Clinical policy bulletins

Changes to Review Schedule

Please note that the attached document sets forth the anticipated schedule for review of the specified Clinical Policy Bulletin (CPB) in the ordinary course. This schedule is subject to change based on various factors, including but not limited to intervening clinical developments and available resources. Aetna does not hereby commit to review any specific CPB by a specific date, and expressly reserves the right to change any CPB without notice. Aetna does not hereby assume any obligation to update information presented in this document, so information contained herein may be out of date at any given time.

The CPB review dates below are the anticipated start dates of the CPB review process for each CPB listed. The “reviewed” date appearing on the CPB is the date the review is completed.

January 10 (1 - 48) January 24 (49 - 124) February 14 (126 - 177) February 28 (179 - 225) March 14 (226 - 269) March 25 (270 - 316) April 11 (317 - 358)

April 25 (361 - 395) May 9 (396 - 430) May 23 (431 - 473) June 13 (474 - 512) June 27 (514 - 548) July 11 (549 - 585) July 25 (586 - 620)

August 8 (621 - 653) August 22 (654 - 689) September 12 (690 - 722) September 23 (723 - 755) October 10 (756 - 789) October 24 (790 - 832)

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Anticipated CPB Review Date: January 10

001 - Transrectal Ultrasound
002 - Oxygen
003 - Apnea Monitors for Infants
004 - Obstructive Sleep Apnea in Adults
005 - Septoplasty and Rhinoplasty
007 - Erectile Dysfunction
008 - Color-Flow Doppler Echocardiography in Adults
009 - Orthopedic Casts, Braces and Splints
010 - Continuous Passive Motion (CPM) Machines
011 - Electrical Stimulation for Pain
013 - Cochlear Implants and Auditory Brainstem Implants
016 - Back Pain - Invasive Procedures
017 - Breast Reduction Surgery and Gynecomastia Surgery
019 - Holter Monitors
020 - Injectable Medications
021 - Cardiac Rehabilitation
022 - Calcitriol and Paricalcitol Injection
023 - Corneal Remodeling
024 - Interleukin-2 (Aldesleukin, Proleukin, IL-2)
025 - Automated Ambulatory Blood Pressure Monitoring
027 - Implantable Vas Deferens Ligation Clip (Vasclip)
028 - Temporomandibular Disorders
029 - Thermography
031 - Cosmetic Surgery
032 - Pulmonary Rehabilitation
034 - Aural Rehabilitation
035 - Influenza Vaccine
037 - Pneumococcal Vaccine
038 - Allergy Testing and Allergy Immunotherapy
039 - Weight Reduction Medications and Programs
046 - Routine Foot Care
047 - Prenatal Care Provided by Primary Care Physicians
048 - Hepatitis A Vaccine

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Anticipated CPB Review Date: January 24

049 - Nutritional Counseling
050 - Varicose Veins
055 - Hematopoietic Colony-Stimulating Factors (CSFs)
059 - Peak Flow Meters
061 - Nutritional Support
062 - Burn Garments
065 - Nebulizers
067 - Chest Physiotherapy and Airway Clearance Devices
069 - Lymphedema
070 - Diabetes Tests, Programs and Supplies
071 - Positron Emission Tomography (PET)
073 - Cardiac Event Monitors
078 - Learning Disabilities, Dyslexia, & Vision
079 - Benign Prostatic Hypertrophy (BPH) Treatments
082 - Dental Services and Oral and Maxillofacial Surgery: Coverage Under Medical Plans
083 - Stereotactic Radiosurgery
084 - Ptosis Surgery
088 - Antepartum Fetal Surveillance
091 - Endometrial Ablation
093 - Open Air, Low Field Strength, and Standing MRI Units
094 - Magnetic Resonance Angiography (MRA) and Magnetic Resonance Venography (MRV)
095 - Orthognathic Surgery
097 - External Breast Prosthesis
100 - Cryoablation
105 - Magnetic Resonance Imaging (MRI) of the Breast
106 - Fetal Echocardiograms
107 - Chiropractic Services
111 - Indocyanine Green Angiography
112 - Surface Scanning and Macro Electromyography
113 - Botulinum Toxin
115 - Varicella and Herpes Zoster Vaccines
116 - Frenulectomy for Ankyloglossia
124 - General Anesthesia and I.V. Sedation for Oral and Maxillofacial Surgery and Dental Services

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Anticipated CPB Review Date: February 14

