Clinical policy bulletins

  Additions, Revisions, Updates, and Deletions Sorted by Date

New:

• September 4, 2009 - 0793 - Esophageal Doppler Monitoring
• August 21, 2009 - 0792 - Human Fibrinogen Concentrate (RiaSTAP)
• August 14, 2009 - 0767 - Extended Ophthalmoscopy
• July 24, 2009 - 0791 - Cardiac Devices for Occlusion of the Left Atrial Appendage

• November 20, 2009 - 0650 - Polymerase Chain Reaction Testing: Selected Indications 
• November 20, 2009 - 0652 - Therapeutic Phlebotomy 
• November 20, 2009 - 0661 - Hip Resurfacing 
• November 20, 2009 - 0665 - Constraint-Induced Therapy 
• November 20, 2009 - 0667 - Esophageal/Airway pH Monitoring 
• November 20, 2009 - 0669 - Subtalar Implant for Foot Deformity 
• November 20, 2009 - 0670 - Xolair (Omalizumab) 
• November 20, 2009 - 0672 - Pamidronate (Aredia) 
• November 20, 2009 - 0675 - Bortezomib (Velcade) 
• November 20, 2009 - 0677 - Functional Electrical Stimulation and Neuromuscular Electrical Stimulation 
• November 20, 2009 - 0678 - Gastric Pacing and Gastric Electrical Stimulation 
• November 20, 2009 - 0685 - Bevacizumab (Avastin) 
• November 20, 2009 - 0687 - Pemetrexed (Alimta) 
• November 20, 2009 - 0688 - Intra-oral Appliances for Headaches and Trigeminal Neuralgia 
• November 13, 2009 - 0502 - Nerve Conduction Velocity Studies 
• November 6, 2009 - 0004 - Obstructive Sleep Apnea in Adults
• November 6, 2009 - 0070 - Diabetes Tests, Programs, and Supplies 
• November 6, 2009 - 0648 - Pervasive Developmental Disorders 
• November 6, 2009 - 0649 - Extracorporeal Shock-Wave Therapy for Musculoskeletal Indications and Soft Tissue Injuries 
• November 6, 2009 - 0654 - Ventricular Assist Devices 
• November 6, 2009 - 0655 - Adalimumab (Humira) 
• November 6, 2009 - 0656 - Phototherapy for Acne 
• November 6, 2009 - 0657 - Hysteroscopic Tubal Sterilization 
• November 6, 2009 - 0683 - Oxaliplatin (Eloxatin) 
• October 23, 2009 - 0016 - Back Pain - Invasive Procedures 
• October 23, 2009 - 0071 - Positron Emission Tomography 
• October 23, 2009 - 0325 - Physical Therapy Services 
• October 23, 2009 - 0602 - Thermal Intradiscal Procedures 
• October 23, 2009 - 0618 - Brain Natriuretic Peptide Testing 
• October 23, 2009 - 0625 - Dysphagia Therapy 
• October 23, 2009 - 0633 - Benign Skin Lesion Removal 
• October 2, 2009 - 0035 - Influenza Vaccine 
• October 2, 2009 - 0170 - Growth Hormone and Growth Hormone-Releasing Hormone 
• October 2, 2009 - 0171 - MRI of the Extremities 
• October 2, 2009 - 0279 - Magnetic Source Imaging/Magnetoencephalography 
• October 2, 2009 - 0352 - Tumor Markers 
• October 2, 2009 - 0386 - Breast Transillumination, Electrical Impedance Scanning (EIS), and Breast Elastography 
• October 2, 2009 - 0530 - Transvaginal Ultrasonography for Ovarian and Endometrial Cancer Screening 
• October 2, 2009 - 0559 - Pulsed Dye Laser Treatment 
• October 2, 2009 - 0561 - Celiac Disease Laboratory Testing 
• October 2, 2009 - 0569 - Lumbar Traction Devices 
• October 2, 2009 - 0577 - Psoriasis: Laser Treatment 
• October 2, 2009 - 0578 - Lower Limb Prostheses 
• October 2, 2009 - 0582 - Titanium Rib
• October 2, 2009 - 0666 - Teriparatide (Forteo)
• October 2, 2009 - 0715 - Pharmacogenetic Testing
• September 18, 2009 - 0106 - Fetal Echocardiograms 
• September 18, 2009 - 0206 - Intravenous Immunoglobulins (IVIG) 
