Medical Policy Updates

Table Of Contents

Notification of Policy Revisions Effective August 12, 2004 (Posted June 10,2004)

Medical Policy Revision
Adoptive Immunotherapy Specialty Matched Consultant Advisory Panel. No change to criteria. References added. Notification given 6/10/2004. Effective date 8/12/2004.
Charged Particle Radiotherapy Specialty Matched Consultant Panel review. No changes to policy. Resources added. Notification given 6/10/2004. Effective date 8/12/2004.
Colon Cancer Screening Specialty Matched Consultant Advisory Panel review. Under the section When Colon Cancer Screening is covered, A. second bullet, changed wording from "screened as per average risk guidelines" to "screened as per standard guidelines for the risk category". Removed the sentence "Medical policy will be updated as appropriate." from Policy Guidelines section. This is standard for all Medical Policy. References added. Notification 6/10/2004. Effective date 8/12/2004.
Cutaneous Electrogastrography (EGG) New policy originated. Cutaneous Electrogastrography (EGG) is considered investigational. Reviewed by the Medical Policy Advisory Group. Notification given 6/10/04. Effective date 8/12/ 04.
Endoscopic Ultrasonography (EUS) Specialty Matched Consultant Advisory Panel review. Added codes 43237 and 43238 to the Billing and Coding section. No change to criteria. References added. Notification given 6/10/2004. Effective date 8/12/2004.
Fecal Analysis for Intestinal Dysbiosis Specialty Matched Consultant Advisory Panel. No change to criteria. References added. Notification given 6/10/2004. Effective date 8/12/2004.
Gastric Electrical Stimulation Medical Policy Advisory Group review. No changes to criteria. References added. Notification given 6/10/2004. Effective date 8/12/2004.
Gastroesophageal Reflux Disease Transendoscopic Therapies Specialty Matched Consultant Advisory Panel review. Coding updated. Added codes 43201 and 0057T, removed 43499. No change to criteria. References added. Notification given 6/10/2004. Effective date 8/12/2004.
Genetic Testing for Colon Cancer New policy originated. Genetic Testing for Colon Cancer may be covered when medically necessary criteria is met. Specialty Matched Consultant Advisory Panel review. Notification 6/10/2004. Effective date 8/12/2004.
Human Tumor Stem Cell Drug Sensitivity Assay Specialty Matched Consultant Advisory Panel review. No changes to policy. Referenced added. Notification given 6/10/2004. Effective date 8/12/2004.
Monoclonal Antibody Imaging Specialty Matched Consultant Advisory Panel review. Benefit Application and Billing/Coding Section updated for consistency. Added "Technetium-99m Nofetumomab Merpentan (Verluma) Not Applicable" under section When Monoclonal Antibody Imaging is covered. Added "Technetium-99m Nofetumomab Merpentan (Verluma) is considered investigational for all malignancies, including but not limited to lung, colorectal, breast, ovary, gastroesophageal, pancreas, renal, bladder, or cervical cancer. BCBSNC does not provide coverage for investigational procedures." under section When Monoclonal Antibody Imaging is Not Covered. Added codes 78804 and A4641. References added. Notification given 6/10/2004. Effective date 8/12/2004.
Pancreas Transplant Specialty Matched Consultant Advisory Panel review. No change to criteria. References added. Notification given 6/10/2004. Effective 8/12/2004.
Selective Internal Radiation Therapy for Primary and Metastatic Tumors of the Liver New policy originated. Specialty Matched Consultant Advisory Panel review. Selective Internal Radiation Therapy for Tumors of the Liver is considered investigational. References added. Notification date 6/10/2004. Effective date 8/12/2004.
Small Bowel, Small Bowel with Liver and Multivisceral Transplant Specialty Matched Consultant Advisory Panel review. No change to criteria. References added. Notification 6/10/04. Effective date 8/12/2004.
Tumor Vaccines Specialty Matched Consultant Advisory Panel review. Updated Benefit Application and Billing/ Coding sections for consistency. No policy changes. References added. Notification given 6/10/ 2004. Effective 8/12/2004.