List of Investigational Procedures Updated: December 2016

List of Investigational Procedures Updated: December 2016 Initial Date: August 2004 Revisions: January 2012, February 2012, April 2012, May 2012, Jun...
Author: Rosa Wilcox
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List of Investigational Procedures Updated: December 2016

Initial Date: August 2004 Revisions: January 2012, February 2012, April 2012, May 2012, June 2012, August 2012, September 2012, October 2012, November 2012, January 2013, March 2013, April 2012, June 2013, September 2013, October 2013, January 2014, March 2014, May 2014, August 2014, November 2014, December 2014, January 2015, February 2015, April 2015, June 2015, August 2015, November 2015, January 2016, February 2016, March 2016, April 2016, May 2016, August 2016, September 2016, November 2016, December 2016 This National Medical Policy is subject to the terms in the IMPORTANT NOTICE at the end of this document

Definition

Health Net considers as Experimental or Investigational if it meets any of the following: 

It is currently the subject of active and credible evaluation (e.g., clinical trials or research) to determine: o o o

clinical efficacy, therapeutic value or beneficial effects on health outcomes, or benefits beyond any established medical based alternative.



It is the subject of an active and credible evaluation and does not have final clearance from applicable governmental regulatory bodies (such as the US Food and Drug Administration “FDA”) and unrestricted market approval for use in the treatment of a specified medical condition or the condition for which authorization of the Service is requested.



The most recent peer-reviewed scientific studies published or accepted for publication by nationally recognized medical journals do not conclude, or are inconclusive in finding, that the Service is safe and effective for the treatment if the condition for which authorization of the Service is requested.

A Absorb bioresorbable vascular scaffold (BVS) stents (Abbott Vascular) in patients who are able or unable to comply with ≥ 1 years of dual-antiplatelet therapy or with allergy or sensitivity to antiplatelet drugs, heparin, or various stent components and/or degradants. Acoustic heart sound recording, computer analysis and interpretation Acoustic rhinometry Active Specific Immunotherapy With Therapeutic Melanoma Vaccines Aerosolized Anti-infective Treatment for Sinusitis (AdhesENT) Amniotic Grafts for Surgical Sites AMPLIFY Recombinant Human Bone Morphogenetic Protein (rhBMP-2) Matrix

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Angelchik anti-reflux prosthesis Angiotensin Receptor 1 (AGTR1) c.*86A>C (1166A>C, A1166C) Polymorphism testing for evaluation of hypertension in symptomatic patients Angiotensin Receptor 1 (AGTR1) c.*86A>C (1166A>C, A1166C) Polymorphism testing for evaluation of hypertension risk in asymptomatic individuals Anticonvulsants in the treatment of posttraumatic stress disorder Anti-silicone antibody testing Apheresis for:  AIDS  LAK cells for reinfusion with Interleukin II  Sepsis Antineoplastin Therapy Apligraft in conjunction with breast reconstruction surgery Apostherapy as a medical program for the treatment of various orthopedic conditions ARISk Autism Risk Assessment Test Argon Plasma Coagulation for Hemostasis in Patients with Gastric Antral Vascular Ectasia (GAVE) Argon laser stapedectomy Arthroscopic Microdiscectomy for Lumbar Disc Herniation Ascend Genomics, "Myeloma Panel" Aspen Minimally Invasive Fusion System Aspiration of osteoprogenitor cells for augmenting spinal fusion ATI Neurostimulation System for Electrical Stimulation of the Sphenopalatine Ganglion for Headache AtriCure Isolator bipolar ablation system in cardiac procedures Auricular cartilage graft for TMJ Autologous serum eyedrops Automated whole breast ultrasound (e.g., somo-v Automated Breast Ultrasound System) Autosomal Dominant Hereditary Spastic Paraplegia (AD-HSP) Evaluation for Hereditary Spastic Paraplegia Aversion therapy for treatment of chemical dependency Axial lumbar interbody fusion (AxiaLIF)

B Biochemical markers of Alzheimer's disease Biocleanse meniscal allograft Bioimpedance for assessment of lymphedema Biological terrain assessment Biomagnetic Therapy, Bioelectromagnetic Therapy Biomet Signature System BluePrint Molecular Subtyping Profile for Breast Cancer Body Restoration Technique Brachytherapy of the femoralpopliteal arterial system Bracing for the treatment of pectus carinatum (e.g., T-Joe brace, WPC compressor) Breast Elastography BreastNextNext-Gen Cancer Panel Breast reduction for reduction of breast cancer risk BREVAGen

