ALLOWABLE PROCEDURES and SERVICES ADM1001.024 COVERAGE: the Procedures and Services Listed Below Are Allowable. This List Is Ma

ALLOWABLE PROCEDURES AND SERVICES ADM1001.024 POSTED DATE: 6/11/2003 EFFECTIVE DATE: 8/15/2003 ______

COVERAGE:

The procedures and services listed below are allowable. This list is made available instead of creating a medical policy for each individual procedure and/or service.

PROCEDURE OR SERVICE Apligraf Blood Glucose Monitors Body Jackets (other than for scoliosis) Brachytherapy for Prostate Cancer Cerebrovascular Reconstruction for the treatment of Moyamoya Disease Cerumen Removal Chronic Pulmonary Thromboendarterectomy Continent Ileostomy and Urostomy Coronary Artery Atherectomy (laser or by any other means) Correction of Surgically Induced Astigmatism Electroretinography Endometrial Ablation Endoscopic Laser for Tracheobronchial Obstruction Ergonovine Provocation ESSURE – Hysteroscopic Placement of Micro-Inserts as a Technique of Permanent Sterilization Extracranial Arterial Studies External Infusion Pumps External Ocular Photography Extracorporeal Shock Wave Lithotripsy (ESWL) for Kidney Stones Extremity Arterial Studies Free Vascularized Fibular Grafting for Treatment of Osteonecrosis of the Hip Gonioscopy Home Phototherapy for Neonatal Jaundice Human Antihemophilic Factor (Factor VIII, Human AHF) Infrared Coagulation for Hemorrhoids Intracanalicular Implants Intracardiac Electrophysiologic Studies Intracarotid Amobarbital Test (WADA Test) Intraoperative Radiation Therapy (IORT) Maze Procedure Methotrexate as a Treatment of Ectopic Tubal Pregnancy Over the Door Traction Pacemaker Analysis and Reprogramming

Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company* Southwest Texas HMO, Inc.* d/b/a HMO BlueÒ Texas * Independent Licensees of the Blue Cross and Blue Shield Association

ALLOWABLE PROCEDURES AND SERVICES ADM1001.024 POSTED DATE: 6/11/2003 EFFECTIVE DATE: 8/15/2003 ______

Pallidotomy for Treatment of Parkinson’s Disease Partial Coherence Interferometry as a Technique to Measure the Axial Length of the Eye Percutaneous Balloon Valvuloplasty Percutaneous Lithotripsy Percutaneous Transluminal Coronary Angioplasty Percutaneous Transluminal Pulmonary Artery Balloon Angioplasty Phonocardiogram Posterior Capsulotomy Pulsed Irrigation of Fecal Impaction Ross Pulmonary Autograft Scanning Computerized Ophthalmic Imaging (Scanning Laser) Scoliosis Brace(s) Selective Posterior Rhizotomy for Spasticity in Cerebral Palsy Stereotactic Electroencephalography Stereotactic Radiosurgery and Fractionated Stereotactic Radiotherapy Stimulation of sacral anterior nerve roots (using an implantable device) in conjunction with a posterior rhizotomy for patients with a suprasacral complete spinal cord lesion and an associated neurogenic bladder. (Vocare Bladder System) Thrombolytic Therapy Trachea Button, Plug Device Transjugular Intrahepatic Portosystemic Shunt (TIPS) Transmyocardial Revascularization Transrectal Ultrasound (Echography) Transurethral Microwave Thermotherapy Transurethral Radiofrequency Needle Ablation of the Prostate Treatment of Twin-Twin Transfusion Syndrome with Amnioreduction and/or Fetoscopic Laser Therapy Trimedyne Laser Twister (a torsion cable locked to a shoe and a pelvic band, a type of orthotic.) Visceral Arterial Studies Vitrectomy Walking Aids (walker, crutches, cane)

______DESCRIPTION:

The procedures and services listed within this policy are allowable. This list is made available instead of creating a medical policy for each individual procedure and/or service. ______Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company* Southwest Texas HMO, Inc.* d/b/a HMO BlueÒ Texas * Independent Licensees of the Blue Cross and Blue Shield Association

ALLOWABLE PROCEDURES AND SERVICES ADM1001.024 POSTED DATE: 6/11/2003 EFFECTIVE DATE: 8/15/2003 ______

RATIONALE:

See Description. ______PRICING:

None ______

REFERENCES:

None ______DISCLAIMER:

State and federal law, as well as contract language, including definitions and specific inclusions/exclusions, takes precedence over Medical Policy and must be considered first in determining coverage. The member’s contract benefits in effect on the date that services are rendered must be used. Any benefits are subject to the payment of premiums for the date on which services are rendered. Medical technology is constantly evolving, and we reserve the right to review and update Medical Policy periodically. HMO Blue Texas physicians who are contracted/affiliated with a capitated IPA/medical group must contact the IPA/medical group for information regarding HMO claims/reimbursement information and other general polices and procedures.