• September 18, 2009 - 0227 - BRCA Testing, Prophylactic Mastectomy, and Prophylactic Oophorectomy 
• September 18, 2009 - 0244 - Wound Care 
• September 18, 2009 - 0264 - Multiple Sclerosis 
• September 18, 2009 - 0270 - Proton Beam and Neutron Beam Radiotherapy 
• September 18, 2009 - 0528 - Androgens and Anabolic Steroids 
• September 18, 2009 - 0529 - Transabdominal Cerclage 
• September 18, 2009 - 0539 - Fundus Photography 
• September 18, 2009 - 0545 - Electrothermal Arthroscopy 
• September 18, 2009 - 0546 - Extracorporeal Membrane Oxygenation (ECMO) 
• September 18, 2009 - 0553 - Lead Testing 
• September 18, 2009 - 0710 - Actigraphy and Accelerometry
• September 18, 2009 - 0779 - Plerixafor Injection (Mozobil)
• September 4, 2009 - 0492 - Radiofrequency Tumor Ablation 
• September 4, 2009 - 0501 - Gonadotropin-Releasing Hormone Analogs and Antagonists 
• September 4, 2009 - 0504 - Hyperhidrosis (Hyperhydrosis) 
• September 4, 2009 - 0511 - Eating Disorders (Anorexia and Bulimia) 
• September 4, 2009 - 0512 - Premenstrual Syndrome/Premenstrual Dysphoric Disorder 
• September 4, 2009 - 0517 - Breast Ductal Lavage and Fiberoptic Ductoscopy 
• September 4, 2009 - 0518 - Nitric Oxide, Inhalational (INO) 
• September 4, 2009 - 0520 - Magnetic Resonance Imaging of the Cardiovascular System - Cardiac MRI 
• September 4, 2009 - 0521 - Prostate Cancer Screening 
• August 21, 2009 - 0055 - Hematopoietic Colony-Stimulating Factors (CSFs) 
• August 21, 2009 - 0113 - Botulinum Toxin 
• August 21, 2009 - 0313 - Herceptin (Trastuzumab) 
• August 21, 2009 - 0447 - Complex Regional Pain Syndrome (CRPS) / Reflex Sympathetic Dystrophy (RSD): Treatments 
• August 21, 2009 - 0449 - Fetal Surgery In Utero 
• August 21, 2009 - 0451 - Foot Orthotics 
• August 21, 2009 - 0462 - Migraine and Cluster Headache: Nonsurgical Management 
• August 21, 2009 - 0464 - Serum Marker Screening for Down Syndrome 
• August 21, 2009 - 0465 - Mifepristone (RU 486) 
• August 21, 2009 - 0469 - Transcranial Magnetic Stimulation and Cranial Electrical Stimulation 
• August 21, 2009 - 0479 - Respiratory Devices: Incentive Spirometers and Intermittent Positive Pressure Breathing Machines 
• August 21, 2009 - 0484 - Glaucoma Surgery 
• August 21, 2009 - 0500 - Intermittent Pneumatic Compression Devices for the Legs 
• August 21, 2009 - 0743 - Spinal Surgery: Laminectomy and Fusion 
• August 7, 2009 - 0297 - Cryoanalgesia and Therapeutic Cold 
• August 7, 2009 - 0327 - Infertility 
• August 7, 2009 - 0381 - Cardiovascular Disease Risk Tests 
• August 7, 2009 - 0396 - Gastrointestinal Function: Selected Tests 
• August 7, 2009 - 0415 - Optic Nerve Decompression Surgery 
• August 7, 2009 - 0419 - Graves' Ophthalmopathy Treatments 
• August 7, 2009 - 0422 - Vitiligo 
• August 7, 2009 - 0423 - Alopecia Areata 
• August 7, 2009 - 0426 - Attention Deficit/Hyperactivity Disorder 
• August 7, 2009 - 0431 - Nocturnal Enuresis Treatments 
• August 7, 2009 - 0434 - Therapeutic Chairs 
• August 7, 2009 - 0443 - Cervical Cancer Screening and Diagnosis 
• August 7, 2009 - 0658 - Psoriasis: Biological Therapies 
• August 7, 2009 - 0684 - Cetuximab (Erbitux) 
• August 7, 2009 - 0693 - Somatostatin Analogs 
• August 7, 2009 - 0748 - Panitumumab (Vectibix) 
• July 31, 2009 - 0318 - Synagis (Palivizumab) for Prevention of Respiratory Syncytial Virus (RSV) Infections 