C Calypso 4D Localization System CancerIntercept Detect CancerIntercept Monitor

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CancerNext Next-Gen Cancer Panel Candida hypersensitivity syndrome testing Candida hypersensitivity syndrome treatment Carbogen therapy Cardiac Contractility Modulation Therapy Cardioblate Ablation Systems (Medtronic Inc.) for Atrial Fibrillation CardioMems (i.e., pulmonary artery pressure monitoring) Catalys Precision Laser System for Cataract Surgery Cautery-Assisted Palatal Stiffening (CAPSO) Cefaly device for migraines Cerebral stimulation/pacemaker Cellular therapy Cervical plasma disc decompression Cervicography Chemical endarterectomy Chemokine CC Motif Receptor 5 (CCR5)CCR5- Δ32 Polymorphism testing to Predict Resistance to Human Immunodeficiency Virus (HIV) Infection Chronic Intermittent Intravenous Insulin Therapy (CIIIT), (also know as hepatic activation therapy, metabolic activation therapy, pulse insulin therapy, and pulsatile intravenous insulin therapy) CMI Magnetocardiograph Model 2409 (CardioMag Imaging Inc.) for Diagnosis of Acute Chest Pain CO2 laser for the treatment of breast cancer Cognitive Evoked Potential Testing Cognitive Therapy for bed-wetting Collagen cross links Collagen and Procollagen analysis for screening, diagnosis or management of any disease affecting bone formation or resorption Collagen nerve conduit Color Doppler for breast cancer screening Color Doppler for prostate cancer (CDI-TRUS) Combined Full Spectrum Therapy for nocturnal enuresis Comprehensive Urine Elements Profile Computer-Aided Semen Analysis (CASA) for the Diagnosis of Male Infertility Conchal cartilage graft for TMJ Conexa Reconstructive Matrix Confocal Microendoscopy (e.g. Cell-viZio, image enhanced endoscopy) Continuous Rotation Therapy for Patients with Acute Respiratory Distress Syndrome (e.g. RotoRest bed, Effica bed) Convection-enhanced drug delivery for breast cancer Cooling vests for multiple sclerosis CorMatrix pericardial patch Corneal hysteresis determination by air impulse stimulation (e.g. ocular response analyzer) C-RAD Sentinel System (radiotherapy postioning system) Craniosynostosis NGS Panel and/or HDT array (Connective Tissue Gene Tests) CRBI / DNA extraction and storage for pigmentary retinal dystrophy Cryoablation for the treatment of breast fibroadenoma Cryoablation of sural nerve Cryoangioplasty of the femoral-popliteal arteries Cunningham Panel (Moleculera Labs) Current Perception Threshold Testing/Sensory Nerve Conduction Threshold Custom (personalized ) knee replacement

D

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Deep Brain Stimulation for minimally conscious state (MCS) Deflux subureteral injections Delcath drug delivery system Diamondback 3600 Orbital System for the treatment of peripheral arterial disease Digital Mole Mapping Devices for annular repair (e.g., Xclose Tissue Repair System) DNA banking/storage Decompression System Dune Margin Probe Dynamic cardiomyoplasty Dynamic MRI for identification of urethrocele, uterine prolapse, omentocele, sigmoidocele, peritoneocele, rectal intussusception, dyssynergic defecation, or other abnormalities of the pelvic floor Dynamic spinal visualization (not medically necessary)

E Early CDT-Lung Risk Assessment Test (Oncimmune) Electrical impedance scan of the breast Electromagnetic therapy in healing of pressure sores Electrical stimulation for:  Amyotrophic Lateral Sclerosis  Dyspareunia  Dysphagia  Facial nerve palsy  Tinnitus Electrothermal coagulation of knee, wrist, ankle and elbow joints (thermal shrinkage) Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) for diagnosis of malignancy when a pancreatic mass lesion is resectable by CT or EUS evaluation ENDURAGen Enzyme-potentiated desensitization epiSEEK Comprehensive Sequence Analysis for Epilepsy and Seizure Disorders Eovist contrast agent for Magnetic resonance imaging of the liver E-tegrity Test for Evaluation of Uterine Receptivity eVox system (Evoke Neuroscience) Exhaled Breath Condensate pH Testing for Asthma Management Extracorporeal liver assist device (ELAD) Extracorporeal shock wave therapy (ESWT) for:  Peyronie's disease

