Investigational/Experimental Services Not Eligible for Reimbursement

SERVICES LISTED IN THIS CORPORATE MEDICAL POLICY ARE CONSIDERED INVESTIGATIONAL/EXPERIMENTAL

Medical Necessity: Based upon our findings, the Company has determined that the following services have not demonstrated equivalence or superiority to currently accepted standard means of treatment or standard diagnostic technique. The Company considers the following services as indicated by the Applicable Code(s) or other related code(s) not listed here investigational and not eligible for reimbursement:

Coverage may differ for Medicare Advantage plan members; please see any applicable national and/or local coverage determinations for details. This information may be available at the Centers for Medicare & Medicaid Services (CMS) website.

NUMBER TITLE DESCRIPTION APPLICABLE EFFECTIVE/ CODE(S) REVISED DATE 200139 Extracorporeal Extracorporeal shock wave therapy CPT Codes 28890, 01/22/2021 Shock Wave (ESWT) is a noninvasive technique that Category III 0101T, Therapy for directs low or high energy pulses to a 0102T, 0512T, 0513T Musculoskeletal specific painful tissue area. These pulses Conditions aim to break down calcium deposits, decrease scar tissue, and reduce inflammation, thereby decreasing pain and promoting healing at the affected site. Musculoskeletal conditions include (but are not limited to) plantar fasciitis, shoulder tendonitis, Achilles tendinopathy, and lateral epicondylitis.

200211 Breast Cancer Breast ductal lavage, fiberoptic CPT 19499† 10/08/2020 Screening and ductoscopy, mammory ductoscopy, and Diagnostic breast duct endoscopy (i.e Acueity †When unlisted procedure, breast (19499) is determined Procedures System, Acueity, Inc., Larkspur, CA) are to be breast ductal lavage or (Breast Ductal utilized to evaluate individuals at high fiberoptic ductoscopy. Lavage and risk for breast cancer. These procedures Fiberoptic are intended to be used in conjunction Ductoscopy) with routine clinical breast examination and mammography for early detection

This document is subject to the disclaimer found at https://provider.medmutual.com/Tools_and_Resources/Care_Management/MedPolicies/Disclaimer.aspx. If printed, this document is subject to change. Always verify with the most current version of the official document at https://provider.medmutual.com/Tools_and_Resources/Care_Management/MedPolicies/Disclaimer.aspx. CPT © 2021 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association

NUMBER TITLE DESCRIPTION APPLICABLE EFFECTIVE/ CODE(S) REVISED DATE and histopathologic diagnosis of nonpalpable breast cancers.

Breast ductal lavage is a technique in which epithelial cells (nipple aspirate fluid) are collected from the breast ductal system for cytological analysis. Mild suction is applied to the nipple to identify fluid-yielding duct(s). A microcatheter is then advanced through a duct orifice into the duct(s) and a saline solution is introduced. Saline and cellular material are withdrawn through the catheter and collected in a syringe for cytologic examination. Ductal fluid is analyzed to detect cytological abnormalities suggestive of breast cancer.

Fiberoptic ductoscopy is performed by inserting a fiberoptic microendoscope into a ductal orifice and advancing the scope under direct visualization. Abnormal intraductal areas are either biopsied or marked for image-guided core biopsy.

200224 Sublingual Sublingual immunotherapy (SLIT) is a CPT Code 95199† 01/25/2021 Immunotherapy form of allergy treatment that utilizes repeated, sublingual placement of diluted †When unlisted allergen extract drops as an allergen allergy/clinical immunologic service or procedure (95199) delivery system. Gradually increased is determined to be sublingual doses of the allergen are administered in (allergy) immunotherapy. an effort to achieve tolerance to the allergy-causing substance. Theoretical NOTE: Odactra, advantages include a lower risk of Grastek, Ragwitek, or

NUMBER TITLE DESCRIPTION APPLICABLE EFFECTIVE/ CODE(S) REVISED DATE serious side effects and better patient Oralair may be acceptance. covered, please see Drug Policy Sublingual Allergen Extract Immunotherapy for more information.

