Medical Policy Updates

Table Of Contents

Notification of Policy Revisions Effective October 28, 2014 (Posted August 26, 2014)

Medical Policy Revision
Sacral Nerve Neuromodulation/Stimulation for Pelvic Floor Dysfunction "Notification" "When Covered" section revised to clarify length of time after rectal surgery before trial stimulation can take place. "#2 There is documented failure or intolerance to conventional conservative therapy (e.g., dietary modification, the addition of bulking and pharmacologic treatment for at least a sufficient duration to fully assess its efficacy", performed more than 12 months [or 24 months in case of cancer] previously); Added item #6: "The patient has not had rectal surgery in the previous 12 months, or in the case of cancer, the patient has not had rectal surgery in the past 24 months." References updated. Medical Director review 8/2014. Policy noticed 8/26/14 for effective date 10/28/14.
Saturation Biopsy for Diagnosis and Staging of Prostate Cancer "Notification" CPT code 88305 added to Billing/Coding section. The following statement added to Billing/Coding section: "When CPT code 88305 is submitted for greater than 10 units with prostate related diagnoses, the corresponding G code will be substituted." Medical Director review 8/2014. Policy noticed on 8/26/2014 for effective date 10/28/2014.
Eculizumab (Soliris®) "Notification" New policy developed. BCBSNC will provide coverage for Eculizumab (Soliris®) when it is determined to be medically necessary because the medical criteria and guidelines are met. Medical Director review 8/2014. Policy noticed 8/26/14 for effective date 10/28/14.