126 - Contact Lens and Eyeglasses
127 - Home Uterine Activity Monitoring
130 - Computerized Corneal Topography
131 - Clotting Factor
132 - Biofeedback
134 - Bone Mass Measurements
135 - Acupuncture
136 - Skilled Home Private Duty Nursing Care
140 - Genetic Testing
142 - Breast Implant Removal
145 - Alpha 1-Antitrypsin Inhibitor Therapy
147 - Reflex Sympathetic Dystrophy Diagnosis
151 - Hippotherapy
153 - Thalamotomy
155 - Ribavirin (Virazole)
157 - Obesity Surgery
158 - Neuropsychological and Psychological Testing
160 - Lung Volume Reduction Surgery
161 - Infusion Pumps
163 - Transmyocardial and Endovascular Laser Revascularization
165 - Cardiac Catheter Ablation Procedures
166 - Fetal Fibronectin, Inflammatory Biomarkers, and Salivary Estriol Testing for Preterm Labor
168 - Tumor Scintigraphy
169 - Outpatient Medical Self Care Programs
170 - Growth Hormone (GH) and Growth Hormone Antagonists
171 - MRI of the Extremities
172 - Hyperbaric Oxygen Therapy (HBOT)
173 - Prothrombin Time (INR) Home Testing Devices
174 - Pool Therapy, Aquatic Therapy or Hydrotherapy
175 - High-Frequency Pulsed Electromagnetic Stimulation
177 - Helicobacter pylori Infection Testing

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Anticipated CPB Review Date: February 28

179 - Viscosupplementation
180 - Vertebral Axial Decompression Therapy
181 - Evoked Potential Studies
182 - Ventricular Remodeling Operation (Batista Procedure) / and Surgical Ventricular Restoration (Dor Procedure)
184 - Prostaglandin Infusion Therapy for Pulmonary Hypertension
185 - Breast Reconstructive Surgery
188 - Total Body Photography and Dermoscopy
189 - Genetic Counseling
190 - Stem Cells for Bone Marrow Transplant
191 - Vagus Nerve Stimulation
194 - Dorsal Column Stimulation
195 - Erythropoesis Stimulating Agents
198 - Work Hardening Programs
199 - Ultrasound for Pregnancy
200 - Coumadin (Warfarin) to Heparin Conversion Before and After Elective Surgery
201 - Skilled Home Health Care Nursing Services
202 - Magnetic Resonance Spectroscopy (MRS)
204 - Spinal Manipulation Under Anesthesia
205 - Phototherapy and Photochemotherapy (PUVA) for Skin Conditions
206 - Parenteral mmunoglobulins
207 - Prolotherapy
208 - Deep Brain Stimulation
210 - Phonophoresis
211 - Abdominoplasty, Suction Lipectomy, and Ventral Hernia Repair
212 - Skeletal Analysis Systems
213 - Gastroesophageal Reflux Disease (GERD): Treatment Devices
214 - Cognitive Rehabilitation
215 - Lyme Disease and other Tick-Borne Diseases
218 - Home Health Aides
220 - Distraction Osteosynthesis
221 - Quantitative EEG (Brain Mapping)
223 - Urinary Incontinence Treatments
225 - Maze Procedure

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Anticipated CPB Review Date: March 14

226 - Hospitalization for the Initiation of Ketogenic Diet for the Treatment of Intractable Seizures
227 - BRCA Testing, Prophylactic Mastectomy, and Prophylactic Oophorectomy
228 - Cardiac CT, Coronary CT Angiography and Calcium Scoring
229 - Iontophoresis
231 - Grenz Ray Therapy for Skin Disorders
232 - Back Pain - Non Invasive Treatments
234 - Chelation Therapy
235 - Plantar Fasciitis Treatments
236 - MRI and CT of the Spine
237 - Chronic Pain Programs
238 - Chronic Vertigo
240 - Antineoplaston Therapy and Sodium Phenylbutyrate
241 - Extracorporeal Photochemotherapy (Photopheresis)
243 - Speech Therapy
244 - Wound Care
245 - Tumor Chemosensitivity
247 - Autologous Chondrocyte Implantation
248 - Fiberoptic Endoscopic Evaluation of Swallowing (FEES) / Fiberoptic Endoscopic Evaluation of Swallowing with Sensory Testing (FEESST)
249 - Inflammatory Bowel Disease: Serologic Markers and Pharmacogenomic and Metabolic Assessment of Thiopurine Therapy
250 - Occupational Therapy Services
251 - Dermabrasion, Chemical Peels, and Acne Surgery
253 - Vocal Cord Paralysis/Insufficiency Treatments
255 - Inpatient Admission Prior to Surgery (Preop Days)
256 - Sensory and Auditory Integration Therapy
259 - Transjugular Intrahepatic Portosystemic Shunt (TIPSS)
262 - External Counterpulsation (ECP)
263 - Gait Analysis and Electrodynogram
264 - Multiple Sclerosis
265 - Surgical Treatments to Control Drooling (Sialorrhea)
266 - Cholecystokinin Cholescintigraphy
267 - Ornish Cardiac Treatment Program
268 - Liver Neoplasms - Treatment Approaches
269 - Breast Biopsy Procedures

