

    57

    Intensity-Modulated Radiotherapy of the Prostate

    8.01.47

    Admin Update

    58

    Intraocular Radiotherapy for Age-Related Macular Degeneration

    9.03.20

    ARCHIVED

    59

    Keratoprosthesis

    9.03.01

    ARCHIVED

    60

    Knee Braces

    BSC1.05

    Minor Update

    61

    Lifestyle Modification Program for Reversing Heart Disease

    BSC8.01

    Minor Update

    62

    Magnetic Resonance Imaging for Detection and Diagnosis of Breast Cancer

    6.01.29

    Admin Update

    63

    Moderate Penetrance Variants Associated with Breast Cancer in Individuals at High Breast Cancer Risk

    2.04.126

    Admin Update

    64

    Myocardial Strain Imaging

    2.02.31

    Minor Update

    65

    Myoelectric Prosthetic and Orthotic Components for the Upper Limb

    1.04.04

    Minor Update

    66

    Negative Pressure Wound Therapy in the Outpatient Setting

    1.01.16

    Admin Update

    67

    Oncologic Applications of Positron Emission Tomography Scanning

    6.01.26

    Admin Update

    68

    Ophthalmologic Techniques That Evaluate the Posterior Segment for Glaucoma

    9.03.06

    Minor Update

    69

    Optical Coherence Tomography of the Anterior Eye Segment

    9.03.18

    Minor Update

    70

    Orthoptic Training for the Treatment of Vision or Learning Disabilities

    9.03.03

    Minor Update

    71

    Paravertebral Facet Joint Denervation (Radiofrequency Neurolysis)

    BSC_NIA_CG_302

    ARCHIVED

    72

    Partial Thickness Rotator Cuff Tears and Acromioplasty/ Subacromial Decompression

    BSC7.14

    Minor Update

    73

    Patient-Controlled End Range of Motion Stretching Devices

    1.03.05

    Minor Update

    74

    Personalized Breast Cancer Screening Clinical Trial

    BSC2.08

    Minor Update

    75

    Photodynamic Therapy for Choroidal Neovascularization

    9.03.08

    ARCHIVED

    76

    Physical Therapy

    BSC8.03

    Minor Update

    77

    Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers

    1.01.18

    Minor Update

    78

    Postsurgical Home Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis

    1.01.28

    ARCHIVED

    79

    Power Morcellation for the Treatment of Uterine Fibroids

    BSC7.06

    Minor Update

    80

    Powered Exoskeleton for Ambulation in Patients With Lower-Limb Disabilities

    1.03.04

    Minor Update

    81

    Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors

    7.01.95

    Admin Update

    82

    Reconstructive Services

    BSC7.08

    Minor Update

    83

    Reduction Mammaplasty

    7.01.21

    Minor Update

    84

    Retinal Prosthesis

    9.03.15

    Minor Update

    85

    Retinal Telescreening for Diabetic Retinopathy

    9.03.13

    ARCHIVED

    86

    Semi-Implantable and Fully Implantable Middle Ear Hearing Aids

    7.01.84

    Minor Update

    87

    Sensory Integration Therapy and Auditory Integration Therapy

    8.03.13

    Minor Update

    88

    Surgery for Groin Pain in Athletes

    7.01.142

    ARCHIVED

    89

    Surgical Deactivation of Headache Trigger Sites

    7.01.135

    Minor Update

    90

    Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome

    7.01.101

    Admin Update

    91

    Surgical Ventricular Restoration

    7.01.103

    Minor Update

    92

    Testing Serum Vitamin D Levels

    2.04.135

    Minor Update

    93

    Transcatheter Aortic Valve Implantation for Aortic Stenosis

    7.01.132

    Minor Update

    94

    Transmyocardial Revascularization

    7.01.54

    ARCHIVED

    95

    Transtympanic Micropressure Applications as a Treatment of Meniere Disease

    1.01.23

    ARCHIVED

    96

    Treatment of Tinnitus

    8.01.39

    ARCHIVED

    97

    Treatment of Varicose Veins/Venous Insufficiency

    7.01.124

    Admin Update

    98

    Ultrasound Accelerated Fracture Healing Device

    1.01.05

    ARCHIVED

    99

    Vagus Nerve Blocking Therapy for Treatment of Obesity

    7.01.150

    Minor Update

    100

    Vagus Nerve Stimulation

    7.01.20

    ARCHIVED

    101

    Vestibular Function Testing

    2.01.104

    ARCHIVED

    102

    Viscocanalostomy and Canaloplasty

    9.03.26

    ARCHIVED

    103

    Wireless Capsule Endoscopy to Diagnose Disorders of the Small Bowel, Esophagus, and Colon

    6.01.33

    Admin Update

  • New and updated policies effective April 1, 2020

     

    Policy Title – April 1, 2020

    Policy#

    Status

    1

    Ambulatory Surgery Center

    BSC10.01

    New

    2

    Accelerated Breast Irradiation and Brachytherapy Boost After Breast-Conserving Surgery for Early-Stage Breast Cancer 

    8.01.13

    Admin Update

    3

    Adipose-Derived Stem Cells in Autologous Fat Grafting to the Breast

    7.01.153

    Minor Update

    4

    Adjustable Cranial Orthoses for Positional Plagiocephaly and Craniosynostoses

    1.01.11

    ARCHIVED

    5

    Allogeneic Hematopoietic Cell Transplantation for Genetic Diseases and Acquired Anemias

    8.01.22

    Minor Update

    6

    Allogeneic Hematopoietic Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms

    8.01.21

    Minor Update

    7

    Auditory Brainstem Implant

    7.01.83

    Minor Update

    8

    Biofeedback as a Treatment of Fecal Incontinence or Constipation

    2.01.64

    ARCHIVED

    9

    Blepharoplasty, Blepharoptosis Repair (Levator Resection) and Brow Lift (Repair of Brow Ptosis)

    BSC7.01

    Minor Update

    10

    Bone Mineral Density Studies

    6.01.01

    Minor Update

    11

    Bone Turnover Markers for the Diagnosis and Management of Osteoporosis and Diseases Associated with High Bone TurNover

    2.04.15

    Minor Update

    12

    Breast Implant Management

    BSC7.12

    Minor Update

    13

    Chronic Intermittent Intravenous Insulin Therapy

    2.01.43

    Minor Update

    14

    Cryosurgical Ablation of Primary or Metastatic Liver Tumors                                                                                                       

    7.01.75

    Minor Update

    15

    Dermatologic Applications of Photodynamic Therapy

    2.01.44

    Minor Update

    16

    Drug Testing in Pain Management and Substance Use Disorder Treatment

    2.04.98

    Minor Update

    17

    Elective Percutaneous Coronary Intervention (PCI)

