Medical Clinical Policy Bulletins

  Additions, Revisions, Updates, and Deletions Sorted by Date

New:

• March 16 - 2012 - 0827 - Electric Tumor Treatment Fields     

Revised:

• May 22, 2012 - 0024 - Interleukin-2 (Aldesleukin, Proleukin, IL-2) 
• May 22, 2012 - 0073 - Cardiac Event Monitors 
• May 22, 2012 - 0181 - Evoked Potential Studies 
• May 22, 2012 - 0184 - Pulmonary Hypertension Treatments and Selected Indications of Prostanoids 
• May 22, 2012 - 0195 - Erythropoiesis Stimulating Agents 
• May 22, 2012 - 0199 - Ultrasound for Pregnancy 
• May 22, 2012 - 0205 - Phototherapy and Photochemotherapy (PUVA) for Skin Conditions 
• May 22, 2012 - 0206 - Parenteral Immunoglobulins 
• May 22, 2012 - 0208 - Deep Brain Stimulation 
• May 22, 2012 - 0259 - Transjugular Intrahepatic Portosystemic Shunt (TIPSS) 
• May 22, 2012 - 0341 - Remicade (Infliximab) 
• May 22, 2012 - 0410 - Hepatitis B Vaccine 
• April 27, 2012 - 0130 - Computerized Corneal Topography 
• April 27, 2012 - 0131 - Clotting Factors 
• April 27, 2012 - 0132 - Biofeedback 
• April 27, 2012 - 0135 - Acupuncture 
• April 27, 2012 - 0155 - Ribavirin (Virazole) 
• April 27, 2012 - 0157 - Obesity Surgery 
• April 27, 2012 - 0165 - Cardiac Catheter Ablation Procedures 
• April 27, 2012 - 0166 - Fetal Fibronectin, Inflammatory Biomarkers, and Salivary Estriol Testing for Preterm Labor 
• April 27, 2012 - 0170 - Growth Hormone (GH) and Growth Hormone Antagonists 
• April 27, 2012 - 0172 - Hyperbaric Oxygen Therapy (HBOT) 
• April 27, 2012 - 0173 - Prothrombin Time (INR) Home Testing Devices 
• April 27, 2012 - 0188 - Total Body Photography and Dermoscopy 
• April 27, 2012 - 0191 - Vagus Nerve Stimulation 
• April 27, 2012 - 0751 - Natalizumab (Tysabri) 
• April 24, 2012 - 0065 - Nebulizers 
• April 24, 2012 - 0069 - Lymphedema 
• April 24, 2012 - 0071 - Positron Emission Tomography (PET) 
• April 24, 2012 - 0079 - Benign Prostatic Hypertrophy (BPH) Treatments 
• April 24, 2012 - 0083 - Stereotactic Radiosurgery  
• April 24, 2012 - 0094 - Magnetic Resonance Angiography (MRA) and Magnetic Resonance Venography (MRV) 
• April 24, 2012 - 0100 - Cryoablation 
• April 24, 2012 - 0105 - Magnetic Resonance Imaging (MRI) of the Breast 
• April 24, 2012 - 0106 - Fetal Echocardiograms 
• April 24, 2012 - 0107 - Chiropractic Services 
• April 24, 2012 - 0111 - Indocyanine Green Angiography 
• April 24, 2012 - 0113 - Botulinum Toxin 
• April 24, 2012 - 0115 - Varicella and Herpes Zoster Vaccines 
• March 16, 2012 - 0011 - Electrical Stimulation for Pain 
• March 16, 2012 - 0013 - Cochlear Implants and Auditory Brainstem Implants 
• March 16, 2012 - 0016 - Back Pain - Invasive Procedures 
• March 16, 2012 - 0021 - Cardiac Rehabilitation 
• March 16, 2012 - 0022 - Calcitriol and Paricalcitol Injections 
• March 16, 2012 - 0024 - Interleukin-2 (Aldesleukin, Proleukin, IL-2) 
• March 16, 2012 - 0025 - Automated Ambulatory Blood Pressure Monitoring 
• March 16, 2012 - 0027 - Implantable Vas Deferens Occlusion Devices 
• March 16, 2012 - 0031 - Cosmetic Surgery 
• March 16, 2012 - 0038 - Allergy and Hypersensitivity 
• March 16, 2012 - 0352 - Tumor Markers 
• March 16, 2012 - 0421 - Breast Pumps 
• March 16, 2012 - 0701 - Vascular Endothelial Growth Factor Inhibitors for Ocular Neovascularization 
• March 16, 2012 - 0765 - Age-Related Macular Degeneration -- Treatments 
• March 13, 2012 - 0005 - Septoplasty and Rhinoplasty 
• March 13, 2012 - 0007 - Erectile Dysfunction 
• March 13, 2012 - 0008 - Color-Flow Doppler Echocardiography in Adults 
• March 13, 2012 - 0009 - Orthopedic Casts, Braces and Splints 
• March 1, 2012 - 0004 - Obstructive Sleep Apnea in Adults 
• February 20, 2012 - 0482 - Compression Garments for the Legs 
• February 3, 2012 - 0161 - Infusion Pumps 
• February 3, 2012 - 0227 - BRCA Testing, Prophylactic Mastectomy, and Prophylactic Oophorectomy 
• February 3, 2012 - 0250 - Occupational Therapy Services 
• February 3, 2012 - 0493 - Kidney Transplantation 
• February 3, 2012 - 0510 - Progestins                   

