Medical Policy Updates

Table Of Contents

Notification of Policy Revisions Effective November 27, 2006 (Posted September 18, 2006)

Medical Policy Revision
Chiropractic Services Added 4.g. to the "When not covered" section to indicate "low level laser therapy (cold laser therapy) for all indications, including but not limited to: pain relief, arthritis, carpal tunnel syndrome, Raynaud’s phenomenon, fibromyalgia, other musculoskeletal disorders, chronic non-healing wound, and neurological dysfunctions." HPCPS code S8948 added to "Billing/Coding" section. Notification given 9/18/06. Effective date 11/27/06.
External Defibrillators Additional information added to Policy Guidelines section to support continued Investigational sta­tus. CPT Codes updated. References updated. Specialty Matched Consultant Advisory review 10/ 23/06. No changes to policy coverage criteria. CPT codes updated.
Growth Factors in Wound Healing Description section revised. Under When Covered #1-adequate tissue oxygenation may be deter¬mined by transcutaneous partial pressure of oxygen or "an ankle-brachial index (ABI) of 0.7 or greater, or if an ABI is not obtainable, then a toe pressure of 40 or greater". Under When Not Cov¬ered added "Autologous blood-derived preparations (i.e., platelet-rich plasma) are considered investigational as a primary procedure for other miscellaneous conditions including, but not limited to, epicondylitis (i.e., tennis elbow), plantar fasciitis, or Dupuytren’s contracture." Medical Terms and Reference sources added.
Hyperhidrosis, Treatment of Intra Articular Hyaluronan Injections for Osteoarthritis of the Knee Specialty Matched Consultant Advisory Panel review 8/30/2006. No changes to criteria. Refer¬ence sources added. Information regarding repeated treatment cycles deleted from the When Covered section. The fol¬lowing statement added to When Not Covered section: "Repeated treatment cycles are considered investigational." Also added a statement to Policy Guidelines section "There is limited evidence regarding the effectiveness of multiple courses of intra-articular hyaluronan injections, therefore repeated treatment cycles are considered investigational. BCBSNC does not provide coverage for investigational services." Notification date 9/18/06. Effective date 11/27/06.
MRI-Guided High Intensity Ultrasound Ablation of Uterine Fibroids References updated. Specialty Matched Consultant Advisory Panel review 10/23/06. No changes to policy coverage criteria.
MRI of the Breast Deleted the following statements from the "When MRI of the Breast is covered" section: as a screening technique of the contralateral breast in patients who have breast cancer, for detection of a suspected occult breast primary tumor in patients with axillary nodal adenocarcinoma with a nega¬tive mammography and physical exam, for presurgical planning in patients with locally advanced breast cancer before and after completion of neoadjuvant chemotherapy, and to determine the pres¬ence of pectoralis major muscle/chest wall invasion in patients with posteriorly located tumor. Added the statement regarding neoadjuvant chemotherapy: MRI of the breast may be performed before, during and after chemotherapy to assess response to treatment and extent of residual disease prior to surgery. Added the statements regarding evaluation for multi-centric disease in newly diag¬nosed breast carcinomas: in the contralateral breast to interrogate for lesions not suspected by mammography and physical exam and in the same breast when this affects clinical treatment. Deleted the following statements from the "When MRI of the Breast is not covered" section: MRI of the breast to determine response during neoadjuvant chemotherapy in patients with locally advanced breast cancer is considered investigational and MRI of the breast for evaluation of resid¬ual tumor in patients with positive margins after lumpectomy is considered investigational. Refer¬ences and CPT codes updated.
Screening for Vertebral Fracture with Dual X-Ray Absorptiometry (DEXA) References updated. Specialty Matched Consultant Advisory Panel review 10/23/06. No changes to policy coverage criteria.