F Factor XIIIA1 (F13A1) p.Val34Leu Polymorphism Testing for Hypercoagulability Fecal analysis for diagnosis of intestinal dysbiosis Fetal mesencephalic transplantation for treatment of Parkinson's Disease Fibrinogen-Beta (FGB) c.-455G>A Polymorphism Testing FirstStepDx for Autism Spectrum Disorder FirstStepDX PLUS for disorders of childhood development FlexHD Acellular Dermis for Hernia Repair Functional anesthetic discography

G Galvanic stimulation devices for home use Ganz Trochanteric Flip Osteotomy Approach to Hip Resurfacing for Treatment of Osteoarthritis

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Gene expression profiling for cancers of unknown origin Genetic Testing for Capillary Malformation-Arteriovenous Malformation Syndrome (CMAVM) Genetic testing for classic Ehlers-Danlos Syndrome (EDS) using COL5A1 and COL5A2 gene sequencing for any of the following:  Individuals with the clinical symptoms of classic EDS (EDS I/II)  Testing in the asymptomatic family members of patients with genetically confirmed classic EDS (EDS I/II)  For the prenatal testing or PGD of classic EDS (EDS I/II) in families transmitting a known COL5A1/COL5A2 gene variant. Genetic testing for Immune Dysregulation, Polyendocrinopathy, Enteropathy, XLinked (IPEX) Syndrome Genetic testing [Factor XI Deficiency (Boston University School of Medicine); Factor XI Mutation Analysis (Ashkenazi Jewish) (Quest Diagnostics Inc.)] for any of the following:  For confirmation of diagnosis of factor XI deficiency in patients with symptoms compatible with factor XI deficiency.  In asymptomatic individuals with a family history of factor XI deficiency and a known familial pathogenic variant, for prediction of risk of factor XI deficiency.  In asymptomatic individuals with a family history of factor XI deficiency and a known familial pathogenic variant, to facilitate reproductive decision making.  For prenatal genetic diagnosis in families with genetically confirmed factor XI deficiency. Genetic testing for Generalized Epilepsy with Febrile Seizures Plus:  For the diagnosis of generalized epilepsy with febrile seizures plus (GEFS+) in symptomatic individuals.  For the presymptomatic diagnosis of GEFS+ in at-risk relatives of individuals with genetically confirmed GEFS+.  For prenatal or preimplantation genetic diagnosis in families with genetically confirmed GEFS+. Genetic testing for isolated autosomal dominant thrombocytopenia. Genetic Testing for Loeys-Dietz syndrome Genetic testing for narcolepsy Genetic testing for obstructive hypertrophic cardiomyopathy (previously IHSS) Genetic testing for Oculofaciocardiodental (OFCD) Syndrome (Syndromic Microphthalmia 2; MCOPS2) Genetic Testing for Parkinson Disease Genetic test for Partial HPRT Deficiency (Kelley-Seegmiller Syndrome) for Gout Genetic testing for Pediatric Neurology Region of Interest Trio (Claritas Genomics Inc.) Genetic testing for polycystic kidney disease Genetic testing for Nonsyndromic Peripheral Pulmonary Stenosis; PPS for Nonsyndromic Peripheral Pulmonary Stenosis Genetic Testing for Proteus Syndrome Genetic testing for Phenylalanine Hydroxylase (PAH) Deficiency (including Phenylketonuria (PKU) for PAH Deficiency for any of the following:  For the diagnosis of a PAH deficiency (e.g., PKU) in patients with signs of the disease (clinical symptoms or laboratory findings).  For PAH gene testing in patients with a clinical diagnosis of PAH deficiency, for the purpose of assessing BH4 (PAH cofactor tetrahydrobiopterin) responsiveness.  For PAH gene testing in the asymptomatic relatives of patients with a genetically confirmed PAH deficiency, for the purpose of carrier identification

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For the prenatal or preimplantation genetic diagnosis of a PAH deficiency in families transmitting known PAH gene variants. Genetic testing for SCN9A-Related Inherited Erythromelalgia Genetic testing for sequence variants and deletions/duplications in the COL2A1, COL11A1, COL11A2, COL9A1, and COL9A2 gene in individuals with a suspected diagnosis of Stickler syndrome, and to detect the presence or absence of a familial variant in an at-risk asymptomatic relative of an individual with Stickler syndrome. Genetic testing of individuals clinically diagnosed with thoracic aortic aneurysms and dissections, with a positive family history of the disorder, and for whom a genetic syndrome has been excluded Gene Testing for von Willebrand Disease GenoType IL-1 testing for periodontal disease

