Medical Policy Updates

Table Of Contents

Notification of Policy Revisions Effective October 1, 2011 (Posted July 1, 2011)

Medical Policy Revision
Abatacept (Orencia®) Added quantity limitations to Policy Guidelines. Medical director review 6/2011. Notification date 7/1/11 for effective date of 10/1/11.
Belimumab (Benlysta) New medical policy issued. Belimumab is considered medically necessary for treatment of active, autoantibody-positive, systemic lupus erythematosus. Notification date 7/1/2011 for effective date 10/1/2011. PPA implementation 10/1/2011. Medical director review 6/2011.
Denosumab (ProliaTM,XGEVATM) New policy developed. BCBSA will provide coverage for denosumab when it is determined to be medically necessary because the medical criteria and guidelines outlined in the policy are met. ProliaTMmay be considered medically necessary for treatment of postmenopausal women with osteoporosis at high risk for fracture. XGEVATM may be considered medically necessary for prevention of skeletal-related events in patients with bone metastases from solid tumors. Notification given 7/1/2011 for effective date 9/29/2011.
Infliximab (Remicade) Added quantity limitations to Policy Guidelines. Medical director review 6/2011. Notification date 7/1/11 for effective date 10/1/2011.
Ipilimumab (Yervoy) New policy implemented. Ipilimumab (Yervoy) is considered medically necessary for the treatment of unresectable or metastatic melanoma. Medical Director review 6/2011. Notification given 7/1/11 for effective date 9/27/11.
Radiology Services Reimbursement Guidelines New policy developed. When multiple radiological procedures are performed during the same outpatient patient session, the technical component of the second and subsequent imaging procedures will be subject to a fee reduction. Notification given 7/1/11 for effective date of 10/1/11.
Tocilizumab (Actemra) Added quantity limitations to Policy Guidelines. Medical director review 6/2011. Notification date 7/1/11 for effective date of 10/1/11.
Topical Negative Pressure Therapy for Wounds Description section updated to include information regarding the non-powered NPWT and added new link to FDA website. The term "powered" added to existing policy statements. Statement added to the Not Covered section that reads: "Use of non-powered NPWT systems for the treatment of acute or chronic wounds is considered investigational." Rationale section updated. The following codes added to the Billing/Coding section: A7000, A7001, K0743, K0744, K0745, K0746. Notification given 7/1/2011 for effective date 9/29/2011.
Ustekinumab (Stelara) Added quantity limitations to Policy Guidelines. Medical director review 6/2011. Notification date 7/1/11 for effective date of 10/1/11.
Code Bundling Rules Not Addressed In Claim Check or Correct Coding Initiative Added the phrase "correct coding initiative" throughout policy where appropriate. Notification given 7/1/11 for effective date 10/1/11.