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Anticipated CPB Review Date: March 25

270 - Proton Beam and Neutron Beam Radiotherapy
271 - Wheelchairs and Power Operated Vehicles (Scooters)
272 - Pectus Excavatum and Poland's Syndrome Surgical Correction
274 - Ablation of Hepatic Lesions
276 - Angioplasty and Stenting of Extra-Cranial and Intra-Cranial Arteries
278 - Hyperthermia in Cancer Therapy
279 - Magnetic Source Imaging/Magnetoencephalography
282 - Noninvasive Down Syndrome Screening
284 - Melodic Intonation Therapy for Persistent Aphasia
285 - Plasmapheresis/Plasma Exchange/Therapeutic Apheresis
287 - Total Hip Implants
288 - Stereotactic Cingulotomy
289 - Grid Monitoring: Presurgical Evaluation for Patients with Intractable Seizures
290 - Scalp Cooling (Hypothermia) To Prevent Hair Loss During Chemotherapy
291 - Hemodialysis for Schizophrenia
292 - Transcatheter Closure of Septal Defects
293 - Corneal Graft with Amniotic Membrane Transplantation
294 - Pedobarography
295 - Peripheral Atherectomy
297 - Cryoanalgesia and Therapeutic Cold
298 - Non-invasive Negative Pressure Ventilation: Body Ventilators and Poncho Wrap
299 - Tilt Table Testing
300 - Hair Analysis
302 - Electrical Stimulation for Xerostomia
304 - Fibroid Treatment
305 - Videostroboscopy
306 - Dexamethasone Suppression Test in Psychiatry
307 - Parkinson's Disease
310 - Thoracoscopic Sympathectomy
313 - Herceptin (Trastuzumab)
314 - Rituximab (Rituxan)
315 - Enbrel™ (Etanercept)
316 - HIV Drug Susceptibility and Resistance Tests

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Anticipated CPB Review Date: April 11

317 - Ultra Rapid Detoxification (UROD)
318 - Synagis (Palivizumab) for Prevention of Respiratory Syncytial Virus (RSV) Infections
319 - RET Proto-Oncogene Testing
321 - Visual Perceptual Training
322 - Electroencephalographic (EEG) Video Monitoring
323 - Preconceptional Sex Selection Techniques
325 - Physical Therapy Services
327 - Infertility
329 - Home Births
330 - Multiple Sleep Latency Test (MSLT)
332 - Neonatal Hyperbilirubinemia
334 - Negative Pressure Wound Therapy
336 - Acoustic Pharyngometers and SNAP™ Testing System
337 - BreastAlert™ Differential Temperature Sensor
339 - Pulse Oximeter for Home Use
340 - Antibody Screening Tests for Neurologic Diseases
341 - Remicade (infliximab)
342 - Intestinal Rehabilitation Programs
343 - Bone Growth Stimulators
344 - Optic Nerve and Retinal Imaging Methods
345 - Implantable Hormone Pellets
346 - Low-Molecular-Weight Heparins
347 - Transcervical Balloon Tuboplasty
348 - Recurrent Pregnancy Loss
349 - Alzheimer’s Disease: Diagnosis
351 - Flow Cytometry, DNA Ploidy, and S-phase Fraction
352 - Tumor Markers
353 - Transcranial Doppler Ultrasonography
354 - YAG Laser in Ophthalmology: Selected Indications
355 - Extracorporeal Immunoadsorption (Prosorba column)
356 - Meningococcal Vaccine
357 - Quantitative Sensory Testing Methods
358 - Invasive Prenatal Diagnosis of Genetic Diseases

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Anticipated CPB Review Date: April 25

361 - Radiopharmaceuticals Metastron® (Strontium-89) and Samarium-153 (Quadramet) for Metastatic Bone Pain
362 - Spasticity Management
363 - Cold Laser and High-Power Laser Therapies
364 - Allograft Transplants of the Extremities
365 - Pancreaticoduodenectomy (Whipple Resection) for Zollinger-Ellison Syndrome
366 - Paralytic Lagophthalmos: Treatments
367 - Home Cholesterol Monitors
368 - Obstetrical Hypertension Programs
369 - Chronic Fatigue Syndrome
370 - Phototherapy for Seasonal Affective Disorder
371 - Brachytherapy
372 - Noncontact Normothermic/Nonthermal Wound Therapy
373 - Crit-Line In-Line Monitor
374 - Trigeminal Neuralgia Surgery
375 - Photodynamic Therapy
376 - Single Photon Emission Computed Tomography (SPECT)
377 - Dendritic Cell Immunotherapy
378 - NeuroControl Freehand System
379 - Cranial Remodeling Bands and Helmets
380 - Lung Cancer Screening
381 - Cardiac Disease Risk Tests
382 - Intravascular Ultrasound
383 - Mohs Micrographic Surgery
384 - Magnetic Resonance Cholangiopancreatography
386 - Breast Transillumination and Electrical Impedance Scanning (EIS), and Elastography
387 - Magnetic Resonance Neurography
388 - Complementary and Alternative Medicine
389 - Hypertrophic Scars and Keloids
390 - Smell and Taste Disorders, Diagnosis
392 - Metabolic and Environmental Profiling and Imaging for Kidney Stone Risk
393 - Vitrectomy
394 - Epilepsy Surgery
395 - Ethanol Injection for Thyroid Lesions

