Medical Policy Update Summary April 2019


BRCA 1 and 2 Genetic Testing (Sequence Analysis/Rearrangement)

  • Minor changes commensurate with updated National Cancer Care Network® (NCCN) criteria.

Gene Expression Profiling

  • Added Oncotype DCIS, Oncotype DX AR-V7 Nucleus and Xpresys Lung tests for Medicare members.

Gene Expression Profiling and Biomarker Testing for Breast Cancer

  • Created preferred test section to denote ASCO endorsements.
  • Removed MammaPrint® from preferred section to communicate ASCO’s position of utility for high clinical risk.
  • Removed BCI test from preferred section to denote change of ASCO endorsement to not recommended.
  • Added Oncotype DX® DCIS for Medicare members.

Insulin Delivery Devices and Continuous Glucose Monitoring Systems

  • Added alternate controller enabled (ACE) infusion pump (t:slim X2™) to Limitations/Exclusions as investigational.

Orthognathic Surgery

  • Added “palatal” to vertical discrepancies definition related to deep overbite.
  • Added congenital, acquired, or other demonstrated significant functional deficiency that contributes to obstructive sleep apnea (regarding craniofacial skeletal deformities).
  • Added photographic to documentation section.

Radiofrequency Ablation for Spinal Pain

  • Added thoracic pain as a covered indication.

Selective Internal Radiation Therapy

  • Added repeat radioembolization criteria.

Sacroiliac Joint Fusion

  • Removed Trial of ≥ 1 therapeutic intra-articular SIJ injection as minimally-invasive surgical fusion prerequisite.