Revised:
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.
