Medical Policy Updates

Notification of Policy Revisions Effective Januaary 4, 2011 (Posted September 28, 2010)

Medical Policy	Revision
Cardiac Hemodynamic Monitoring in the Outpatient Setting	New policy implemented as a combination of policies titled, "Non-Invasive Left Ventricular End Diastolic Pressure" and "Non-Invasive Measurements of Cardiac Hemodynamics in the Outpatient Setting". Cardiac hemodynamic monitoring in the outpatient setting is considered investigational. Reviewed by Senior Medical Director 9/2010. Notice given 9/28/10 Effective date 1/4/11.
Dental, Reconstructive Services	Policy extensively revised to include additional indications based on updated benefit language. Extensively expanded the "When Covered" section for clarity. Removed the following statement previously stated as a covered indication; "For dental extraction related to radiation therapy." This is not considered reconstructive services. Removed the following statement under the "When Not Covered" section; "For reconstructive procedures delayed without medical cause beyond the immediate post-injury period (2 years)." "Policy Guidelines" section revised to discuss dental services that are not considered reconstructive. Specialty Matched Consultant Advisory Panel review 1/2010. Senior Medical Director review 6/2010 and 8/2010. References added. Notification given 9/28/2010. Effective date 1/4/2011.
Extracorporeal Photopheresis as a Treatment of Graft-versus-Host Disease, Autoimmune Disease, and Cutaneous T-Cell Lymphoma	New policy written. "Extracorporeal photopheresis may be considered medically necessary as a technique to treat chronic graft-versus-host disease that is refractory to medical therapy. Extracorporeal photopheresis may be considered medically necessary as a technique to treat late-stage (III/IV) cutaneous T-cell lymphoma. Extracorporeal photopheresis may be considered medically necessary as a technique to treat early stage (I/II) cutaneous T-cell lymphoma that is progressive and refractory to established nonsystemic therapies." "Extracorporeal photopheresis is considered investigational as a technique to treat acute graft-versus-host disease or chronic graft-versus-host disease that is either previously untreated or is responding to established therapies. Extracorporeal photopheresis is considered investigational as a technique to treat either the cutaneous or visceral manifestations of autoimmune diseases, including but not limited to scleroderma, systemic lupus erythematosus, rheumatoid arthritis, pemphigus, psoriasis, multiple sclerosis, or diabetes. Extracorporeal photopheresis is considered investigational as a technique to treat early stage (I/II) cutaneous T-cell lymphoma that is either previously untreated or is responding to established nonsystemic therapies." Reviewed with Medical Director 8/31/2010. Notification given 9/28/2010. Policy effective date 1/4/2011.
Lumbar Spine Fusion Surgery	New policy written. BCBSNC will provide coverage for Lumbar Spinal Fusion when it is determined to be medically necessary because the medical criteria and guidelines are met. Notice given 9/28/2010. Policy effective 1/1/2011.