Medical Policy Updates
Blue Cross and Blue Shield of North Carolina Medical Policy Update for September 28, 2010
| Medical Guidelines | Reason for Update |
|---|---|
| Computer-Aided Evaluation of Malignancy with MRI of the Breast | Name of policy changed from Computer-Aided Detection to Computer Aided Evaluation. The word "detection" changed to "evaluation" throughout the policy. Acronym "CAD" changed to "CAE" throughout the policy. Description section extensively revised. Specialty Matched Consultant Advisory Panel review 8/25/10. No change in policy statement. Draft policy approved as written. |
| CT Perfusion Imaging | Description section extensively revised. Rationale added to Policy Guidelines section. References updated. Specialty Matched Consultant Advisory Panel review 8/25/2010. No change to policy statement. Draft policy approved as written. |
| Dental, Criteria for use of Hospital Inpatient or Outpatient Facility Services or Ambulatory Surgery Center Facility Services | Under "When Covered" section 1.c. and 2.d. changed from 9 years and under to below the age of 9 years. Under Policy Guidelines added "Prior review and certification are required for inpatient admission for dental/oral surgery." Under Policy Guidelines, changed statement "Claims should be reviewed by individual consideration for documentation of medical necessity to "Claims should be reviewed for documentation of medical necessity." Specialty Matched Consultant Advisory Panel review 1/2010. Reviewed by Senior Medical Director. |
| 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. Policy status changed to "Archived." |
| Electrothermal Arthroscopic Capsulorrhaphy | Specialty Matched Consultant Advisory Panel review 7/2010. Removed Medical Policy number. Description section extensively revised. In Policy section and in When not covered section changed "Investigational" to "Not Medically Necessary". Policy Guidelines updated. References updated. |
| Growth Hormone | Specialty Matched Consultant Advisory Panel review 8/2010. Added the following statements to When Covered section: "a. Documentation of significant growth deceleration is sufficient for children with history of relevant CNS pathology or history of brain irradiation. b. Neonates with hypoglycemia and growth hormone deficiency (one abnormal GH test is sufficient for hypoglycemic neonates in whom growth hormone deficiency is suspected) " and "GH therapy may be resumed one year following kidney transplant if catch up growth has not occurred." References updated. |
| Hematopoietic Stem-Cell Transplantation for Hodgkin Lymphoma | Policy named changed from "Bone Marrow Transplant for Hodgkin's Disease" to "Hematopoietic Stem-Cell Transplantation for Hodgkin Lymphoma". "Description" revised. Removed the statement in the "Benefit Application" section that indicated "Services for or related to the search for a donor are not covered." Changed reference to "bone marrow transplant with high dose chemotherapy with stem cell support" to "hematopoietic stem-cell transplantation" where appropriate. Added to the "When covered" section the following: "Tandem autologous HSCT may be considered medically necessary:*in patients with primary refractory HL or *in patients with relapsed disease with poor risk features who do not attain a complete remission to cytoreductive chemotherapy prior to transplantation (see Policy Guidelines)." And "Reduced-intensity allogeneic HSCT may be considered medically necessary to treat HL in patients:*who have failed a prior autologous HSCT used to treat primary refractory or relapsed disease or *in patients who would otherwise qualify for a myeloablative allogeneic transplant, but would be unable to tolerate a standard myeloablative conditioning regimen (see Policy Guidelines) or *when insufficient stem cells are collected for an autologous HSCT." Updated "Policy Guidelines". References added. |
| High-Intensity Focused Ultrasound for Treatment of Prostate Cancer | Added the following statement to the When HIFU Is Not Covered section: Use for the palliative treatment of bone metastases is also considered investigational. Updated Policy Guidelines section. Specialty Matched Consultant Advisory Panel review meeting 8/25/10. No change in policy statement. |
| Insulin Therapy, Chronic Intermittent Intravenous (CIIIT) | Specialty Matched Consultant Advisory Panel review 8/2010. References updated. |
| Islet Cell Transplantation | Specialty Matched Consultant Advisory Panel review 8/2010. Updated references. Updated Policy Guidelines. |
| Lung Cancer Screening, CT Scanning or Chest Radiographs | Description section revised. Investigational statements reworded, but intent is unchanged. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 8/25/10. Draft policy accepted as written. |
