Medical Policy Updates

Table Of Contents

Notification of Policy Revisions Effective October 1, 2012 (Posted June 29, 2012)

Medical Policy Revision
Capsaicin (Qutenza®) New policy. "Capsaicin (Qutenza®)" may be considered medically necessary when criteria are met. Medical Director review June 10, 2012. Notification given 6/29/2012. Policy effective 10/1/2012.
Genetic Testing for Alpha-1 Antitrypsin Deficiency New policy developed. Genetic testing for alpha-1 antitrypsin deficiency may be considered medically necessary when both of the following conditions are met: 1. Patient is suspected of having alpha-1 antitrypsin deficiency because of clinical factors and/or because the patient may be at high risk of having alpha-1 antitrypsin deficiency due to a first degree relative with AAT deficiency; AND 2. Patient has a serum alpha-1 antitrypsin level in the range of severe deficiency. Medical Director review 5/2012. Policy noticed on 6/29/2012 for effective date of 10/01/2012.
Genetic Testing for Hereditary Hemochromatosis New policy developed. Genetic testing for HFE gene mutations may be considered medically necessary in a patient with abnormal serum iron indices indicating iron overload. Genetic testing for HFE gene mutations may be considered medically necessary in individuals with a family history of hemochromatosis in a first degree relative. Genetic testing for hereditary hemochromatosis in screening of the general population is considered investigational. Medical Director review 6/2012. Policy noticed on 6/29/12 for effective date of 10/01/12.
Treatment of Hereditary Angioedema New policy developed to address the FDA approved products used as treatment of Hereditary Angioedema. BCBSNC will provide coverage for Cinryze®, Berinert®, Kalbitor® (Ecallantide), and Firazyr® (Icatibant) when it is determined to be medically necessary because the medical criteria and guidelines are met. Medical Director review 6/2012. Notification given 6/29/12 for effective date 10/01/12.
Repository Corticotropin (H.P. Acthar Gel) Repository Corticotropin (H.P. Acthar Gel) - "Notification" New policy BCBSNC will provide coverage for repository corticotropin when it is determined to be medically necessary because the medical criteria and guidelines are met. Medical Director review 5/20/2012. Notification given 7/1/2012. Effective date 10/1/2012.