Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for June 22, 2010

Medical Guidelines Reason for Update
Accelerated Partial Breast Radiotherapy (Breast Brachytherapy) Specialty Matched Consultant Advisory Panel review 5/24/10. Removed CPT 0182T from "Billing Code Section" The code is not specific to the Accelerated Partial Breast Radiotherapy policy, it is investigational and is noted in the Breast Brachytherapy policy. No changes to policy statement.
Brachytherapy, Intracavitary Balloon Catheter For Brain Cancer Specialty Matched Consultant Advisory Panel review 5/24/10. Description extensively revised. Added wording in the "When Not Covered" section: "Intracavitary balloon catheter brain brachytherapy is considered investigational, alone or as part of a multimodality treatment regimen, for primary or recurrent malignant gliomas and Intracavitary balloon catheter brain brachytherapy also is considered investigational, alone or as part of a multimodality treatment regimen, for metastasis to the brain from primary malignancies outside the brain." References added.
Brachytherapy Treatment of Breast Cancer Specialty Matched Consultant Advisory Panel review 5/24/10. Removed Medical Policy number. No policy statement changes. References updated.
Cellular Immunotherapy for Prostate Cancer New policy. Reviewed by Senior Medical Director 5/26/10. "Sipuleucel-T therapy may be considered medically necessary in the treatment of asymptomatic or minimally symptomatic, metastatic, androgen-independent (hormone-refractory) prostate cancer." "Sipuleucel-T therapy is considered investigational in all other situations, including but not limited to treatment of hormone-responsive prostate cancer, treatment of those with moderate to severe symptomatic metastatic prostate cancer, and those with visceral (liver, lung or brain) metastases."
Chemoembolization of the Hepatic Artery, Transcatheter Approach Specialty Matched Consultant Advisory Panel review 5/24/10. No policy statement changes.
Electrical Stimulators, Neuromuscular Policy number(s) removed. "Description" sections revised. "Therapeutic" removed from the name of Threshold Electrical Stimulation throughout policy as appropriate. Information added to the "Functional Neuromuscular Electrical Stimulation" section to indicate; Neuromuscular stimulation is considered investigational as a technique to restore function following nerve damage or nerve injury. This includes its use in the following situations: *As a technique to provide ambulation in patients with spinal cord injury; or *To provide upper extremity function in patients with nerve damage (e.g., spinal cord injury or post-stroke); or *To improve ambulation in patients with foot drop caused by nerve damage (e.g., post-stroke or in those with multiple sclerosis)." No change to policy intent. Reviewed by Senior Medical Director 5/26/10. References added.
Image-Guided Radiation Therapy for Prostate Cancer Specialty Matched Consultant Advisory Panel review 5/24/10. No criteria changes. Description section extensively revised for consistency with BCBSA Medical Policy. Reference added.
Intensity Modulated Radiation Therapy (IMRT) of Abdomen and Pelvis 5/24/10. Policy statement change-added statement under "When covered" section indicating: "Intensity modulated radiation therapy may be considered medically necessary for patients with squamous cell cancer of the anus/anal canal." Reference added.
Intensity Modulated Radiation Therapy (IMRT) of Breast and Lung Specialty Matched Consultant Advisory Panel 5/24/10. Policy statement change-added statement under "When not covered" section indicating "Intensity-modulated radiation therapy (IMRT) is considered not medically necessary as a technique to deliver whole breast irradiation in patients receiving treatment for breast cancer after breast conserving surgery and in patients receiving treatment for lung cancer." Also added statement under "When not covered" section indicating "Intensity-modulated radiation therapy (IMRT) is considered not medically necessary as a technique to deliver radiation therapy in patients receiving treatment for lung cancer, because the clinical outcomes with this treatment have not been shown to be superior to other approaches such as 3D-conformal radiation therapy, yet IMRT is generally more costly than these alternatives." References added.
Intensity Modulated Radiation Therapy (IMRT) of Head and Neck Specialty Matched Consultant Advisory Panel 5/24/10. No changes in policy statement. Medical Policy number removed.
Intensity-Modulated Radiation Therapy (IMRT) of the Prostate Specialty Matched Consultant Advisory Panel review 5/24/10. No changes to policy statement. Medical policy number removed.
Radiosurgery, Stereotactic Approach Specialty Matched Consultant Advisory Panel review 5/24/10. Under "When covered" section: 5th bullet - removed "up to three" to indicate that stereotactic radiosurgery is no longer limited to 3 or fewer metastases. Medical Policy number removed. References added
Selective Internal Radiation Therapy for Tumors of the Liver Specialty Matched Consultant Advisory Panel review 5/24/10. Medical Policy number removed. Applicable diagnoses added to "Billing/Coding" section.
Evidence Based Guidelines
Charged Particle Radiotherapy Specialty Matched Consultant Advisory Panel review 5/24/2010. Updated "Description section". Added additional indication to "When not covered section: C. "In patients with clinically localized prostate cancer, because the clinical outcomes with this treatment have not been shown to be superior to other approaches including intensity modulated radiation therapy (IMRT) or conformal radiation therapy, yet proton beam therapy is generally more costly than these alternatives." Removed this indication from the "When covered section." References added.
Intraoperative Radiation Therapy Specialty Matched Consultant Advisory Panel 5/24/10. No changes to policy statement. EBG policy number removed.
Radiofrequency Ablation of Osteoid Osteomas and Bone Metastases Specialty Matched Consultant Advisory Panel review 5/24/10. No changes to Evidence Based Guideline statement. Evidence Based Guideline number removed.
TENS (Transcutaneous Electrical Nerve Stimulator) Policy status returned to active, converted from Corporate Medical Policy to Evidence Based Guideline. "Description" section revised. Evidence Based Guideline indicates; "A trial of transcutaneous electrical nerve stimulation (TENS) of at least 30 days may be appropriate to establish efficacy for the management of refractory chronic pain (e.g., chronic musculoskeletal or neuropathic pain) that causes significant disruption of function The pain is unresponsive to at least 3 months of conservative medical therapy; AND The trial is monitored by a physician." "Continued use of transcutaneous electrical nerve stimulation (TENS) may be appropriate for treatment of refractory chronic pain (e.g., chronic musculoskeletal or neuropathic pain) that causes significant disruption of function when the following conditions have been met: Efficacy has been demonstrated in an initial therapeutic trial (see policy guidelines); AND Compliance has been demonstrated in the therapeutic trial with the device used on a regular basis (e.g., daily or near daily use) throughout the trial period." "TENS is not recommended for the management of acute pain (e.g., postoperative or during labor and delivery)." "The use of TENS for any other condition, including the treatment of dementia, is not recommended." Removed HCPCS code E0731, since this is a non-covered item. Reviewed with Senior Medical Director 5/26/2010. References added.