    BSC6.02

    Minor Update

    18

    Electromagnetic Navigation Bronchoscopy

    7.01.122

    ARCHIVED

    19

    Electrostimulation and Electromagnetic Therapy for Treating Wounds

    2.01.57

    Minor Update

    20

    Fecal Calprotectin Testing

    2.04.69

    ARCHIVED

    21

    Gene Expression Profiling and Protein Biomarkers for Prostate Cancer Management

    2.04.111

    Minor Update

    22

    General Approach to Evaluating the Utility of Genetic Panels

    2.04.92

    Minor Update

    23

    General Approach to Genetic Testing

    2.04.91

    Minor Update

    24

    Genetic Testing for Alpha Thalassemia

    2.04.104

    ARCHIVED

    25

    Genetic Testing for BRCA1 or BRCA2 for Hereditary Breast/Ovarian Cancer Syndrome and Other High-Risk Cancers

    2.04.02

    Minor Update

    26

    Genetic Testing for FLT3, NPM1, and CEBPA Variants in Cytogenetically Normal Acute Myeloid Leukemia

    2.04.124

    Minor Update

    27

    Genetic Testing for Idiopathic Dilated Cardiomyopathy

    2.04.114

    ARCHIVED

    28

    Handheld Radiofrequency Spectroscopy for Intraoperative Assessment of Surgical Margins During Breast-Conserving Surgery

    7.01.140

    Minor Update

    29

    Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia

    8.01.32

    Minor Update

    30

    Hematopoietic Cell Transplantation for Acute Myeloid Leukemia

    8.01.26

    Minor Update

    31

    Hematopoietic Cell Transplantation for Autoimmune Diseases

    8.01.25

    Minor Update

    32

    Hematopoietic Cell Transplantation for Central Nervous System Embryonal Tumors and Ependymoma

    8.01.28

    Minor Update

    33

    Hematopoietic Cell Transplantation for Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma

    8.01.15

    Minor Update

    34

    Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia

    8.01.30

    Minor Update

    35

    Hematopoietic Cell Transplantation for Non-Hodgkin Lymphomas

    8.01.20

    Minor Update

    36

    Hematopoietic Cell Transplantation for Plasma Cell Dyscrasias, Including Multiple Myeloma and POEMS Syndrome

    8.01.17

    Minor Update

    37

    Hematopoietic Cell Transplantation for Primary Amyloidosis

    8.01.42

    Minor Update

    38

    Hematopoietic Cell Transplantation for Solid Tumors of Childhood

    8.01.34

    Minor Update

    39

    Hematopoietic Cell Transplantation for Waldenström Macroglobulinemia

    8.01.54

    Minor Update

    40

    Hematopoietic Cell Transplantation in the Treatment of Germ Cell Tumor

    8.01.35

    Minor Update

    41

    Hysterectomy Surgery for Benign Conditions

    BSC7.09

    Admin Update

    42

    Identification of Microorganisms Using Nucleic Acid Probes

    2.04.10

    Minor Update

    43

    Immune Cell Function Assay

    2.04.56

    Minor Update

    44

    Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence

    7.01.19

    Minor Update

    45

    Knee Arthroplasty for Adults

    BSC7.10

    Admin Update

    46

    Knee Arthroscopy in Knee Osteoarthritis

    BSC7.16

    Admin Update

    47

    KRAS, NRAS, and BRAF Variant Analysis (Including Liquid Biopsy) in Metastatic Colorectal Cancer

    2.04.53

    ARCHIVED

    48

    Laparoscopic and Percutaneous Techniques for the Myolysis of Uterine Fibroids

    4.01.19

    Minor Update

    49

    Meniscal Allografts and Other Meniscal Implants

    7.01.15

    ARCHIVED

    50

    Neural Therapy

    2.01.85

    ARCHIVED

    51

    Neuropsychological Testing

    BSC2.06

    Admin Update

    52

    Noninvasive Fetal RHD Genotyping Using Cell-Free Fetal DNA

    2.04.108

    ARCHIVED

    53

    Orthopedic Applications of Stem Cell Therapy (Including Allograft and Bone Substitute Used With Autologous Bone Marrow)

    8.01.52

    Minor Update

    54

    Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence

    1.01.17

    Minor Update

    55

    Placental and Umbilical Cord Blood as a Source of Stem Cells

    7.01.50

    Minor Update

    56

    Plugs for Anal Fistula Repair

    7.01.123

    Minor Update

    57

    Polysomnography for Non-Respiratory Sleep Disorders

    2.01.99

    ARCHIVED

    58

    Proteomic Testing for Systemic Therapy in Non-Small-Cell Lung Cancer

    2.04.125

    Minor Update

    59

    Radiofrequency Ablation of Primary or Metastatic Liver Tumors   

    7.01.91

    Minor Update

    60

    Sphenopalatine Ganglion Block for Headache

    7.01.159

    ARCHIVED

    61

    Steroid-Eluting Sinus Stents

    7.01.134

    Minor Update

    62

    Temporomandibular Joint Disorder

    2.01.21

    Minor Update

    63

    Transanal Endoscopic Microsurgery

    7.01.112

    ARCHIVED

    64

    Treatment of Hyperhidrosis

    8.01.19

    Minor Update

     

  • New and updated policies effective March 1, 2020

    Policy Title- March 1, 2020

    Policy#

    Status

    Continuous or Intermittent Monitoring of Glucose in Interstitial Fluid

    1.01.20

    New

    Ablation of Peripheral Nerves to Treat Pain

    7.01.154

    Admin Update

    Adipose-Derived Stem Cells in Autologous Fat Grafting to the Breast

    7.01.153

    Admin Update

    Ambulatory Event Monitors and Mobile Cardiac Outpatient Telemetry

    2.02.08

    Admin Update

    Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer

    2.04.36

    Admin Update

    Autologous Platelet-Derived Growth Factors for Wound Healing and Other Non‒Orthopedic Conditions

    2.01.16

    Admin Update

    Automated Ambulatory Blood Pressure Monitoring for Diagnosis of Hypertension in Patients With Elevated Office Blood Pressure

    1.01.02

    Admin Update

    Balloon Ostial Dilation for Treatment of Chronic Rhinosinusitis

    7.01.105

    Admin Update

    Bioengineered Skin and Soft Tissue Substitutes

    7.01.113

    Minor Update

    Biofeedback as a treatment of Urinary Incontinence in Adults

    2.01.27

    Admin Update

    Bioimpedance Devices for Detection and Management of Lymphedema

    2.01.82

    Minor Update

    Breast Implant Management

    BSC7.12

    Admin Update

    Cardiac Applications of Positron Emission Tomography Scanning

    6.01.20

    Admin Update

    Chemical Peels

    8.01.16

    Minor Update

    Circulating Tumor DNA and Circulating Tumor Cells for Cancer Management (Liquid Biopsy)

