Medical Policy Updates

Blue Cross and Blue Shield of North Carolina Medical Policy Update for September 14, 2010

Medical Guidelines	Reason for Update
Cosmetic and Reconstructive Surgery	Revised comments regarding Telangiectasis or spider veins under the Reconstructive Procedures that states, "Laser treatment of port wine stains in the presence of functional impairment related to the port wine stain may be considered medically necessary. Refer to Medical Policy entitled, Laser Treatment of Port Wine Stain for policy guidelines." Reference added.
Electrical Impedance Scanning of the Breast	Description section updated. CPT Code 0060T deleted from the Billing/Coding section. Policy Guidelines section updated. There is no specific code for this policy. BCBSA policy archived 12/09. Policy archived
Enhanced External Counterpulsation (EECP)	Policy statement revised to read: "BCBSNC will provide coverage for Enhanced External Counterpulsation when it is determined to be medically necessary because the medical criteria and guidelines shown below are met." Added the following criteria to When Covered section: "Coverage is provided for the use of EECP for patients who have been diagnosed with disabling angina (New York Heart Association Class III or IV, or equivalent classification) who, in the opinion of a cardiologist or cardiothoracic surgeon, are refractory to maximum medical therapy and are not readily amenable to surgical intervention, such as PTCA or cardiac bypass because: Their condition is inoperable, or at high risk of operative complications or post-operative failure; or Their coronary anatomy is not readily amenable to such procedures; or They have co-morbid states that create excessive risk." Revised the When Not Covered section to read: "The use of EECP is considered investigational for all other indications not noted above including, but not limited to the treatment of Class II angina, arrhythmia, aortic insufficiency, peripheral vascular disease or phlebitis, severe hypertension, acute retinal artery occlusion, acute myocardial infarction, cardiogenic shock or congestive heart failure." Removed the following statement from the Policy Guidelines section: "Use of EECP in patients who meet the Medicare coverage criteria noted above may be approved on an individual consideration basis."
Hematopoietic Stem-Cell Transplantation for Chronic Myelogenous Leukemia	Policy name changed from Bone Marrow Transplant for Chronic Myelogenous Leukemia. "Description" section completely revised. Removed statement under "Benefit Application" indicating that "Services for or related to the search for a donor are not covered." Changed wording in the "When Covered" section to indicate; "Allogeneic stem-cell transplantation using a myeloablative conditioning regimen may be considered medically necessary as a treatment of chronic myelogenous leukemia (see Policy Guidelines). Allogeneic SCT using a reduced-intensity conditioning (RIC) regimen may be considered medically necessary as a treatment of chronic myelogenous leukemia in patients who meet clinical criteria for an allogeneic SCT but who are not considered candidates for a myeloablative conditioning allogeneic SCT." Updated "Policy Guidelines" section. References updated.
Home Uterine Activity Monitoring	Description section revised. Policy statement revised to read: "Home Uterine Activity Monitoring is considered not medically necessary. BCBSNC does not provide coverage for services or procedures that are not medically necessary."
Monoclonal Antibody Imaging	Specialty Matched Consultant Advisory Panel review 5/24/2010. "Description" section revised. No change to policy statement. References added.
Positional Magnetic Resonance Imaging (MRI)	Description section revised. Policy Guidelines updated. Policy status changed to "Active policy, no longer scheduled for routine literature review."
Surgical Ventricular Restoration	New policy developed. Surgical ventricular restoration is considered investigational for the treatment of ischemic dilated cardiomyopathy or post-infarction left ventricular aneurysm. Senior Medical Director review 5/3/10. Specialty Matched Consultant Advisory Panel review 6/2010. Notification given 6/8/10 for effective date of 9/14/10.
Whole Body Computed Tomography Scan as a Screening Test	Description section revised. No change in policy statement. Policy status changed to "Active policy, no longer scheduled for routine literature review."
Evidence Based Guidelines
Biochemical Markers of Alzheimer's Disease	New evidence based guideline written. Reviewed by Medical Director 8/10/10. "Biochemical markers of Alzheimer's disease using measurement of cerebrospinal fluid biomarkers, including but not limited to tau protein, amyloid beta peptides, or neural thread proteins, is not recommended." "Measurement of urinary biomarkers of Alzheimer's disease is not recommended, including but not limited to neural thread proteins."
Gene-Based Tests for Screening, Detection, and/or Management of Prostate Cancer	"Description" section rewritten. Added examples of tests under the "Not Recommended" section to include; single-nucleotide polymorphisms (SNPs) for risk assessment, PCA3 for disease diagnosis, TMPRSS fusion genes for diagnosis and prognosis, multiple gene tests (gene panels) for prostate cancer diagnosis, gene hypermethylation for diagnosis and prognosis". Updated the rationale. Reviewed by Medical Director 8/10/2010. References added
Genetic Testing for Familial Alzheimer's Disease	New evidence based guideline. Reviewed by Medical Director 8/10/2010. "Genetic testing for the diagnosis or risk assessment of Alzheimer's disease not recommended. Genetic testing includes, but is not limited to, testing for the apolipoprotein E epsilon 4 allele, presenilin genes, or amyloid precursor gene."
Herceptin	"Description" section extensively revised. Reworded the "When Recommended" section to indicate; "Trastuzumab may be appropriate, when used in combination with systemic chemotherapy, for treatment of patients with advanced (locally advanced or metastatic) gastric cancer or gastroesophageal junction adenocarcinoma whose tumors overexpress the HER2 protein (HER2-positive cancer). " The "When Not Recommended" section reworded to remove reference to gastric cancer and gastroesophageal adenocarcinoma. Medical Director review 8/10/2010. References added.
Uterine Artery Occlusion in the Treatment of Uterine Fibroids	Guideline status changed--has been returned to active review. Description section revised. Evidence Based Guideline statement changed to read: "Transcatheter embolization of uterine arteries may be appropriate as a treatment of uterine fibroids." Added the recommendation from the American College of OB/GYN regarding general criteria for treatment of fibroid tumors All other statements in this section were deleted. Everything in the Not Recommended section was deleted except for the statements regarding repeat embolization treatments and laparoscopic occlusion using bipolar coagulation. A Rationale section was added with supporting documentation.