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Health Care Service Corporation November 2017 Pending Medical Policy Updates

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November 2017 Pending Medical Policies

Title Policy Number Release Date
Aquablation of the Prostate SUR710.024 12-01-2017
Artificial Intervertebral Disc SUR712.028 11-15-2017
Artificial Liver Assist Devices for the Treatment of Liver Failure SUR709.034 11-15-2017
Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions SUR705.020 02-01-2018
Automated Percutaneous Discectomy and Percutaneous Endoscopic Discectomy SUR712.004 02-15-2018
Breast Implant, Removal and/or Insertion SUR716.009 12-01-2017
Cabazitaxel (Jevtana) RX502.032 12-01-2017
Cellular Immunotherapy for Prostate Cancer (Sipuleucel-T [Provenge]) RX501.074 12-01-2017
Continuous Passive Motion (CPM) Device DME101.023 11-15-2017
Coronary Computed Tomography Angiography (CCTA), Including Noninvasive Fractional Flow Reserve (FFR) RAD604.007 12-01-2017
DME Introduction DME101.000 12-01-2017
Dermatologic Applications of Photodynamic Therapy (PDT) THE801.027 12-01-2017
Diagnosis and Treatment of Chronic Cerebrospinal Venous Insufficiency in Multiple Sclerosis MED202.064 01-15-2018
Electroconvulsive Therapy PSY301.013 11-15-2017
Electroretinography (ERG), Multi-focal Electroretinography (mfERG) And Pattern Electroretinography (PERG) OTH903.036 01-15-2018
Erythropoiesis-Stimulating Agents (ESAs) RX501.069 02-15-2018
Hematopoietic Stem-Cell Transplantation for Acute Myelogenous Leukemia (AML) SUR703.037 12-01-2017
Hematopoietic Stem-Cell Transplantation for Solid Tumors in Children SUR703.044 12-15-2017
Home Uterine Activity Monitoring OB401.017 11-15-2017
Image-Guided Minimally Invasive Decompression for Spinal Stenosis SUR712.035 02-15-2018
Intravitreal Corticosteroid Implants OTH903.024 01-01-2018
Isolated Limb Perfusion/Infusion for Malignant Melanoma SUR701.010 01-01-2018
Laparoscopic, Percutaneous and Transcervical Techniques for the Myolysis of Uterine Fibroids SUR701.033 12-01-2017
Leadless Cardiac Pacemaker SUR707.030 11-15-2017
Lipid Apheresis THE802.003 12-01-2017
Low Intensity Ultrasound Accelerated Fracture Healing Device DME101.030 12-01-2017
Lung and Lobar Lung Transplant SUR703.010 12-01-2017
Magnetic Esophageal Ring to Treat Gastroesophageal Reflux Disease (GERD) SUR709.036 12-01-2017
Magnetic Resonance-Guided Focused Ultrasound (MRgFUS) SUR701.022 12-01-2017
Magnetoencephalography (MEG) and Magnetic Source Imaging (MSI) RAD601.038 12-01-2017
Management of Hereditary Angioedema (HAE) with Cinryze or Kalbitor RX504.013 12-01-2017
Manipulation Under Anesthesia THE803.016 11-30-2017
Nutritional Support MED201.011 12-15-2017
Oncologic Applications of Photodynamic Therapy, Including Barretts Esophagus THE801.029 11-15-2017
Optical Coherence Tomography for Imaging of Coronary Arteries MED202.065 01-15-2018
Pancreas and Related Organ Tissue Transplantation SUR703.013 12-01-2017
Pelvic Floor Stimulation (PFS) as a Treatment of Urinary or Fecal Incontinence DME101.037 11-15-2017
Percutaneous Tibial Nerve Stimulation (PTNS) MED205.035 12-01-2017
Progesterone Therapy as a Technique to Reduce Preterm Delivery in High-Risk Pregnancies RX501.062 12-15-2017
Prophylactic Mastectomy (PM) SUR716.015 11-15-2017
Psychological and Neuropsychological Testing PSY301.020 11-15-2017
Reduction Mammaplasty SUR716.012 01-15-2018
Surgical Deactivation of Headache Trigger Sites SUR712.031 02-15-2018
Sympathetic Therapy MED201.043 12-01-2017
Three-dimensional (3D) and Four-dimensional (4D) Obstetrical Ultrasound RAD602.020 12-01-2017
Transcatheter Arterial Chemoembolization (TACE) of the Liver THE801.022 11-15-2017
Treatment of Hyperhidrosis MED201.014 11-15-2017

 

Click here to view the Health Care Service Corporation Pending Medical Policy Updates »

 

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