2003-C Electrical Transcutaneous electrical stimulation CPT Codes 97014, 12/30/2020 Stimulation for (neuromuscular electrostimulation; 97032 and 97039† Treatment of transcutaneous electrical stimulation) of Dysphagia muscles coordinating swallowing is a HCPCS Code E0745 noninvasive therapy reported to be utilized for treatment of oropharyngeal †When unlisted dysphagia. A hand-held electrical modality (specify stimulator (e.g. VitalStim) is connected type and time if to a pair of external electrodes positioned constant attendance) to deliver electric current to swallowing (97039) is muscles of the neck. The device provides determined to be external electrical stimulation to electrical stimulation pharyngeal swallowing musculature in for treatment of an attempt to strengthen neuromuscular dysphagia. pathways involved in the swallow reflex. 200305 Nondurable Based upon our findings, the Company HCPCS Code A9272 6/25/2020 powered or has determined nondurable powered Nonpowered negative pressure wound therapy (e.g., negative pressure PICO Single Use Negative Pressure wound therapy Wound Therapy System) has not demonstrated equivalence or superiority to currently accepted standard means of treatment. The Company considers nondurable powered negative pressure wound therapy investigational and not eligible for reimbursement.

NUMBER TITLE DESCRIPTION APPLICABLE EFFECTIVE/ CODE(S) REVISED DATE Based upon our findings, the Company has determined nonpowered negative pressure wound therapy (e.g., SNaP Wound Therapy System) has not demonstrated equivalence or superiority to currently accepted standard means of treatment. The Company considers nonpowered negative pressure wound therapy investigational and not eligible for reimbursement.

200310 Gastroesophageal Gastroesophageal reflux disease (GERD) CPT 43201, 43210, 05/03/2021 Reflux Disease: is the chronic abnormal reflux of gastric 43236, 43284, 43289, Endoscopic and contents into the esophagus, resulting in 43257, 43499† and Laparoscopic symptoms of heartburn and/or 43999† Therapies regurgitation. This gastric reflux may at † times result in mucosal injury with When unlisted procedure, esophagitis or other complications. esophagus (43499) or unlisted procedure, stomach (43999) Endoscopic and laparoscopic therapies is determined to be have been developed to treat GERD; endoscopic plication/suturing these approaches alter the for treatment of gastroesophageal reflux gastroesophageal junction structure in disease. order to diminish proximal migration of gastric contents and decrease reflux and regurgitation symptoms, thereby resolving esophagitis.

Endoscopic and laparoscopic therapies may be classified into four basic categories as outlined below, with some examples (NOTE: this list is not all- inclusive):

• Radiofrequency energy: o Stretta®

NUMBER TITLE DESCRIPTION APPLICABLE EFFECTIVE/ CODE(S) REVISED DATE • Endoscopic plication/suturing o Bard® EndoCinch™ Suturing System o NDO Surgical Endoscopic Plication™ System o The EndoGastric Solutions (EGS) Transoral Incisionless Fundoplication (TIF) EsophyX™ with SeroFuse™ Fastener • Polymer injection o Ethylene-vinyl alcohol co- polymer (Enteryx®) o Hydrogel prosthesis (Gatekeeper™ Reflux Repair System) • Laparoscopic magnetic sphincter augmentation o LINX device (LINXTM Reflux Management System)

2005-D Percutaneous Percutaneous neuromodulation therapy is CPT 64999† 03/29/2021 neuromodulation a minimally invasive therapy reported to HCPCS E1399† therapy be effective in chronic spinal pain treatment. The procedure involves †When unlisted procedure, insertion of pairs of fine-gauge, filament nervous system (64999) or electrodes into the skin of the lower back durable medical equipment, miscellaneous (E1399) is region with the intent of stimulating determined to be nerve fibers that lie deep within the percutaneous tissue. Treatment may be administered neuromodulation therapy. several times per week, typically performed in 30-minute intervals procedure.

NUMBER TITLE DESCRIPTION APPLICABLE EFFECTIVE/ CODE(S) REVISED DATE

2005-J Vertebral Axial Vertebral axial decompression devices HCPCS S9090 07/20/2021 Decompression (e.g., VAX-D®, Accu-SPINA System, Devices etc.) are computer-controlled tables that apply distractive tension along the spinal column. These devices are promoted as non-invasive, non-surgical procedures that treat low back pain due to conditions such as lumbar disc herniation, degenerative disc disease, posterior facet syndrome, sciatica, or radiculopathy.

