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Medical Policy Updates

Table Of Contents

Notification of Policy Revisions Effective May 31, 2016 (Posted April 1, 2016)

Medical Policy Revision
Intensity Modulated Radiation Therapy (IMRT) for Sarcoma of the Extremities "Notification" New policy issued. Intensity-modulated radiation therapy (IMRT) may be considered medically necessary for the treatment of sarcoma of the extremities when the following criteria are met: 3D results in >=50% of the full circumference of the femur or humerus cortex receiving >=40Gy, AND IMRT results in a reduction in the absolute percent of the circumference of the bone receiving >=40Gy of at least 20% (e.g. from 60% to 40% of the bone's circumference); OR 3D results in >=50% of the joint spaces (e.g. shoulder, elbow, wrist, hip, knee, ankle) receiving >=35Gy, AND IMRT results in a reduction in the absolute percent of the joint space receiving >=35Gy of at least 20% (e.g. from 60% to 40% of the joint space). Senior medical director review 3/2016. Specialty Matched Consultant Advisory Panel review. Notification given 4/1/16 for effective date 5/31/16.
Intensity Modulated Radiation Therapy (IMRT) of Abdomen and Pelvis "Notification" Added covered indication for Lymphoma involving aortic/periaortic nodes (e) and retroperitoneal sarcomas of the abdominal cavity (f) under "When Covered" section. Deleted statement ("including liver and pancreas") under "When Covered" section 3(c). Deleted references to vaginal or cervical cancer when brachytherapy will not be performed and GE junction/lower esophagus under "When Covered" section. Senior medical director review 3/2016. Specialty Matched Consultant Advisory Panel review. Notification given 4/1/16 for effective date 5/31/16.
Intensity Modulated Radiation Therapy (IMRT) of the Chest "Notification" Under "When Covered" section for lung and thoracic esophageal cancer: added bullet #4 in Section B to address sparing the normal esophagus : "3D conformal will expose >17% of the esophagus to more than 60 Gy (V60); and IMRT dosimetry demonstrates an absolute reduction in the V60 to at least 10% below the V60 that is achieved with the 3D plan (e.g. from 20% down to 10%)." Changed statement in bullet #3 to read "reduction in the V30 to at least 10% instead of 15%." Under "When Covered" section bottom of page 3 added: thoracic lymphoma as covered indication to statement of coverage for lung and thoracic esophageal cancer and also added cancer of the (GE) gastroesophageal junction as covered indication. Senior Medical Director review 3/2016. Specialty Matched Consultant Advisory Panel review. Notification given 4/1/16 for effective date 5/31/16.
Maternal and Fetal Diagnostics "Notification" Policy reformatted. The following information added to the Guidelines for Ultrasound in Maternity Care: Ultrasound codes 76801 and 76802 are reported when the maternal and fetal ultrasound evaluation is performed during the first trimester. CPT codes 76813 and 76814 are to be used between 10 and 14 weeks' gestation for the evaluation of the nuchal translucency as part of the first trimester screening process. The only indication for performing the 76813 examination is to measure the fetal nuchal translucency as one component of screening for fetal aneuploidy. 76813/76814 should not be billed routinely in combination with the 76801/76802 codes. Specialty Matched Consultant Advisory Group review 3/30/2016. Notification given 4/1/16 for effective date 5/31/16.
Percutaneous Tibial Nerve Stimulation for Voiding Dysfunction "Notification" Title changed to Percutaneous Tibial Nerve Stimulation. "Posterior" changed to "percutaneous" in existing policy statement. Medical Policy Statement revised to state: "BCBSNC will provide coverage for percutaneous tibial nerve stimulation when it is determined to be medically necessary because the medical criteria and guidelines noted below are met." "When Covered" section revised to state: "Percutaneous tibial nerve stimulation may be considered medically necessary in patients with nonneurogenic overactive bladder syndrome who meet the following criteria: 1) Symptoms of overactive bladder syndrome for at least 3 months duration AND 2) Failed behavioral therapies (e.g., pelvic floor muscle training, biofeedback, timed voids and/or fluid management), AND 3) Failed pharmacological therapy that includes at least 2 anticholinergic medications and/or smooth muscle relaxants OR patient has a contraindication to pharmacological therapy. If the criteria are met, a total of 12 treatments (one per week) will be initially approved. Patients who experience improvement in their OAB symptoms after the 12 initial treatments may receive on-going treatments every 3 weeks (every 1 to 2 months) for up to one year. Treatments after 12 months are considered experimental/investigational." "When not Covered" section revised to state: "Percutaneous tibial nerve stimulation is considered investigational in all other situations not described above. Treatments after 12 months are considered experimental/investigational." Policy Guidelines updated. References updated. Medical Director review 11/2015. Policy noticed on 4/1/16 for effective date 5/31/16.