Medical Policy Updates: Second Quarter 2017

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1 Medical Policy Updates: Second Quarter 2017 Medical guidelines are written to address frequently occurring clinical situations. Medical policies are not medical advice and do not guarantee any results or outcomes. We review and update medical policies and guidelines regularly. In addition to updating existing medical policies, we also review frequently occurring clinical situations and may create new medical policies. We recently reviewed these medical policies. Please be sure to read the actual medical policies for details. CAM Policy Name Review Date 069 Abatacept (Orencia ) 108 Abdominoplasty, Panniculectomy and Lipectomy Actigraphy Acupuncture and Dry Needling Advanced Therapies for Pharmacologic Treatment of Pulmonary Hypertension Analysis of Human DNA in Stool Samples as a Technique for Colorectal Cancer Screening 012 Anesthesia Services Antigen Leukocyte Antibody Test Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer Automated Point-of-Care Nerve Conduction Tests BCR-ABL1 Testing in Chronic Myelogenous Leukemia and Acute Lymphoblastic Leukemia 365 Behavioral Health Guidelines 067 Bevacizumab (Avastin) for Oncologic Use Biofeedback as a Treatment of Chronic Pain Bioimpedance Devices for Detection and Management of Lymphedema 040 Blepharoplasty (Upper and Lower) Brachytherapy for Clinically Localized Prostate Cancer Using Permanently Implanted Seeds Breast Duct Endoscopy Cardiac Applications of PET Scanning Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting Catheter Ablation for Cardiac Arrhythmias Cellular Immunotherapy for Prostate Cancer Chemical Peels 065 Chiropractic Services Chromoendoscopy as an Adjunct to Colonoscopy Chromosomal Microarray Analysis for the Evaluation of Pregnancy Loss Chronic Pulmonary Thromboendarterectomy Confocal Laser Endomicroscopy Conjunctival Incision with Posterior Juxtascleral Placement of Anecortave Acetate Depot Suspension Continuous or Intermittent Monitoring of Glucose in Interstitial Fluid 1

2 10126 Cooling Devices Used in the Outpatient Setting Corneal Collagen Cross-linking 082 Cosmetic/Reconstructive Services Cytochrome p450 Genotyping Decompression of the Intervertebral Disc Using Laser (Laser Discectomy) or Radiofrequency Coblation (Nucleoplasty ) Deep Brain Stimulation Diagnosis and Management of Idiopathic Environmental Intolerance (i.e., Clinical Ecology) Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome DNA-Based Testing for Adolescent Idiopathic Scoliosis Dry Needling and Trigger Point Injections for Myofascial Pain Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures Electronic Brachytherapy for Nonmelanoma Skin Cancer Endobronchial Brachytherapy Endoscopic Laser for Gastrointestinal Bleeding Endoscopic Radiofrequency Ablation or Cryoablation for Barrett's Esophagus Erectile Dysfunction Expanded Molecular Panel Testing of Cancers to Identify Targeted Therapies 116 External Insulin Infusion Pump Extracorporeal Shock Wave Treatment for Plantar Faciitis and Other Musculoskeletal Conditions Facet Arthroplasty 168 Familial Adenomatous Polyposis and MUYTH-Associated Polyposis Testing Fecal Analysis in the Diagnosis of Intestinal Dysbiosis First-Trimester Detection of Down Syndrome Using Fetal Ultrasound Markers Combined with Maternal Serum Assessment 120 Flow Cytometry Focal Treatments for Prostate Cancer Functional Neuromuscular Electrical Stimulation, Robotic-assisted Rehabilitation & Robotic-assisted Orthotics 145 Gender Reassignment Surgery Gene Expression Testing to Predict Coronary Artery Disease Gene Expression Based Assays for Cancers of Unknown Primary 166 General Genetic Testing, Germline Disorders 167 General Genetic Testing, Somatic Disorders Genetic Cancer Susceptibility Panels Using Next Generation Sequencing Genetic Testing for Alpha Thalassemia Genetic Testing for Alpha-1 Antitrypsin Deficiency Genetic Testing for Alzheimer s Disease Genetic Testing for Cardiac Ion Channelopathies Genetic Testing for CHARGE Syndrome Genetic Testing for Dilated Cardiomyopathy Genetic Testing for Epilepsy Genetic Testing for Facioscapulohumeral Muscular Dystrophy Genetic Testing for FLT3 and NPM1 Mutations in Acute Myeloid Leukemia 2