† CMP 2006- Radiofrequency Radiofrequency microtenotomy CPT Codes 23929 , 08/03/2021 D microtenotomy (radiofrequency-based microtenotomy) is 24999†, 27599†, a minimally invasive procedure for 27899† and 28899† treatment of chronic tendinosis. are considered Coblation® (ArthroCare® Corporation, investigational and Austin, TX) technology, a controlled, not eligible for non-heat driven process, uses reimbursement. radiofrequency energy in an attempt to † stimulate healing by initiating an When unlisted procedure - inflammatory response in damaged shoulder (23929), unlisted procedure, humerus or elbow tissue. A damaged tendon is surgically (24999), unlisted procedure, exposed and radiofrequency energy is femur or knee (27599), directly applied to the tendon surface unlisted procedure, leg or ® ankle (27899) or unlisted with a TOPAZ MicroDebrider probe procedure, foot or toes (ArthroCare® Corporation, Austin, TX) (28899) is determined to be radiofrequency at 0.5 second intervals. Radiofrequency microtenotomy for tendinosis. microtenotomy has been evaluated for the treatment of chronic tendinosis refractory to conventional therapy, including the supraspinatus tendon, forearm extensor muscle aponeurosis (at lateral epicondyle), patellar tendon, Achilles tendon and plantar fascia.

NUMBER TITLE DESCRIPTION APPLICABLE EFFECTIVE/ CODE(S) REVISED DATE 2006-G Fluid-Ventilated Fluid-ventilated, gas-permeable scleral CPT 92499 10/28/2020 Gas-Permeable lenses (e.g., BostonSight PROSE device) HCPCS S0515 Scleral Lenses are utilized for management of irregular corneal astigmatism that is unable to be corrected with traditional contact lenses or for treatment of diseases of the corneal surface. These devices can be custom- fitted and sized to rest largely on the surrounding sclera, creating a fluid-filled space overlying the cornea, which optically neutralizes corneal surface irregularities. The fluid-filled space protects the corneal surface from atmospheric desiccation, reduces the intensity of ocular pain and may facilitate healing of persistent epithelial defects.

2009-C Anal Fistula Plug An anal fistula plug (e.g., Surgisis® CPT Code 46707 06/15/2021 AFP™ Anal Fistula Plug, Cook Anal Fistula Plug, Gore Anal Fistula Plug) is a freeze-dried bioabsorbable xenograft formulated from porcine small intestinal submucosa, which is intended as a minimally invasive treatment for anorectal or rectovaginal fistulas.

2011-C Wireless Wireless gastrointestinal motility CPT Code 91112 03/08/2021 Gastrointestinal monitoring systems (e.g., SmartPill® GI Motility Monitoring System) have been proposed Monitoring as an alternative testing method for System evaluation of suspected gastrointestinal -Suspected motility disorders (e.g., gastroparesis). Gastric Motility The system senses and records Disorders temperature, pH, and pressure

NUMBER TITLE DESCRIPTION APPLICABLE EFFECTIVE/ CODE(S) REVISED DATE measurements via sensors contained within an ingestible capsule as it travels through the gastrointestinal tract. Measurements are transmitted from the capsule via a radiofrequency signal to an external data receiver and subsequently downloaded to a personal computer for analysis and review by a physician.

2011-E Suit Therapy Suit therapy is a form of physical and CPT 97039†, 97139† 08/14/2020 occupational therapy that includes specialized resistance training through †When unlisted modiality, specify place and time the use of specific mechanical devices, (97039) or therapeutic including home use of a suit therapy procedure, each 15 min; device (e.g., Adeli® suit, NeuroSuit, unlisted procedure (97139) ™ ™ are determined to be suit Penguin suit, TheraSuit , TheraTogs ). therapy. Proponents of this type of high frequency intervention program maintain that this approach can produce faster and more substantial improvements in motor skills and muscle strength in children and young adults with certain disabilities (e.g., cerebral palsy, gait rehabilitation).

2012-A Interferential Interferential stimulation (e.g. RS-4i HCPCS Codes 07/26/2021 Therapy Sequential Stimulator) is a G0283†, S8130, and transcutaneous electrical stimulation S8131 technique whereby two different, medium-frequency alternating currents †When electrical stimulation (unattended), to one or more are simultaneously applied to the target areas for indication(s) other area via electrodes. The resultant than wound care, as part of a interference current mimics a low therapy plan of care (G0283) is determined to be frequency stimulation to the underlying interferential therapy. tissue but avoids the skin discomfort normally associated with low frequency

NUMBER TITLE DESCRIPTION APPLICABLE EFFECTIVE/ CODE(S) REVISED DATE stimulation. Interferential stimulation is reported to be beneficial in reducing pain, edema, and muscle spasm associated with musculoskeletal disorders.