• May 22, 2012 - 0168 - Tumor Scintigraphy 
• May 21, 2012 - 0317 - Ultra Rapid Detoxification (UROD) 
• May 21, 2012 - 0319 - RET Proto-Oncogene Testing 
• May 21, 2012 - 0323 - Preconceptional Sex Selection Techniques 
• May 21, 2012 - 0329 - Home Births 
• May 21, 2012 - 0330 - Multiple Sleep Latency Test (MSLT) 
• May 21, 2012 - 0336 - Acoustic Pharyngometers and SNAP Testing System 
• May 21, 2012 - 0337 - BreastAlert Differential Temperature Sensor 
• May 21, 2012 - 0339 - Pulse Oximetry for Home Use 
• May 21, 2012 - 0340 - Antibody Tests for Neurologic Diseases 
• May 11, 2012 - 0247 - Autologous Chondrocyte Implantation 
• May 11, 2012 - 0248 - Fiberoptic Endoscopic Evaluation of Swallowing (FEES)/Fiberoptic Endoscopic Evaluation of Swallowing with Sensory Testing (FEESST) 
• May 11, 2012 - 0250 - Occupational Therapy Services 
• May 11, 2012 - 0253 - Vocal Cord Paralysis/Insufficiency Treatments 
• May 11, 2012 - 0255 - Inpatient Admission Prior to Surgery (Preop Days) 
• May 11, 2012 - 0256 - Sensory and Auditory Integration Therapy 
• May 11, 2012 - 0262 - External Counterpulsation (ECP) 
• May 11, 2012 - 0265 - Surgical Treatments to Control Drooling (Sialorrhea) 
• May 11, 2012 - 0266 - Cholecystokinin Cholescintigraphy 
• May 11, 2012 - 0267 - Ornish Cardiac Treatment Program 
• May 11, 2012 - 0269 - Breast Biopsy Procedures 
• May 1, 2012 - 0212 - Skeletal Analysis Systems 
• May 1, 2012 - 0213 - Gastroesophageal Reflux Disease (GERD): Treatment Devices 
• May 1, 2012 - 0214 - Cognitive Rehabilitation 
• May 1, 2012 - 0218 - Home Health Aides 
• May 1, 2012 - 0220 - Distraction Osteosynthesis 
• May 1, 2012 - 0226 - Hospitalization for the Initiation of Ketogenic Diet for the Treatment of Intractable Seizures 
• May 1, 2012 - 0229 - Iontophoresis 
• May 1, 2012 - 0231 - Grenz Ray Therapy for Skin Disorders 
• May 1, 2012 - 0232 - Back Pain - Non Invasive Treatments 
• May 1, 2012 - 0234 - Chelation Therapy 
• May 1, 2012 - 0236 - MRI and CT of the Spine 
• May 1, 2012 - 0237 - Chronic Pain Programs 
• May 1, 2012 - 0240 - Antineoplaston Therapy and Sodium Phenylbutyrate 
• May 1, 2012 - 0243 - Speech Therapy 
• May 1, 2012 - 0245 - Tumor Chemosensitivity Assays 
• May 1, 2012 - 0823 - Brentuximab (Adcetris) 
• April 27, 2012 - 0174 - Pool Therapy, Aquatic Therapy or Hydrotherapy  
• April 27, 2012 - 0175 - High-Frequency Pulsed Electromagnetic Stimulation 
• April 18, 2012 - 0179 - Viscosupplementation 
• April 18, 2012 - 0180 - Vertebral Axial Decompression Therapy 
• April 18, 2012 - 0182 - Ventricular Remodeling Operation (Batista Procedure) and Surgical Ventricular Restoration (Dor Procedure) 
• April 18, 2012 - 0189 - Genetic Counseling 
• April 18, 2012 - 0190 - Stem Cells for Bone Marrow Transplant 
• April 18, 2012 - 0198 - Work Hardening Programs 
• April 18, 2012 - 0200 - Coumadin (Warfarin) to Heparin Conversion Before and After Elective Surgery 
• April 18, 2012 - 0201 - Skilled Home Health Care Nursing Services 
• April 18, 2012 - 0202 - Magnetic Resonance Spectroscopy (MRS) 
