3.0 POLICY
TIPS is covered for the following
indications. The list of indications is not all inclusive. Other
indications are covered when documented by reliable evidence as
safe, effective and comparable or superior to standard care (proven).
3.1 Therapy of acute or recurrent
esophageal variceal bleeding which is not controlled by or is unresponsive to
standard treatment such as endoscopic therapy, pharmacological therapy
or surgical shunt.
3.2 Patients
with irreversible hepatic disease who are candidates for liver transplantation
and require control of esophageal variceal bleeding.
3.3 For the treatment of patients
with refractory ascites.
4.0 EFFECTIVE DATES
4.1 September
29, 1995, for acute or recurrent esophageal varical bleeding.
4.2 June 8, 2000, for refractory
ascites.