† 2013-C Tenex Health TX Tenex Health TX Procedure employs a CPT Code 20999 , 10/22/2020 Procedure minimally invasive technique intended to 23929†, 24999†, treat symptomatic tendon and soft tissue 27599†, 27899† and injuries that are unresponsive to 28899† conventional medical therapy. The † procedure involves percutaneous When unlisted procedure- insertion of the TX1 MicroTip™ through musculoskeletal system, general (20999), unlisted a 3mm incision near a tendon or soft procedure, shoulder (23929), tissue injury site (i.e., lateral or medial unlisted procedure, humerus epicondyle, patellar tendon, rotator cuff, or elbow (24999), unlisted procedure, femur or knee plantar fascia or Achilles tendon) under (27599), unlisted procedure, ultrasonic guidance. The probe leg or ankle (27899) or unlisted procedure, foot or ultrasonically emulsifies and removes toes (28899) is determined to tendon scar tissue, thereby reportedly be focused aspiration of scar alleviating tendon pain. tissue.

2014-A Oral Pressure Oral pressure therapy (e.g., Attune Sleep HCPCS A7002†, 07/30/2021 Therapy Apnea System, iNAP One Sleep Therapy A7047† and E0600† System, Winx Sleep Therapy System) involves the use of an intraoral negative † When tubing used with pressure gradient device intended to suction pump, each (A7002) or oral interface used with improve airflow by increasing airway respiratory suction pump, size for the treatment of obstructive sleep each (A7047) or respiratory apnea. suction pump, home model, portable or stationary, electric (E0600) is determined to be oral pressure therapy for treatment of obstructive sleep apnea.

NUMBER TITLE DESCRIPTION APPLICABLE EFFECTIVE/ CODE(S) REVISED DATE 2015-D Hydrogen Breath Hydrogen breath tests (HBTs) can be CPT 91065† 07/30/2021 Test for Irritable assessed by obtaining breath samples † Bowel Syndrome before and after the ingestion of various When 91065 is determined carbohydrate substrates (lactulose, to be Hydrogen breath tests for the detection of Irritable lactose, glucose, sucrose, fructose, Bowel Syndrome. xylose, rice flour). Malabsorption of the substrate in the small intestine or an excess of bacteria in the small bowel can produce large amounts of hydrogen (H2), which is absorbed into the bloodstream and then expired through the breath. Breath samples are analyzed for H2 content by gas chromatography. Detection of expelled H2 can be symptomatic of malabsorption, small intestinal bacterial overgrowth (SIBO), or carbohydrate intolerance.

2016-B Myoelectric Myoelectric orthotic mobility systems HCPCS A9300, 06/16/2021 Orthotic Devices- (e.g., MyoPro®, Myomo e100, mPower E1399, L3904, Upper Extremity 1000, Myomo, Inc., Cambridge, MA) are L3999, L7499, designed to provide limb and joint L8701, and L8702 support as well as powered range of motion. These systems are intended to † When exercise equipment (A9300), durable medical compensate for muscle weakness and equipment, miscellaneous disability resulting from cerebrovascular (E1399), upper limb orthosis, disease, neuromuscular disorders and not otherwise specified (L3999); or upper extremity injuries. Sensors are placed on the skin to prosthesis, not otherwise detect weak muscle signals, which drive specified (L7499) is determined to be myoelectric limb movement via electric motors upper limb orthotic devices. located in the brace. Myoelectric orthotic mobility systems may help weak or paralyzed individuals to regain function and perform activities of daily living.

NUMBER TITLE DESCRIPTION APPLICABLE EFFECTIVE/ CODE(S) REVISED DATE 2017-A Electromagnetic Electromagnetic navigational CPT Code 31627 09/18/2020 Navigational bronchoscopy is an image-guided Bronchoscopy localization system that is designed to increase pulmonary tissue accessibility to trans-bronchial needle aspiration and biopsy. Chest computed tomography (CT) is performed to create a 3- dimensional (3D) map of the bronchial tree. Using a “Locatable Guide” sensor attached to a standard bronchoscope, the precise anatomic position of the bronchoscope can be determined as it receives electromagnetic signals from a “Localization Board” placed beneath the individual. A computer screen displays a 3-dimensional real-time map of the lung, including the location of the tip of the bronchoscope, purported to allow more precise navigation into the targeted area.

2017-B Leadless Cardiac The MicraTM Transcatheter Pacemaker CPT 33274 and 9/16/2021 Pacemaker (i.e., System (TPS) is a miniaturized, leadless, 33275 MicraTM full featured single chamber ventricular Transcatheter pacemaker that is implanted directly in Pacemaker the right ventricle. It provides a treatment System) option for patients with Class I or Class II indication for bradycardia pacing therapy. 2018-A Eversense Continuous glucose monitoring is CPT Codes 0446T, 07/09/2020 Implanted intended to guide diabetes mellitus 0447T, 0448T Continuous management by identifying blood Glucose Monitor glucose fluctuations that are not detected (CGM) Device by intermittent glucose monitoring. Implanted Continuous glucose monitor (CGM) devices such as Eversense are

NUMBER TITLE DESCRIPTION APPLICABLE EFFECTIVE/ CODE(S) REVISED DATE CGMs that include a fully implantable glucose sensor. The CGM System consists of three components (1) an implantable fluorescence-based cylindrical glucose sensor measuring 3 mm × 16 mm, (2) a wearable smart transmitter, and (3) a handheld device running a mobile medical application. Examples include: Eversense implantable CGM sensor and the GlySens ICGM system.