3 20402 Genetic Testing for Hereditary Breast and/or Ovarian Cancer Syndrome (BRCA1/BRCA2) Genetic Testing for Hereditary Hemochromatosis Genetic Testing for Hereditary Pancreatitis 056 Genetic Testing for Inherited Disorders and Cancer Susceptibility Genetic Testing for Inherited Thrombophilia Genetic Testing for Lactase Insufficiency Genetic Testing for Li-Fraumeni Syndrome Genetic Testing for Lipoprotein(a) Variant(s) as a Decision Aid for Aspirin Treatment Genetic Testing for Macular Degeneration Genetic Testing for Mental Health Conditions Genetic Testing for Neurofibromatosis Genetic Testing for Nonsyndromic Hereditary Hearing Loss Genetic Testing for PALB2 Mutations Genetic Testing for PTEN Hamartoma Tumor Syndrome Genetic Testing for Statin-Induced Myopathy Genetic Testing for the Diagnosis of Inherited Peripheral Neuropathies Genetic Testing of Mitochondrial Disorders Genotyping for 9p21 Single Nucleotide Polymorphisms to Predict Risk of Cardiovascular Disease or Aneurysm Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia Hematopoietic Cell Transplantation for Primary Amyloidosis Hematopoietic Cell Transplantation in the Treatment of Germ Cell Tumors Hematopoietic Stem-Cell Transplantation for Solid Tumors of Childhood High-Dose Rate Temporary Prostate Brachytherapy HIV Genotyping and Phenotyping 250 Hospital Medical Services (Inpatient and Observation) and Consultation Human Leukocyte Antigen (HLA) Testing for Celiac Disease 026 Human Papillomavirus (HPV) Vaccines Image-Guided Minimally Invasive Lumbar Decompression (IG-MLD) for Spinal Stenosis 019 Implantable Hormone Pellets for Females Infliximab 457 Inpatient Rehabilitation Insulin Potentiation Therapy Intensity-Modulated Radiation Therapy (IMRT): Abdomen and Pelvis Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers) Interspinous Fixation (Fusion) Devices Interventions for Progressive Scoliosis Intracellular Micronutrient Analysis Intracoronary Doppler Ultrasound Intravenous Anesthetics for the Management of Chronic Neuropathic Pain Intravenous Antibiotic Therapy for Lyme Disease Intravitreal Corticosteroid Implants 091 Ipilimumab (Yervoy) JAK2 and MPL Mutation Analysis in Myeloproliferative Neoplasms 3

4 20467 KIF6 Genotyping for Predicting Cardiovascular Risk and/or Effectiveness of Statin Therapy KRAS, NRAS, and BRAF Mutation Analysis in Metastatic Colorectal Cancer Laboratory and Genetic Testing for Use of 5-Fluorouracil in Patients With Cancer Laboratory Testing for HIV Tropism Laparoscopic, Percutaneous and Transcervical Techniques for the Myolysis of Uterine Fibroids Laser Treatment of Onychomycosis 163 Light Therapy for Dermatologic Conditions Light Therapy for Vitiligo and Alopecia Areata Lipid Apheresis Low-Level Laser Therapy Lung and Lobar Lung Transplant 169 Lynch Syndrome Testing Magnetic Resonance Angiography of Vessels of the Head, Neck, Abdomen, Pelvis and Lower Extremity Magnetic Resonance Spectroscopy Magnetic Resonance Guided Focused Ultrasound Manipulation Under Anesthesia Marfan Syndrome Testing Melanoma Vaccines Meniscal Allografts and Other Meniscal Implants Methadone Treatment for Opiate Addiction Minimally Invasive Coronary Artery Bypass Graft Surgery Molecular Analysis for Targeted Therapy of Non-Small-Cell Lung Cancer Molecular Markers in Fine Needle Aspirates of the Thyroid Multigene Expression Assay for Predicting Recurrence in Colon Cancer Mutation Testing for Limb-Girdle Muscular Dystrophies Negative Pressure Wound Therapy in the Outpatient Setting Nerve Graft with Radical Prostatectomy 106 Nivolumab (Opdivo) Noninvasive Fetal RHD Genotyping Using Cell-Free Fetal DNA Noninvasive Prenatal Screening for Fetal Aneuploidies Using Cell-Free Fetal DNA Noninvasive Techniques for the Evaluation and Monitoring of Patients With Chronic Liver Disease Nusinersen for Spinal Muscular Atrophy Occipital Nerve Stimulation Occupational Therapy 170 Ocrelizumab (Ocrevus ) 058 Omalizumab (Xolair ) Opioid Antagonists Under Heavy Sedation or General Anesthesia as a Technique of Opioid Detoxification 077 Oral Screening, Lesion Identification Systems and Genetic Screening Orthopedic Applications of Platelet-Rich Plasma Orthopedic Applications of Stem Cell Therapy (Including Allografts and Bone Substitutes Used With Autologous Bone Marrow) 4