| Magnetic Resonance Spectroscopy | Description section extensively revised. Investigational statement reworded but intent is unchanged. Specialty Matched Consultant Advisory Panel review 8/25/10. Draft policy accepted as written. |
| Magnetoencephalography/Magnetic Source Imaging |
Statement in the When MEG/MSI is Covered section reworded for clarity: Magnetoencephalography may be considered medically necessary |
| MRI-Guided High Intensity Ultrasound Ablation of Uterine Fibroids | Description section revised. Investigational statement reworded but intent remains unchanged. Policy Guidelines updated. Coding information added to Billing/Coding section. Specialty Matched Consultant Advisory Panel review 8/25/10. Draft approved as written. |
| Non-Invasive Measurement of Left Ventricular End Diastolic Pressure | Policy archived. Non-Invasive Measurement of Left Ventricular End Diastolic Pressure is now included in the Corporate Medical Policy titled, "Cardiac Hemodynamic Monitoring in the Outpatient Setting". |
| Non-Pharmacologic Treatment of Rosacea | Added Diagnosis code 695.3 to "Billing/Coding" section. |
| Orthognathic Surgery | Under "When covered section" changed wording from Orthognathic surgery "is covered" to "may be medically necessary" for elements A-E. Added new element E and new coverage criteria under element E to include treatment of documented obstructive sleep apnea (OSA). Under the "When not covered section" added to bullet #4: Orthognathic surgery performed to reshape or enhance the size of the chin to restore facial harmony and chin projection, chin implants, mandibular osteotomies, ostectomiest to address genial hypoplasia, hypertrophy or asymmetry when performed either as an isolated procedure or with other procedures is considered cosmetic in nature. Added bullet #5: Cosmetic augmentation of the mandibular angle or body is not covered. This procedure may be performed to add prominence and balance to the face. Under "policy guidelines" added new information to bullet #3: as indicated under "when not covered", genioplasty, mentoplasty chin augmentation, chin implants, mandibular osteotomies, ostectomies (21120, 21121, 21122, 21123, and 21198) are considered cosmetic procedures and are not covered. Also in the non-covered section, added cosmetic augmentation of the mandibular angle or body (21125 and 21127) is not covered (a.k.a. "jaw augmentation"). Specialty Matched Consultant Advisory Panel review 1/2010. Reviewed with Senior Medical Director 8/2010. 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." |
| Spinal Manipulation under Anesthesia | Policy status changed from "Active Policy: No longer scheduled for routine literature review" to active policy. "Description" section extensively revised,." Spinal manipulation (and manipulation of other joints, e.g., hip joint, performed during the procedure) with the patient under anesthesia, spinal manipulation under joint anesthesia, and spinal manipulation after epidural anesthesia and corticosteroid injection are considered investigational for treatment of chronic spinal (cranial, cervical, thoracic, lumbar) pain and chronic sacroiliac and pelvic pain." No change to policy intent. Reviewed by Medical Director.8/10/10. References added. |
| Thermography | Description section revised. Investigational statement reworded but intent is unchanged. Specialty Matched Consultant Advisory Panel review 8/25/10. Draft accepted as written. |
| Treatment for Severe Primary IGF-1 Deficiency | Specialty Matched Consultant Advisory Panel review 8/2010. References updated |
| Vertebroplasty, Kyphoplasty, and Sacroplasty Percutaneous | Policy reviewed by Medical Director 8/26/2010. Added Sacroplasty to policy name. Added information pertaining to Percutaneous Sacroplasty to "Description" section. Added under "Policy" section; "Percutaneous Sacroplasty is considered investigational for all applications. BCBSNC does not provide coverage for investigational services or procedures." Added comment to the "When Not Covered" section to indicate; "Percutaneous sacroplasty is considered investigational for all indications." CPT 0200T and 0201T added to the "Billing/Coding" section. "Policy Guidelines" updated. References added. |
| 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 | |
| Dynamic Spinal Visualization | Description section revised. Specialty Matched Consultant Advisory Panel review 8/25/2010. No change in guideline statement. Draft policy approved as written. |
| External Insulin Pumps | Specialty Matched Consultant Advisory Panel review 8/2010. References updated. |
| Hospice Care | Added new HCPCS code, Q5010 effective 10/1/10 to the "Billing/Coding" section. Archive policy as treatment is standard of care. |
| Screening for Vertebral Fracture with Dual X-ray Absorptiometry (DEXA) | Specialty Matched Consultant Advisory Panel review. No changes to guideline. |
| Ultraviolet Light Box Therapy in the Home (UVB) | Added diagnosis code 709.1 to "Billing/Coding" section |