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Bone Marrow Transplant for Autoimmune Diseases
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Specialty Matched Consultant Advisory Panel review 11/6/06. No changes to policy statement. Added the following statement to the "Policy" section; Some patients may be eligible for coverage under Clinical Trials. Refer to the policy on Clinical Trial Services for Life-Threatening Conditions. Updated rationale in "Policy Guidelines" section. References added.
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Bone Marrow Transplant for Chronic Myelogenous Leukemia
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Specialty Matched Consultant Advisory Panel review 11/6/06. Added the following statement to the "Policy" section; "If the medical criteria and guidelines are not met, some patients may be eligible for coverage under clinical trials. Refer to the policy, Clinical Trial Services for Life-Threatening Conditions." References added.
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Bone Marrow Transplant for CLL and SLL
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Specialty Matched Consultant Advisory Panel review 11/6/06. Updated "Policy Guidelines" section. References added.
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Bone Marrow Transplant for Epithelial Ovarian Cancer
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Specialty Matched Consultant Advisory Panel review 11/6/2006. No changes to policy statement. "Policy Guidelines" section updated. References added.
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Bone Marrow Transplant for Germ Cell Tumors
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Specialty Matched Advisory Consultant Panel review 11/6/2006. Added statement regarding clinical trials to "Policy" section.Clarified the first bullet under the "When Covered" section from "HDC and autologous stem cell support may be considered medically necessary as a treatment of germ cell tumors that do not achieve a complete remission. (i.e., refractory germ cell tumors or those exhibiting a partial response to standard chemotherapy)." to "HDC and autologous stem cell support may be considered medically necessary as salvage therapy for patients with germ cell tumors that do not achieve a complete remission. (i.e., refractory germ cell tumors or those exhibiting a partial response or less to standard chemotherapy)." References added.
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Bone Marrow Transplant for Hodgkin's Disease
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Specialty Matched Consultant Advisory Panel review 11/6/2006. No changes to policy statement. Added the following statement to the "Policy" section; "If the medical criteria and guidelines are not met, some patients may be eligible for coverage under Clinical Trials. Refer to the policy, Clinical Trial Services for Life-Threatening Conditions." References added.
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Bone Marrow Transplant for Miscellaneous Tumors in Adults
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Specialty Matched Consultant Advisory Panel review 11/6/2006. No changes to policy statement. Added the following statement to the "Policy" section; "If the medical criteria and guidelines are not met, some patients may be eligible for coverage under Clinical Trials. Refer to the policy, Clinical Trial Services for Life-Threatening Conditions." Added "Malignant Melanoma" to the "When Not Covered" section for clarification. Updated rationale in "Policy Guidelines" section. References added.
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Bone Marrow Transplant for Multiple Myeloma
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Specialty Matched Consultant Advisory Panel review 11/6/2006. Added the following statement to the "Policy" section; "If the medical criteria and guidelines are not met, some patients may be eligible for coverage under Clinical Trials. Refer to the policy, Clinical Trial Services for Life-Threatening Conditions." No changes to policy statement. References added.
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Bone Marrow Transplant for Neuroectodermal Tumors and Ependymoma
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Specialty Matched Consultant Advisory Panel review 11/6/2006. Added the following statement to the "Policy" section; "If the medical criteria and guidelines are not met, some patients may be eligible for coverage under Clinical Trials. Refer to the policy, Clinical Trial Services for Life-Threatening Conditions." Changed the wording in the "When Covered" section from "refractory" to "residual". Updated "Policy Guidelines" section. References added.
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Bone Marrow Transplant for Non Hodgkins Lymphomas
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Transplant for Non Hodgkins Lymphomas Specialty Matched Consultant Advisory Panel review 11/6/2006. Clarified mantle cell lymphoma, marginal lymph node lymphoma and lymphoplasmacytoid lymphoma in "When Covered" section. References added.
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Bone Marrow Transplant for Primary Amyloidosis or Waldenstrom's Macroglobulinemia
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Specialty Matched Consultant Advisory Panel review 11/6/2006. No changes to policy statement. Rationale updated in "Policy Guidelines" section. References added.
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Bone Marrow Transplant for Solid Tumors of Childhood
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Specialty Matched Consultant Advisory Panel review 11/6/2006. Added the following statement to the "Policy" section; "If the medical criteria and guidelines are not met, some patients may be eligible for coverage under Clinical Trials. Refer to the policy, Clinical Trial Services for Life-Threatening Conditions." Updated rationale in "Policy Guidelines" section. References added.
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Breast Surgeries
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Policy status changed to "Active policy, no longer scheduled for routine literature review.”
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Cerebral Angioplasty
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Added CPT codes 61630 and 61635 to the "Billing/Coding" section.
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Common Carotid Intima-Media Thickness Study
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New Policy issued. Ultrasonographic measurement of carotid artery intima-media thickness (IMT) is considered investigational as a technique of identifying and monitoring subclinical atherosclerosis.