• July 24, 2009 - 0107 - Chiropractic Services 
• July 24, 2009 - 0140 - Genetic Testing 
• July 24, 2009 - 0382 - Intravascular Ultrasound 
• July 24, 2009 - 0383 - Mohs Micrographic Surgery 
• July 24, 2009 - 0388 - Complementary and Alternative Medicine 
• July 24, 2009 - 0389 - Hypertrophic Scars and Keloids 
• July 24, 2009 - 0394 - Epilepsy Surgery 
• July 24, 2009 - 0398 - Idiopathic Scoliosis: Treatments 
• July 24, 2009 - 0404 - Interferons 
• July 24, 2009 - 0405 - Mechanical Stretching Devices for Contracture and Joint Stiffness 
• July 24, 2009 - 0411 - Bone and Tendon Graft Substitutes and Adjuncts 
• July 24, 2009 - 0761 - Certolizumab Pegol (Cimzia) 

• November 20, 2009 - 0660 - Unicompartmental, Bicompartmental, and Bi-unicompartmental Knee Arthroplasties 
• November 18, 2009 - 0227 - BRCA Testing, Prophylactic Mastectomy, and Prophylactic Oophorectomy 
• November 17, 2009 - 0640 - Bone Marrow or Peripheral Stem Cell Transplant for Acute Lymphocytic Leukemia
• November 17, 2009 - 0641 - Adoptive Immunotherapy
• November 17, 2009 - 0642 - Neuralgia Inducing Cavitational Osteonecrosis (NICO) and Ultrasonograph Bone Densitometer to Detect NICO
• November 17, 2009 - 0644 - Smallpox Vaccine 
• November 17, 2009 - 0645 - Total Ankle Arthroplasty 
• November 17, 2009 - 0646 - Voice Therapy 
• November 17, 2009 - 0647 - Histamine Desensitization Therapy for Intractable Headaches 
• November 17, 2009 - 0651 - Endovascular Repair of Aortic Aneurysms 
• November 17, 2009 - 0653 - Diphtheria, Tetanus, and Pertussis Vaccines 
• November 13, 2009 - 0627 - Allogeneic Bone Marrow or Peripheral Stem Cell Transplant for Aplastic Anemia 
• November 13, 2009 - 0628 - Spinal Ultrasound 
• November 13, 2009 - 0629 - Bunionectomy 
• November 13, 2009 - 0630 - Vacuum Assisted Socket System (VASS) 
• November 13, 2009 - 0634 - Non-myeloablative Bone Marrow/Peripheral Stem Cell Transplantation (Mini-Allograft / Reduced Intensity Conditioning Transplant) 
• November 13, 2009 - 0636 - Hammertoe Repair 
• November 13, 2009 - 0637 - Osteochondral Autografts (Mosaicplasty, OATS) 
• November 13, 2009 - 0638 - Donor Lymphocyte Infusion 
• November 13, 2009 - 0639 - Autotransfusers 
• November 6, 2009 - 0685 - Bevacizumab (Avastin) 
• November 3, 2009 - 0609 - Laser Photocoagulation of Drusen 
• November 3, 2009 - 0611 - Fecal Incontinence Treatments 
• November 3, 2009 - 0612 - Implantable Hearing Aids: Vibrant Soundbridge 
• November 3, 2009 - 0613 - Stereolithography 
• November 3, 2009 - 0614 - Fetal Striatal Transplantation for Huntington's Disease 
• November 3, 2009 - 0616 - Antroduodenal Manometry 
• November 3, 2009 - 0619 - Eye Prosthesis 
• November 3, 2009 - 0620 - Facial Prostheses, External 
• November 3, 2009 - 0621 - Drug-Eluting Stents 
• November 3, 2009 - 0623 - Safety Items 
• October 30, 2009 - 0592 - Radiofrequency Ablation of Hypertrophied Nasal Turbinates 
• October 30, 2009 - 0594 - Visudyne (Verteporfin) Photodynamic Therapy 
• October 30, 2009 - 0597 - Heart-Lung Transplant 
• October 30, 2009 - 0601 - Pancreas Transplantation Alone (PTA) and Islet Cell Transplantation 
• October 30, 2009 - 0603 - Total-Body CT Screening 
• October 30, 2009 - 0604 - Infrared Therapy 
• October 30, 2009 - 0605 - Intestinal Transplantation 
