Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for July 6, 2010

Medical Guidelines Reason for Update
Allogeneic Hematopoietic Transplant for Genetic Diseases THIS POLICY IS NOT EFFECTIVE UNTIL 10/12/2010, Policy reactivated from "Policy Active, No .Longer Scheduled for Routine Review." Title changed from "Bone Marrow Transplant Allogeneic for Genetic Diseases and Acquired Anemias". Specialty Matched Consultant Advisory Panel review 5/24/2010. Revised "Description" section. Updated the "When Covered" and "Policy Guidelines" section. Clarified that treatment of Hunter, Sanfilippo, and Morquio syndromes are not included in the list of lysosomal and peroxisomal storage diseases for which allo-HSCT may be considered medically necessary. References added. Notice given 7/6/2010. Policy effective 10/12/2010.
Allogeneic Stem-Cell Transplantation for Myelodysplastic Syndromes Policy name changed from Bone Marrow Transplant Allogeneic for Myelodysplastic Diseases. Policy status changed from "Active policy, no longer scheduled for routine literature review." to active policy. "Description" section extensively revised. References to "High-dose chemotherapy with stem-cell support" changed to Hematopoietic stem-cell transplantation" throughout the policy as appropriate. No change to policy statement. "Policy Guidelines" updated and expanded. Specialty Matched Consultant Advisory Panel review 5/24/2010.
Balloon Sinuplasty for Treatment of Chronic Sinusitis Added reference to related policy "Functional Endoscopic Sinus Surgery (FESS)." Specialty Matched Consultant Advisory Panel review 5/24/10. No change to policy statement.
Canalith Repositioning for Benign Paroxysmal Positional Vertigo Description section revised. The following statement was added to the Billing/Coding section: The Hallpike-Dix maneuver, used to initially diagnose BPPV, may be coded using CPT code 92532 (positional nystagmus test). Policy Guidelines section updated. No change in policy statement.
Cochlear Implant Description section revised. Criteria in the When Covered section was deleted and replaced with the following: "Unilateral or bilateral cochlear implantation of an FDA approved cochlear implant device may be considered medically necessary in patients age 12 months and older with bilateral severe-to-profound pre- or post-lingual (sensorineural) hearing loss defined as a hearing threshold of pure-tone average of 70dB (decibels) hearing loss or greater at 500 Hz (hertz), 100 Hz and 2000 Hz, and have shown limited or no benefit from hearing aids." The following statement was added to the When Not Covered section: "Upgrades of an existing, functioning external system to achieve aesthetic improvement, such as smaller profile components or a switch from a body-worn, external sound processor to a behind-the-ear model, are considered not medically necessary." The other information in the When Not Covered section (contraindications) was revised to state "contraindications to cochlear implantation may include deafness due to lesions of the eighth cranial nerve or brain stem, chronic infections of the middle ear and mastoid cavity or tympanic membrane perforation. The absence of cochlear development as demonstrated in CT scans remains an absolute contraindication." The following was added to the Policy Guidelines section: "Bilateral cochlear implantation should be considered only when it has been determined that the alternative of unilateral cochlear implant plus hearing aid in the contralateral ear will not result in a binaural benefit; i.e., in those patients with hearing loss of a magnitude where a hearing aid will not produce the required amplification." References updated. Specialty Matched Consultant Advisory Panel review 5/24/10. No change to policy statement.
Dynamic Posturography Description section revised. Not Covered section revised slightly to read: "Dynamic Posturography is not covered. It is considered not medically necessary." The following added to Policy Guidelines section: "An updated literature review did not identify any studies that demonstrated in any improvement in health outcomes over standard physical therapy, and it has not been shown to be clinically appropriate for diagnosis or treatment." References updated. Specialty Matched Consultant Advisory Panel review 5/24/10. No change to policy statement.
Functional Endoscopic Sinus Surgery (FESS) Specialty Matched Consultant Advisory Panel review 5/24/10. No change to policy statement or coverage criteria.
