Medical Policies for Providers
See the latest updates to our medical policies.
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. The prop...
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. Using an algorithm, a quantitative score is then generated whic...
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. More recently, investigation has focused on examining the gene expression ...
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. There are currently two well-defined types of hereditary colorectal cancer, familial adenomatous p...
MP321-Gene Expression Profiling for Cutaneous Melanoma
Melanoma is an aggressive cancer that can be difficult to diagnose. Improved patient outcomes is 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 much of the inherited forms of breast and ovarian cancer. Triple negative brea...
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. The system delivers site-specific, internal radiation,...
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