    2.04.141

    Admin Update

    Circulating Tumor DNA for Management of Non-Small Cell Lung Cancer (Liquid Biopsy)

    2.04.143

    Admin Update

    Corneal Collagen Cross-Linking

    9.03.28

    Admin Update

    Cranial Electrotherapy Stimulation and Auricular Electrostimulation

    8.01.58

    Admin Update

    Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate, or Dermatologic Tumors

    7.01.92

    Admin Update

    Cytochrome P450 Genotype-Guided Treatment Strategy

    2.04.38

    Admin Update

    Diabetes Prevention Program

    BSC2.11

    Admin Update

    Diagnosis and Medical Management of Obstructive Sleep

    2.01.18

    Admin Update

    DNA-Based Testing for Adolescent Idiopathic Scoliosis

    2.04.74

    Minor Update

    Drug Testing in Pain Management and Substance Use Disorder Treatment

    2.04.98

    Admin Update

    Dry Needling of Myofascial Trigger Points

    2.01.100

    Admin Update

    Dynamic Posturography

    2.01.02

    Admin Update

    Elective Percutaneous Coronary Intervention (PCI)

    BSC6.02

    Overlay

    External Insulin Infusion Pump

    BSC1.03

    Admin Update

    Eyelid Thermal Pulsation for the Treatment of Dry Eye Syndrome

    9.03.29

    Admin Update

    Fecal Analysis in the Diagnosis of Intestinal Dysbiosis

    2.04.26

    Minor Update

    Fecal Calprotectin Testing

    2.04.69

    Minor Update

    Focal Treatments for Prostate Cancer

    8.01.61

    Admin Update

    Gender Reassignment Surgery

    BSC7.02

    Admin Update

    Gene Expression Profiling and Protein Biomarkers for Prostate Cancer Management

    2.04.111

    Admin Update

    General Approach to Evaluating the Utility of Genetic Panels

    2.04.92

    Admin Update

    Genetic Cancer Susceptibility Panels Using Next-Generation Sequencing

    2.04.93

    Admin Update

    Genetic Testing for BRCA1 or BRCA2 for Hereditary Breast/Ovarian Cancer Syndrome and Other High-Risk Cancers

    2.04.02

    Admin Update

    Genetic Testing for Cardiac Ion Channelopathies

    2.04.43

    Minor Update

    Genetic Testing for Developmental Delay/Intellectual Disability, Autism Spectrum Disorder, and Congenital Anomalies

    2.04.59

    Admin Update

    Genetic Testing for Diagnosis and Management of Mental Health Conditions

    2.04.110

    Admin Update

    Genetic Testing for Fanconi Anemia

    2.04.128

    Minor Update

    Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes

    2.04.08

    Admin Update

    Homocysteine Testing in the Screening, Diagnosis, and Management of Cardiovascular Disease and Venous Thromboembolic Disease

    2.04.23

    Minor Update

    Hydrogel Spacer use During Radiotherapy for Prostate Cancer

    7.01.164

    Minor Update

    Hyperbaric Oxygen Therapy

    2.01.04

    Minor Update

    Identification of Microorganisms Using Nucleic Acid Probes

    2.04.10

    Admin Update

    Implantable Cardioverter Defibrillators

    7.01.44

    Admin Update

    In Vitro Chemoresistance and Chemosensitivity Assays

    2.03.01

    Admin Update

    Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence

    7.01.19

    Admin Update

    Intensity-Modulated Radiotherapy of the Prostate

    8.01.47

    Overlay

    Intracellular Micronutrient Analysis

    2.04.73

    Minor Update

    Measurement of Serum Antibodies to Infliximab and Adalimumab

    2.04.84

    Admin Update

    Moderate Penetrance Variants Associated with Breast Cancer in Individuals at High Breast Cancer Risk

    2.04.126

    Admin Update

    Monitored Anesthesia Care

    7.02.01

    Admin Update

    Myocardial Strain Imaging

    2.02.31

    Admin Update

    Myocardial Sympathetic Innervation Imaging in Patients With Heart Failure

    6.01.56

    Admin Update

    Negative Pressure Wound Therapy in the Outpatient Setting

    1.01.16

    Minor Update

    Noncontact Ultrasound Treatment for Wounds

    2.01.79

    Minor Update

    Noninvasive Prenatal Screening for Fetal Aneuploidies and Microdeletions Using Cell-Free Fetal DNA

    4.01.21

    Admin Update

    Novel Biomarkers in Risk Assessment and Management of Cardiovascular Disease

    2.04.65

    Minor Update

    Nutrient/Nutritional Panel Testing

    2.04.136

    Minor Update

    Orthopedic Applications of Platelet-Rich Plasma

    2.01.98

    Admin Update

    Orthopedic Applications of Stem Cell Therapy (Including Allografts and Bone Substitutes Used with Autologous Bone Marrow)

    8.01.52

    Admin Update

    Power Wheelchairs and Power Operated Vehicles for Permanent Use

    BSC1.02

    Admin Update

    Quantitative Assay for Measurement of HER2 Total Protein Expression and HER2 Dimers

    2.04.76

    Minor Update

    Radioimmunoscintigraphy (Monoclonal Antibody Imaging) With Indium 111 Capromab Pendetide for Prostate Cancer

    6.01.37

    Admin Update

    Reproductive Techniques

    4.02.04

    Admin Update

    Scintimammography and Gamma Imaging of the Breast and Axilla

    6.01.18

    Admin Update

    Stem Cell Therapy for Peripheral Arterial Disease

    8.01.55

    Minor Update

    Stereotactic Radiosurgery and Stereotactic Body Radiotherapy

    6.01.10

    Minor Update

    Surgical Treatment of Gynecomastia

    BSC7.13

    Admin Update

    Transcatheter Arterial Chemoembolization to Treat Primary or Metastatic Liver Malignancies

    8.01.11

    Admin Update

    Transurethral Water Vapor Thermal Therapy for Benign Prostatic Hyperplasia

    2.01.49

    Admin Update

     

  • New and updated policies effective February 1, 2020

     

    Policy Title – February 1, 2020

    Policy#

    Status

    1

    Circulating Tumor DNA for Management of Non-Small-Cell Lung Cancer (Liquid Biopsy)

