Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for August 31, 2010

Medical Guidelines Reason for Update
Analysis of Proteomic Patterns In Serum to Identify Ovarian Cancer Senior Medical Director review 7/7/2010. "Description" revised. No changes to policy statement. References added.
Correlated Audioelectric Cardiography Billing Information updated with new codes 0223T, 0224T, 0225T. Removed codes 0068T, 0069T, and 0070T
Growth Factors in Wound Healing Coding update. CPT 0232T added to Billing/Coding section.
Hematopoietic Stem-Cell Transplantation for Multiple Myeloma Policy name changed from "Bone Marrow Transplantation for Multiple Myeloma" to Hematopoietic Stem-Cell Transplantation for Multiple Myeloma. The policy has been extensively revised. Policy number removed. "Description" revised. The policy statements have been updated to reflect current practice. Removed the statement in the "Benefit Application" section that indicated "Services for or related to the search for a donor are not covered." Deleted the following "When Covered" statements: "1. HDC and autologous stem cell support may be considered medically necessary in the treatment of newly diagnosed or responsive multiple myeloma. OR 2.HDC and autologous stem cell support may be considered medically necessary in the treatment of multiple myeloma patients with primary progressive disease who are not at high risk. OR 3.A second course of high-dose chemotherapy with autologous stem-cell support may be considered medically necessary to treat responsive multiple myeloma that has relapsed after a durable complete or partial remission following an autologous transplant. OR 4 .Tandem high-dose chemotherapy with autologous stem-cell support may be considered medically necessary to treat newly diagnosed or responsive multiple myeloma. OR 5.Tandem transplantation with an initial round of autologous stem cell support followed by a non- marrow-ablative conditioning regimen and allogeneic stem cell transplant may be considered medically necessary to treat newly diagnosed multiple myeloma patients with an Human leukocyte antigens (HLA)-identical sibling donor and who are in otherwise reasonably good health." Removed the following "When Not Covered" statements: " HDC and autologous stem cell support is considered investigational in the treatment of multiple myeloma in refractory relapse." and "Monotherapy using high-dose chemotherapy with allogeneic stem-cell support is considered investigational, either as initial therapy or after a prior failed course of high dose chemotherapy and autologous stem cell support." Policy Guidelines revised. Senior Medical Director review 5/3/10 References added.
Hematopoietic Stem-Cell Transplantation for CLL and SLL Policy name changed from "Bone Marrow Transplant for CLL and SLL" to Hematopoietic Stem-Cell Transplantation for CLL and SLL'. Removed policy number. Policy extensively revised. "Description" section revised. "Hematopoietic Stem-Cell Transplantation for Chronic Lymphocytic Leukemia (CLL) and Small Lymphocytic Lymphoma (SLL) when it is determined to be medically necessary because the medical criteria and guidelines shown below are met." Added two indications under the "When Covered" section to state; "Allogeneic hematopoietic stem-cell transplantation may be considered medically necessary to treat chronic lymphocytic leukemia or small lymphocytic lymphoma in patients with markers of poor-risk disease (see Guidelines). "Use of a myeloablative or reduced-intensity pretransplant conditioning regimen should be individualized based on factors that include patient age, the presence of comorbidities, and disease burden." Added the following statements to the "When Not Covered" section: "Allogeneic hematopoietic stem-cell transplantation is considered investigational to treat chronic lymphocytic leukemia or small lymphocytic lymphoma except as noted above." "Autologous hematopoietic stem-cell transplantation is considered investigational to treat chronic lymphocytic leukemia or small lymphocytic lymphoma." Policy Guidelines written to include staging information, "Table 1 Rai and Binet Classification for CLL/SLL", and "Table 2. Markers of Poor Prognosis in CLL/SLL". Reviewed by Senior Medical Director 5/3/2010.