2018-C Actigraphy Actigraphy involves monitoring motor CPT Code 95803 02/04/2021 activity with a portable device over an extended period of time. Devices include a small accelerometer that is typically worn on the wrist to record movement during sleep and may be used in a facility-based laboratory or in the home setting. Actigraphy has been proposed as a useful technique in combination with, or in place of, polysomnography to detect sleep disorders such as obstructive sleep apnea.

201844 Treatments for Waterjet tissue ablation (e.g. AquaBeam CPT Codes 0421T 03/16/2021 Benign Prostatic System) is meant to provide relief for and 53855 Hyperplasia lower urinary tract symptoms due to BPH by means of water by the selective ablation of prostatic glandular tissue.

Temporary prostatic urethral stents (e.g. Spanner Prostatic Stent) are meant to maintain urine flow while retaining volitional voiding. It is typically used

NUMBER TITLE DESCRIPTION APPLICABLE EFFECTIVE/ CODE(S) REVISED DATE after procedures that cause prostatic swelling.

The Rezum System (transurethral water vapor therapy) is a covered treatment for BPH. Medical mutual uses MCG Care Guidelines (A-0259) to guide medical necessity determinations.

The UroLift System (NeoTract Inc.) is a covered treatment for BPH and is found in CMP 201913.

2019-A Wireless The CardioMEMS HF System is CPT Codes 33289, 01/15/2021 pulmonary artery intended to wirelessly monitor 93264 pressure pulmonary artery pressure and heart rate HCPCS Code C2624 monitoring in New York Heart Association class III (CardioMEMS) heart failure patients who have been hospitalized for heart failure in the previous year.

2019-B Subchondroplasty The Subchondroplasty® Procedure CPT Codes 29855†, 03/08/2021 ® (SCP®) with (SCP®) is a minimally invasive, 29856†, 29892† AccuFill® Bone fluoroscopically assisted procedure in Substitute which subchondral bone defects are †When arthroscopically aided treatment of tibial fracture, Material (BSM) filled with AccuFill® Bone Substitute proximal (plateau); Material (BSM), a calcium phosphate unicondylar (29855), compound. Inside the subchondral arthroscopically aided treatment of tibial fracture, defects AccuFill forms a hard, proximal (plateau); nanocrystalline scaffold that is replaced bicondylar (29856), or arthroscopically aided repair with new bone over time. This procedure of large osteochondritis is typically performed arthroscopically. dissecans lesion, talar dome fracture, or tibial plafond fracture (29892), or any other code is determined to be Subchondroplasty® (SCP®)

NUMBER TITLE DESCRIPTION APPLICABLE EFFECTIVE/ CODE(S) REVISED DATE with AccuFill® Bone Substitute Material (BSM); this includes but is not limited to hips and knees.

NOTE: This list of applicable codes is not all-inclusive. The Company reserves the right to apply this policy to the procedure performed regardless of how the procedure was coded by the provider.

2019-E Eustachian tube The Eustachian tube connects the middle CPT Codes 30999†, 04/13/2021 † dilation ear to the back of the throat and helps to 69705, 69706, 69799 balance pressure inside the ear with the surrounding environment by opening and closing. When this valve-like function is impaired, patients can experience discomfort, impaired hearing, persistent ear infections, tinnitus, or other symptoms. Dilation is one approach to correcting this Eustachian tube dysfunction, whereby a small balloon is inserted into the Eustachian tube and inflated, opening a pathway for mucus and air to flow and restoring proper function. After dilation, the balloon is deflated and removed.

