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Medical Policies for Providers

See the latest updates to our medical policies. 

Choose a letter to view policies by first letter.

A B C D E F G H I J K L M N O P Q R S T U V W 


MP134-Gastric Electrical Stimulation
Gastric electrical stimulation has been proposed for use in patients with gastroparesis who are refractory to medical treatment. This implanted device delivers high-frequency electrical stimulation at four times the basal rate to the stomach.

MP307 Gender Dysphoria and Gender Confirmation Treatment

MP273-Gene-based Testing and/or Protein Biomarkers for Diagnosis and Management of Prostate Cancer
Prostate cancer antigen 3 (PCA3, also referred to as DD3) is a gene that expresses a non-coding RNA. PCA3 is only expressed in human prostate tissue, and the gene is highly overexpressed in prostate cancer.

MP279-Gene Expression Testing to Predict Coronary Artery Disease
The Corus® CAD (coronary artery disease) test (CardioDx, Inc., Palo Alto, CA) is a genetic test which analyzes 23 genes that are involved in the development or response to atherosclerosis.

MP170 Gene Expression Profiling for Breast Cancer Treatment
Conventionally, the prognosis of breast cancer patients is determined by age, tumor size, histology, status of axillary lymph nodes, histologic type and hormone receptor status.

MP350-Genetic and Biochemical Testing for Alzheimer's Disease and Dementia
Alzheimer disease is the most common cause of dementia. Alzheimer disease is a progressive, irreversible neurodegenerative disease. Individuals are typically classified into early-onset and late-onset disease using the age of 65 years as a cutoff. Genetic testing and biomarker testing has been proposed as a means to identifying a definitive diagnosis, improving understanding for the family, and allowing at-risk relatives to have predictive testing.

MP328-Genetic Susceptibility Cancer Panels
Hereditary cancer syndromes are a group of disorders in which the presence of one or a combination of gene variants have been shown to increase the risk for the development of specific cancers. genetic cancer susceptibility panel testing using next generation sequencing will be considered to be medically necessary when the medical criteria outlined in this policy are met.

MP325-Genetic Testing for Familial Hypercholesterolemia
Familial hypercholesterolemia is an inherited genetic condition that results in premature atherosclerotic cardiovascular disease due to lifelong exposure to elevated low-density lipoprotein cholesterol (LDL-C). The condition encompasses a spectrum of clinical phenotypes with a broad range of pathogenic variants.

MP304-Genetic Testing for Inherited Cardiomyopathies and Channelopathies 
Cardiomyopathies are diseases of the heart muscle. Cardiac channelopathies are disorders involving cardiac cells membranes that allow passage of specific ions. 

MP374-Genetic Testing for Inheritable Diseases

MP336-Genetic Testing for Inherited Thrombophilia/ Hypercoagulability
Inherited thrombophilia is a genetic predisposition to develop a group of clinical conditions caused by associated gene variants and defects. Common causes include Factor V Leiden, a prothrombin gene variation, and deficiencies in protein S, protein C, and antithrombin.

MP334-Genetic Testing for Macular Degeneration
Age-related macular degeneration (AMD) is an eye condition that causes damage to the central portion of the retina (the macula) and can lead to complete vision loss. AMD is the leading cause of blindness in industrialized countries.

MP356-Genetic Testing for Mitochondrial Disorders
Mitochondrial disorders may be caused by mutation of a mitochondrial DNA (mtDNA) gene or mutation of a nuclear gene (nDNA).

MP324-Genetic Testing for Non-Cancer Heritable Disease Carrier Status
Genetic testing for the purposes of carrier status screening is performed to identify genetic risk that may impact reproductive decision-making. Individuals identified as being “carriers” are typically not affected by the condition but have an increased risk of having a child with a genetic condition.
MP098-Genetic Testing Related to Colorectal Cancer
Genetic testing involves the analysis of DNA, RNA, chromosomes, proteins, and certain metabolites in order to detect heritable disease-related genotypes.

MP321-Gene Expression Profiling for Cutaneous Melanoma
Melanoma is an aggressive cancer that can be difficult to diagnose. Improved patient outcomes are attributed to accurate and early diagnosis of melanocytic lesions.

MP097-Genetic Testing for BRCA1 or BRCA2 for Breast or Ovarian Cancer
Approximately 5 - 10% of all breast and ovarian cancer can be attributed to a dominantly inherited susceptibility. Mutations in two genes, BRCA1 and BRCA2, are associated with many of the inherited forms of breast and ovarian cancer.

MP329-Genicular Nerve Ablation
Genicular nerve ablation (e.g., radiofrequency {RFA}, pulsed radiofrequency, cooled radiofrequency {COOLIEF} cryoablation, cryoneurolysis or chemical neurolysis {chemodenervation}) has been proposed as a treatment for chronic knee pain due to osteoarthritis that have not been effectively managed by pharmacologic or other standard therapies or as a treatment to control pain pre or post knee replacement.

MP303-Genomic Analysis to Predict Thyroid FNA (Fine-Needle Aspiration)
 Gene expression analysis and mutation analysis has been developed as a means to identify benign nodules when cytopathology of thyroid fine needle aspirate is indeterminate, thereby reducing the number of unnecessary thyroid surgeries.

MP311 Genotyping or Phenotyping for Thiopurine Methyltransferase
Thiopurine drugs are used to treat patients with leukemia, rheumatic disease, inflammatory bowel disease, or solid organ transplant. To be effective, those drugs require conversion to thioguanine nucleotides. That process can be blocked by methylation or oxidation.

MP101-GliaSite® Radiation Therapy
GliaSite® is a balloon catheter device used to deliver liquid brachytherapy to the brain. It is intended for the treatment of surrounding tissue after a malignant brain tumor is surgically removed. 

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