Medical Policy Updates

Blue Cross and Blue Shield of North Carolina Medical Policy Update for July 20, 2010

Medical Guidelines	Reason for Update
Functional Endoscopic Sinus Surgery (FESS)	Minor changes in Description section. In the When FESS is covered section: Revised Item 1.c. to read "For chronic rhinosinusitis, documentation of coronal CT and/or nasal endoscopy following optimal medical therapy showing persistent sinus pathology." Added item 1.d. which reads "For recurrent acute rhinosinusitis, coronal CT and nasal endoscopy may be normal after treatment. However, CT and/or nasal endoscopy during acute rhinosinusitis should document sinus pathology amenable to surgical treatment." Revised Item 2 to read "Multiple or recurrent polyps with airway obstruction and failure of optimal medical management (including assessment for allergy symptoms, and allergy evaluation if indicated) with persistent sinus disease on follow up CT scan and/or nasal endoscopy." Revised Item 4 to read "Chronic anterior headache or facial pain..." Inserted new items 6, 7 and 8 which read "6) Recurrent sinusitis with significant associated comorbid conditions (some examples include immune system disorders, and congenital or acquired ciliary dyskinesia), 7) Recurrent sinusitis which exacerbates significant comorbid conditions (including but not limited to asthma, recurrent bronchitis or pneumonia, diabetes), and 8) Multidrug resistant organisms identified by culture. Revised newly numbered Item 9 to read "Sinonasal benign or malignant tumor (including inverted papilloma)." In the Policy Guidelines section, revised item 3.f. to read "antibiotic therapy consisting of three consecutive weeks of appropriate antibiotic drugs, OR multiple two to three week courses of appropriate antibiotic drugs during the symptomatic periods." CPT Codes 31237 and 31240 deleted from the Billing/Coding section
Genetic Testing for Long QT Syndrome	Description section extensively revised to include the Schwartz Diagnostic Scoring System for LQTS. Policy Guidelines updated. References updated. No change to Policy Statement.
Sacral Nerve Neuromodulation/Stimulation for Pelvic Floor Dysfunction	Description section updated. Removed Medical Policy number. References updated. Updated Policy Guidelines. When Covered section updated to include fecal incontinence with the following criteria: "chronic fecal incontinence of greater than 2 incontinent episodes on average per week with duration greater than 6 months or for more than 12 months after vaginal childbirth; AND documented failure or intolerance to conventional therapy (e.g., dietary modification, the addition of bulking and pharmacologic treatment for at least a sufficient duration to fully assess its efficacy, and/or surgical corrective therapy performed more than 12 months [or 24 months in case of cancer] previously); AND the patient is an appropriate surgical candidate; AND a successful percutaneous test stimulation, defined as at least 50% improvement in symptoms, was performed; AND condition is not related to an anorectal malformation (e.g., congenital anorectal malformation; defects of the external anal sphincter over 60 degrees; visible sequelae of pelvic radiation; active anal abscesses and fistulae) or chronic inflammatory bowel disease; AND incontinence is not related to another neurologic condition such as peripheral neuropathy or complete spinal cord injury."
Sleep Apnea: Diagnosis and Medical Management	Specialty Matched Consultant Advisory Panel Review 5/24/10. No change to policy statement or coverage criteria.
Surgery for Obstructive Sleep Apnea and Upper Airway Resistance Syndrome	Specialty Matched Consultant Advisory Panel review 5/24/10. No change to policy statement or coverage criteria.
Varicose Veins, Treatment For	This policy is NOT effective until October 26, 2010, Description section extensively revised. The sections for when treatment for varicose veins is and is not covered were reformatted. The following was added to the When Varicose Vein Treatment Is Covered section: "Surgical ligation (including subfascial endoscopic perforator surgery) or endovenous radiofrequency or laser ablation of incompetent perforator veins may be considered medically necessary as a treatment of leg ulcers associated with chronic venous insufficiency when the following conditions have been met: There is demonstrated perforator reflux; AND The superficial saphenous veins (greater, lesser, or accessory saphenous and symptomatic varicose tributaries) have been previously eliminated; AND Ulcers have not resolved following combined superficial vein treatment and compression therapy for at least 3 months; AND The venous insufficiency is not secondary to deep venous thromboembolism." The following statements were added to the When Varicose Vein Treatment Is Not Covered section: "Treatment of symptomatic varicose tributaries when performed either at the same time or following prior treatment of saphenous veins using any other techniques than noted above is considered investigational. Ligation or ablation of incompetent perforator veins performed concurrently with superficial venous surgery is not medically necessary." Also "Endovenous cryoablation of any vein" is investigational and not covered. Definition of "compressive therapy" moved to Policy Guidelines section. Rationale for coverage added to Policy Guidelines section. The following statements were added to the Billing/Coding section: "There is no specific CPT code for transilluminated powered phlebectomy. CPT codes 37765, 37766 or 37799 could be used.If CPT 76942 is used for ultrasound guidance of sclerotherapy of the varicose tributaries, it would be considered either not medically necessary or incidental to the injection procedure". References updated. Notification given 7/20/10 for effective date of 10/26/10.
Evidence Based Guidelines
Isolated Limb Perfusion/Infusion	Policy status changed from Active Archive to Active. Medical Policy converted to Evidence Based Guideline. Policy name changed to include "Infusion". "Description" completely revised to include information regarding isolated limb infusion. Added new indication under the “When Covered” section to state; "Isolated limb infusion (ILI) with melphalan may be considered medically necessary when used as a therapeutic treatment of local recurrence of nonresectable melanoma (i.e., satellite lesions or "in transit" melanoma)." Clarified the "When Not Covered" section by including an additional statement; "Isolated limb infusion in the treatment of melanoma is considered investigational for all other indications." "Guidelines" updated. Specialty Matched Consultant Advisory Panel review 5/24/2010. References added.
Monoclonal Antibodies for Non-Hodgkin Lymphoma & Acute Myeloid Leukemia	Specialty Matched Consultant Advisory Panel review 5/24/2010. No changes to Guideline. References added.