• October 30, 2009 - 0606 - Stem Cell Transplant for Autoimmune Diseases 
• October 30, 2009 - 0607 - Anesthetic Infusion Pumps 
• October 30, 2009 - 0608 - Salivary Hormone Tests 
• October 20, 2009 - 0574 - Female Erectile Devices for the Treatment of Female Sexual Dysfunction (FSD) 
• October 20, 2009 - 0576 - Laminoplasty 
• October 20, 2009 - 0579 - T-Wave Alternans 
• October 20, 2009 - 0580 - Low Vision Programs 
• October 20, 2009 - 0581 - Lung Imaging Fluorescence Endoscopy (LIFE) 
• October 20, 2009 - 0585 - Cardioverter-Defibrillators 
• October 20, 2009 - 0587 - Pancreas Kidney Transplantation 
• October 20, 2009 - 0588 - Capsule Endoscopy 
• October 20, 2009 - 0590 - Intensity Modulated Radiation Therapy 
• October 16, 2009 - 0560 - Voice Prosthesis for Voice Rehabilitation Following Total Laryngectomy 
• October 16, 2009 - 0562 - Biochemical Markers of Bone Remodeling for Osteoporosis 
• October 16, 2009 - 0563 - Diabetic Retinopathy Telescreening Systems 
• October 16, 2009 - 0564 - Electrocochleogram and Perilymphatic Pressure Measurement 
• October 16, 2009 - 0565 - Ankle Orthoses, Ankle-Foot Orthoses (AFOs), and Knee-Ankle-Foot Orthoses (KAFOs) 
• October 16, 2009 - 0566 - Strabismus Repair in Adults 
• October 16, 2009 - 0567 - Actinic Keratoses Treatment 
• October 16, 2009 - 0568 - AngioJet Rheolytic Thrombectomy System 
• October 16, 2009 - 0570 - Chemotherapy Inpatient 
• October 16, 2009 - 0571 - Dehydration Testing for Endolymphatic Hydrops (Meniere's Disease) 
• October 16, 2009 - 0572 - Home/Ambulatory Spirometry 
• October 2, 2009 - 0195 - Erythropoiesis Stimulating Agents 
• October 2, 2009 - 0575 - Intravenous Iron Therapy 
• October 2, 2009 - 0583 - Eye Movement Desensitization and Reprocessing (EMDR) Therapy 
• September 29, 2009 - 0503 - Suction Pumps 
• September 29, 2009 - 0505 - Ambulatory Assist Devices: Walkers, Canes, and Crutches 
• September 29, 2009 - 0507 - High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Breast Cancer 
• September 29, 2009 - 0509 - Contact Dissolution for Gallstones 
• September 29, 2009 - 0510 - Progestins 
• September 29, 2009 - 0514 - Meniere's Disease Surgery 
• September 29, 2009 - 0515 - Thyrogen (Thyrotropin Alfa) 
• September 29, 2009 - 0522 - Pulsed Irrigation Evacuation (PIE) 
• September 29, 2009 - 0523 - Car-Ride Simulators for Infantile Colic 
• September 25, 2009 - 0490 - Transpupillary Thermal Therapy 
• September 25, 2009 - 0491 - Coronary Artery Brachytherapy and Other Adjuncts to Coronary Interventions 
• September 25, 2009 - 0493 - Kidney Transplantation 
• September 25, 2009 - 0494 - High Dose Chemotherapy with Bone Marrow or Peripheral Stem Cell Transplant for Non-Hodgkin's Lymphoma 
• September 25, 2009 - 0495 - High Dose Chemotherapy Bone Marrow or Peripheral Stem Cell Transplant for Hodgkin's Disease 
• September 25, 2009 - 0496 - High Dose Chemotherapy and Bone Marrow or Peripheral Stem Cell Transplant for Neuroblastoma 
• September 25, 2009 - 0497 - High Dose Chemotherapy with Bone Marrow or Peripheral Stem Cell Transplant for Multiple Myeloma 
• September 22, 2009 - 0544 - Immune Globulins for Post-exposure Prophylaxis 
• September 22, 2009 - 0547 - Rosacea 
• September 22, 2009 - 0549 - Distraction Osteogenesis for Craniofacial Defects 