    2.04.143

    Major Update

    2

    Next-Generation Sequencing for the Assessment of Measurable Residual Disease

    2.04.147

    Major Update

    3

    Digital Breast Tomosynthesis

    BSC6.07

    Archived

    4

    Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients With Breast Cancer

    2.04.36

    Minor Update

    5

    Biofeedback as a Treatment of Chronic Pain

    2.01.30

    Minor Update

    6

    Biofeedback for Miscellaneous Indications

    2.01.53

    Minor Update

    7

    Cardiovascular Risk Panels

    2.04.100

    Minor Update

    8

    Cerebrospinal Fluid and Urinary Biomarkers of Alzheimer Disease

    2.04.14

    Minor Update

    9

    Chromoendoscopy as an Adjunct to Colonoscopy

    2.01.84

    Minor Update

    10

    Confocal Laser Endomicroscopy

    2.01.87

    Minor Update

    11

    Fecal Microbiota Transplantation

    2.01.92

    Minor Update

    12

    Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer

    2.04.33

    Minor Update

    13

    Genetic Testing for Li-Fraumeni Syndrome

    2.04.101

    Admin Update

    14

    Genetic Testing for Statin-Induced Myopathy

    2.04.96

    Minor Update

    15

    Human Leukocyte Antigen Testing for Celiac Disease

    2.04.95

    Minor Update

    16

    Intravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric Disorders

    5.01.16

    Minor Update

    17

    Laser Treatment of Onychomycosis

    2.01.89

    Minor Update

    18

    Light Therapy for Psoriasis

    2.01.47

    Minor Update

    19

    Magnetic Esophageal Sphincter Augmentation to Treat Gastroesophageal Reflux Disease

    7.01.137

    Minor Update

    20

    Measurement of Lipoprotein-Associated Phospholipase A2 in the Assessment of Cardiovascular Risk

    2.04.32

    Minor Update

    21

    Monitored Anesthesia Care

    7.02.01

    Minor Update

    22

    Multimarker Serum Testing Related to Ovarian Cancer

    2.04.62

    Minor Update

    23

    Multitarget Polymerase Chain Reaction Testing for Diagnosis of Bacterial Vaginosis

    2.04.127

    Minor Update

    24

    Nerve Fiber Density Measurement

    2.04.58

    Minor Update

    25

    Noninvasive Techniques for the Evaluation and Monitoring of Patients With Chronic Liver Disease

    2.04.41

    Minor Update

    26

    Nonpharmacologic Treatment of Rosacea

    2.01.71

    Minor Update

    27

    Peroral Endoscopic Myotomy for Treatment of Esophageal Achalasia

    2.01.91

    Minor Update

    28

    Pharmacogenetic Testing for Pain Management

    2.04.131

    Minor Update

    29

    Pharmacogenomic and Metabolite Markers for Patients Treated With Thiopurines

    2.04.19

    Minor Update

    30

    Prolotherapy

    2.01.26

    Minor Update

    31

    Proteogenomic Testing for Patients With Cancer

    2.04.140

    Admin Update

    32

    Serum Biomarker Human Epididymis Protein 4

    2.04.66

    Minor Update

    33

    Targeted Phototherapy and Psoralen with Ultraviolet A for Vitiligo

    2.01.86

    Minor Update

    34

    Transcutaneous Electrical Nerve Stimulation

    1.01.09

    Minor Update

    35

    Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease

    2.01.38

    Minor Update

    36

    Urinary Biomarkers for Cancer Screening, Diagnosis, and Surveillance

    2.04.07

    Minor Update

    37

    Wireless Capsule Endoscopy to Diagnose Disorders of the Small Bowel, Esophagus, and Colon

    6.01.33

    Minor Update

  • New and updated policies effective January 1, 2020

     

    Policy Title – January 1, 2020

    Policy#

    Status

    1

    Analysis of Human DNA in Stool Samples as a Technique for Colorectal Cancer Screening

    2.04.29

    Minor Update

    2

    Biofeedback as a Treatment of Headache

    2.01.29

    Minor Update

    3

    Carrier Screening for Genetic Diseases

    2.04.107

    Minor Update

    4

    Endoscopic Radiofrequency Ablation or Cryoablation for Barrett Esophagus

    2.01.80

    Minor Update

    5

    Esophageal pH Monitoring

    2.01.20

    Minor Update

    6

    Genetic Testing for PTEN Hamartoma Tumor Syndrome

    2.04.88

    Admin Update

    7

    Ingestible pH and Pressure Capsule

    2.01.81

    Minor Update

    8

    Lysis of Epidural Adhesions

    8.01.18

    Minor Update

    9

    Measurement of Serum Antibodies to Monoclonal Antibodies

    2.04.84

    Minor Update

    10

    Moderate Penetrance Variants Associated with Breast Cancer in Individuals at High Breast Cancer Risk

    2.04.126

    Minor Update

    11

    Transanal Radiofrequency Treatment of Fecal Incontinence

    2.01.58

    Minor Update

  • New and updated policies effective December 1, 2019

     

    Policy Title – December 16, 2019

    Policy#

    Status

    1

    Charged-Particle (Proton or Helium Ion) Radiotherapy for Neoplastic Conditions

    BSC8.04

    Major Update

    2

    Comprehensive Genomic Profiling for Selecting Targeted Cancer Therapies

    2.04.115

    Major Update

    3

    Drug Testing in Pain Management and Substance Use Disorder Treatment

    2.04.98  

    Major Update

    4

    Microwave and Locoregional Laser Tumor Ablation

    7.01.133

    Major Update

    5

    Radiofrequency Ablation of Primary or Metastatic Liver Tumors

    7.01.91

    Major Update

    6

    Cardiac Applications of Positron Emission Tomography Scanning

    6.01.20

    Minor Update

    7

    Extracorporeal Photopheresis

    8.01.36

    Minor Update

    8

    Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence

    7.01.19

    Minor Update

    9

    Intravenous Antibiotic Therapy and Associated Diagnostic Testing for Lyme Disease

    5.01.08

    Minor Update

    10

    KRAS, NRAS, BRAF Variant Analysis (Including Liquid Biopsy) in Metastatic Colorectal Cancer

    2.04.53

    Minor Update

    11

    Laparoscopic and Percutaneous Techniques for the Myolysis of Uterine Fibroids

    4.01.19

    Minor Update

    12

    Magnetic Resonance Imaging for Detection and Diagnosis of Breast Cancer

    6.01.29

    Minor Update

    13

    Microarray-Based Gene Expression Profile Testing for Multiple Myeloma Risk Stratification

