Autologous Blood-Derived Products (Platelet-Rich Plasma, Autologous Conditioned Serum, Autologous Whole Blood)
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Re-Reviewed
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05/20/2019 |
Investigative and therefore not covered
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No change in determination
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Continuous Glucose Monitoring (CGM) for Managing Diabetes |
New and Re-Reviewed |
03/20/2019
05/20/2019
- Implantable glucose sensor CGM
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Covered for some indications; investigative and therefore not covered for all other indications |
Change in determination:
- Real-time CGM (non-implantable): Covered for insulin-dependent Type 2 diabetes mellitus using an FDA-approved device. (Previously investigative and therefore not covered.)
New determination:
- CGM using an implantable glucose sensor (e.g., Eversense): Investigative and therefore not covered.
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Genetic Testing for Cardiac Channelopathies |
New |
03/20/2019 |
Covered for some indications; investigative and therefore not covered for all other indications |
No change in determination.
Covered for:
- Brugada syndrome
- Catecholaminergic polymorphic ventricular tachycardia
- Long QT syndrome
- Short QT syndrome
Investigative and therefore not covered for all other indications.
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Genetic Testing for Cardiomyopathies |
New |
03/20/2019
Enhanced Benefit
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Covered for some indications; investigative and therefore not covered for all other indications |
Two indications added to the three previous covered indications:
- Left ventricular noncompaction
- Restrictive cardiomyopathy
Investigative and therefore not covered for all other indications.
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Genetic Testing of Thyroid Nodules for Thyroid Cancer |
Re-Reviewed |
03/20/2019
Enhanced Benefit
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Covered for some indications; investigative and therefore not covered for all other indications |
Change in determination:
The following genetic tests are no longer investigative for testing cytological indeterminate thyroid nodules:
- Afirma® BRAF and MTC reflex testing
- ThyroSeq® Genomic Classifier
- ThyroSeq® v.3
- ThyraMIRTM
- ThyGenX® with or without ThyraMIRTM
Afirma® Gene Expression Classifier remains not investigative.
All other genetic molecular profiling of thyroid nodules in fine-needle aspirates of the thyroid for thyroid cancer is investigative
|
Meniett™ Portable Pulse Generator for Treatment of Meniere’s
Disease
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Re-Reviewed |
05/20/2019 |
Investigative and therefore not covered
|
No change in determination |
Palatal Implants for Obstructive Sleep Apnea Syndrome |
Re-Reviewed |
05/20/2019 |
Investigative and therefore not covered
|
No change in determination |
Percutaneous Radiofrequency and Laser Ablation Denervation Procedures for Facet and Sacroiliac Joints |
Re-Reviewed |
05/20/2019 |
Covered for some indications; investigative and therefore not covered for all other indications
|
No change in determination |
Quantitative Sensory Tests |
Re-Reviewed |
05/20/2019 |
Investigative and therefore not covered
|
No change in determination |
Salivary Estriol Test for Preterm Labor |
Re-Reviewed |
05/20/2019 |
Investigative and therefore not covered
|
No change in determination |
Single Photon Emission Computed Tomography (SPECT) for
Attention Deficit Hyperactivity Disorder (ADHD)
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Re-Reviewed |
05/20/2019 |
Investigative and therefore not covered
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No change in determination |
Tissue-Engineered Skin Substitutes for Wound and Surgical Care |
Re-Reviewed |
03/20/2019
Enhanced Benefit |
Covered for some indications; investigative and therefore not covered for all other indications
|
Change in determination:
The following products are no longer investigative for the specific indication listed:
Breast reconstructive surgery:
- AlloDerm®
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- AlloMax™
- AlloMend®
- Cortiva®
- DermACELL®
- DermaMatrix™
- FlexHD®
- Graftjacket® Regenerative Tissue Matrix (RTM)
- hMatrix®
- Neoform™ Dermis
Treatment of (1) non-infected wounds, or (2) non-infected chronic ulcers (diabetic or venous insufficiency) of the lower-extremity, either of which have not adequately responded to conventional therapy:
- Apligraf®
- Dermagraft®
- EpiFix®
- Integra® Omnigraft, Dermal Regeneration Template, and Bilayer Matrix Wound Dressing (excludes flowable wound matrix)
- Graftjacket® Regenerative Tissue Matrix
- Oasis® Wound Matrix
Deep dermal or full thickness burns (2nd or 3rd degree burns):
- Epicel®
- Integra® Dermal Regeneration Template™
- OrCel™ (HDE)
- TranCyte®
- Biobrane®
Stevens-Johnson syndrome and toxic epidermal necrolysis:
Dystrophic epidermolysis bullosa:
All other uses of the tissue-engineered skin substitutes not listed above are investigative.
All other tissue-engineered skin substitutes not listed above are investigative for all indications.
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