Medical Policy Updates

Table Of Contents

Notification of Policy Revisions Effective February 26, 2013 (Posted November 27, 2012)

Medical Policy Revision
Chelation Therapy - "Notification" Revised description section. Changed status of policy to active from active archive. Added autism, alzheimer's disease and rheumatoid arthritis as investigational indications under "When Not Covered" section. Reference added. Notification given 11/27/12 for effective date 2/26/13. Medical director review 11/2012.
Cranial Electrotherapy Stimulation (CES) and Auricular Electrostimulation - "Notification" New policy. Cranial electrotherapy stimulation (also known as cranial electrostimulation therapy or CES) is considered investigational. Electrical stimulation of auricular acupuncture points is considered investigational. Reviewed by Senior Medical Director 11/3/12. Notification given 11/27/12. Policy effective 2/26/13.
Electrical Bone Growth Stimulation - "Notification" Added related policy to Description section. Revised the following statement in the "When not Covered" section: "2.Investigational applications of electrical bone growth stimulation in the appendicular skeleton include, but are not limited to, immediate post-surgical treatment, and treatment of fresh fractures, delayed union or failed arthrodesis. Delayed union is defined as a decelerating fracture healing process, as identified by serial x-rays. 3. Semi-invasive electrical bone growth stimulators are considered investigational as an adjunct to lumbar fusion and for failed lumbar fusion." References updated. Medical Director review. Policy noticed on 11/27/12 for effective date 2/26/13.
Identification of Microorganisms Using Nucleic Acid Probes - "Notification" New policy developed. BCBSNC will provide coverage for identification of microorganisms using nucleic acid probes when it is determined to be medically necessary because the medical criteria and guidelines are met. Medical Director review 10/2012. Policy noticed on 11/27/12 for effective date 2/26/13.
Optical Diagnostic Devices for Evaluating Skin Lesions Suspected of Malignancy - "Notification" Policy re-titled from "Dermatoscopy" to "Optical Diagnostic Devices for Evaluating Skin Lesions Suspected of Malignancy." Description section updated to include computer based optical imaging information. "When not Covered" section revised to state: "Dermatoscopy, using either direct inspection, digitization of images, or computer-assisted analysis, is considered investigational as a technique to evaluate or serially monitor pigmented skin lesions. Computer-based optical imaging devices e.g., multispectral digital skin lesion analysis, are considered investigational as a technique to evaluate or serially monitor pigmented skin lesions. Dermatoscopy and computer-based optical imaging devices are considered investigational for defining peripheral margins of skin lesions suspected of malignancy prior to surgical excision." Policy Guidelines updated. References updated. Medical Director review 11/2012. Policy noticed on 11/27/12 for effective date of 2/26/13.
Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers - "Notification" Reference added. Title changed to Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers. Statement on two-phase pumps deleted. Statement added that use of lymphedema pumps to treat the trunk or chest in patients with lymphedema limited to the upper and/or lower limbs is considered investigational. Statement added that use of lymphedema pumps to treat venous ulcers is considered investigational. Medical Director review. Notification given 11/27/12. Policy effective 2/26/13.
Pulmonary Hypertension, Drug Management - "Notification" Under "When Not Covered" section added: "Use of other advanced therapies for the pharmacologic treatment of pulmonary arterial hypertension (PAH/WHO Group 1), including but not limited to imatinib and simvistatin, is considered investigational." Notification given 11/27/12 for effective date 2/26/13.
Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors - "Notification" Reference added. Information on thyroid tumors added to Description section. Thyroid tumors added to non covered indications. Policy Guidelines updated. Medical Director review. Notification given 11/27/12. Policy effective 2/26/13.
Sacroiliac Joint Fusion - "Notification" New policy. "Sacroiliac joint fusion procedures may be considered medically necessary for any of the following indications: as an adjunct to sacrectomy or partial sacrectomy related to tumors involving the sacrum; or as an adjunct to the medical treatment of sacroiliac joint infection/sepsis; or severe traumatic injuries associated with pelvic ring fracture; or when multisegment spinal constructs extend to the sacrum/ilium, for covered lumbar spine fusion procedures (See medical policy, 'Lumbar Spine Fusion Surgery')." "When none of the above indications are present, the procedure is considered not medically necessary. Sacroiliac joint fusion surgery is considered investigational for the treatment of mechanical low back pain when the sacroiliac joint is the suspected cause." Senior Medical Director review 10/28/2012. Notification given 11/27/12. Policy effective 2/26/13.
Ultrasound Accelerated Fracture Healing Device - "Notification" Revised following statement in the "When not Covered" section: "Other applications of low intensity ultrasound treatment are investigational, including but not limited to, congenital pseudoarthroses, open fractures, arthrodeses, or stress fractures." Policy Guidelines updated. Medical Director review 11/2012. Policy noticed 11/27/12 for effective date 2/26/2013.