    2.04.97

    Minor Update

    14

    Myocardial Sympathetic Innervation Imaging in Patients With Heart Failure

    6.01.56

    Minor Update

    15

    Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence

    1.01.17

    Minor Update

    16

    Radiofrequency Ablation of the Renal Sympathetic Nerves as a Treatment for Resistant Hypertension

    7.01.136

    Minor Update

     

     

     

    Policy Title – December 1, 2019

    Policy#

    Status

    1

    Molecular Analysis for Targeted Therapy of Non-Small-Cell Lung Cancer

    2.04.45

    Major Update

    2

    Reproductive Techniques

    4.02.04

    Major Update

    3

    Absorbable Nasal Implant for Treatment of Nasal Valve Collapse

    7.01.163

    Minor Update

    4

    Antigen Leukocyte Antibody Test

    2.01.93

    Minor Update

    5

    Aqueous Shunts and Stents for Glaucoma

    9.03.21

    Minor Update

    6

    BCR-ABL1 Testing in Chronic Myelogenous Leukemia and Acute Lymphoblastic Leukemia

    2.04.85

    Minor Update

    7

    Computed Tomography Perfusion Imaging of the Brain

    6.01.49

    Minor Update

    8

    Computed Tomography to Detect Coronary Artery Calcification

    6.01.03

    Minor Update

    9

    Contrast-Enhanced Coronary Computed Tomography Angiography for Coronary Artery Evaluation

    6.01.43

    Minor Update

    10

    Cryosurgical Ablation of Primary or Metastatic Liver Tumors

    7.01.75

    Minor Update

    11

    Dopamine Transporter Imaging With Single-Photon Emission Computed Tomography

    6.01.54

    Minor Update

    12

    Elective Percutaneous Coronary Intervention (PCI)

    BSC6.02

    Minor Update

    13

    Endobronchial Ultrasound for Diagnosis and Staging of Lung Cancer

    6.01.58

    Minor Update

    14

    Focal Treatments for Prostate Cancer

    8.01.61

    Minor Update

    15

    Genetic Cancer Susceptibility Panels Using Next-Generation Sequencing

    2.04.93

    Minor Update

    16

    Genetic Testing for Developmental Delay/Intellectual Disability, Autism Spectrum Disorder, and Congenital Anomalies

    2.04.59

    Minor Update

    17

    Genetic Testing for Heterozygous Familial Hypercholesterolemia

    2.04.139

    Minor Update

    18

    Genetic Testing for Lipoprotein(a) Variant(s) as a Decision Aid for Aspirin Treatment

    2.04.70

    Minor Update

    19

    Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes

    2.04.08

    Minor Update

    20

    Heart/Lung Transplant

    7.03.08

    Admin Update

    21

    Hyperthermic Intraperitoneal Chemotherapy for Select Intra-Abdominal and Pelvic Malignancies

    2.03.07

    Minor Update

    22

    Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers)

    7.01.107

    Minor Update

    23

    Knee Arthroscopy in Knee Osteoarthritis

    BSC7.16

    Minor Update

    24

    Laboratory Tests for Heart and Kidney Transplant Rejection

    2.01.68

    Minor Update

    25

    Lower Limb Prostheses

    BSC1.01

    Minor Update

    26

    Miscellaneous (Noncardiac, Nononcologic) Applications of Fluorine 18 Fluorodeoxyglucose Positron Emission Tomography

    6.01.06

    Minor Update

    27

    Neuropsychological Testing

    BSC2.06

    Minor Update

    28

    Next-Generation Sequencing for the Assessment of Measurable Residual Disease

    2.04.147

    Minor Update

    29

    Power Wheelchairs and Power Operated Vehicles for Permanent Use

    BSC1.02

    Minor Update

    30

    Preimplantation Genetic Testing

    4.02.05

    Minor Update

    31

    Prostatic Urethral Lift

    7.01.151

    Minor Update

    32

    Quantitative Electroencephalography as a Diagnostic Aid for Attention-Deficit/Hyperactivity Disorder

    3.01.03

    Minor Update

    33

    Radioactive Seed Localization of Nonpalpable Breast Lesions

    6.01.57

    Minor Update

    34

    Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors

    7.01.95

    Minor Update

    35

    Regional Sympathetic Blocks

    BSC6.04

    Minor Update

    36

    Thermography

    6.01.12

    Minor Update

    37

    Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders

    2.01.50

    Minor Update

    38

    Use of Common Genetic Variants (Single Nucleotide Variants) to Predict Risk of Nonfamilial Breast Cancer

    2.04.63

    Minor Update

    39

    Vertebral Fracture Assessment with Densitometry

    6.01.44

    Minor Update

    40

    Whole Body Dual X-Ray Absorptiometry to Determine Body Composition

    6.01.40

    Minor Update

     

     

  • New and updated policies effective November 1, 2019

     

    Policy Title – November 1, 2019   

    Policy#

    Status

    1

    Electromagnetic Navigation Bronchoscopy

    7.01.122

    Major Update

    2

    Ablation of Peripheral Nerves to Treat Pain

    7.01.154

    Minor Update

    3

    Allogeneic Hematopoietic Cell Transplantation for Genetic Diseases and Acquired Anemias

    8.01.22

    Admin Update

    4

    Allogeneic Hematopoietic Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms

    8.01.21

    Admin Update

    5

    Amniotic Membrane and Amniotic Fluid

    7.01.149

    Admin Update

    6

    Beta-Amyloid Imaging with Positron Emission Tomography for Alzheimer Disease

    6.01.55

    Minor Update

    7

    Bioengineered Skin and Soft Tissue Substitutes

    7.01.113

    Admin Update

    8

    Cardiovascular Risk Panels

    2.04.100

    Admin Update

    9

    Cellular Immunotherapy for Prostate Cancer

    8.01.53

    Minor Update

    10

    Composite Tissue Allotransplantation of the Hand and Face

    7.03.13

    Minor Update

    11

    Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate, or Dermatologic Tumors

    7.01.92

    Minor Update

    12

    Drug Testing in Pain Management and Substance Use Disorder Treatment

    2.04.98

    Admin Update

    13

    Dynamic Spinal Visualization and Vertebral Motion Analysis

    6.01.46

    Minor Update

    14

    External Insulin Infusion Pump

    BSC1.03

    Minor Update

    15

    Fecal Analysis in the Diagnosis of Intestinal Dysbiosis

    2.04.26

    Admin Update

    16

    Fecal Microbiota Transplantation

    2.01.92

    Admin Update

    17

    Functional Magnetic Resonance Imaging of the Brain

    6.01.47

    Minor Update

    18

    Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer

    2.04.33

    Admin Update

    19

    Genetic Cancer Susceptibility Panels Using Next-Generation Sequencing

    2.04.93

    Admin Update

    20

    Genetic Testing for BRCA1 or BRCA2 for Hereditary Breast/Ovarian Cancer Syndrome and Other High-Risk Cancers

