Medical Policy Updates

Table Of Contents

Notification of Policy Revisions Effective March 3, 2005 (Posted December 23, 2004)

Medical Policy Revision
Bone Marrow Transplant for Multiple Myeloma Specialty Matched Consultant Advisory Panel review 11/29/2004. Split policy to remove reference to Primary Amyloidosis and changed name. Created new policy for Primary Amyloidosis/ SUR6090.18. Revised Description of Procedure or Service section. Added new indications (bullets 2 and 3) to "When covered section" which states; "A second course of high-dose chemotherapy with autologous stem-cell support may be considered medically necessary to treat responsive multiple myeloma that has relapsed after a durable complete or partial remission following an autologous transplant or" "tandem high-dose chemotherapy with autologous stem-cell support may be considered medically necessary to treat newly diagnosed or responsive multiple myeloma". Added the 3rd and 4th bullet under When not covered" which states; "Non-marrow ablative chemotherapy and allogeneic stem cell support following high-dose chemotherapy with autologous stem-cell support is considered investigational as the initial therapy of multiple myeloma." "Monotherapy using high-dose chemotherapy with allogeneic stem-cell support is considered investigational, either as initial therapy or after a prior failed course of high dose chemotherapy and autologous stem cell support." Added additional information regarding "responsive multiple myeloma", "partial remission", and "refractory multiple myeloma" to Policy Guidelines section. Removed reference to tandem autologous bone marrow transplants from the Policy Guidelines section. Added policy number to Policy Key Words. "Hematopoietic" and "Opportunistic" added to Definitions. References added. Notice given 12/23/2004. Effective date 3/3/2005.
Bone Marrow Transplant for Non Hodgkins Lymphomas Specialty Matched Consultant Advisory Panel review 11/29/2004. Revised Description of Procedure or Service section. Added additional indications under "When covered" section which indicates; "1. High-dose chemotherapy with either autologous or allogeneic stem-cell support may be medically necessary in patients with either intermediate or high grade Non-Hodgkin’s lymphoma in any of the following circumstances: a. As salvage therapy for patients who do not achieve a complete remission after first-line treatment (induction) with a full course of standard-dose chemotherapy; b. To consolidate a first complete remission for patients with an age-adjusted IPI (International Prognostic Indicator) that predicts a high or high-intermediate risk of relapse; c.To achieve or consolidate complete remission in a chemosensitive first or subsequent relapse. 2. High-dose chemotherapy with either autologous or allogeneic stem-cell support may be considered medically necessary in patients with Non-Hodgkin’s lymphoma who are classified as indolent and for new subtypes defined by the WHO/REAL scheme in any of the following circumstances: a.As salvage therapy for patients who do not achieve a complete remission after first-line treatment (induction) with a full course of standard-dose chemotherapy; b.To achieve or consolidate complete remission for those in first or subsequent chemosensitive relapse, whether or not their lymphoma has undergone transformation to a higher grade." Added additional information under the "When not covered" section which indicates; "High-dose chemotherapy with either autologous or allogeneic stem-cell support is considered investigational in the following: 1.High-dose chemotherapy with either autologous or allogeneic stem-cell support is considered investigational in the following: a.As initial therapy without full course of standard-dose induction chemotherapy for all types of Non-Hodgkin’s Lymphoma; b.To consolidate a first complete remission for patients with Non-Hodgkin’s Lymphoma subtypes classified as intermediate or high grade with IPI scores that predict a low or low-intermediate risk of relapse; and c. To consolidate a first complete remission for those with Non-Hodgkin’s Lymphoma classified as indolent or new subtypes defined by the WHO/ REAL scheme. 2.Tandem transplants with any stage, grade, or sub-type of Non-Hodgkin’s Lymphoma is considered investigational. 3. High-dose chemotherapy with allogeneic stem-cell support is considered investigational when Non-Hodgkin’s Lymphoma progresses or relapses soon after a prior course of high-dose chemotherapy with autologous stem-cell support." Additional information added to Policy Guidelines section related to "chemosensitive relapse". Policy number added to Key Words. "Hematopoietic" and "Opportunistic" added to definitions. Notice given 12/ 23/2004. Effective date of policy 3/3/2005.
