Extracorporeal Photopheresis (Photochemotherapy)
|
Re-reviewed
|
07/16/2018
|
Covered for some indications; investigative and therefore not covered for all other indications
|
- Both skin and non-skin, graft-versus-host disease is not investigative.
- Atopic (neuro-) dermatitis (atopic eczema), recalcitrant and Dermatomyositis/polymyositis are investigative.
|
Gene Expression Profiling Assays for Breast Cancer
|
Re-reviewed
|
05/16/2018
Enhanced member benefit
|
Covered for some indications; investigative and therefore not covered for all other indications
|
- Oncotype DX Breast Breast Cancer Assay: now covered for early stage breast cancer that is hormone receptor (+), HER2-receptor (-) and either Node (-) or Node (+) in 1-3 ipsilateral lymph nodes. (Previously covered for only Node (-) tumors.)
- Following 4 tests now covered for hormone receptor (+), HER2-receptor (-) and Node (-) breast tumors:
- Breast Cancer Index (BCI)
- EndoPredict
- MammaPrint
- Prosigna (PAM 50)
- The use of more than one gene expression profile assay per each breast cancer tumor type (either repeat testing of a previously performed assay or using a different assay) is investigative.
|
Gene Expression Profiling Assays for Predicting Colon Cancer Recurrence Risk
|
Re-reviewed
|
07/16/2018
|
Investigative and therefore not covered
|
No change in determination
|
Genetic Testing for Prostate Cancer
|
Re-reviewed
|
07/16/2018
|
Investigative and therefore not covered
|
Added the following Investigative genetic tests:
- Decipher® Prostate Cancer Classifier
- ProMark Proteomic Prognostic Test
- ConfirmMDx® for Prostate Cancer
- SelectMDx for Prostate Cancer
|
Liquid Biopsy: Testing of Circulating Tumor Cells or Cell-Free Tumor DNA
Former Title: Circulating Tumor Cell Laboratory Testing
|
Re-reviewed
|
07/16/2018
|
Investigative and therefore not covered
|
Cell-free Tumor DNA (cfDNA) added to this policy. Testing of both circulating tumor cells and cell-free DNA are investigative. .
|
Lower Limb Activity-Based Locomotor Training
|
New
|
07/16/2018
Note: Former policy, Lower-Limb Functional Electrical Stimulation, will be inactivated on 7/16/2018 and incorporated into this policy.
|
Covered for some indications; investigative and therefore not covered for all other indications
|
Not Investigative Determination:
- Functional electrical stimulation (FES) and neuromuscular electrical stimulation (NMES) using stationary equipment when used as one component of a comprehensive facility-based rehabilitation program.
Investigative Determination:
- FES/NMES for all indications not listed above
- FES ergometic cycles used in the home setting
- Dynamic spinal unloading devices (e.g., GIGER MD coordinated dynamic therapy device)
- Robotic-assisted locomotor treadmill therapy (e.g., Lokomat®)
Note: Exercise programs, and the equipment used, are usually excluded services in the member’s plan document.
|
Multivariate Biomarker Blood Testing for Predicting Malignancy in Women with Adnexal Mass
|
Re-reviewed
|
07/16/2018
|
Investigative and therefore not covered
|
No change in determination.
|
Nebulized Intranasal Antibiotics/Antifungals for Sinusitis
|
Re-reviewed
|
07/16/2018
|
Investigative and therefore not covered
|
No change in determination.
|
Therapeutic Apheresis (TA): Plasmapheresis, Plasma Exchange
|
Re-reviewed
|
07/16/2018
|
Covered for some indications; investigative and therefore not covered for all other indications
|
Adjustments made to the covered and non-covered indications to reflect the indications re-assessed in the 2016 American Society for Apheresis Guideline: Use of Therapeutic Apheresis in Clinical Practice, and documented in the published clinical assessment monographs.
|
Thoracic Electrical Bioimpedance
|
Re-reviewed
|
07/16/2018
|
Investigative and therefore not covered
|
No change in determination.
|