    2.04.02

    Admin Update

    21

    Genetic Testing for Li-Fraumeni Syndrome

    2.04.101

    Admin Update

    22

    Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes

    2.04.08

    Admin Update

    23

    Genetic Testing for PTEN Hamartoma Tumor Syndrome

    2.04.88

    Admin Update

    24

    Heart Transplant

    7.03.09

    Minor Update

    25

    Heart/Lung Transplant

    7.03.08

    Minor Update

    26

    Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia

    8.01.32

    Admin Update

    27

    Hematopoietic Cell Transplantation for Acute Myeloid Leukemia

    8.01.26

    Admin Update

    28

    Hematopoietic Cell Transplantation for Autoimmune Diseases

    8.01.25

    Admin Update

    29

    Hematopoietic Cell Transplantation for Central Nervous System Embryonal Tumors and Ependymoma

    8.01.28

    Admin Update

    30

    Hematopoietic Cell Transplantation for Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma

    8.01.15

    Admin Update

    31

    Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia

    8.01.30

    Admin Update

    32

    Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer

    8.01.23

    Admin Update

    33

    Hematopoietic Cell Transplantation for Hodgkin Lymphoma

    8.01.29

    Admin Update

    34

    Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors in Adults

    8.01.24

    Admin Update

    35

    Hematopoietic Cell Transplantation for Non-Hodgkin Lymphomas

    8.01.20

    Admin Update

    36

    Hematopoietic Cell Transplantation for Plasma Cell Dyscrasias, Including Multiple Myeloma and POEMS Syndrome

    8.01.17

    Admin Update

    37

    Hematopoietic Cell Transplantation for Primary Amyloidosis

    8.01.42

    Admin Update

    38

    Hematopoietic Cell Transplantation for Solid Tumors of Childhood

    8.01.34

    Admin Update

    39

    Hematopoietic Cell Transplantation for Waldenstrom Macroglobulinemia

    8.01.54

    Admin Update

    40

    Hematopoietic Cell Transplantation in the Treatment of Germ Cell Tumors

    8.01.35

    Admin Update

    41

    Identification of Microorganisms Using Nucleic Acid Probes

    2.04.10

    Admin Update

    42

    Intensity-Modulated Radiotherapy: Central Nervous System Tumors

    8.01.59

    Minor Update

    43

    Interim Positron Emission Tomography Scanning in Oncology to Detect Early Response During Treatment

    6.01.51

    Minor Update

    44

    Isolated Small Bowel Transplant

    7.03.04

    Minor Update

    45

    KRAS, NRAS, BRAF Variant Analysis (Including Liquid Biopsy) in Metastatic Colorectal Cancer

    2.04.53

    Admin Update

    46

    Laboratory Tests for Heart and Kidney Transplant Rejection

    2.01.68

    Admin Update

    47

    Liver Transplant and Combined Liver-Kidney Transplant

    7.03.06

    Minor Update

    48

    Lung and Lobar Lung Transplant

    7.03.07

    Minor Update

    49

    Magnetic Resonance Imaging to Monitor the Integrity of Silicone Gel-Filled Breast Implants

    6.01.50

    Minor Update

    50

    Magnetic Resonance ImagingTargeted Biopsy of the Prostate

    7.01.152

    Minor Update

    51

    Magnetic Resonance Spectroscopy

    6.01.24

    Minor Update

    52

    Magnetoencephalography/Magnetic Source Imaging

    6.01.21

    Minor Update

    53

    Meniscal Allografts and Other Meniscal Implants

    7.01.15

    Minor Update

    54

    Miscellaneous Genetic and Molecular Diagnostic Tests

    2.04.121

    Minor Update

    55

    Moderate Penetrance Variants Associated with Breast Cancer in Individuals at High Breast Cancer Risk discusses genetic testing for the ATM, PALB2, and CHEK2 genes

    2.04.126

    Admin Update

    56

    Molecular Testing for the Management of Pancreatic Cysts, Barrett Esophagus, and Solid Pancreatic Lesions

    2.04.52

    Admin Update

    57

    Noninvasive Prenatal Screening for Fetal Aneuploidies and Microdeletions Using Cell-Free Fetal DNA

    4.01.21

    Admin Update

    58

    Oncologic Applications of Positron Emission Tomography Scanning

    6.01.26

    Minor Update

    59

    Percutaneous Tibial Nerve Stimulation

    7.01.106

    Minor Update

    60

    Placental and Umbilical Cord Blood as a Source of Stem Cells

    7.01.50

    Admin Update

    61

    Polysomnography for Non-Respiratory Sleep Disorders

    2.01.99

    Minor Update

    62

    Positional Magnetic Resonance Imaging

    6.01.48

    Minor Update

    63

    Positron Emission Mammography

    6.01.52

    Minor Update

    64

    Radioembolization for Primary and Metastatic Tumors of the Liver

    8.01.43

    Minor Update

    65

    Radioimmunoscintigraphy (Monoclonal Antibody Imaging) With Indium 111 Capromab Pendetide for Prostate Cancer

    6.01.37

    Minor Update

    66

    Scintimammography and Gamma Imaging of the Breast and Axilla

    6.01.18

    Minor Update

    67

    Steroid-Eluting Sinus Stents

    7.01.134

    Admin Update

    68

    Virtual Colonoscopy/Computed Tomography Colonography

    6.01.32

    Minor Update

     

  • New and updated policies effective September 1, 2019

     

    Policy Title – September 1, 2019

    Policy#

    Status

    1

    Treatment of Varicose Veins/Venous Insufficiency

    7.01.124

    Major Update

    2

    Ablation Procedures for Peripheral Neuromas

    7.01.147

    Minor Update

     3

    Adjustable Cranial Orthoses for Positional Plagiocephaly and Craniosynostoses

    1.01.11

    Minor Update

    4

    Alcohol Injections for Treatment of Peripheral Neuromas

    2.01.97

    Minor Update

    5

    Ambulatory Event Monitors and Mobile Cardiac Outpatient Telemetry

    2.02.08

    Admin Update

    6

    Autonomic Nervous System Testing

    2.01.96

    Minor Update

    7

    Brachytherapy for Clinically Localized Prostate Cancer Using Permanently Implanted Seeds

    8.01.14

    Minor Update

    8

    BRAF Gene Variant Testing to Select Melanoma or Glioma Patients for Targeted Therapy