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Anticipated CPB Review Date: May 9

396 - Gastrointestinal Function: Selected Tests
397 - Knee Ligament Arthrometer Testing
398 - Idiopathic Scoliosis Treatments
399 - Myoelectric Prosthesis
400 - Ernest Eagle’s Syndrome (Stylomandibular Ligament Pain): Treatment with Radiofrequency Thermoneurolysis
401 - Selective Peripheral Denervation (Bertrand Procedure) for Spasmodic Torticollis
402 - Polio Vaccine
403 - Bone-anchored Hearing Aid
404 - Interferons
405 - Mechanical Stretching Devices for Contracture and Joint Stiffness
406 - Tinnitus Treatments
407 - Selected Aortic Valve Procedures: Ross Pulmonary Autograft and Aortic Valve-Sparing Re-implantation
409 - Macular / Foveal Translocation
410 - Hepatitis B Vaccine
411 - Bone Graft Substitutes and Adjuncts
412 - Therabite® Jaw Motion Rehabilitation System
413 - Varicocele: Selected Treatments
414 - AcuTect/Scintigraphic Imaging for Detection/Localization of Lower Limb Deep Vein Thrombosis
415 - Optic Nerve Decompression Surgery
416 - Sural Nerve Graft During Radical Retropubic Prostatectomy
417 - Amnioinfusion
418 - Myringotomy and Tympanostomy Tube
419 - Graves' Ophthalmopathy Treatments
420 - Balloon Dacryocystoplasty/Dacryoplasty for Nasolacrimal Duct Obstruction
421 - Breast Pumps
422 - Vitiligo
423 - Alopecia Areata
425 - Ambulatory Electroencephalography
426 - Attention Deficit/Hyperactivity Disorder
427 - Carbon Dioxide Laser for Actinic Lesions of the Skin
428 - Carbogen Inhalation Therapy
429 - Bathroom and Toilet Equipment and Supplies
430 - Pressure Reducing Support Surfaces

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Anticipated CPB Review Date: May 23

431 - Nocturnal Enuresis Treatments
432 - Computerized Motion Diagnostic Imaging
433 - Chlamydia Trachomatis - Screening and Diagnosis
434 - Therapeutic Chairs
435 - Viscocanalostomy and Canaloplasty
437 - Speech Generating Devices
438 - Obsolete and Unreliable Tests and Procedures
441 - Ovarian Vein Embolization for Pelvic Congestion Syndrome
442 - Enzyme-replacement Therapy for Lysosomal Storage Disorders
443 - Cervical Cancer Screening
444 - Early Intervention Programs
445 - Electroconvulsive Therapy
446 - Endoscopic Ultrasonography
447 - Complex Regional Pain Syndrome (CRPS) / Reflex Sympathetic Dystrophy (RSD): Treatments
449 - Fetal Surgery In Utero
450 - Fluidized Therapy (Fluidotherapy)
451 - Foot Orthotics
452 - Noninvasive Positive Pressure Ventilation
453 - Cervical Traction Devices
456 - Pillows and Cushions
457 - Dry Eyes
458 - Peripheral Vascular Rehabilitation Programs
459 - Seat Lifts and Patient Lifts
462 - Migraine and Cluster Headache: Nonsurgical Management
464 - Serum Marker Screening for Down Syndrome
465 - Mifepristone (RU 486)
466 - Clinical Trials, Coverage of Routine Patient Care Costs
467 - Vestibular Autorotation Test (VAT)
468 - Terbutaline Pump for Preterm Labor
469 - Transcranial Magnetic Stimulation and Cranial Electrical Stimulation
471 - Tuberculosis Testing
472 - Thoracic Electrical Bioimpedance for Cardiac Output Monitoring
473 - Vaccines for Travel

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Anticipated CPB Review Date: June 13