Hematopoietic Stem-Cell Transplantation for Breast Cancer Policy renamed from Bone Marrow Transplant for Breast Cancer. Policy status changed from "Active policy, no longer scheduled for literature review" to "Active" status. Description section extensively revised. "When Hematopoietic Stem-Cell Transplantation Is Not Covered" changed to read "Single or tandem autologous hematopoietic stem-cell transplantation is considered not medically necessary to treat any stage of breast cancer. Allogeneic hematopoietic stem-cell transplantation is investigational to treat any stage of breast cancer." Policy Guidelines section updated with new research information. Reference added.
Hematopoietic Stem-Cell Transplantation for Acute Lymphoblastic Leukemia Specialty Matched Consultant Advisory Panel review 5/24/2010. Policy name changed from Bone Marrow Transplant for Acute lymphocytic Leukemia to Hematopoietic Stem-Cell Transplantation for Lymphoblastic Leukemia. Removed reference to "Bone Marrow Transplant, high dose chemotherapy and stem cell support" and inserted "hematopoietic stem-cell transplantation" throughout policy as appropriate. Description extensively revised. Updated high risk of relapse" criteria for both children and adults. Added under "When Covered" section;"Adult", "2. Allogeneic hematopoietic stem-cell transplantation may be considered medically necessary as a treatment of adult ALL in first complete remission for any risk level." Added "4. Reduced-intensity conditioning allogeneic hematopoietic SCT may be considered medically necessary as a treatment of ALL in patients who are in complete marrow and extramedullary first or second remission, and who, for medical reasons would be unable to tolerate a standard myeloablative conditioning regimen. These include patients whose age (typically older than 60 years) or comorbidities (e.g., liver or kidney dysfunction, generalized debilitation, prior intensive chemotherapy, low Karnofsky Performance Status) preclude use of a standard myeloablative conditioning regimen." Revised the "When Not Covered" section to indicate; "Children 1. Allogeneic hematopoietic SCT is considered investigational to treat relapsing ALL after a prior autologous SCT. "Adults 1.Autologous hematopoietic SCT is investigational to treat adult ALL in second or greater remission or those with refractory disease.2.Allogeneic hematopoietic SCT is investigational to treat relapsing ALL after a prior autologous SCT." "NOTE: The use of donor leukocyte infusions to treat relapse after allogeneic SCT for either children or adults is considered separately in the policy entitled, Donor Leukocyte Infusion." "Policy Guidelines" updated. References added.
Hematopoietic Stem-Cell Transplantation for Malignant Astrocytomas and Gliomas Policy name changed from Bone Marrow Transplant for Astrocytomas and Gliomas to Hematopoietic Stem-Cell Transplantation for Malignant Astrocytomas and Gliomas. Status changed from "Active Policy, no longer scheduled for routine review" to active status. Description completely re-written. References to "Bone marrow transplant" changed to hematopoietic stem-cell transplantation throughout policy where appropriate. Updated "Policy Guidelines". Specialty Matched Consultant Advisory Panel review 5/24/2010. References added.
Hematopoietic Stem-Cell Transplant for Acute Myeloid Leukemia Specialty Matched Consultant Advisory Panel review 5/24/2010. Changed the title from "Myelogenous to "Myeloid". Removed the following statement; Services for or related to the search for a donor is not covered." From the "Benefits Application" section. No changes to policy statement. References added.
Immune Cell Function Assay in Solid Organ Transplantation Added statement to "Billing/Coding" section to indicate; "Please note: 86352 is not specific to this policy and may be submitted for other laboratory tests."
Implantable Bone Conduction Hearing Aids Specialty Matched Consultant Advisory Panel review 5/24/10. No change to policy statement or coverage criteria.