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Cord Blood as a Source of Stem Cells
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Specialty Matched Consultant Advisory Panel review 11/6/2006. No changes to policy statement. Clarified second bullet under "When not covered" section from; "Prophylactic collection and storage of cord blood from a neonate is considered not medically necessary when proposed for some unspecified future use as an autologous stem-cell transplant in the original donor, or for some unspecified future use as an allogeneic stem cell transplant in a related or unrelated recipient." to "Prophylactic collection and storage of cord blood from a neonate is non-covered when proposed for some unspecified future use as an autologous stem-cell transplant in the original donor, or for some unspecified future use as an allogeneic stem cell transplant in a related or unrelated recipient." Policy status changed to: "Active policy, no longer scheduled for routine literature review". Added CPT code 38206 to "Billing/Coding" section. References added.
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Durable Medical Equipment (DME)
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Description of DME expanded for clarification. In the section When DME Is Covered, deleted phrase "within the scope of his license" from item 2. Additional information added to "Coverage for DME Add-ons or Upgrades" that reads: "Standard DME is one that will adequately meet the medical needs of the patient and is not designed or customized for a specific individual's use. Non-standard DME is any item that has certain convenience or luxury features that make it more expensive than a standard item. Electrical or mechanical features which enhance standard or basic equipment usually serve a convenience function." In the section When DME is Not Covered, deleted phrase "within the scope of his license" from 3rd bulleted item. In the Rental versus Purchase section, deleted "ROHO cushion" from item 1. Policy number added to Key Words. References and HCPCS Codes updated. Speciality Matched Consultant Advisory Panel review meeting 6/28/06.
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Magnetic Resonance Spectroscopy
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Policy statement changed to indicate BCBSNC will not provide coverage for MRS. It is considered investigational. Information in the "When MRS is Covered" section replaced with the statement "not applicable." Information in the "When MRS is Not Covered" section replaced with the statement "The use of Magnetic Resonance Spectroscopy is considered investigational for all applications. BCBSNC does not provide coverage for investigational services." Policy Guidelines section updated to include the following rationale for noncoverage: The available studies all have some degree of shortcomings, and the overall body of evidence does not provide strong and consistent evidence regarding the diagnostic test characteristics or clinical utility of MRS for any condition. Studies of diagnostic performance often included a heterogeneous mix of patients that had clinically important differences and did not clearly delineate how MRS information would be used to guide patient management. Furthermore, there were differences in MRS technique and methods of analysis across studies that make it difficult to synthesize findings from different studies. References added. Notification date 10/2/06. Effective date 12/11/06.
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Medical Supplies and Surgical Dressings
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Specialty Matched Consultant Advisory Panel review. No changes to critieria. Code range in Billing/Coding section now includes A4206 through A7527.
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Oscillatory Devices for the Treatment of Respiratory Conditions
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Added a statement to Item #4 in the section "When Oscillatory Devices are covered" that reads: Appropriate usage is defined as daily treatment sessions for an absolute minimum of 15 minutes per session.
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Reconstructive Eyelid Surgery and Brow Lift
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Under Section I-Blepharoplasty; When Covered, A.6.clarified MRD reading "Records must document that the upper eyelid margin approaches to within 2.5 mm (1/4 of the diameter of the visible iris) of the corneal light reflex." Added A.8. "To relieve chronic symptomatic dermatitis of pretarsal skin caused by redundant upper eyelid skin which has not been successfully treated by normal first line measures such as education regarding hygiene, antibiotics, etc. Documentation must include a description of onset, prior treatment, extent, presence and description of discharge, color, etc." Physician Documentation Information moved to Sections I and II When Covered sections as appropriate. Medical terms definitions added.
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Speech Generating Devices
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Notification of new policy. Speech Generating Devices may be considered medically necessary when the criteria listed in the policy are met. Medical necessity criteria includes: a formal, written evaluation of the member's cognitive and communication abilities by a speech-language pathologist; the member's medical condition is one resulting in a severe expressive speech impairment; other forms of treatment have been considered and ruled out; the member's speech impairment will benefit from the device ordered; a copy of the speech-language pathologist's written evaluation and recommendation have been forwarded to the member's treating physician prior to ordering the device. Notification given 10/2/06. Effective date 12/11/06.
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Evidence Based Guidelines
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Reason for Update
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Human Papillomavirus (HPV) Vaccine
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Specialty Matched Consultant Advisory Panel review 11/6/2006. Medical Policy changed to Evidence Based Guideline. Wording changed in the "Evidence Based Guideline" section from "It is recommended that it be routinely given to girls, 11-12 years old as a preventive service against cervical cancer." to "It is recommended that it be routinely given to girls, 11-12 years old to reduce the risk of cervical cancer." References added.
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Treatment for Age Related Macular Degeneration
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New Evidence Based Guideline issued.
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