474 - Total Body Plethysmography
475 - Coblation™ Non-thermal Volumetric Tissue Reduction
476 - Influenza Rapid Diagnostic Tests
477 - Balloon Valvuloplasty
479 - Respiratory Devices: Incentive Spirometers and Intermittent Positive Pressure Breathing Machines
480 - Tourette Syndrome
481 - Tables and Boards
482 - Compression Garments for the Legs
483 - Anthrax Vaccine
484 - Glaucoma Surgery
485 - Autonomic Testing / Sudomotor Tests
489 - Vision Therapy
490 - Transpupillary Thermal Therapy
491 - Coronary Artery Brachytherapy and Other Adjuncts to Coronary Interventions
492 - Radiofrequency Tumor Ablation
493 - Kidney Transplantation
494 - High Dose Chemotherapy with Bone Marrow or Peripheral Stem Cell Transplant for Non-Hodgkin's Lymphoma
495 - High Dose Chemotherapy Bone Marrow or Peripheral Stem Cell Transplant for Hodgkin's Disease
496 - High Dose Chemotherapy and Bone Marrow or Peripheral Stem Cell Transplant for Selected Childhood Solid Tumors
497 - High Dose Chemotherapy Bone Marrow or Peripheral Stem Cell Transplant for Multiple Myeloma
500 - Intermittent Pneumatic Compression Devices for the Legs
501 - Gonadotropin-Releasing Hormone Analogs and Antagonists
502 - Nerve Conduction Velocity Studies
503 - Suction Pumps
504 - Hyperhidrosis (Hyperhydrosis)
505 - Ambulatory Assist Devices: Walkers, Canes, and Crutches
507 - High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Breast Cancer
508 - Cataract Removal Surgery
509 - Contact Dissolution for Gallstones
510 - Progestins
511 - Eating Disorders
512 - Premenstrual Syndrome/Premenstrual Dysphoric Disorder

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Anticipated CPB Review Date: June 27

514 - Meniere's Disease Surgery
515 - Thyrogen (Thyrotropin Alfa)
516 - Colorectal Cancer Screening
517 - Breast Ductal Lavage and Fiberoptic Ductoscopy
518 - Nitric Oxide, Inhalational (INO)
520 - Magnetic Resonance Imaging of the Cardiovascular System - Cardiac MRI
521 - Prostate Cancer Screening
522 - Pulsed Irrigation Evacuation (PIE)
523 - Car-Ride Simulators for Infantile Colic
524 - Zoledronic Acid
525 - Screening for Lipid Disorders
526 - Surgical Dressings (Wound Care Supplies)
527 - Intragastric Hypothermia
528 - Androgens and Anabolic Steroids
529 - Transabdominal Cerclage
530 - Transvaginal Ultrasonography for Ovarian and Endometrial Cancer Screening and Other Selected Indications
531 - Balloon-Expandable Venous Stents
532 - Scrotal Ultrasonography
533 - Urological Supplies
534 - Vesicoureteral Reflux Treatment by Endoscopic Injection of Bulking Agents
535 - Virtual Gastrointestinal Endoscopy
536 - Vitamin B-12 Therapy
538 - Endothelial Cell Photography
539 - Fundus Photography
540 - Heating Devices
541 - Home Dialysis
542 - HIV Testing
543 - Hospital Beds and Accessories
544 - Immune Globulins for Post-exposure Prophylaxis
545 - Electrothermal Arthroscopy
546 - Extracorporeal Membrane Oxygenation (ECMO)
547 - Rosacea
548 - Cardiovascular Monitoring Equipment for Home Use: Pulse, Blood Pressure, Telemonitors, and Pacemaker Monitors

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Anticipated CPB Review Date: July 11

549 - Distraction Osteogenesis for Craniofacial Defects
551 - Radiation Treatment of Keloids
552 - Laser Neurolysis
553 - Lead Testing
556 - Bio-Surgery: Medicinal Leech Therapy and Medical Maggots
557 - Melanoma Vaccine
558 - Percutaneous Transluminal Septal Myocardial Ablation (PTSMA)
559 - Pulsed Dye Laser Treatment
560 - Voice Prosthesis for Voice Rehabilitation Following Total Laryngectomy
561 - Celiac Disease Laboratory Testing
562 - Biochemical Markers of Bone Remodeling for Osteoporosis
562 - Biochemical Markers of Bone Remodeling
564 - Electrocochleogram and Perilymphatic Pressure Measurement
565 - Ankle Orthoses, Ankle-Foot Orthoses (AFOs), and Knee-Ankle-Foot Orthoses (KAFOs)
566 - Strabismus Repair in Adults
567 - Actinic Keratoses Treatment
568 - AngioJet Rheolytic Thrombectomy System
569 - Lumbar Traction Devices
570 - Chemotherapy Inpatient
571 - Dehydration Testing for Endolymphatic Hydrops (Meniere's Disease)
572 - Home/Ambulatory Spirometry
574 - Female Erectile Devices for the Treatment of Female Sexual Dysfunction (FSD)
575 - Intravenous Iron Therapy
576 - Laminoplasty
577 - Select Skin Conditions: Laser Treatment
578 - Lower Limb Prostheses
579 - T-Wave Alternans
580 - Low Vision Programs
581 - Lung Imaging Fluorescence Endoscopy (LIFE)
582 - Titanium Rib
583 - Eye Movement Desensitization and Reprocessing (EMDR) Therapy
584 - Mammography
585 - Cardioverter-Defibrillators

