Breast-Specific Gamma Imaging, Scintimammography, and Molecular Breast Imaging |
Re-Reviewed |
12/16/2019 |
Investigative and therefore not covered |
No change in determination |
Electric Tumor Treatment Fields (Optune®) |
New |
10/16/2019 |
Covered for some indications; investigative and therefore not covered for all other indications |
This was a previous utilization management policy, which has now been converted to a coverage policy.
Covered for:
- Individuals 22 years of age or older for the treatment of newly diagnosed, histologically-confirmed supratentorial glioblastoma following debulking surgery and completion of radiation therapy, in conjunction with chemotherapy.
- Individuals 22 years of age or older for the treatment of histologically- or radiologically-confirmed recurrent supratentorial glioblastoma as monotherapy, after surgical, chemotherapy, and radiological treatment have been exhausted.
Investigative for all other indications.
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Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Indications and Soft Tissue Injuries |
Re-Reviewed |
12/16/2019 |
Investigative and therefore not covered |
No change in determination |
LTX 3000™ (Spinal Unloading Device for Treatment of Low Back Pain) |
Re-Reviewed |
12/16/2019 |
Investigative and therefore not covered |
Coverage Policy inactivated 12/16/2019. |
Mechanized Spinal Decompression Traction Tables for Low Back Pain |
Re-Reviewed |
12/16/2019 |
Investigative and therefore not covered |
No change in determination |
Orthotrac™ Pneumatic Vest (Spinal Unloading Device for the Treatment of Low Back Pain) |
Re-Reviewed |
12/16/2019 |
Investigative and therefore not covered |
No change in determination |
Synthetic Ceramic-Based and Bioactive Glass Bone Substitutes/ Fillers |
New |
12/16/2019 |
Investigative and therefore not covered |
Ceramic-based bone grafts are made up of collagen, calcium phosphate, calcium sulfate and one or more of the following products:
- Synthetic hydroxyapatite, a component in bone and teeth
- Beta-tricalcium phosphates
- Biphasic calcium phosphate, which consists of both 1. and 2., above
- Bioactive glass.
These have been suggested for use as stand-alone products or in combination with other bone substitutes and/or enhancement products.
Note: This policy does not apply to dental applications.
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