    2.04.77

    Minor Update

    9

    Bronchial Thermoplasty

    7.01.127

    Minor Update

    10

    Catheter Ablation as Treatment for Atrial Fibrillation

    2.02.19

    Minor Update

    11

    Electromyography and Nerve Conduction Studies

    2.01.95

    Minor Update

    12

    Electronic Brachytherapy for Nonmelanoma Skin Cancer

    8.01.62

    Minor Update

    13

    Endobronchial Brachytherapy

    8.03.11

    Minor Update

    14

    Genetic Testing for Alpha Thalassemia

    2.04.104

    Minor Update

    15

    Genotype-Guided Tamoxifen Treatment

    2.04.51

    Minor Update

    16

    High-Dose Rate Temporary Prostate Brachytherapy

    8.01.33

    Minor Update

    17

    Home Cardiorespiratory Monitoring

    1.01.06

    Minor Update

    18

    In Vitro Chemoresistance and Chemosensitivity Assays

    2.03.01

    Minor Update

    19

    Intensity-Modulated Radiotherapy of the Breast and Lung

    8.01.46

    Minor Update

    20

    Intensity-Modulated Radiotherapy of the Prostate

    8.01.47

    Minor Update

    21

    Intensity-Modulated Radiotherapy: Cancer of the Head and Neck or Thyroid

    8.01.48

    Minor Update

    22

    Intraoperative Radiotherapy

    8.01.08

    Minor Update

    23

    Low-Level Laser Therapy

    2.01.56

    Minor Update

    24

    Magnetic Resonance-Guided Focused Ultrasound

    7.01.109

    Minor Update

    25

    Magnetic Resonance Imaging for Detection and Diagnosis of Breast Cancer

    6.01.29 

    Admin Update

    26

    Molecular Testing for the Management of Pancreatic Cysts, Barrett Esophagus, and Solid Pancreatic Lesions

    2.04.52

    Minor Update

    27

    Navigated Transcranial Magnetic Stimulation

    2.01.90

    Minor Update

    28

    Neurofeedback

    2.01.28

    Minor Update

    29

    Oncologic Applications of Photodynamic Therapy, Including Barrett Esophagus

    8.01.06

    Minor Update

    30

    Percutaneous Electrical Nerve Stimulation and Percutaneous Neuromodulation Therapy

    7.01.29

    Minor Update

    31

    Proteogenomic Testing for Patients With Cancer

    2.04.140

    Minor Update

    32

    Radiofrequency Ablation of Primary or Metastatic Liver Tumors

    7.01.91

    Minor Update

    33

    Saturation Biopsy for Diagnosis, Staging, and Management of Prostate Cancer

    7.01.121

    Minor Update

    34

    Serum Biomarker Panel Testing for Systemic Lupus Erythematosus and Other Connective Tissue Diseases

    2.04.123

    Minor Update

    35

    Surgical Treatments for Breast Cancer-Related Lymphedema

    7.01.162

    Minor Update

    36

    Synthetic Cartilage Implants for Joint Pain

    7.01.160

    Minor Update

    37

    Three-Dimensional Printed Orthopedic Implants

    7.01.161

    Minor Update

    38

    Transcatheter Pulmonary Valve Implantation

    7.01.131

    Minor Update

     

  • New and updated policies effective August 1, 2019

     

    Policy Title – August 1, 2019

    Policy#

    Status

    1

    Circulating Tumor DNA for Management of Non-Small-Cell Lung Cancer (Liquid Biopsy)

    2.04.143

    Major Update

    2

    Closure Devices for Patent Foramen Ovale and Atrial Septal Defects

    2.02.09

    Major Update

     3

    Noninvasive Prenatal Screening for Fetal Aneuploidies and Microdeletions Using Cell-Free Fetal DNA

    4.01.21

    Major Update

    4

    Testing Serum Vitamin D Levels

    2.04.135

    Major Update

    5

    Transcatheter Mitral Valve Repair

    2.02.30

    Major Update

    6

    Hepatitis C Positive Organs for Transplantation to Non-Viremic Patients

    7.03.14

    New

    7

    Transurethral Water Vapor Thermal Therapy for Benign Prostatic Hyperplasia

    2.01.49

    New

    8

    Actigraphy

    2.01.73

    Minor Update

    9

    Automated Ambulatory Blood Pressure Monitoring for Diagnosis of Hypertension in Patients with Elevated Office Blood Pressure

    1.01.02

    Minor Update

    10

    Automated Point-of-Care Nerve Conduction Tests

    2.01.77

    Minor Update

    11

    Bronchial Valves

    7.01.128

    Minor Update

    12

    Carrier Screening for Genetic Diseases

    2.04.107

    Admin Update

    13

    Catheter Ablation for Cardiac Arrhythmias

    BSC2.12

    Minor Update

    14

    Coronary Computed Tomography Angiography With Selective Noninvasive Fractional Flow Reserve

    6.01.59

    Minor Update

    15

    Cytochrome P450 Genotype-Guided Treatment Strategy

    2.04.38

    Minor Update

    16

    Endovascular Stent Grafts for Abdominal Aortic Aneurysms

    7.01.67

    Minor Update

    17

    Expanded Molecular Panel Testing of Cancers to Identify Targeted Therapies

    2.04.115

    Admin Update

    18

    Extracorporeal Membrane Oxygenation for Adult Conditions

    8.01.60

    Minor Update

    19

    Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions

    2.01.40

    Minor Update

    20

    Gene Expression Profiling for Cutaneous Melanoma

    2.04.146

    Minor Update

    21

    General Approach to Evaluating the Utility of Genetic Panels

    2.04.92

    Admin Update

    22

    Genetic Testing for Alpha1-Antitrypsin Deficiency

    2.04.79

    Minor Update

    23

    Genetic Testing for BRCA1 or BRCA2 for Hereditary Breast/Ovarian Cancer Syndrome and Other High-Risk Cancers