H Healthy Weight DNA Insight HemiCap patello-femoral resurfacing sysrem (Knee joint patello-femoral resurfacing prosthesis) Hepatic Dialysis High powered therapeutic laser therapy for pain (K-Laser) Hivamat Therapy HLA-B*27 testing for confirmation of diagnosis in patients with symptoms compatible with ankylosing spondylitis (AS). For HLA-B*27 testing for presymptomatic testing of relatives of AS patients. Holmium Laser Endopyelotomy for Ureteropelvic Junction Obstruction in Adults and Children Home monitoring of pulmonary function Hysteroscopic morcellation for treatment of uterine submucosal fibroids and endometrial polyps H-Wave electrical stimulation device for home use Hydrodiscectomy (e.g., Spinejet HydroSurgery system)

I IBD sgi Diagnostic Test for Inflammatory Bowel Disease Idiopathic environmental intolerance testing Ileoinguinal nerve block, for indications other than regional anesthetic technique or management of post op pain following groin surgery (e.g. hernia repair) or ileoinguinal nerve entrapment Ilizarov technique for the treatment of short stature (cosmetic) Infantile Epilepsy Panel Infrared light therapy (Anodyne Therapy) for treatment of pain or neuropathy Infrared therapy for the treatment of in-situ anal carcinoma Infrared therapy for the treatment of high-grade squamous intraepithelial lesions (HSIL) with anal carcinoma Interscalene block for outpatient management of post-op pain Interspinous fixation devices (e.g., Univise Spinous Process Fixation Plate, Affix, Spire etc) IntraLase-enabled keratoplasty(IEK). Intravenous lidocaine for tinnitus aurium ImmuKnow Immunohistochemistry and staining of skin fibers for neuropathies to rule out migraines Immunologic treatment for miscarriage  Paternal and fetal antigen immunotherapy for recurrent fetal loss, if identified

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Intratympanic Steroid Injection For Ménière’s Disease Iontophoresis for Epicondylitis Infantile Epilepsy Panel Insulin-like growth factor receptor (IGF-IR) for cancer treatment Insuflon Catheter for insulin infusion Insu flow laparoscopic gas conditioning device Intelligent Prosthesis Interferential stimulation devices (PIRT) Interferential stimulation devices for home use Interstitial hyperthermia for malignant brain tumor Intestinal rehabilitation therapy - inpatient and outpatient Intravascular near infrared spectroscpy (e.g LipiScan Coronary Imaging System, InfraReDx) Intravenous Vitamin C injection for treatment of cancer Intravenous lidocaine infusion test I-Port injection port

J JaundiceChip Resequencing Array

K Ketamine infusion for reflex sympathetic dystrophy Knee ligament arthometer testing

L Lokomat (Hocoma AG) Driven Gait Orthosis (DGO) for Use in Children with Cerebral Palsy Laparoscopic Electromechanical Morcellation of Uterine Fibroids During Myomectomy or Hysterectomy Laparoscopic Ileal Interposition for treatment of type 2 diabetes Laparoscopic Ultrasound-Guided Radiofrequency Ablation of Uterine Fibroids (e.g. Acessa) Laser Ablation (Interstitial Laser Coagulation) for Treatment of Localized Breast Cancer Laser photocoagulation for macular drusen Laser prostatectomy for prostate cancer Laser treatment of onychomycosis Laser Vitreolysis for treatment of vitreous floaters of the eye Ligament Augmentation and Reconstruction System (LARS) for Ligament Repairs of the Knee Low pressure pulse generator (Meniett Pressure Therapy)

M Macula Risk PGx Test Magnetic bio-stimulation therapy Magnetic Resonance Imaging of the extremities (e.g., hands, knees, feet, etc.) for management of Rheumatologic Disorders MelanoSITE FISH Test for the Diagnosis of Melanoma Metatarsal to TMJ transplant Micra Leadless Pacemaker Microcurrent stimulation for home use

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Microwave thermotherapy for breast cancer MindStreams Cognitive Health Assessment for Assessing Mild Cognitive Impairment Mist Therapy System 5.0 MitoMet Mitochondrial/MetabolicMicroarray Analysis Molecular Topographic genotyping Monochromatic infrared energy (MIRE) therapy Monocusp surgery for chronic deep venous insufficiency Morcher 67B artificial iris implant MiRInform thyroid for evaluation of thyroid nodule fine needle aspiration specimens for evidence of malignancy MRI guided ultrasound ablation of uterine fibroids MtDNA testing for mitochondrial dysfunction (e.g., mtSEEK) Multifunction Cardiogram Multifocal Electroretinography (mfERG) Multigene Panels for X-Linked Intellectual Disability (XLID) myPath Melanoma test

