Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for August 17, 2010

Medical Guidelines Reason for Update
Ankle Replacement, Total Specialty Matched Consultant Advisory Panel review 7/2010. Medical Policy number removed. Medical Terms and Definition section removed. References updated. Added statement to "Absolute Contraindications" that states, "Peripheral vascular disease which would potentially affect healing of the involved limb"
Surgery for Femoroacetabular Impingement Removed "Arthroscopic" from title of policy to reflect that the policy addresses both open and arthroscopic procedures for treatment of FAI. Specialty Matched Consultant Advisory Panel review 7/2010. References updated. Medical Policy number removed. Information regarding treatment of slipped capital femoral epiphysis (SCFE) added to Description section and Policy Guidelines. No changes to policy coverage criteria.
Autologous Chondrocyte Implantation Specialty matched Consultant Advisory Panel review 7/2010.
Bioimpedance Devices for Detection of Lymphedema New policy issued. Devices using bioimpedance (bioelectrical impedance spectroscopy) are considered investigational for use in the diagnosis, surveillance, or treatment of patients with lymphedema, including use in subclinical secondary lymphedema.
Bone Morphogenetic Protein Specialty Matched Consultant Advisory Panel review 7/2010. References updated. Removed policy number.
Computer Assisted Surgical Navigational Orthopedic Procedures Specialty Matched Consultant Advisory Panel review 7/2010. Removed Medical Policy number. Updated references. Updated Description section.
Congenital Heart Defect, Repair Devices Specialty Matched Consultant Advisory Panel review 6/2010. Removed Medical Policy number. Updated references
Continuous Passive Motion in the Home Setting Specialty Matched Consultant Advisory Panel review 7/2010. Removed Medical Policy number. Updated references.
Electrical Bone Growth Stimulation Specialty Matched Consultant Advisory Panel review 7/2010. Removed Medical Policy number. Updated references. Updated the "Policy Guidelines" section. Existing medically necessary policy statements modified by adding lumbar (spine) to the statements. Steroid use added as another high-risk condition for non-fusion. Added the following criteria to "When Not Covered” section: "3. Implantable and semi-invasive electrical bone growth stimulators are considered investigational. 4. Invasive, semi-invasive, and noninvasive electrical stimulation are considered investigational as an adjunct to cervical fusion surgery and for failed cervical spine fusion."
Endovascular Stent Graft for Aortic Aneurysm Specialty Matched Consultant Advisory Panel review 6/2010. Removed Medical Policy number. Description section revised. Statement added to the When Covered section that reads: "4. A ruptured abdominal aneurysm. For treatment of ruptured abdominal aortic aneurysm with endoprostheses, several factors must be considered including the following: a. The patient must be sufficiently stable to undergo detailed CT examination for anatomic measurements, b. The aneurysm should be anatomically appropriate for endovascular repair, and c. Specialized personnel should be available." Policy Guidelines updated. References updated. Added new CPT codes 0254T and 0255T.
Extracorporeal Shock Wave Treatment for Musculoskeletal Conditions Specialty Matched Consultant Advisory Panel review 7/2010. Medical Policy number removed. References updated.
Injectable Clostridial Collagenase for Fibroproliferative Disorders Specialty Matched Consultant Advisory Panel review 7/2010. No change in policy statement.
Intensity Modulated Radiation Therapy (IMRT) of Breast and Lung Under "when not covered section: removed the phrase "including but not limited to its use” within the statement " IMRT of the breast is considered investigational as a technique of partial breast irradiation after breast-conserving surgery".
Meniscal Allografts and Collagen Meniscus Implants Policy renamed from "Meniscal Allograft Transplantation" to "Meniscal Allografts and Collagen Meniscus Implants". Revised Description section. Removed Medical Policy number. New statements added to Policy section that state: "BCBSNC will not cover collagen meniscus implants. They are considered investigational. BCBSNC does not cover investigational services." New statement added to "Not Covered" section that states: "Collagen meniscus implants are considered investigational." Policy Guidelines section updated to include information regarding collagen meniscus implants. New code G0428 added to Billing section. References updated. Specialty Matched Consultant Advisory Panel review 7/2010.