Bone Marrow Transplant for PrimaryAmyloidosis or Waldenstroms New policy. Split primary amyloidosis from policy SUR6090.14/Multiple Myeloma and added Waldenstrom’s macroglobulinemia to new policy’s content. Specialty Matched Consultant Advisory Panel review 11/29/2004. Added Policy statement indicating that "Bone Marrow Transplant for Waldenstrom’s Macroglobulinemia is considered investigational." Added new indication to "When Covered" indicating that "High-dose chemotherapy with autologous stem-cell support may be considered medically necessary to treat primary systemic amyloidosis." Notice given 12/23/ 2004. Effective date of policy 3/3/2005.
Bone Marrow Transplant for Solid Tumors of Childhood Specialty Matched Consultant Advisory Panel review 11/29/2004. Revised Description of Procedure or Service section. Added additional information to "When covered" to indicate; "3.High-dose chemotherapy (with or without associated radiotherapy) and autologous or syngeniec (harvested from an identical twin) stem cell support may be considered medically necessary to consolidate remissions of poor-risk Ewing’s sarcoma, or as salvage therapy for those with residual, recurrent or refractory Ewing’s sarcoma." "When not covered" revised to indicate; "1. High-dose chemotherapy (with or without associated radiotherapy) and hematopoietic stem cell support is considered investigational as initial treatment or to consolidate remission of low or intermediate risk Ewing’s sarcoma. 2.Salvage allogeneic transplant for neuroblastoma or other solid tumors of childhood that relapse after autologous transplant or fail to respond is considered investigational. 3. High-dose chemotherapy (with or without associated radiotherapy) and hematopoietic stem-cell support is considered investigational as initial treatment of low or intermediate risk neuroblastoma. 4. High-dose chemotherapy for other solid tumors of childhood is considered investigational, including but not limited to, Wilms’ tumor, retinoblastoma, osteosarcoma, rhabdomyosarcoma, hepatoblastoma, and undifferentiated tumors." Rationale added to Policy Guidelines section. Policy number added to Key Words. "Hematopoietic" and "Opportunistic" added to Definitions. References added. Notice given 12/23/2004. Effective date of policy 3/3/2005.
Intrauterine Ablation or Resection of the Endometrium Specialty Matched Consultant Advisory Panel review 12/9/2004. Added microwave energy devices (such as MEA system) and radiofrequency energy devices (such as NovaSure system) that are approved by the FDA as covered. Under "When not covered" section: Added photodynamic endometrial ablation as non-covered (investigational); Listed VestaBlate with 12 RF electrodes as a multi-electrode balloon under second bullet; Removed "including high frequency radiofrequency (RF) probes" and "microwave energy"; Contraindications updated. CPT Code 0009T removed from Billing/Coding section-code will be deleted as of 12/31/04. To report 0009T effective 1/1/05 providers should use CPT code 58356. CPT code 58356 added. Sources added. Notice given 12/ 23/04. Effective 3/3/05.
Myolysis of Uterine Fibroids Notification of new policy. Specialty Matched Consultant Advisory Panel review 12/9/2004. Laparoscopic and Percutaneous Techniques for the Myolysis of Uterine Fibroids are considered investigational. BCBSNC does not cover investigational services. Notification given 12/23/04. Effective date 3/3/2005.
Ovarian and Internal Iliac Vein Embolization Specialty Matched Consultant Advisory Panel review 12/9/04. Notification of new policy indicating that ovarian and internal iliac vein embolization for pelvic congestion syndrome is investigational. Notification given 12/23/04. Effective date 3/3/05.
Salivary Hormone Tests for Menopause Specialty Matched Consultant Advisory Panel review -12/9/2004. Notification of new policy indicating that salivary hormone tests are not covered for the screening, diagnosing or monitoring of menopause. These tests are considered investigational and BCBSNC does not cover investigational services. Notification given 12/23/2004. Effective 3/3/2005.
Surgical Interruption of Pelvic Nerve Pathways for Dysmenorrhea Specialty Matched Consultant Advisory Panel review - 12/9/04. Notification of new policy indicating that laparoscopic uterine nerve ablation or presacral neurectomy as a technique to treat primary or secondary dysmenorrhea is investigational. Notification given 12/23/04. Effective date 3/3/05.
Electrical Impedance Scanning of the Breast New policy issued. Electrical impedance scanning of the breast is considered investigational. Reference added. Notification 12/23/2004. Effective 3/3/2005.
Respiratory Syncytial Virus Prophylaxis Policy Description, When Covered, and Policy Guidelines sections revised. What is covered section updated to add that infants born between 32 weeks and 35 weeks of gestation and are younger than 6 months at the start of the RSV season should have at least 2 or more risk factors. Risk factors are listed as well. Policy number added to Key Words section. Title changed from "RSV-IGIV Palivizumab" to "Respiratory Syncytial Virus Prophylaxis". Benefits Application and Billing/ Coding sectios reformatted for consistent policy language. References added. Notification 12/23/ 2004. Effective 03/03/2005.