Medical Policy Updates

Table Of Contents

Notification of Policy Revisions Effective July 24, 2012 (Posted April 17, 2012)

Medical Policy Revision
Cytochrome p450 Genotyping "Notification Evidence Based Guideline converted to Corporate Medical Policy. "CYP450 genotyping for CYP2C19 *2 and *3 alleles may be considered medically necessary in patients with cardiovascular disease undergoing treatment with clopidogrel (Plavix®) in order to identify those who are poor metabolizers of the drug (patients with CYP2C19*2/2,*3/3, and *2/3 genotypes) and who are, therefore, likely to exhibit poor response to the drug." "Aside from the use with clopidogrel treatment noted above and the separate policies noted above, genotyping to determine specific cytochrome p450 (CYP450) genetic polymorphisms for the purpose of aiding in the choice of drug or dose to increase efficacy and/or avoid toxicity is considered investigational. This includes, but is not limited to, CYP450 genotyping for the following applications: selection or dose of selective serotonin reuptake inhibitor (SSRI), selection or dose of antipsychotic drugs, deciding whether to prescribe codeine for nursing mothers, dose of atomoxetine HCl (approved for treatment of attention-deficit/hyperactivity disorder), dose of efavirenz (common component of highly active antiretroviral therapy for HIV infection), dose of immunosuppressant for organ transplantation, or selection or dose of beta blockers (e.g., metoprolol)." Notification given 4/17/2012. Policy effective 7/24/2012
Immune Cell Function Assay "Notification" Policy Name changed from "Immune Cell Function Assay in Solid Organ Transplantation" to "Immune Cell Function Assay". Additional investigational indications added; "The immune cell function assay is considered investigational for all indications, including to monitor and predict immune function after solid organ transplantation or hematopoietic stem cell transplantation. BCBSNC does not cover investigational services." Notification given 4/17/12. Policy effective 7/24/12. Reference added.
Immune Globulin Therapy "Notification" Specialty Matched Consultant review 2/29/12. Description section updated. Related policies and Evidence-based guidelines added. Added the following indications to When Immune Globulin Therapy is Covered: Ataxia telangiectasia; X-linked hyper-IgM syndrome; Acute Humoral Rejection; Autoimmune Mucocutaneous Blistering Diseases; and Eaton-Lambert myasthenic syndrome. Added Appendix B Diagnostic Criteria for Diagnosis of Multifocal Motor Neuropathy (MMN) Added new reference. Added the following clinical conditions to "When not Covered" section: "complex regional pain syndrome, Alzheimer's disease, IGG sub-class deficiency, sepsis." Removed the "European Federation of Neurological Societies/Peripheral Nerve Society Guideline on management of chronic inflammatory demyelinating polyradiculoneuropathy" from Appendix. Policy noticed on 4/17/12 to be effective 7/24/12.
Microwave Tumor Ablation "Notification" New policy. "Microwave ablation of primary and metastatic tumors is considered investigational for all applications." Medical Director review 3/12/2012. Notification given 4/17/12. Policy effective 7/24/12.
Neural Therapy "Notification" New policy. Neural therapy is considered investigational for all indications. Notification given 4/17/12. Policy effective 7/24/12.