2019-F Allogeneic, Peripheral nerve injuries or defects may CPT Codes 64910, 05/12/2020 xenographic, compromise sensory and/or motor 64912, 64913, synthetic, and function and can profoundly impact 64999†, HCPCS

NUMBER TITLE DESCRIPTION APPLICABLE EFFECTIVE/ CODE(S) REVISED DATE composite nerve quality of life as well as autonomy. Codes C9352, C9353, grafts and Autologous nerve transplantation is the C9355, C9361, conduits standard surgical treatment but has Q4170 significant limitations, such as a need for a secondary surgery and an associated †When unlisted procedure, nervous system (CPT 64999) risk for surgical donor site morbidity. is determined to be Nerve allografts comprise another allogeneic, xenographic, approach, but some allogeneic nerve synthetic, or composite nerve grafts and/or conduits. transplants may require concurrent immunosuppression. Tissue-engineered, decellularized nerve grafts and nerve conduits, as well as grafts and conduits from other sources, are intended to treat peripheral nerve injuries or defects while minimizing the potential for adverse events that are common to current treatments.

2019-G Minimally Decompression procedures involve CPT 22869, 22870, 08/09/2021 Invasive minimally invasive techniques intended 62287†, 62380†, Decompression to treat symptomatic disc herniation, 63020†, 63030†, † † Procedures intervertebral disc disease, or lumbar 63035 , and 64999 • Automated spinal stenosis unresponsive to Percutaneous conventional medical therapy. These Category III 0274T Lumbar procedures are designed to remove or and 0275T Discectomy ablate disc material or other tissue, • Endoscopic thereby reducing pressure on the HCPCS C1821, Disc intervertebral disc and/or the S2348 Decompression corresponding neural elements. Spinal distraction devices are implants † When aspiration of nucleus • Laser Disc pulposus of intervertebral Decompression designed to relieve pressure on the disk, lumbar (62287), • Minimally nerves affected by lumbar spinal laminotomy/decompression stenosis. They are purported to prevent nerve root(s); one Invasive interspace/cervical (63020), Lumbar extension of the spine while still endoscopic decompression of allowing flexion. spinal cord, nerve root(s),

NUMBER TITLE DESCRIPTION APPLICABLE EFFECTIVE/ CODE(S) REVISED DATE Decompression including laminotomy, partial ® facetectomy, foraminotomy, (mild )* discectomy and/or excision of • Nucleoplasty herniated intervertebral disc, 1 interspace, lumbar (62380), Disc laminotomy/decompression Decompression nerve root(s); one interspace, • Spinal lumbar (63030); laminotomy with decompression of nerve distraction using root(s);each addl. (63035); or a spacer device unlisted procedure, nervous (including but system (64999) is determined to be minimally-invasive disc not limited to decompression procedures. Superion™ Indirect Decompression System)

*Approval for mild® may be permitted for a Medicare Advantage member if they are enrolled in an approved clinical study that meets criteria put forth by the Centers for Medicare & Medicaid Services (CMS). This information may be available through the CMS website.

202009 Dry Needling Dry needling, also known as CPT Codes 20560, 04/19/2021 intramuscular stimulation, involves the 20561 use of solid ‘noninjection’ needles which are used to penetrate the skin and stimulate specific triggerpoints, muscles and connective tissue. Dry needling is intended to reduce pain and improve range of motion, however more studies

NUMBER TITLE DESCRIPTION APPLICABLE EFFECTIVE/ CODE(S) REVISED DATE are needed to demonstrate its safety and effectiveness. 202011 Microsurgical Lymphedema refers to the accumulation CPT Codes 35206†, 05/25/2021 Treatments for of fluid in tissues with inadequate 35226†, 35236†, Lymphedema – lymphatic drainage, which often results 35266†, 37799†, Lymphatic from breast cancer surgery, mastectomy, 38308†, 38790†, Bypass or radiation treatments. Microsurgical 38999† Procedures treatments for lymphedema aim to increase the capacity of the lymphatic †When repair blood vessel, direct; upper extremity system by creating new channels for (35206), repair blood vessel, lymphatic fluid to travel. There are direct; lower extremity several methods of lymphatic bypass, (35226), repair blood vessel with vein graft; upper including (but not limited to) extremity (35236), repair lymphovenous bypass, blood vessel with graft other than vein; upper extremity lymphaticovenular anastomosis, and (36266), unlisted procedure, lymphatic-capsular-venous anastomosis. vascular surgery (37799), lymphangiotomy or other operations on lymphatic channels (38308), or unlisted procedure, hemic or lymphatic system (38999) is determined to be microsurgical treatments for lymphedema. 202015 Irreversible Irreversible electroporation (IRE) is a CPT Codes 0600T, 08/07/2020 Electroporation nonthermal ablative technique that 0601T, 47399† (IRE) induces cell death by directly delivering multiple pulses of high-voltage electrical ICD 10 Procedure current to a targeted area. The electrical Codes 0F500ZF- current permanently changes cell 0F504ZF, 0F510ZF- permeability by causing tiny holes to 0F514ZF, 0F520ZF- open in the cell membrane. This 0F524ZF, 0F5G0ZF- technique preferentially impacts cells, 0F5G4ZF thereby causing less damage to surrounding tissues than with thermal †When unlisted procedure, liver (47399) is determined to ablative techniques. be irreversible electroporation

