Medical Policy Updates

Blue Cross and Blue Shield of North Carolina Medical Policy Update for June 8, 2010

Medical Guidelines	Reason for Update
Anterior Eye Segment Optical Imaging	Notification of new policy. Scanning computerized ophthalmic (e.g., OCT) imaging of the anterior eye segment is considered investigational. Notification given 3/2/2010. Effective date 6/8/2010.
Autologous Chondrocyte Implantation	Description section extensively revised. Added new criteria to "When Autologous Chondrocyte Implantation is not covered", which states, "Autologous chondrocyte implantation for all other joints, including patellar and talar, or any other indications is considered investigational. Matrix-induced autologous chondrocyte implantation is considered investigational. Treatment of focal articular cartilage lesions with autologous or allogeneic minced cartilage is considered investigational." Updated Policy Guidelines. References updated. Removed Medical Policy number.
Gait Analysis	Description section extensively revised. Policy statement changed to read: "BCBSNC will provide coverage for gait analysis when it is determined to be medically necessary because the medical criteria and guidelines shown below are met." Comprehensive gait analysis may be considered medically necessary as an aid in surgical planning in patients with gait disorders associated with cerebral palsy. Comprehensive gait analysis is considered investigational for all other applications. Gait analysis that is not comprehensive is considered investigational. Policy Guidelines and References updated.
Injectable Clostridial Collagenase for	Implementation of new policy titled "Injectable Clostridial Collagenase for Fibroproliferative Disorders". Injectable clostridial collagenase is considered investigational for all indications including, but not limited to, Dupuytren's contracture, Peyronie's disease, and adhesive capsulitis.
Oscillatory Devices for the Treatment of Respiratory Conditions	Description section extensively revised. The following Policy statement was deleted: "BCBSNC does not provide coverage for intrapulmonary percussive ventilation devices." The section titled When Oscillatory Devices for the Treatment of Respiratory Conditions Are Covered was replaced with the following: Use of the FLUTTER® valve or Acapella device may be considered medically necessary in patients with hypersecretory lung disease (i.e., produce excessive mucus) who have difficulty clearing the secretions and recurrent disease exacerbations. High-frequency chest wall compression devices and intrapulmonary percussive ventilation devices may be considered medically necessary in patients with cystic fibrosis or chronic diffuse bronchiectasis as determined by specific criteria (see Policy Guidelines) including chest computed tomography scan) when standard chest physiotherapy has failed OR standard chest physiotherapy is unavailable or not tolerated. In considering the chest wall compression and IPV devices, there should be demonstrated need for airway clearance. There should also be documented failure of standard treatments, i.e., the patient has frequent severe exacerbations of respiratory distress involving inability to clear mucus despite standard treatment (chest physiotherapy and, if appropriate, use of the FLUTTER device), or valid reasons why standard chest physiotherapy cannot be performed, such as inability of the caregiver to perform it. The section titled When Oscillatory Devices for the Treatment of Respiratory Conditions Are Not Covered was replaced with the following: High-frequency chest wall compression devices are considered not medically necessary as an alternative to chest physical therapy in patients with cystic fibrosis or chronic bronchiectasis in any other clinical situations; there are no clinical data to show that these devices provide any additional health benefit compared to conventional chest physical therapy in situations other than those specified here. Other applications of high-frequency chest wall compression devices and intrapulmonary percussive ventilation devices, including, but not limited to, their use as an adjunct to chest physical therapy or their use in other lung diseases, such as COPD, are considered investigational.
Ovarian and Internal Iliac Vein Embolization	Coding information added to the Billing/Coding section. There is no specific CPT code for this procedure, however CPT 75894 and 37204 might be used.
Tocilizumab Actemra	New medical policy issued. Tocilizumab (Actemra®) may be medically necessary for the treatment of adult patients with moderately to severely active rheumatoid arthritis who have had an inadequate response to one or more TNF antagonist therapies. Notification date 3/02/10 for effective date of 6/08/10.
Ustekinumab Stelara	New policy issued. Ustekinumab (StelaraTM) may be considered medically necessary for the treatment of moderate to severe plaque psoriasis in patients who are 18 years of age or older; and have already been treated with phototherapy (i.e., PUVA or broadband or narrowband UVB) unless the patient is not a candidate for phototherapy or phototherapy is not available to the patient; and have already been treated with or are not a candidate for any other systemic treatments such as methotrexate (oral or IM), cyclosporin, and acitretin (Soriatane®). Notification date 3/02/10 for effective date of 6/08/10.