    2.04.02

    Admin Update

    24

    Genetic Testing for Diagnosis and Management of Mental Health Conditions

    2.04.110

    Minor Update

    25

    Genetic Testing for Hereditary Hemochromatosis

    2.04.80

    Minor Update

    26

    Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes

    2.04.08

    Admin Update

    27

    Genetic Testing for Mitochondrial Disorders

    2.04.117

    Minor Update

    28

    Genotype-Guided Warfarin Dosing

    2.04.48

    Minor Update

    29

    Inhaled Nitric Oxide

    8.01.37

    Minor Update

    30

    Interferential Current Stimulation

    1.01.24

    Minor Update

    31

    Intradialytic Parenteral Nutrition

    8.01.44

    Minor Update

    32

    Knee Braces

    BSC1.05

    Minor Update

    33

    Lipid Apheresis

    8.02.04

    Minor Update

    34

    Lung Volume Reduction Surgery for Severe Emphysema

    7.01.71

    Minor Update

    35

    Multibiomarker Disease Activity Blood Test for Rheumatoid Arthritis

    2.04.119

    Minor Update

    36

    Orthognathic Surgery

    BSC7.03

    Minor Update

    37

    Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Conditions

    1.01.15

    Minor Update

    38

    Paraspinal Surface Electromyography to Evaluate and Monitor Back Pain

    2.01.35

    Minor Update

    39

    Percutaneous Left Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation

    2.02.26

    Minor Update

    40

    Power Wheelchairs and Power Operated Vehicles for Permanent Use

    BSC1.02

    Admin Update

    41

    Progenitor Cell Therapy for the Treatment of Damaged Myocardium due to Ischemia

    2.02.18

    Minor Update

    42

    Quantitative Sensory

    2.01.39

    Minor Update

    43

    Ultrafiltration in Decompensated Heart Failure

    2.02.22

    Minor Update

     

  • New and updated policies effective July 1, 2019

     

    Policy Title – July 1, 2019

    Policy#

    Status

    1

    Genetic Testing for Idiopathic Dilated Cardiomyopathy

    2.04.114

    Major Update

    2

    Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders

    2.04.102

    Major Update

     3

    Ambulatory Event Monitors and Mobile Cardiac Outpatient Telemetry

    2.02.08

    Minor Update

    4

    Baroreflex Stimulation Devices

    8.01.57

    Minor Update

    5

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

    2.02.10

    Minor Update

    6

    Blepharoplasty, Blepharoptosis Repair (Levator Resection) and Brow Lift (Repair of Brow Ptosis)

    BSC7.01

    Minor Update

    7

    Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting

    2.02.24

    Minor Update

    8

    Cervical Spine Surgery

    BSC_NIA_CG_307

    Admin Update

    9

    Circulating Tumor DNA and Circulating Tumor Cells for Cancer Management (Liquid Biopsy)

    2.04.141

    Admin Update

    10

    Electrical Bone Growth Stimulation of the Appendicular Skeleton

    7.01.07

    Minor Update

    11

    Endovascular Stent Grafts for Disorders of the Thoracic Aorta

    7.01.86

    Minor Update

    12

    Endovascular Therapies for Extracranial Vertebral Artery Disease

    7.01.148

    Minor Update

    13

    Enhanced External Counterpulsation

    2.02.06

    Minor Update

    14

    Epidural Spine Injections

    BSC_NIA_CG_300

    Admin Update

    15

    Extracranial Carotid Artery Stenting

    7.01.68

    Minor Update

    16

    Fecal Analysis in the Diagnosis of Intestinal Dysbiosis

    2.04.26

    Admin Update

    17

    Functional Neuromuscular Electrical Stimulation

    8.03.01

    Minor Update

    18

    Gender Reassignment Surgery

    BSC7.02

    Admin Update

    19

    General Approach to Genetic Testing

    2.04.91

    Minor Update

    20

    Genetic Cancer Susceptibility Panels Using Next-Generation Sequencing

    2.04.93

    Admin Update

    21

    Genetic Testing for Alzheimer Disease

    2.04.13

    Minor Update

    22

    Genetic Testing for Hereditary Hearing Loss

    2.04.87

    Minor Update

    23

    Genetic Testing for Inherited Thrombophilia

    2.04.82

    Minor Update

    24

    Genetic Testing for Lactase Insufficiency

    2.04.94

    Minor Update

    25

    Genetic Testing for Rett Syndrome

    2.04.81

    Minor Update

    26

    Genetic Testing of CADASIL Syndrome

    2.04.75

    Minor Update

    27

    Identification of Microorganisms Using Nucleic Acid Probes

    2.04.10

    Admin Update

    28

    Implantable Cardioverter Defibrillators

    7.01.44

    Minor Update

    29

    Interspinous Fixation (Fusion) Devices

    7.01.138

    Minor Update

    30

    Interventions for Progressive Scoliosis

    2.01.83

    Minor Update

    31

    KIF6 Genotyping for Predicting Cardiovascular Risk and/or Effectiveness of Statin Therapy

    2.04.67

    Minor Update

    32

    Laboratory Tests for Heart and Kidney Transplant Rejection

    2.01.68

    Admin Update

    33

    Low-Level Laser Therapy

    2.01.56

    Admin Update

    34

    Lumbar Spine Surgery

    BSC_NIA_CG_304

    Admin Update

    35

    Manipulation Under Anesthesia

    8.01.40

    Minor Update

    36

    Molecular Testing in the Management of Pulmonary Nodules

    2.04.142

    Minor Update

    37

    Open and Thoracoscopic Approaches to Treat Atrial Fibrillation and Atrial Flutter (Maze and Related Procedures)

    7.01.14

    Minor Update

    38

    Orthopedic Applications of Platelet-Rich Plasma

    2.01.98

    Minor Update

    39

    Panniculectomy, Abdominoplasty, and Surgical Management of Diastasis Recti

    BSC7.04

    Minor Update

    40

    Paravertebral Facet Joint Denervation (Radiofrequency Neurolysis)

    BSC_NIA_CG_302

    Admin Update

    41

    Paravertebral Facet Joint Injections or Blocks

    BSC_NIA_CG_301

    Admin Update

    42

    Partial Thickness Rotator Cuff Tears and Acromioplasty/Subacromial Decompression

    BSC7.14

    Admin Update

    43

    Phrenic Nerve Stimulation For Central Sleep Apnea

    2.02.33

    New

    44

    Reconstructive Services

    BSC7.08

    Minor Update

    45

    Reduction Mammaplasty for Breast-Related Symptoms

    7.01.21

    Admin Update

    46

    Responsive Neurostimulation for the Treatment of Refractory Focal Epilepsy

    7.01.143

    Minor Update

    47

    Sacroiliac Joint Injections

    BSC_NIA_CG_305

    Admin Update

    48

    ST2 Assay for Chronic Heart Failure and Heart Transplant Rejection

    2.04.130

    Minor Update

    49

    Thoracic Spine Surgery

    BSC_NIA_CG_308

    Admin Update

    50

    Three-Dimensional Printed Orthopedic Implants

    7.01.161

    Admin Update

    51

    Trigger Point and Tender Point Injections

    2.01.103

    Minor Update

    52

    Ultrasonographic Measurement of Carotid Intima-Medial Thickness as an Assessment of Subclinical Atherosclerosis

    2.02.16

    Minor Update

    53

    Wearable Cardioverter Defibrillators

    2.02.15

    Minor Update