Medical Policy Updates

Table Of Contents

Notification of Policy Revisions Effective January 29, 2013 (Posted October 30, 2012)

Medical Policy Revision
Hyperbaric Oxygen Pressurization, "Notification" Description section revised. The following statement was added to the Policy section: "Topical Hyperbaric Oxygen Therapy is considered investigational. BCBSNC does not cover investigational services." Acute osteomyelitis, acute surgical and traumatic wounds, idiopathic femoral neck necrosis, chronic wounds, other than those in patients with diabetes who meet the criteria specified in the medically necessary statement, acute ischemic stroke, Bell's palsy, and chronic arm lymphedema following radiotherapy for cancer added to the list of non-covered indications in the When HBO is Not Covered section. Utilization of hyperbaric oxygen information added to Policy Guidelines Section. Summary statements for Hyperbaric Oxygen Therapy and Topical Hyperbaric Oxygen Therapy added to Policy Guidelines Section. Added HCPCS code A4575 and E0446 to Billing/Coding section. Senior Medical Director review 10/14/2012. Notification given 10/30/2012 for effective date of 1/29/2013.