NUMBER TITLE DESCRIPTION APPLICABLE EFFECTIVE/ CODE(S) REVISED DATE 202016 Cryoablation for Cryoablation involves the use of extreme CPT Code 30117 08/27/2020 Allergic and Non- cold to destroy tissue. The ClariFix Allergic Rhinitis device is a hand-held, disposable device (ClariFix) used to destroy tissue during surgical procedures, including in adults with chronic allergic and non-allergic rhinitis.

A-0242 Electromagnetic Pulsed electromagnetic field therapy is a HCPCS E0761, 11/08/2019 Therapy noninvasive, adjunctive therapy utilized E0769, G0295, to accelerate improvement and stimulate G0329 MCG™ Care healing in chronic, nonhealing dermal Guideline® ulcers unresponsive to conventional wound therapy.

A-0289 MRI-Guided Magnetic resonance imaging-guided high- CPT Codes 0071T, 11/15/2019 Focused intensity focused ultrasound ablation is a 0072T Ultrasound noninvasive procedure developed to ablate Surgery, Uterus uterine fibroid tissue.

MCG™ Care Guideline®

A-0567 Ovarian and Pelvic congestion syndrome (PCS) is CPT Codes 37241, 02/13/2020 Internal Iliac Vein characterized by chronic pelvic pain that is 75894, 75898 Embolization unexplained by other etiologies. PCS may develop due to varicosities and/or valvular MCG™ Care incompetence within the pelvic veins. Guideline® Embolization of the ovarian vein and/or internal iliac vein is a treatment approach that involves the use of embolic agents to reroute blood flow, aiming to reduce pressure within the targeted veins.

A-0578 Migraine Migraine, cluster and other headache CPT: 15824, 15826, 11/08/2019 Headache, syndromes are common, often 21299, 30130, 30140,

NUMBER TITLE DESCRIPTION APPLICABLE EFFECTIVE/ CODE(S) REVISED DATE Surgical debilitating, primary headache disorders. 30520, 30801, 30802, Treatment Surgical interventions have been 31200, 31201, 31205, proposed for the prevention, reduction or 31254, 31255, 64732, MCG™ Care elimination of these headache types. 64734, 64744, 67900 Guideline® Similar therapies have been proposed for tension-type headaches and occipital (or any codes found neuralgia. Examples of these procedures to be for services include: resection or manipulation of listed) facial muscles or soft tissue from the forehead, periorbital, occipital or other facial or scalp areas; resection of the trigeminal nerve or its branches; surgical modification of the sinuses; and patent foramen ovale closure.

A-0634 Bronchial Bronchial thermoplasty (Alair® CPT 31660 and 11/08/2019 Thermoplasty Bronchial Thermoplasty System, Boston 31661 Scientific, Sunnyvale, CA) is a procedure MCG™ Care purported to weaken and partially Guideline® destroy the airway smooth muscle responsible for the bronchoconstriction associated with asthma attacks. A course of bronchial thermoplasty usually consists of several treatment sessions performed under moderate sedation by a pulmonologist for adults with severe persistent asthma that has not been well controlled by conventional medical therapy, including optimal doses of long- acting bronchodilators and glucocorticoids.

A-0667 Bioimpedance Bioimpedance spectroscopy (BIS) is a CPT 93702 11/08/2019 Spectroscopy noninvasive technique utilized in the measurement of extracellular fluid

NUMBER TITLE DESCRIPTION APPLICABLE EFFECTIVE/ CODE(S) REVISED DATE MCG™ Care volume differences between the arms and Guideline® has been reported to aid in detection of unilateral arm lymphedema in women. A small electrical current is passed through electrodes attached to the wrists to measure resistance (impedance) to current. A device is utilized to record impedance at varying frequencies (e.g., ImpediMED L-Dex U400 BIS Extra Cellular Fluid Analyzer, ImpediMed Limited, Queensland Australia; San Diego, CA). Results are analyzed to determine if more fluid exists as compared to the contralateral limb. This technique has been proposed as an alternative to circumferential measurements and water immersion methods to indicate trends toward the potential development of lymphedema.