N Naltrexone implant (e.g. Vivitrol implant) NanoKnife System for Irreversible Electroporation Treatment of Pancreatic Cancer NanoKnife System for Irreversible Electroporation Treatment of Primary and Metastatic Liver Tumors Nanoparticle Albumin-Bound Paclitaxel for Breast Cancer in men Neurobiofeedback Ness H200 (neuroprosthetic and rehabilitation system) Neutralizing antibody testing in multiple sclerosis NeuroCybernetic Prosthesis System for intractable hiccups Neurodevelopmental Treatment (e.g. Bobath method) for cerebral palsy NeuraGen Nerve Guide (Integra LifeSciences Corp.) for Repair of Severed Peripheral Nerves of the Upper Extremity Neuroform (NF) Microdelivery Stent System for Intracranial Aneurysms:  NF stent-assisted coiling of wide-neck intracranial aneurysms in adult in whom antiplatelet or anticoagulant use is contraindicated  NF stent-assisted coiling of unruptured or ruptured wide-neck intracranial aneurysms in adults Neuroma surgery of peripheral nerves for pain Neuromuscular retraining for facial paralysis Neuro-optometric rehabilitation Nerve Integrity Monitoring System (NIMS) NexCourse CRC for evaluation of colorectal cancer Nitric oxide measurements for asthma and other respiratory conditions NKX2-5 Testing for Atrial septal defect (ASD)  For testing asymptomatic individuals with no family history of congenital heart defects or known NKX2-5 variants (population screening)  For testing clinically affected individuals to assist with diagnosis or patient care Non-contact normothermic wound therapy (NNWT) - also known as non-contact radiant heat bandage devices or Warm-Up Active Wound Therapy Noninvasive Peripheral Arterial Tonometry NovoSeven coagulation factor VIIa (recombinant) for treatment of acute intracerebral hemorrhage NuclearMitoDx (formerly MitoNucleomeDx) for Nuclear Genes Associated with Mitochondrial Diseases nucSEEK Comprehensive Sequence Analysis of Nuclear Mitochondrial Exome for testing of nuclear mitochondrial DNA in cases of suspected mitochondrial disorders.

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NutrEval test

O O-arm Imaging System (Medtronic Inc.) for Guiding Pedicle Screw Placement in Thoracic and Lumbosacral Spinal Surgery Ocular Blood flow analyzer Olfactory ensheathing cell transplantation for spinal cord injury Omnicardiogram/Cardiointegram OnDose (My5-FU) Onyx liquid embolization system Opiod detoxification under sedation/general anesthesia Optical Coherence Tomography for Coronary Artery Plaque Characterization and Stent Evaluation for assessment of intracoronary plaques and stents Optiwave Refractive Analysis (ORA) system OrthAdapt Bioimplant Orthoptics (eye exercises) for learning disabilities and traumatic brain injury Osom BVBlue Test for bacterial vaginosis Osteopathic manipulative treatment (OMT) of back pain in patients with contraindications to spinal manipulation (e.g., as nerve root problems, neurological deficits, infection or malignancy involving the spine, vertebral osteoporosis, or major structural abnormalities.) Osteopathic cranial manipulation OtoSCOPE genetic testing for hereditary hearing loss

P Paraspinal surface electromyography Partial left ventriculectomy (e.g., Batista procedure) Paternal and fetal antigen immunotherapy for recurrent fetal loss Penile vein embolization Pentothal interviews Percutaneous Mechanical Thrombectomy for Pulmonary Embolism:  For use of ultrasound-assisted percutaneous mechanical thrombectomy (PMT) in adult patients for treatment of acute massive or submassive pulmonary embolism (PE).  For use of rheolytic PMT in adult patients for treatment of acute massive or submassive PE.  For use of rotational PMT in adult patients for treatment of PE. Percutaneous mitral valve repair by Carillon device implantation in patients who have moderate or severe mitral valve regurgitation. Permacol Biologic Implant Permacol Crosslinked Porcine Dermal Collagen Surgical Mesh Permacol Surgical Implant Permacol Surgical Implant T-piece Personalized Knee replacement (e.g., Biomet signature system, Trumatch, OtisKnee, Visionaire technology) Photodynamic Therapy with Visudyne (verteporfin) for Choroidal Hemangioma Photodynamic Therapy with Visudyne (verteporfin) for Idiopathic Subfoveal Choroidal Neovascularization (CNV) Physiologic recording of tremor using accelerometer(s) and gyroscope(s), (including frequency and amplitude including interpretation and report Placement alpha miroglobulin-1-rapid immunoassay for detection of rupture of fetal membranes (e.g., AmniSure) Placement of interstitial devices in bone for radiostereometric analysis performed during joint replacement surgery