Hematopoietic Stem-Cell Transplantation in the Treatment of Germ Cell Tumors Policy name changed from "Bone Marrow Transplant for Germ Cell Tumors" to "Hematopoietic Stem-Cell Transplantation in the Treatment of Germ Cell Tumors". Removed reference to "Bone Marrow Transplant, high dose chemotherapy and stem cell support" and inserted "hematopoietic stem-cell transplantation" throughout policy as appropriate. Senior Medical Director Review 7/25/2010. Policy statements reworded extensively. Policy statements changed to indicate that tandem-sequential autologous SCT may be considered medically necessary in certain types of testicular cancers. "Guidelines" section revised. References added.
Orthopedic Applications of Stem Cell Therapy Policy Guideline section updated with clinical trial and product information. References updated.
Spinal Cord Stimulation Medical Director review 8/5/2010. "Description" section revised. Added to the "When Covered" section, 1."that has been refractory to all other pain therapies." and "5. No untreated drug habituation exists". Removed the following criteria statements; "Treatment is consistent with the multidisciplinary evaluation findings and management recommendations; and The patient is capable and willing to comply with the treatment plan." Changed statement in "B" from "the patient has demonstrated pain relief of at least 50% for at least 48 hours" to "the patient has demonstrated pain relief of at least 50% for a minimum of 48 hours with the temporarily implanted electrode with the temporarily implanted electrode No change to policy intent. References added.
Ustekinumab (Stelara) Billing Information updated to include code J3490.
Evidence Based Guidelines
Apolipoprotein B in Cardiac Disease Risk Assessment Policy Archived. Apolipoprotein B in Cardiac Disease Risk Assessment is now included in Evidence Based Guideline titled, "Novel Lipid Risk Factors in Risk Assessment and Management of Cardiovascular Disease".
Apolipoprotein E Genotype or Phenotype in Cardiac Disease Risk Assessment Policy Archived Apolipoprotein E Genotype or Phenotype in Cardiac Disease Risk Assessment is now included in Evidence Based Guideline titled, "Novel Lipid Risk Factors in Risk Assessment and Management of Cardiovascular Disease".
Arthroscopic Debridement and Lavage as Treatment of Knee Osteoarthritis New Evidence Based Guideline developed. Arthroscopic debridement and/or lavage is not recommended for treatment of osteoarthritis of the knee. Note: Arthroscopic debridement may be recommended when preoperative imaging indicates that specific anatomic lesions other than osteoarthritis, e.g., large meniscal tears, loose bodies, are the cause of the patient’s symptoms regardless of the presence of osteoarthritis.
High-Density Lipoprotein Subclass Testing in Cardiac Disease Risk Assessment Policy Archived. High-Density Lipoprotein Subclass Testing in Cardiac Disease Risk Assessment is now included in Evidence Based Guideline titled, "Novel Lipid Risk Factors in Risk Assessment and Management of Cardiovascular Disease".
Lipoprotein(a) Enzyme Immunoassay in Cardiac Disease Risk Assessment Policy Archived. Lipoprotein (a) Enzyme Immunoassay in Cardiac Disease Risk Assessment is now included in Evidence Based Guideline titled, "Novel Lipid Risk Factors in Risk Assessment and Management of Cadiovascular Disease".
dxNovel Lipid Risk Factors in Risk Assessment of Cardiovascular Disease New Evidenced Based Guideline created by consolidating the following policies: "Apolipoprotein B in Cardiac Disease Risk Assessment", "Lipoprotein(a) Enzyme Immunoassay in Cardiac Disease Risk Assessment", "High-Density Lipoprotein Subclass Testing in Cardiac Disease Risk Assessment", and "Apolipoprotein E Genotype or Phenotype in Cardiac Disease Risk Assessment". Novel lipid risk factor measurements are not recommended for risk assessment of cardiovascular disease.
Sacroiliac Joint Arthrography and Injection New Evidence Based Guideline implemented. Sacroiliac joint arthrography and/or injection are not recommended as treatment for sacroiliac pain.