Medical Policy Updates

Notification of Policy Revisions Effective January 5, 2010 (Posted September 28, 2009)

Medical Policy	Revision
Cosmetic and Reconstructive Surgery	Reformatted information related to medical necessity for panniculectomy and added a requirement of "a BMI of <35". Also added informational note indicating; "The majority of requests for coverage for panniculectomy are for patients who have sustained significant weight loss, or who remain morbidly obese. Because surgical outcomes are superior when performed in patients who have achieved stable weight loss, BCBSNC requires that stable weight loss with BMI less than 35 be obtained prior to authorization of coverage for panniculectomy surgery, except in rare, unusual cases." Reviewed with Senior Medical Director 9/2/09. Notice given 9/28/09. Policy effective 1/5/10.
Extracorporeal Shock Wave Treatment for Musculoskeleteal Conditions	Policy name changed from Lithotripsy, Extracorporeal, for Orthopedic Problems to Extracorporeal Shock Wave Treatment for Musculoskeletal Conditions. Description section extensively revised. Policy statement changed to read: BCBSNC will not provide coverage for extracorporeal shockwave treatment for musculoskeletal conditions. It is considered investigational and BCBSNC does not cover investigational services. Information in the When Covered section was deleted and replaced with the statement: "not applicable." Information in the When Not Covered section was deleted and replaced with the following: "Extracorporeal shock wave therapy (ESWT), using either a high- or lo-dose protocol or radial ESWT, is considered investigational, as a treatment of musculoskeletal conditions, including but limited to: plantar fasciitis; tendinopathies, including tendinitis of the shoulder and tendinitis of the elbow (epicondylitis, tennis elbow); stress fractures; delayed union and non-union fractures; avascular necrosis of the femoral head." Notification given 9/28/09. Effective date 1/01/10.
Immune Globulin Therapy	Description section extensively revised. Specific FDA-labeled indications noted in the When IVIg Is Covered section. Relapsing/remitting multiple sclerosis (formerly Item 12) was deleted from the list of covered indications. The following statement was added to the When IVIg Is Not Covered section, "IVIg is considered not medically necessary as a treatment of relapsing/remitting multiple sclerosis." Notification given 9/28/09. Effective date 1/01/10.
Selective Internal Radiation Therapy for Tumors of the Liver	Reviewed with Senior Medical Director 9/1/09. "Description" section revised. "Policy" statement changed to indicate "BCBSNC will not provide coverage for selective internal radiation therapy using intra-arterial injection of radiolabeled microspheres to treat primary or metastatic liver tumors because it is considered investigational." Removed coverage statement in the "When Covered" section that stated; "Selective internal radiation therapy may be considered medically neces¬sary for treatment of unresectable hepatocellular carcinoma." and replaced with "Not applicable." Under the "When Not Covered" section revised non coverage statement to indicate; "BCBSNC will not provide coverage for selective internal radiation therapy using intra-arterial injection of radiolabeled microspheres to treat primary or metastatic tumors of the liver because it is considered investigational." Updated rationale in the "Policy Guidelines" section. Added CPT codes "75894 and 77778" to "Billing/Coding" section. References added. Notice given 9/28/09. Policy effective 1/5/2010.