Medical Policy Updates

Notification of Policy Revisions Effective November 11, 2004 (Posted September 9, 2004)

Medical Policy	Revision
Bioengineered Skin	Policy name changed from Bioengineered Skin for the Treatment of Skin Ulcers to Bioengineered Skin. Specialty Matched Consultant Advisory Panel review 7/14/2004. Added information in Description of Procedure or Service section to include burns. Added statement in Policy section indicating "BCBSNC will provide coverage for bioengineered skin for the treatment of burns when it is determined to be medically necessary because the medical criteria and guidelines shown below have been met." In section regarding When Bioengineered Skin is Covered, added "C. Bioengineered skin may be considered medically necessary in the treatment of burns when all of the following criteria are met. 1.When the product has full FDA approval. and 2.When the product is used within the scope of the FDA indications." Removed reference to Biobrane in that it is a biosynthetic wound dressing for burns and does not apply to this policy. Added HCPCS code Q0183. References added. Notification given 9/9/2004. Effective date 11/11/2004.
Breast Duct Endoscopy	Notification of new policy. Specialty Matched Consultant Advisory Panel review. Breast duct endoscopy is not covered. It is considered investigational. BCBSNC does not cover investigational services. Notification given 9/9/04. Effective date 11/11/04.
Canalith Repositioning for Benign Paroxymal Positional Vertigo	Notification of new policy. Canalith Repositioning may be considered medically necessary as a treatment of benign positional paroxysmal vertigo that has been diagnosed by the patient's history and physical and a positive Dix-Hallpike test or analogous testing for horizontal canaliths. Notification given 9/9/04. Effective date 11/11/04.
Rhinoplasty	Specialty Matched Consultant Advisory Panel review. First bullet under "When Covered" section revised as follows: "For deformities of the bony nasal pyramid (nasal bones and nasal process of the maxilla) that directly cause significant and symptomatic airway compromise, sleep apnea, or recurrent or chronic rhinosinusitis when these conditions are not responsive to appropriate medical management." Under "Billing/Coding" section, first bullet revised to indicate that pre-operative photos must be submitted consisting at a minimum of legible frontal, lateral, and columellar views. First entry under "Scientific Background and Reference Sources" revised to indicate correct manual title. Notification given 9/9/04. Effective date 11/11/04.
Septoplasty	Specialty Matched Consultant Advisory Panel review 6/21/04. Description, Benefits Application and Billing/Coding sections revised. Under "When Covered" section, B. removed "(ethmoidectomy or turbinate reduction)". Under "When Not Covered" section, added laser septoplasty is considered investigational and radiofrequency volumetric tissue reduction of nasal turbinates is considered investigational for treatment of chronic nasal obstruction due to mucosal hypertrophy of the inferior turbinate. Notification given 9/9/04. Effective date 11/11/04.