| Medical Policy |
Revision |
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Assays of Genetic Expression to Determine Prognosis of Breast Cancer
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New policy written. Assays of genetic expression in tumor tissue as a technique to determine prognosis of breast cancer is considered investigational. Notification given 11/11/2004. Effective date of policy 1/20/2005.
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Autologous Cell Therapy for the Treatment of Damaged Myocardium
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New policy issued. Autologous cell therapyfor the treatment of damaged myocardium is considered investigational. References added. Notification 11/11/04. Effective 01/20/05.
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BioniCare Stimulator
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New policy issued. BioniCare stimulators are considered investigational. References added. Notification 11/11/2004. Effective 1/20/2005.
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Chemoembolization of the Hepatic Artery, Transcatheter Approach
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CPT codes 75896 and 75898 were removed as they do not apply to this policy. Policy remains unchanged. Chemoembolization of the hepatic artery, transcatheter approach is considered investigational. Listed codes will be reviewed. Updated format of Benefit Application and Billing/Coding sections for consistency. Notification given 11/11/2004. Effective date 1/20/2005.
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Computed Tomographic Angiography (CTA) for Coronary Artery Evaluation
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New policy issued. Computed tomographic angiography for coronary artery evaluation is considered investigational. Reference added. Notification 11/11/04. Effective 1/20/05.
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Inflammatory Bowel Disease (IBD) Serology
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New policy written. The determination of anti-neutrophil cytoplasmic antibody (ANCA) and anti-Saccharomyces cerevisiae antibody (ASCA) serology in the workup and monitoring of patients with inflammatory bowel disease is considered investigational. Notification given 11/11/04. Effective date of policy 1/20/05.
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Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Vein
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New policy issued. Transcatheter ablation of arrhythmogenic foci in the pulmonary vein is considered investigational. References added. Notification 11/11/2004. Effective 1/20/2005.
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Venous Insufficiency
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Specialty Matched Consultant Advisory Panel review - 8/27/04. Under Section I - Varicose Vein Excision and Ligation, "When Covered" added #3."Doppler ultrasonographic documentation of saphenofemoral junction incompetence and greater saphenous vein reflux or saphenopopliteal junction incompetence and lesser saphenous vein reflux." Added codes 37700 & 37780 to Billing/ Coding section. Under Section II - Sclerotherapy, Reference to the COMPASS procedure added; Under "When Covered" A. added #3. "Doppler ultrasonographic documentation of reflux of the saphenofemoral junction or reflux isolated to the perforator veins of the upper thigh." Under "When not Covered", #4 following thrombophlebitis, added "(except as indicated above)". Added code S2202 to Billing/Coding section for Sclerotherapy. Under "When Covered" section for Endoluminal Radiofrequency or Laser Ablation, # 3., added e. "Endoluminal laser ablation of the lesser saphenous vein may be considered medically necessary when doppler ultrasonography documents saphenopopliteal junction incompetence and lesser saphenous vein reflux. The other medical necessity criteria listed in numbers 1. (significant medical problems) and 2. (trial of conservative measures) must be met." References added. Notice given 11/11/04. Effective date 1/ 20/05
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