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Plasma kinetic vaporization of prostate (also known as bipolar vaporization) Prometheus Liver Support System Pronto-7 with Rainbow 4D Technology for Noninvasive Hemoglobin Measurement Propel System Proteomic-based testing of serum (e.g. OvaCheck, OvaSure, OVA1, ROMA) for the detection of ovarian cancer P Stim auricular stimulation PTPN11 and SOS1 gene testing in the diagnostic evaluation of patients exhibiting clinical features of Noonan syndrome Pudendal Nerve Block for Treatment of Pudendal Neuralgia Pulmonary artery pressure monitoring (e.g., CardioMems) Pulsed-dye laser treatment of vocal cord polyp Pulsed lavage wound therapy Pulsed radiofrequency ablation Pyrocarbon implants for proximal interphalangeal (PIP) or metacarpophalangeal (MCP) joints in patients with symptomatic joint disease for whom conservative treatment has failed.

Q Quantitative Sensory Thermal Testing (QST)

R Radiation therapy for arthritis Radiofrequency ablation of the following tumors:  Breast cancer  Breast fibroadenoma Radiofrequency ablation for the treatment of complex regional pain syndrome Radiofrequency denervation for sacroiliac joint pain Radiofrequency Discectomy Radiofrequency stimulation devices (e.g., Provant Wound Closure System, MicroVas Vascular Treatment System) Radiofrequency treatment of knee pain Radiologic examination, radiostereometric analysis, proximal femur, knee, and ankle, performed during joint replacement surgery Rapid Anesthesia Assisted Detoxification (RAAD) Reconstruction of the iliac crest following bone graft harvest ResQPOD Impedance Threshold Device (ITD) (Advanced Circulatory Systems Inc.) for Out-of-Hospital Cardiac Arrest Rhinomanometry Ribose Therapy for fibromalygia Roux-en-Y Gastric Bypass for Gastroesophageal Reflux Disease in individuals who are not obese or severely obese Roux-n-Y for the treatment of esophageal achalasia

S Saliva tests:  Estriol hormone level to predict pre-term labor  Hormone levels for menopause and aging (e.g., cortisol, DHEA, estradiol, estriol, estrone, progesterone, testosterone) Sclerotherapy for abdominal wall varicosities ScoliScore Adolescent Idiopathic Scoliosis (AIS) Prognostic Test See Sick Syndrome Treatment (e.g., eye exercises) Semi-implantable electromagnetic hearing aids when used in pediatric patients

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SensiGene Fetal RhD Genotyping Sentinel node mapping for cancers other than breast cancer and melanoma Septin 9 (SEPT9) Methylation Analysis' for Colorectal Cancer Serial Transverse Enteroplasty (STEP) for Short Bowel Syndrome Shoulder Resurfacing for Treatment of Arthritis and Degenerative Joint Disease Signal-Averaged Electrocardiography Silverhawk Plaque Excision System Single Nucleotide Polymorphism (SNP) Testing for Breast Cancer Risk Assessment Sjö test (Nicox Inc.) for Early Detection of Sjögren’s Disease Skin advanced glycation endproducts (AGE) measurement by multi-wavelength fluorescent spectroscopy Skin Autofluorescence (AFR) to Aid in Assessing Diabetes-Related Complications Sleeve gastrectomy for treatment of type 2 diabetes SNaP Wound Care System SPECT for lyme neuroborreliosis SpeechEasy fluency device Specimen ultrasound Sperm Hyaluronan binding assay Staggered Spondaic Word Test Stem Cell Implantation for Spinal Cord Injury Stereotaxis Niobe Magnetic Navigation System (Stereotaxis Inc.) for Percutaneous Coronary Intervention in Coronary Artery Disease ShuntCheck Stealth System for spinal surgery (e.g. Medtronic StealthStation) Suction lipectomy of the breast as a sole procedure for breast reduction surgery Suit Therapy for cerebral palsy Superconducting Quantum Interference Devices (SQUIDs) used to measure the magnetic field strength and record a magnetocardiogram Superconducting Quantum Interference Devices (SQUIDs) for the measurement of hepatic iron concentration when there is chronic iron overload. Supraorbital nerve stimulation for treatment of headache Sural nerve graft for radical prostatectomy Surgical deactivation of migraine headache refractory to conventional medical treatment in patients contraindicated to general surgery or general anesthesia; in patients with infection at the site of surgical incision; in patients with significant medical comorbidities; or in patients who are pregnant or lactating Surgical Repair of athletic pubalgia Surgical Ventricular Restoration for Heart Failure Synthetic Sentence Identification Test