In Vitro Chemoresistance and Chemosensitivity Assays Specialty Matched Consultant Advisory Panel review 5/24/2010. Updated "Description" section. No changes to policy statement. Added the following statement to the "Billing/Coding" section; "The extreme drug resistance assay is a multistep laboratory procedure that might be identified by the following CPT codes: 88358, 88305, 88104, 87230, 88313, and/or 89050. Providers may use 89240 for this service. References added.
Insulin Potentiation Therapy Specialty Matched Consultant Advisory Panel review 5/24/2010. Revised "Description" section. Updated "Policy Guidelines" section. References added.
Multiple Surgical Procedure Guidelines for Professional Providers In the billing/coding/physician documentation information section, revised the wording from" modifier -50 should be used for bilateral procedures. bilateral procedures should be listed on the claim as a single line item, with modifier -50." to "modifier -50 should be used for bilateral procedures. bilateral procedures should be listed on the claim as a single line item, with modifier -50 and two in the units field." reviewed with senior medical director 6/21/2010
Orthopedic Applications of Stem Cell Therapy New Medical Policy implemented. Mesenchymal stem cell therapy is considered investigational for all orthopedic applications, including use in repair or regeneration of musculoskeletal tissue.
PathFinderTG Molecular Testing Specialty Matched Consultant Advisory Panel review 5/24/2010. Updated "Description" section. No change to policy intent. References added.
Rhinomanometry and Acoustic Rhinometry Description section revised and information regarding Optical Rhinometry added. Policy statement revised to read: BCBSNC will not provide coverage for Rhinomanometry and Acoustic/Optical Rhinometry because they are considered investigational. Policy Guidelines section updated. Policy archived.
Rhinoplasty Information added to Description section. Specialty Matched Consultant Advisory Panel review 5/24/10. No change to policy statement.
Septoplasty Specialty Matched Consultant Advisory Panel Review 5/24/10. No change to policy statement or coverage criteria.
Tinnitus Treatment Description section updated. CPT Code 92625 added to Billing/Coding section. Also added information regarding appropriate coding for these services. Specialty Matched Consultant Advisory Panel review 5/24/10. No change to policy statement or coverage criteria.
Transtympanic Micropressure Applications as a Treatment of Meniere's Disease Description section revised. Specialty Matched Consultant Advisory Panel review 5/24/10. No change to policy statement.
Tumor Vaccines Specialty Matched Consultant Advisory Panel review 5/24/2010. No changes to policy statement. "Policy Guidelines" section updated. References added.
Evidence Based Guidelines
Aerosolized Antibiotics as a Treatment of Chronic Sinusitis Specialty Matched Consultant Advisory Panel review 5/24/10. No change to guideline statement.
Ambulatory Blood Pressure Monitoring Medical Policy changed to Evidenced Based Guideline.
Evoked Otoacoustic Emissions Description section revised. No change in guideline statement. Status changed to "Active guideline, no longer scheduled for routine literature review."
Genetic Testing for Tamoxifen Treatment Specialty Matched Consultant Advisory Panel review 5/24/2010. No change to policy statement. Policy Guideline number removed. References added.
Hysteroscopic Tubal Occlusion for Permanent Sterilization Policy updated, description revised to remove references to specific products. No change in coverage criteria.
Interventions for Progressive Scoliosis New Evidence Based Guideline. Cervical-thoracic-lumbar-sacral or thoracic-lumbar-sacral orthosis may be appropriate for the treatment of scoliosis in juvenile and adolescent patients at high-risk of progression. Vertebral Body Stapling and the Vertical Expandable Titanium Prosthetic Rib (with or without expansion thoracoplasty), are not recommended for treatment of Scoliosis. Senior Medical Director review 5/2010.
Laser-Assisted Tonsillectomy Policy archived.
Monoclonal Antibodies for Non-Hodgkin Lymphoma & Acute Myeloid Leukemia Specialty Matched Consultant Advisory Panel review 5/24/2010. Policy number removed. No changes to Guideline. References added.