A-0709 & Proteomics – Proteomics-based ovarian adnexal mass CPT 0003U, 81500, 11/19/2019 A-0858 Ovarian Cancer assessment score test systems (e.g., 81053 and 96040 Biomarker Panel OVA1™ Test, ROMA™ test) measure (ROMA & one or more serum proteins believed to HCPCS S0265 OVA1) preoperatively predict the likelihood that an ovarian adnexal mass represents MCG™ Care ovarian cancer. These systems have been Guideline® proposed as being useful in the preoperative assessment of a pelvic mass suspicious for ovarian cancer and have been reported to augment identification of individuals requiring gynecologic oncology surgical expertise.

NUMBER TITLE DESCRIPTION APPLICABLE EFFECTIVE/ CODE(S) REVISED DATE A-0727 Intrapulmonary Intrapulmonary percussive ventilation CPT Code 94640 and 7/21/2020 Percussive (IPV) is a breathing system that attempts HCPCS Code E0481 Ventilation (IPV) to loosen mucus by internally percussing the airways through the delivery of high- MCG™ Care frequency, high-flow, low-pressure Guideline® bursts of gas in an oscillating fashion to a spontaneously breathing patient via mask, mouthpiece, or tracheostomy; it is most commonly used in patients on mechanical ventilation. Aerosolized bronchodilators or other medications can be delivered in these bursts of gas. Airway clearance is thought to result from improved lung expansion and creation of vibrations within the airways that loosen mucus and secretions.

A-1024 Saphenous Vein Endovenous adhesive injection of the CPT Codes 36482, 9/22/2021 Ablation, saphenous vein is a nonthermal 36483 Adhesive technique that involves injection of an Injection adhesive agent (eg, cyanoacrylate) into a dilated saphenous vein followed by external compression in order to occlude the vessel lumen, thereby leading to vein ablation. Ultrasonography is used to continuously monitor the procedure. For saphenous vein incompetence, evidence is insufficient, conflicting, or poor and demonstrates an incomplete assessment of net benefit vs harm; additional research is recommended. A-1025 Saphenous Vein Mechanical occlusion chemical ablation CPT Codes 36473, 9/22/2021 Ablation, (MOCA) of the saphenous vein is a 36474 Mechanical nonthermal technique that combines Occlusion mechanical epithelial injury via a

NUMBER TITLE DESCRIPTION APPLICABLE EFFECTIVE/ CODE(S) REVISED DATE Chemical catheter-directed rotating wire with Ablation concomitant chemical ablation via (MOCA) simultaneous administration of a sclerosing agent (eg, sodium tetradecyl sulfate, polidocanol) over the rotating wire. Ultrasonography is used to continuously guide the procedure. For saphenous vein incompetence, evidence is insufficient, conflicting, or poor and demonstrates an incomplete assessment of net benefit vs harm; additional research is recommended. 202101 Peroral Peroral endoscopic myotomy (POEM) is CPT Code 43499†, 02/15/2021 Endoscopic a minimally invasive surgical technique. 43999† Myotomy POEM involves guiding an endoscope † (POEM) through the esophagus, making an When unlisted procedure, incision in the mucosa and creating a esophagus (43499), unlisted procedure, stomach (43999) submucosal tunnel to the lower is determined to be D-POEM, esophagus and gastroesophageal G-POEM or Z-POEM. junction, and then cutting the muscle fibers in the lower esophagus and proximal stomach. The internal incisions are closed with clips after myotomy is complete. This technique is regarded as the endoscopic equivalent of the Heller myotomy.

Per-oral endoscopic myotomy (POEM) is a covered procedure and is found in CMP 202101.

The following POEM procedures are considered investigational:

NUMBER TITLE DESCRIPTION APPLICABLE EFFECTIVE/ CODE(S) REVISED DATE • Diverticular peroral endoscopic myotomy (D-POEM) • Gastric peroral endoscopic myotomy (G-POEM) • Zenker peroral endoscopic myotomy (Z-POEM)

Documentation Requirements

The Company reserves the right to request additional documentation as part of its coverage determination process. The Company may deny reimbursement when it has determined that the services performed were not medically necessary, investigational or experimental, not within the scope of benefits afforded to the member and/or a pattern of billing or other practice has been found to be either inappropriate or excessive. Additional documentation supporting medical necessity for the services provided must be made available upon request to the Company. Documentation requested may include patient records, test results and/or credentials of the provider ordering or performing a service. The Company also reserves the right to modify, revise, change, apply and interpret this policy at its sole discretion, and the exercise of this discretion shall be final and binding.

NOTE: The Company reserves the right to apply this policy to the procedure performed regardless of how the procedure was coded by the provider.