• September 22, 2009 - 0551 - Radiation Treatment of Keloids 
• September 22, 2009 - 0552 - Laser Neurolysis 
• September 22, 2009 - 0557 - Melanoma Vaccine 
• September 22, 2009 - 0558 - Percutaneous Transluminal Septal Myocardial Ablation (PTSMA) 
• September 11, 2009 - 0525 - Screening for Lipid Disorders 
• September 11, 2009 - 0526 - Surgical Dressings (Wound Care Supplies) 
• September 11, 2009 - 0527 - Intragastric Hypothermia 
• September 11, 2009 - 0531 - Balloon-Expandable Venous Stents 
• September 11, 2009 - 0532 - Scrotal Ultrasonography 
• September 11, 2009 - 0534 - Vesicoureteral Reflux Treatment by Endoscopic Injection of Bulking Agents 
• September 11, 2009 - 0535 - Virtual Gastrointestinal Endoscopy 
• September 11, 2009 - 0536 - Vitamin B-12 Therapy 
• September 11, 2009 - 0538 - Endothelial Cell Photography 
• September 11, 2009 - 0542 - HIV Testing 
• August 28, 2009 - 0475 - Coblation Non-thermal Volumetric Tissue Reduction 
• August 28, 2009 - 0476 - Influenza Rapid Diagnostic Tests 
• August 28, 2009 - 0477 - Balloon Valvuloplasty 
• August 28, 2009 - 0480 - Tourette Syndrome 
• August 28, 2009 - 0483 - Anthrax Vaccine 
• August 28, 2009 - 0485 - Autonomic Testing / Sudomotor Tests 
• August 25, 2009 - 0450 - Fluidized Therapy (Fluidotherapy) 
• August 25, 2009 - 0453 - Cervical Traction Devices 
• August 25, 2009 - 0456 - Pillows and Cushions 
• August 25, 2009 - 0457 - Punctal Occlusion for Dry Eyes 
• August 25, 2009 - 0458 - Peripheral Vascular Rehabilitation Programs 
• August 25, 2009 - 0466 - Clinical Trials, Coverage of Routine Patient Care Costs 
• August 25, 2009 - 0467 - Vestibular Autorotation Test (VAT) 
• August 25, 2009 - 0468 - Terbutaline Pump for Preterm Labor 
• August 25, 2009 - 0471 - Tuberculosis Testing 
• August 25, 2009 - 0472 - Thoracic Electrical Bioimpedance for Cardiac Output Monitoring 
• August 25, 2009 - 0473 - Vaccines for Travel 
• August 25, 2009 - 0474 - Total Body Plethysmography 
• August 4, 2009 - 0438 - Obsolete and Unreliable Tests and Procedures 
• August 4, 2009 - 0441 - Ovarian Vein Embolization for Pelvic Congestion Syndrome 
• August 4, 2009 - 0442 - Enzyme-replacement Therapy for Lysosomal Storage Disorders 
• August 4, 2009 - 0444 - Early Intervention Programs 
• August 4, 2009 - 0445 - Electroconvulsive Therapy 
• August 4, 2009 - 0446 - Endoscopic Ultrasonography 
• July 31, 2009 - 0432 - Computerized Motion Diagnostic Imaging 
• July 31, 2009 - 0433 - Chlamydia Trachomatis - Screening and Diagnosis 
• July 31, 2009 - 0435 - Viscocanalostomy and Canaloplasty 
• July 31, 2009 - 0437 - Speech Generating Devices 
• July 28, 2009 - 0412 - Therabite Jaw Motion Rehabilitation System 
• July 28, 2009 - 0413 - Percutaneous Embolization of Varicocele 
• July 28, 2009 - 0414 - AcuTect Scintigraphic Imaging for Detection of Lower Limb Deep Vein Thrombosis 
• July 28, 2009 - 0416 - Nerve Graft During Radical Retropubic Prostatectomy 
• July 28, 2009 - 0417 - Amnioinfusion 
• July 28, 2009 - 0418 - Myringotomy and Tympanostomy Tube 
• July 28, 2009 - 0420 - Balloon Dacryocystoplasty/Dacryoplasty for Nasolacrimal Duct Obstruction 
• July 28, 2009 - 0425 - Ambulatory Electroencephalography 
• July 28, 2009 - 0427 - Carbon Dioxide Laser for Actinic Lesions of the Skin 
• July 28, 2009 - 0428 - Carbogen Inhalation for Sudden Hearing Loss