Microprocessor-Controlled Prostheses for the Lower Limb Specialty Matched Advisory Panel review 7/2010. Added the following statements to the When Covered section: "Reimbursement for microprocessor-controlled knees may only occur if there is a documented evaluation by a trained prosthetic clinician. The clinician performing the evaluation may not be an employee of or have a financial relationship with the supplier of the device." Medical Policy number removed.
Myoelectric Prosthetic Components for the Upper Limb New policy implemented. Myoelectric prosthetic components for the upper limb may be considered medically necessary in amputees who meet the criteria and guidelines outlined in the policy.
Osteochondral Grafting in the Treatment of Articular Cartilage Lesions Specialty Matched Consultant Advisory Panel review 7/2010. Medical Policy number removed. References updated. Description section updated. Policy Guidelines updated to state: "If debridement is the only prior surgical treatment, consideration should be given to marrow-stimulating techniques before osteochondral grafting is performed. Severe obesity, e.g., body mass index (BMI) greater than 35 kg/m², may affect outcomes due to the increased stress on weight bearing surfaces of the joint. Misalignment and instability of the joint are contraindications. Therefore additional procedures, such as repair of ligaments or tendons or creation of an osteotomy for realignment of the joint, may be performed at the same time."
Partial Hip Resurfacing Specialty Matched Consultant Advisory Panel review 7/2010. Medical Policy number removed. Information in the When Partial Hip Resurfacing Is Covered section revised to read: "Partial hip resurfacing with an FDA-approved device may be considered medically necessary in patients with osteonecrosis of the femoral head who have one or more contraindications for metal-on-metal implants and meet the following criteria: The patient is a candidate for toal hip replacement, and Is likely to outlive a traditional prosthesis; and The patient has known or suspected metal sensitivity or concern about potential effects of metal ions; and There is no more than 50% involvement of the femoral head; and There is minimal change in acetabular cartilage or articular cartilage space identified on radiography." Statement in the When Partial Hip Resurfacing is Not Covered revised to read: "All other types and applications of partial hip resurfacing are considered investigational." Rationale in the Policy Guidelines section updated. References updated.
Prolotherapy Specialty Matched Consultant Advisory Panel review 7/2010. Description section updated. References updated. Medical Policy number removed.
Real-Time Intra-Fraction Target Tracking During Radiation Therapy Policy name changed from Image Guided Radiation for Prostate Cancer to Real-Time Intra-Fraction Target Tracking During Radiation Therapy for consistency with BCBSA policy. No changes to policy statement. Reviewed with Senior Medical Director.
Reverse Shoulder Arthroplasty Specialty Matched Consultant Advisory Panel review 7/2010. Medical Policy number removed.
Subtalar Arthroereisis Specialty Matched Consultant Advisory Panel review 7/2010. References updated. Medical Policy number removed.
Total Hip Resurfacing Specialty Matched Consultant Advisory Panel review 7/2010. Description section extensively revised. Medical Policy number removed. The When Total Hip Resurfacing is Covered section was revised to state, "Metal-on-metal total hip resurfacing with a device system approved by the U.S. Food and Drug Administration (FDA) may be considered medically necessary as an alternative to total hip replacement when the patient: is a candidate for total hip replacement; AND is likely to outlive a traditional prosthesis; AND does not have a contraindication for total hip resurfacing." Policy Guidelines section updated. References updated.
Ultrasound Accelerated Fracture Healing Device Specialty Matched Consultant Advisory Panel review 7/2010. Medical Policy number removed. References updated.
Vertebral Axial Decompression (VAD-X) Specialty Matched Consultant Advisory Panel review 7/2010. Removed Medical Policy number. References updated.
Evidence Based Guidelines
Intra Articular Hyaluronan Injections for Treatment of Osteoarthritis of the Knee Specialty Matched Consultant Advisory Panel review 7/ 2010. Removed Guideline number. Extensively revised Description section. Updated References.