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Anticipated CPB Review Date: July 25

586 - Heart Transplantation
587 - Pancreas Kidney Transplantation
588 - Capsule Endoscopy
590 - Intensity Modulated Radiation Therapy
591 - Intervertebral Disc Prostheses
592 - Radiofrequency Ablation of Hypertrophied Nasal Turbinates
593 - Aerosolized or Irrigated Anti-infectives for Sinusitis
594 - Visudyne (Verteporfin) Photodynamic Therapy
595 - Kineret (Anakinra)
596 - Liver Transplantation
597 - Heart-Lung Transplant
598 - Lung Transplantation
599 - Autologous Skeletal Myoblast/Mononuclear Bone Marrow Cell Transplantation for Cardiac Diseases
601 - Pancreas Transplantation Alone (PTA) and Islet Cell Transplantation
602 - Thermal Intradiscal Procedures
603 - Total-Body CT Screening
604 - Infrared Therapy
605 - Intestinal Transplantation
606 - Stem Cell Transplant for Autoimmune Diseases and Miscellaneous Indications
607 - Anesthetic Infusion Pumps
608 - Salivary Hormone Tests
609 - Laser Photocoagulation of Drusen
610 - Biventricular Pacing (Cardiac Resynchronization Therapy)/Combination Resynchronization-Defibrillation Devices for Congestive Heart Failure
611 - Fecal Incontinence Treatments
612 - Implantable Hearing Aids
613 - Stereolithography
614 - Huntington's Disease
615 - Gender Reassignment Surgery
616 - Antroduodenal Manometry
617 - High Dose Chemotherapy Bone Marrow or Peripheral Stem Cell Transplant for Testicular Cancer
618 - Brain Natriuretic Peptide Testing
619 - Eye Prosthesis
620 - Facial Prostheses, External

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Anticipated CPB Review Date: August 8

621 - Drug-Eluting Stents
622 - Glaucoma Testing: Ocular Blood Flow Tonometer and Corneal Hysteresis
623 - Safety Items
625 - Dysphagia Therapy
626 - Allogeneic Bone Marrow or Peripheral Stem Cell Transplant for Thalassemia Major and Sickle Cell Anemia
627 - Allogeneic Bone Marrow or Peripheral Stem Cell Transplant for Aplastic Anemia and Other Bone Marrow Failure Syndromes
628 - Spinal Ultrasound
629 - Bunionectomy
630 - Vacuum Assisted Socket System (VASS)
633 - Benign Skin Lesion Removal
634 - Non-myeloablative Bone Marrow/Peripheral Stem Cell Transplantation (Mini-Allograft / Reduced Intensity Conditioning Transplant)
635 - High Dose Chemotherapy Bone Marrow or Peripheral Stem Cell Transplant for Ovarian Cancer
636 - Hammer Toe Repair
637 - Osteochondral Autografts (Mosaicplasty, OATS)
638 - Donor Lymphocyte Infusion
639 - Autotransfusers
640 - Bone Marrow or Peripheral Stem Cell Transplant for Selected Leukemias
641 - Adoptive Immunotherapy
642 - Neuralgia Inducing Cavitational Osteonecrosis (NICO) and Ultrasonograph Bone Densitometer to Detect NICO
643 - Diagnosis of Vaginitis
644 - Smallpox Vaccine
645 - Total Ankle Arthroplasty
646 - Voice Therapy
647 - Histamine Desensitization Therapy for Intractable Headaches
648 - Pervasive Developmental Disorders
649 - Extracorporeal Shock-Wave Therapy for Musculoskeletal Indications and Soft Tissue Injuries
650 - Polymerase Chain Reaction Testing: Selected Indications
651 - Endovascular Repair of Aortic Aneurysms
652 - Therapeutic Phlebotomy
653 - Diphtheria, Tetanus, and Pertussis Vaccines

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Anticipated CPB Review Date: August 22