• April 18, 2012 - 0204 - Manipulation Under Anesthesia 
• April 18, 2012 - 0207 - Prolotherapy 
• April 18, 2012 - 0210 - Phonophoresis 
• April 18, 2012 - 0211 - Abdominoplasty, Suction Lipectomy, and Ventral Hernia Repair 
• March 6, 2012 - 0126 - Contact Lenses and Eyeglasses 
• March 6, 2012 - 0127 - Home Uterine Activity Monitoring 
• March 6, 2012 - 0134 - Bone Mass Measurements 
• March 6, 2012 - 0136 - Skilled Home Private Duty Nursing Care 
• March 6, 2012 - 0142 - Breast Implant Removal 
• March 6, 2012 - 0145 - Alpha 1-Antitrypsin Inhibitor Therapy 
• March 6, 2012 - 0147 - Reflex Sympathetic Dystrophy Diagnosis 
• March 6, 2012 - 0151 - Hippotherapy 
• March 6, 2012 - 0153 - Thalamotomy 
• March 6, 2012 - 0158 - Neuropsychological and Psychological Testing 
• March 6, 2012 - 0160 - Lung Volume Reduction Surgery 
• March 6, 2012 - 0163 - Transmyocardial and Endovascular Laser Revascularization 
• March 2, 2012 - 0049 - Nutritional Counseling 
• March 2, 2012 - 0055 - Hematopoietic Colony-Stimulating Factors (CSFs) 
• March 2, 2012 - 0059 - Peak Flow Meters 
• March 2, 2012 - 0061 - Nutritional Support 
• March 2, 2012 - 0062 - Burn Garments 
• March 2, 2012 - 0067 - Chest Physiotherapy and Airway Clearance Devices 
• March 2, 2012 - 0078 - Learning Disabilities, Dyslexia, and Vision 
• March 2, 2012 - 0082 - Dental Services and Oral and Maxillofacial Surgery: Coverage Under Medical Plans 
• March 2, 2012 - 0084 - Ptosis Surgery 
• March 2, 2012 - 0088 - Antepartum Fetal Surveillance 
• March 2, 2012 - 0091 - Endometrial Ablation 
• March 2, 2012 - 0093 - Open Air, Low Field Strength, and Positional MRI Units 
• March 2, 2012 - 0095 - Orthognathic Surgery 
• March 2, 2012 - 0097 - External Breast Prosthesis 
• March 2, 2012 - 0112 - Surface Scanning and Macro Electromyography 
• March 2, 2012 - 0116 - Frenectomy for Ankyloglossia 
• March 2, 2012 - 0124 - General Anesthesia and Monitored Anesthesia Care for Oral and Maxillofacial Surgery and Dental Services 
• February 24, 2012 - 0001 - Transrectal Ultrasound 
• February 24, 2012 - 0002 - Oxygen 
• February 24, 2012 - 0003 - Apnea Monitors for Infants 
• February 24, 2012 - 0010 - Continuous Passive Motion (CPM) Machines 
• February 24, 2012 - 0017 - Breast Reduction Surgery and Gynecomastia Surgery 
• February 24, 2012 - 0019 - Holter Monitors 
• February 24, 2012 - 0020 - Injectable Medications 
• February 24, 2012 - 0023 - Corneal Remodeling 
• February 24, 2012 - 0028 - Temporomandibular Disorders 
• February 24, 2012 - 0029 - Thermography 
• February 24, 2012 - 0032 - Pulmonary Rehabilitation 
• February 24, 2012 - 0034 - Aural Rehabilitation 
• February 24, 2012 - 0035 - Influenza Vaccine 
• February 24, 2012 - 0037 - Pneumococcal Vaccine 
• February 24, 2012 - 0046 - Routine Foot Care 
• February 24, 2012 - 0047 - Prenatal Care Provided by Primary Care Physicians 
• February 24, 2012 - 0048 - Hepatitis A Vaccine 
• February 14, 2012 - 0004 - Obstructive Sleep Apnea in Adults