Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for August 3, 2010

Medical Guidelines Reason for Update
Adoptive Immunotherapy Specialty Matched Consultant Advisory Panel review 5/24/2010. "Description" section revised. No change to policy statement. The "When Not Covered" section revised no change to policy intent. Added CPT codes 36511, 37799, and 96365 to the "Billing/Coding" section. References added.
Bone Mineral Density Studies Description section revised. Information in the When BMD Studies Are Covered was changed to read: An initial measurement of BMD at the hip or spine may be considered medically necessary to assess fracture risk and the need for pharmacologic therapy in both women and men who are considered at risk for osteoporosis. Repeat measurement of central BMD for individuals who previously tested normal may be considered medically necessary at an interval not more frequent than every 3-5 years; the interval depends on patient risk factors. Regular (not more frequent than every 2-3 years) serial measurements of central BMD to monitor treatment response may be considered medically necessary when the information will affect treatment decisions such as duration of therapy. The following statement added to the When Not Covered section: Dual x-ray absorptiometry (DEXA) body composition studies are considered investigational. Information in the Policy Guidelines section updated. Information regarding whole body dual x-ray absorptiometry added to policy. CPT 76499 added to Billing/Coding section. Notice given 4/27/10 for effective date of 8/3/10.
Bone Turnover Markers for Diagnosis and Management of Osteoporosis Policy retitled to Bone Turnover Markers for Diagnosis and Management of Osteoporosis from Collagen Cross Links as Markers of Bone Turnover. Specialty Matched Consultant Advisory Panel review 2/11/2010. Policy revisions include bone turnover markers other than collagen cross links. Bone turnover markers remain investigational in the diagnosis and management of osteoporosis. Reference sources added. Notice given 4/27/2010. Policy effective date 8/3/2010.
Cardiac Heart Transplantation Specialty Matched Consultant Advisory Panel review meeting. Medical Policy number removed. No changes to policy statement
Carotid Artery Angioplasty/Stenting (CAS) Specialty Matched Consultant Advisory Panel review 6/2010. Medical Policy number removed. Policy Guidelines updated. References updated.
Endothelial Keratoplasty Added statement under "When Endothelial Keratoplasty is not covered" section: Note: Treatment of side effects or complications as a result of a prior non-covered procedure (laser vision correction surgery) is a benefit exclusion under most benefit plans". Reviewed by Senior Medical Director.
Heart-Lung Transplantation Specialty Matched Consultant Advisory Panel review 6/2010. Removed Medical Policy number. References updated.
Intensity Modulated Radiation Therapy (IMRT) of Head and Neck Under Description Section, Head and Neck Tumors: added cancer of the central nervous system and cancer of the thyroid gland to the statement of cancers that are not generally considered as head and neck cancers. This addition per Senior Medical Director. No changes to policy statement.
Occipital Nerve Stimulation New policy. Occipital nerve stimulation is considered investigational for all indications. Reviewed by Senior Medical Director 7/6/2010. Notice given 8/3/2010. Effective date 11/9/2010.
Surgery for Morbid Obesity Description section updated to include information regarding endoluminal bariatric procedures. Revised criteria for Revision Bariatric Surgery in the When Covered section. In the When Not Section, statement regarding Sleeve Gastrectomy revised to read: [it is not covered] either as a stand-alone procedure or as the first step in a planned staged procedure for high-risk, super-obese patients. Also added the statement: Surgery for Morbid Obesity [is not covered] As a cure for type 2 diabetes mellitus. Added "licensed clinical social worker" to the Policy Guidelines section. Notification given 4/27/2010 for effective date 8/3/2010.
Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Vein Specialty Matched Consultant Advisory Panel review 6/2010. Medical Policy number removed. No changes in policy statement.
Evidence Based Guidelines
Biventricular Pacemakers for CHF Specialty Matched Consultant Advisory Panel review 6/2010. Removed Evidenced Based Policy Guideline number. Description section extensively revised. Added "An intrathoracic fluid monitoring sensor as a component of a biventricular pacemaker is not recommended" to the Not Recommended Indications section. References updated
Intravenous Anesthetics for the Treatment of Chronic Neuropathic Pain New Evidence Based Guideline. Intravenous infusion of anesthetics (e.g., ketamine or lidocaine) for the management of chronic neuropathic pain is not recommended. Reviewed by Senior Medical Director 7/6/2010.
Mechanical Embolectomy for Treatment of Acute Stroke Specialty Matched Consultant Advisory Panel review 6/2010. Policy Guideline number removed. References updated.
Transmyocardial Revascularization Status changed to active Evidence Based Guideline and will undergo routine literature review. Guideline Policy number removed. References updated. Specialty Matched Consultant Advisory Panel review 6/2010.
Ventricular Assist Devices and Total Artificial Hearts Guideline policy number removed. Extensively updated Description section. Added the following statement to Bridge to Transplant section: "Contraindications for bridge to transplant LVADs include conditions that would generally exclude patients for heart transplant. Such conditions are chronic irreversible hepatic, renal, or respiratory failure; systemic infection; and blood dyscrasia. Due to potential problems with adequate function of the VAD, implantation is also contraindicated in patients with uncorrected aortic insufficiency." References updated. Specialty Matched Consultant Advisory Panel review 6/2010.