654 - Ventricular Assist Devices
655 - Adalimumab (Humira)
656 - Phototherapy for Acne
657 - Hysteroscopic Tubal Sterilization
658 - Psoriasis: Biological Therapies
659 - Radioimmunotherapy for Non-Hodgkin's Lymphoma: Ibritumomab Tiuxetan (Zevalin) and Tositumomab (Bexxar)
660 - Unicompartmental, Bicompartmental, and Bi-unicompartmental Knee Arthroplasties
661 - Hip and Shoulder Resurfacing
662 - Antiprothrombin Antibody Testing
663 - Cerebral Perfusion Studies
664 - Signal-Averaged Electrocardiography (SAECG)
665 - Constraint-Induced Therapy
666 - Teriparatide (Forteo)
667 - Esophageal pH Monitoring
668 - Auditory Processing Disorder (APD)
669 - Subtalar Implant for the Treatment of Flatfoot Deformity
670 - Xolair (Omalizumab)
671 - Enfuvirtide (Fuzeon)
672 - Pamidronate (Aredia)
673 - Arthroscopic Lavage and Debridement for Osteoarthritis of the Knee
674 - High Dose Chemotherapy and Bone Marrow or Peripheral Stem Cell Transplantation for Chronic Myelogenous Leukemia
675 - Bortezomib (Velcade)
676 - Electrical Stimulation for Nausea, Vomiting and Motion Sickness (PrimaBella and ReliefBand)
677 - Functional Electrical Stimulation and Neuromuscular Electrical Stimulation
678 - Gastric Pacing / Gastric Electrical Stimulation
679 - Electrical Stimulation for Levator Syndrome
680 - Electrical Stimulation for Chronic Ulcers
681 - Corneal Pachymetry
682 - Microwave Thermotherapy for Breast Cancer
683 - Oxaliplatin (Eloxatin)
684 - Cetuximab (Erbitux)
685 - Bevacizumab (Avastin)
686 - Oral Brush Biopsy
687 - Pemetrexed (Alimta)
688 - Intra-oral Appliances for Migraines
689 - Ocular Photoscreening

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Anticipated CPB Review Date: September 12

690 - Noninvasive Tests for Hepatic Fibrosis
691 - Breath Tests of Airway Inflammation: Exhaled Nitric Oxide and Exhaled Breath Condensate pH
692 - Acoustic Heart Sound Recording and Computer Analysis
693 - Somatostatin Analogs
694 - Paranasal Sinus Ultrasound for the Evaluation of Sinusitis
695 - Broth Culture Testing for Interstitial Cystitis
696 - Suit Therapy
697 - Intra-operative Monitoring of Electromyography
698 - Prostate Saturation Biopsy
699 - Dry Hydrotherapy (Hydromassage, Aquamassage, Water Massage)
700 - Rhinomanometry and Acoustic Rhinometry
701 - Vascular Endothelial Growth Factor Inhibitors for Ocular Neovascularization
702 - Abdominal Aortic Aneurysm Screening
703 - Thermal Perfusion Probe for Monitoring Regional Cerebral Blood Flow
704 - Indirect Measurement of Left Ventricular Filling Pressure (LVFP): The VeriCor System
705 - Body Surface Potential Mapping
706 - Anecortave Acetate (Retaane)
707 - Headaches: Invasive Procedures
708 - Metatarsal Phalangeal Joint Replacement
709 - Nesiritide (Natrecor)
710 - Actigraphy and Accelerometry
711 - Insulin-Like Growth Factor-1 (IGF-1) Analogues: Mecasermin (Increlex) and Mecasermin Rinfabate (Iplex)
712 - Ziconotide (Prialt)
713 - Artificial Retina
714 - Re-breathing of Inert Gas for Measurement of Cardiac Output
715 - Pharmacogenetic Testing
716 - Sialolithiasis (Salivary Stones)
717 - Analysis of Volatile Organic Compounds to Detect Bacteriuria
718 - Defecography
719 - Retisert (Fluocinolone Acetonide Intra-vitreal Implant)
720 - Abatacept (Orencia)
721 - Intraoperative Radiation Therapy (IORT)
722 - Selective Nerve Root Blocks

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Anticipated CPB Review Date: September 23

723 - Rotavirus Vaccine
724 - Antiemetic Injection Therapy
725 - Post-Herpetic Neuralgia
726 - Human Papillomavirus (HPV) Vaccines
727 - Ibandronate Sodium (Boniva) Injection
728 - Barrett’s Esophagus Surgery
729 - Diabetic Neuropathy: Selected Treatments
730 - Home Behavioral Healthcare Services
731 - Convection-Enhanced Intraparenchymal Delivery of Drugs to the Brain
732 - Guillain-Barre Syndrome Treatments
733 - Discography
734 - External Ocular Photography
735 - Pulsed Radiofrequency
736 - Femoro-Acetabular Surgery for Hip Impingement Syndrome
737 - Double Balloon Endoscopy
738 - Upper Gastrointestinal Endoscopy
739 - Functional Magnetic Resonance Imaging
740 - Pralatrexate (Folotyn)
741 - Peripheral Ultrafiltration for Acute Decompensated Heart Failure
742 - Intermittent Intravenous Insulin Therapy
743 - Spinal Surgery: Laminectomy and Fusion
744 - Bronchial Thermoplasty
745 - Bell's Palsy
746 - Ultrasound Therapy for Wound Healing
747 - Transanal Endoscopic Microsurgery for Rectal Cancer
748 - Panitumumab (Vectibix)
749 - Anterior Segment Optical Coherence Tomography
750 - Athletic Pubalgia Surgery
751 - Natalizumab (Tysabri)
752 - Obstructive Sleep Apnea in Children
753 - Core Decompression for Avascular Necrosis
754 - Laparoscopic Uterine Nerve Ablation (LUNA) and Presacral Neurectomy (PSN)
755 - Motor Cortex Stimulation