5 90303 Orthoptic Training for the Treatment of Vision or Learning Disabilities Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Conditions 452 Pain Management Services (Chronic Pain and Rehabilitation Therapies) Partial Left Ventriculectomy PathFinderTG Molecular Testing Patient-Specific Cutting Guides and Custom Knee Implants Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence Percutaneous Balloon Kyphoplasty and Mechanical Vertebral Augmentation Percutaneous Treatment of Fracture Non-Unions or Bone Defects with Autologous Bone Marrow with or without Demineralized Bone Matrix (DBM) Percutaneous Vertebroplasty and Sacroplasty PET Scanning in Oncology to Detect Early Response during Treatment Pharmacogenetic Testing for Pain Management Physical Therapy Plasma HIV-1 RNA Quantification for HIV-1 Infection Positional Magnetic Resonance Imaging (MRI) 110 Pre-implantation Genetic Testing 119 Prenatal Screening 086 Preventive Services for Non-Grandfathered (PPACA) Plans: Behavioral Counseling for Prevention Prolotherapy Prophylactic Mastectomy Proteogenomic Testing for Patients With Cancer (GPS Cancer Test) Proteomics-Based Testing Related to Ovarian Cancer Quantitative Sensory Testing Radiofrequency Ablation of Peripheral Nerves to Treat Pain 512 Radiopharmaceutical Agents and Other In Vivo Diagnostic Aids 455 Registered Nurses Practicing in Extended Roles Reproductive Techniques 060 Rituximab Sacral Nerve Neuromodulation/Stimulation Saturation Biopsy for Diagnosis and Staging of Prostate Cancer Screening for Lung Cancer Using CT Scanning Semi-Implantable Middle Ear Hearing Aid for Moderate to Severe Sensorineural Hearing Loss Sensory Integration Therapy and Auditory Integration Therapy Serologic Diagnosis of Celiac Disease Serum Biomarker Tests for Multiple Sclerosis 149 SIMPONI ARIA (golimumab injection for intravenous use) Skin Contact Monochromatic Infrared Energy as a Technique to Treat Cutaneous Ulcers, Diabetic Neuropathy and Miscellaneous Musculoskeletal Conditions Speculoscopy Speech Therapy ST2 Assay for Chronic Heart Failure Stem-cell Therapy for Peripheral Arterial Disease 5

6 70116 Stereotactic Radiofrequency Pallidotomy for the Treatment of Parkinson s Disease Surgery for Groin Pain in Athletes 148 Surgery for Lymphedema 139 Surgical and Minimally Invasive Treatments for Urinary Outlet Obstruction due to Benign Prostatic Hyperplasia (BPH) Surgical Treatment of Femoroacetabular Impingement Surgical Ventricular Restoration Systems Pathology in Prostate Cancer 150 TECENTRIQ (atezolizumab) Testosterone Replacement Therapies Threshold Electrical Stimulation as a Treatment of Motor Disorders 135 Thyroid Disease Testing 061 Tocilizumab (Actemra ) Total Parenteral Nutrition and Enteral Nutrition in the Home 140 Toxicology Transcranial Doppler Ultrasound Transjugular Intrahepatic Portosystemic Shunt (TIPS) Transmyocardial Revascularization Transtympanic Micropressure Applications as a Treatment of Meniere s Disease Trastuzumab Treatment of Hyperhidrosis Treatment of Tinnitus 164 Ultraviolet Light Therapy in the Home Setting (UVB) 036 Unicompartmental and Bicompartmental Knee Arthroplasties Unicondylar Interpositional Spacer as a Treatment of Unicompartmental Arthritis of the Knee Urinary Tumor Markers for Bladder Cancer Use of Magnetic Resonance Imaging to Monitor Integrity of Silicone Gel-Filled Breast Implants Vasectomy Using a Polymeric Clip Vectra DA Blood Test for Rheumatoid Arthritis 104 Vedolizumab (Entyvio ) Vertebral Axial Decompression Vertical Expandable Prosthetic Titanium Rib Virtual Colonoscopy/CT Colonography Viscocanalostomy and Canaloplasty 034 Visual and Auditory Evoked Potentials 130 Vitamin B12 and Methylmalonic Acid Testing 126 Vitamin D Testing Whole Body Computed Tomography Scan as a Screening Test Whole Exome and Whole Genome Sequencing for Diagnosis of Patients With Suspected Genetic Disorders Whole Gland Cryoablation of Prostate Cancer 094 Women's Preventive Services 153 Zika Virus Risk Assessment 6