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Recent Medical Policy Updates


Changes made reflected in Issue 12:2012

Policy Number Policy Title  Comments 
1.01.02 Automated Ambulatory Blood Pressure Monitoring for the Diagnosis of Hypertension in Patients with Elevated Office Blood Pressure

medically necessary/ investigational

1.01.05 Ultrasound Accelerated Fracture Healing Device medically necessary/ investigational
1.01.24 Interferential Current Stimulation investigational
1.01.28* Outpatient Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis medically necessary/ investigational
2.01.64 Biofeedback as a Treatment of Fecal Incontinence or Constipation investigational
2.01.71 Non-Pharmcological Treatment of Rosacea investigational
2.01.85 Neural Therapy



Genetic Testing for Predisposition to Inherited Hypertrophic Cardiomyopathy medically necessary/ investigational
2.04.48 Genetic Testing for Warfarin Dose invesitgational
2.04.53 KRAS and BRAF Mutation Analysis in Metastatic Colorectal Cancer medically necessary/ investigational
3.01.02 Opioid Antagonists Under Heavy Sedation or General Anesthesia as a Techinque of Opioid Detoxification investigational
4.01.10 Fetal Surgery for Prenatally Diagnosed Malformations medically necessary/ investigational
5.01.04 Erythropoiesis-Stimulating Agents (ESAs) medically necessary/ investigational
5.01.20* Pertuzumab for Treatment of HER-2 Positive Malignancies

medically necessary/ investigational

5.01.21* Newer Oral Anticoagulant medically necessary/ investigational
6.01.40 Whole Body Dual X-ray Absortiomerty (DEXA) to Determine Body Composition investigational
7.01.07 Electrical Bone Growth Stimulation of the Appendicular Skeleton medically necessary/ investigational
7.01.58 Intra-Operative Neurophsiologic Monitoring (sensory-evoked potentials, motor-evoked potentials, EEG monitoring) medically necessary/ not medically necessary/ investigational
7.01.75 Cryosurigal Ablation of Primary of Metastatic Liver Tumors investigational
7.01.81 Nerve Graft in Association with Radical Prostatectomy investigational

Interspinous Distraction Devices (Spacers)



Arthroscopic Debridement and Lavage as Treatment for Osteoarthritis of the Knee

not medically necessary
7.01.132 Transcatherter Aortic-Valve Implantation for Aortic Stenosis medically necessary/ investigational
7.03.07 Lung and Lobar Lung Transplant medically necessary
8.01.01 Adoptive Immunotherapy investigational
8.01.05 Immune Globulin Therapy medically necessary
8.01.13 Breast Brachytherapy after Breast-Conserving Surgery, as Boost with Whole Breast Irradiation, or alone as Accelerated Partial Breast Irradiation medically necessary/ investigational
8.01.18 Lysis of Epidural Adhesions investigational
8.01.30 Hematopoietic Stem-Cell Transplantation for Chronic Myelogenous Leukemia medically necessary/ investigational
8.01.49 Intensity-Modulated Radiation Therapy (IMRT):Abdomena and Pelvis medically necessary/ investigational
8.01.50 Radioimmunotherapy in the Treatment of Non-Hodgkin's Lymphoma medically necessary/ investigational
9.03.19 Suprachoroidal Delivery of Pharmacologic Agents investigational

* new policies

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