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Anticipated CPB Review Date: October 10

756 - Epiretinal Radiation Therapy
757 - AmniSure ROM (Rupture of Membranes) Test
758 - Tumor Chemoresistance Assays
759 - Vulvodynia and Vulvar Vestibulitis Treatments
760 - Oral Screening and Lesion Identification Systems
761 - Certolizumab Pegol (Cimzia)
762 - Repository Corticotropin Injection (H.P. Acthar Gel)
763 - Homocysteine Testing
764 - Alemtuzumab (Campath)
765 - Age-Related Macular Degeneration Treatments
766 - High Intensity Focused Ultrasound
767 - Extended Ophthalmoscopy
768 - Romiplostim (Nplate)
769 - Endometrial Cancer Screening and Diagnosis
770 - Cryopyrin-Associated Periodic Syndromes: Treatments
771 - Procalcitonin (PCT)
772 - Axial Lumbar Interbody Fusion (AxiaLIF)
773 - ImmuKnow (Transplantation Immune Cell Function Assay)
774 - Nerve Fiber Density Measurement
775 - RenalVysion
776 - Electromagnetic Navigation-guided Bronchoscopy
777 - Suprachoroidal Injection of Pharmacologic Agents
778 - Robotic-assisted Rehabilitation of the Extremities
779 - Plerixafor Injection (Mozobil)
780 - ADAMTS13 Assay for Thrombotic Thrombocytopenic Purpura (TTP)
781 - Interstitial Laser Therapy (ILT) for Breast Tumors
782 - Hereditary Angioedema
783 - In Vivo Analysis of Colorectal Polyps
784 - Blood Product Injections for Selected Indications
785 - Peripheral Artery Stents
786 - Menaflex
787 - Comparative Genomic Hybridization (CGH)
788 - Alzheimer's Disease: Experimental Treatments
789 - Acute Ischemic Stroke: Treatments

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Anticipated CPB Review Date: October 24

790 - Golimumab (Simponi)
791 - Cardiac Devices for Occlusion of the Left Atrial Appendage
792 - Human Fibrinogen Concentrate (RiaSTAP)
793 - Esophageal Doppler Monitoring
794 - Ofatumumab (Arzerra)
795 - Ozurdex (Dexamethasone Intravitreal Implant)
796 - Near-Infrared (NIR) Spectroscopy for Evaluation of High-Risk Plaques
797 - Evacuation of Meibomian Glands
798 - Distal Interphalangeal (DIP), Metacarpophalangeal (MCP) and Proximal Interphalangeal (PIP) Joint Implants
799 - Tocilizumab (Actemra)
800 - Dupuytren's Contracture: Treatments
801 - Intra-coronary Hyperoxemic Therapy
802 - Prostate Cancer Vaccine
803 - Calcitonin
804 - Denosumab (Prolia)
805 - Pudendal Nerve Decompression
806 - Cabazitaxel (Jevtana)
807 - Eculizumab (Soliris)
808 - High-Resolution Anoscopy
809 - Pediatric Intensive Feeding Programs
810 - Gout
811 - Hematopoietic Stem Cell Transplant for Solid Tumors in Adults
812 - Hypoxic Ischemic Encephalopathy
813 - Computerized Wheeze Detectors
814 - Remote Ischemic Conditioning
815 - Ipilimumab (Yervoy)
816 - Hand Transplantation
817 - Propranolol for Infantile Hemangioma
818 - Belimumab (Benlysta)
819 - Face Transplantation
820 - Carotid Sinus Stimulation for Hypertension
821 - Transcatheter Pulmonary Valve Implantation
822 - Internal Fixation of Rib Fracture
823 - Brentuximab (Adcetris)
824 - Home Hemoglobin Testing Devices
825 - Cardiopulmonary Exercise Testing
826 - Transcatheter Aortic Valve Implantation
827 - Electric Tumor Treatment Fields
828 - Irreversible Electroporation (NanoKnife)
829 - Intra-vascular Optical Coherence Tomography
830 - Stem Cell Transplantation for Primary Immunodeficiency Disorders
831 - Eribulin Mesylate (Halaven)
832 - Implantable Left Atrial Hemodynamic Monitor


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