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Health Care Service Corporation November 2017 Pending Medical Policy Updates

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November 2017 Pending Medical Policies

TitlePolicy NumberRelease Date
Aquablation of the ProstateSUR710.02412-01-2017
Artificial Intervertebral DiscSUR712.02811-15-2017
Artificial Liver Assist Devices for the Treatment of Liver FailureSUR709.03411-15-2017
Autografts and Allografts in the Treatment of Focal Articular Cartilage LesionsSUR705.02002-01-2018
Automated Percutaneous Discectomy and Percutaneous Endoscopic DiscectomySUR712.00402-15-2018
Breast Implant, Removal and/or InsertionSUR716.00912-01-2017
Cabazitaxel (Jevtana)RX502.03212-01-2017
Cellular Immunotherapy for Prostate Cancer (Sipuleucel-T [Provenge])RX501.07412-01-2017
Continuous Passive Motion (CPM) DeviceDME101.02311-15-2017
Coronary Computed Tomography Angiography (CCTA), Including Noninvasive Fractional Flow Reserve (FFR)RAD604.00712-01-2017
DME IntroductionDME101.00012-01-2017
Dermatologic Applications of Photodynamic Therapy (PDT)THE801.02712-01-2017
Diagnosis and Treatment of Chronic Cerebrospinal Venous Insufficiency in Multiple SclerosisMED202.06401-15-2018
Electroconvulsive TherapyPSY301.01311-15-2017
Electroretinography (ERG), Multi-focal Electroretinography (mfERG) And Pattern Electroretinography (PERG)OTH903.03601-15-2018
Erythropoiesis-Stimulating Agents (ESAs)RX501.06902-15-2018
Hematopoietic Stem-Cell Transplantation for Acute Myelogenous Leukemia (AML)SUR703.03712-01-2017
Hematopoietic Stem-Cell Transplantation for Solid Tumors in ChildrenSUR703.04412-15-2017
Home Uterine Activity MonitoringOB401.01711-15-2017
Image-Guided Minimally Invasive Decompression for Spinal StenosisSUR712.03502-15-2018
Intravitreal Corticosteroid ImplantsOTH903.02401-01-2018
Isolated Limb Perfusion/Infusion for Malignant MelanomaSUR701.01001-01-2018
Laparoscopic, Percutaneous and Transcervical Techniques for the Myolysis of Uterine FibroidsSUR701.03312-01-2017
Leadless Cardiac PacemakerSUR707.03011-15-2017
Lipid ApheresisTHE802.00312-01-2017
Low Intensity Ultrasound Accelerated Fracture Healing DeviceDME101.03012-01-2017
Lung and Lobar Lung TransplantSUR703.01012-01-2017
Magnetic Esophageal Ring to Treat Gastroesophageal Reflux Disease (GERD)SUR709.03612-01-2017
Magnetic Resonance-Guided Focused Ultrasound (MRgFUS)SUR701.02212-01-2017
Magnetoencephalography (MEG) and Magnetic Source Imaging (MSI)RAD601.03812-01-2017
Management of Hereditary Angioedema (HAE) with Cinryze or KalbitorRX504.01312-01-2017
Manipulation Under AnesthesiaTHE803.01611-30-2017
Nutritional SupportMED201.01112-15-2017
Oncologic Applications of Photodynamic Therapy, Including Barretts EsophagusTHE801.02911-15-2017
Optical Coherence Tomography for Imaging of Coronary ArteriesMED202.06501-15-2018
Pancreas and Related Organ Tissue TransplantationSUR703.01312-01-2017
Pelvic Floor Stimulation (PFS) as a Treatment of Urinary or Fecal IncontinenceDME101.03711-15-2017
Percutaneous Tibial Nerve Stimulation (PTNS)MED205.03512-01-2017
Progesterone Therapy as a Technique to Reduce Preterm Delivery in High-Risk PregnanciesRX501.06212-15-2017
Prophylactic Mastectomy (PM)SUR716.01511-15-2017
Psychological and Neuropsychological TestingPSY301.02011-15-2017
Reduction MammaplastySUR716.01201-15-2018
Surgical Deactivation of Headache Trigger SitesSUR712.03102-15-2018
Sympathetic TherapyMED201.04312-01-2017
Three-dimensional (3D) and Four-dimensional (4D) Obstetrical UltrasoundRAD602.02012-01-2017
Transcatheter Arterial Chemoembolization (TACE) of the LiverTHE801.02211-15-2017
Treatment of HyperhidrosisMED201.01411-15-2017

 

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