T TenoGlide tendon protector sheet (Tendon Wrap tendon protector) for the management and protection of tendon injuries or for any other indications Thermal shrinkage of knee, wrist, ankle and elbow joints T-Joe Bracing System for pectus carinatum Threshold electrical stimulation Thoracoscopic laser ablation for treatment of emphysema Thyroid Hormone Receptor Beta (THRB) Gene Testing in Resistance to Thyroid Hormone (RTH)with the following:  For THRB gene testing in patients with an established diagnosis of RTH based on family history and laboratory studies.  For THRB gene testing in patients suspected of having RTH but in whom there is some diagnostic uncertainty.  For THRB gene testing in the asymptomatic at-risk relatives of patients with genetically confirmed RTH.

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For the prenatal or preimplantation genetic diagnosis of RTH in families transmitting a known, pathogenic THRB gene variant. Tinnitus maskers Tinnitus retraining therapy Tissue synchronization imaging TMR device for chronic pain Topaz microdebrider for musculoskeletal conditions TP63 testing in patients with symptoms consistent with the diagnosis of EctrodactylyEctodermal Dysplasia-Clefting, Ankyloblepharon-Ectodermal Dysplasia-Clefting, or Nonsyndromic Split-Hand/Split-Foot Malformation TP63 testing in patients with symptoms consistent with the diagnosis of AcroDermato-Ungual-Lacrimal-Tooth or Limb-Mammary Syndrome TP63 prenatal testing when there is a family history of Ectrodactyly-Ectodermal Dysplasia-Clefting, Acro-Dermato-Ungual-Lacrimal-Tooth, AnkyloblepharonEctodermal Dysplasia-Clefting, Nonsyndromic Split-Hand/Split-Foot Malformation, or Limb-Mammary Syndrome, and there is a confirmed pathogenic familial TP63 variant, or when ultrasound findings are suggestive of TP63-related syndromes Transcription Factor 4 (TCF4) Testing for Pitt-Hopkins Syndrome (PTHS) Transoral robotic surgery Transfer, free toe joint, with microvascular anastomosis for TMJ disorder Transmeatal laser irradiation for treatment of tinnitus Transvaginal ultrasound for cervical length:  As a rule-out test as part of routine antenatal care or in asymptomatic women at risk of preterm birth; or  As a rule-in screening test as part of routine antenatal care; or  For assessment of women who have ruptured membranes or who have a twin pregnancy and suspected preterm labor Triangle Tilt Surgery for Treatment of Obstetric Brachial Plexus Injury Trumatch personalized knee replacement Tumor Necrosis Factor (TNF) Receptor – Associated Periodic Syndrome (TRAPS; Familial Hibernian Fever):  Presymptomatic testing in asymptomatic individuals with a family history of TRAPS and an identified pathogenic familial variant in TNFRSF1A  Prenatal or preimplantation genetic diagnosis in familial cases of TRAPS with an identified pathogenic familial variant in TNFRSF1A Tumor vaccines

U Ultrasound evaluation of surgical specimen Ultrasound for evaluation of paranasal sinuses Ultrasound of the carotid and/or femoral artery(s) to assess risk for coronary artery disease Urinary Cross-Linked N-Telopeptide of Type I Collagen Biomarker for Diagnosis of Osteoporosis and Fracture Risk Assessement Use of Information Communication Technology (ICT) to Improve Treatment Adherence in Patients with Diabetes for all of the following:  ICT with 1-way communication or infrequent 2-way communication in adults with type 1 or 2 DM with poor to moderate glycemic control.  ICT in adults with type 1 or 2 DM with good glycemic control.  ICT in children and adolescents with type 1 DM.

V Vacuum therapy for treatment of female sexual dysfunction Vascular stents for deep vein thrombosis

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Vascular surgery as treatments for refractory migraine headache Vascular surgery for impotence Vectra DA VersaJet Hydrosurgery System for treatment of burns Vertebral Axial Decompression (VAX-D) Vertical Auto Profile cholesterol test (VAP) Videofluoroscopy of the elbow Vision therapy for the treatment of learning disabilities and mild traumatic brain injury, including:  Training glasses  Prism glasses  Tinted or colored lens VitalStim therapy Vocal cord injectible gel (eg Radiesse, Prolaryn) for vocal fold insufficiency (e.g. vocal cord paralysis/paresis) or velopharyngeal insufficiency

