Medical Policy Updates

Notification of Policy Revisions Effective November 23, 2010 (Posted August 17, 2010)

Medical Policy	Revision
Proteomics-based Testing for the Evaluation of Ovarian (Adnexal) Masses	New policy issued. The proteomics-based OVA1TM test may be considered medically necessary as an aid to further assess the likelihood that malignancy is present when the physician’s (other than gynecologic oncologist) independent clinical and radiological preoperative evaluations do not indicate malignancy in a patient with an ovarian (adnexal) mass. All other uses of the OVA1TM test are investigational including but not limited to: screening for ovarian cancer; or selecting patients for surgery for an adnexal mass; or evaluation of patients with clinical or radiologic evidence of malignancy; or evaluation of patients with nonspecific signs or symptoms suggesting possible malignancy; or post-operative testing and monitoring to assess surgical outcome and/or to detect recurrent malignant disease following treatment. Notification given 8/17/10 for policy effective date of 11/23/10.

Medical Policy

Revision

Proteomics-based Testing for the Evaluation of Ovarian (Adnexal) Masses

New policy issued. The proteomics-based OVA1TM test may be considered medically necessary as an aid to further assess the likelihood that malignancy is present when the physician’s (other than gynecologic oncologist) independent clinical and radiological preoperative evaluations do not indicate malignancy in a patient with an ovarian (adnexal) mass. All other uses of the OVA1TM test are investigational including but not limited to: screening for ovarian cancer; or selecting patients for surgery for an adnexal mass; or evaluation of patients with clinical or radiologic evidence of malignancy; or evaluation of patients with nonspecific signs or symptoms suggesting possible malignancy; or post-operative testing and monitoring to assess surgical outcome and/or to detect recurrent malignant disease following treatment. Notification given 8/17/10 for policy effective date of 11/23/10.