W WalkAide neuromuscular stimulator Weighted vest for children with ADHD Whole Body CT Scan Whole body DEXA for body composition studies Whole body hyperthermia Whole body vibration (WBV) to bone growth in postmenopausal women diagnosed with osteoporosis Whole Exome Sequencing for noncancer indications, for identification of variants in undiagnosed disorders that may provide guidance in diagnosis. Willow Curve

X Xclose Tissue Repair System following a lumbar discectomy procedure Xpresys Lung Test

Z Zimmer Trabecular Metal Vertebral Body Replacement System Important Notice General Purpose. Health Net's National Medical Policies (the "Policies") are developed to assist Health Net in administering plan benefits and determining whether a particular procedure, drug, service or supply is medically necessary. The Policies are based upon a review of the available clinical information including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the drug or device, evidence-based guidelines of governmental bodies, and evidence-based guidelines and positions of select national health professional organizations. Coverage determinations are made on a case-by-case basis and are subject to all of the terms, conditions, limitations, and exclusions of the member's contract, including medical necessity requirements. Health Net may use the Policies to determine whether under the facts and circumstances of a particular case, the proposed procedure, drug, service or supply is medically necessary. The conclusion that a procedure, drug, service or supply is medically necessary does not constitute coverage. The member's contract defines which procedure, drug, service or supply is covered, excluded, limited, or subject to dollar caps. The policy provides for clearly written, reasonable and current criteria that have been approved by Health Net’s National Medical Advisory Council (MAC). The clinical criteria and medical policies provide guidelines for determining the medical necessity criteria for specific procedures, equipment, and services. In order to be eligible, all services must be medically necessary and otherwise defined in the member's benefits contract as described this "Important Notice" disclaimer. In all cases, final benefit determinations are based on the applicable contract language. To the extent there are any conflicts between medical policy guidelines and applicable contract language, the contract language prevails. Medical policy is not intended to override the policy that defines the member’s benefits, nor is it intended to dictate to providers how to practice medicine.

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Policy Effective Date and Defined Terms. The date of posting is not the effective date of the Policy. The Policy is effective as of the date determined by Health Net. All policies are subject to applicable legal and regulatory mandates and requirements for prior notification. If there is a discrepancy between the policy effective date and legal mandates and regulatory requirements, the requirements of law and regulation shall govern. * In some states, new or revised policies require prior notice or posting on the website before a policy is deemed effective. For information regarding the effective dates of Policies, contact your provider representative. The Policies do not include definitions. All terms are defined by Health Net. For information regarding the definitions of terms used in the Policies, contact your provider representative. Policy Amendment without Notice. Health Net reserves the right to amend the Policies without notice to providers or Members. In some states, new or revised policies require prior notice or website posting before an amendment is deemed effective. No Medical Advice. The Policies do not constitute medical advice. Health Net does not provide or recommend treatment to members. Members should consult with their treating physician in connection with diagnosis and treatment decisions. No Authorization or Guarantee of Coverage. The Policies do not constitute authorization or guarantee of coverage of particular procedure, drug, service or supply. Members and providers should refer to the Member contract to determine if exclusions, limitations, and dollar caps apply to a particular procedure, drug, service or supply. Policy Limitation: Member’s Contract Controls Coverage Determinations. The determination of coverage for a particular procedure, drug, service or supply is not based upon the Policies, but rather is subject to the facts of the individual clinical case, terms and conditions of the member’s contract, and requirements of applicable laws and regulations. The contract language contains specific terms and conditions, including pre-existing conditions, limitations, exclusions, benefit maximums, eligibility, and other relevant terms and conditions of coverage. In the event the Member’s contract (also known as the benefit contract, coverage document, or evidence of coverage) conflicts with the Policies, the Member’s contract shall govern. Coverage decisions are the result of the terms and conditions of the Member’s benefit contract. The Policies do not replace or amend the Member’s contract. If there is a discrepancy between the Policies and the Member’s contract, the Member’s contract shall govern. Policy Limitation: Legal and Regulatory Mandates and Requirements. The determinations of coverage for a particular procedure, drug, service or supply is subject to applicable legal and regulatory mandates and requirements. If there is a discrepancy between the Policies and legal mandates and regulatory requirements, the requirements of law and regulation shall govern. Policy Limitations: Medicare and Medicaid. Policies specifically developed to assist Health Net in administering Medicare or Medicaid plan benefits and determining coverage for a particular procedure, drug, service or supply for Medicare or Medicaid members shall not be construed to apply to any other Health Net plans and members. The Policies shall not be interpreted to limit the benefits afforded Medicare and Medicaid members by law and regulation.

List of Investigational Procedures Dec 16

14