Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for October 26, 2010

Medical Guidelines Reason for Update
Bioengineered Skin Added new product information to "Description" section for Cymetra®, C-Qur™, Avaulta Plus™, Collamend, Cuffpatch™, DermaMatrix Acellular Dermis, E-Z Derm™, Integra™ Matrix Wound Dressing, Mediskin®, Oasis™, OrthADAPT™, Pelvicol®, Pelvisoft®, PriMatrix, Strattice™, Surgimend®, Surgisis®, Unite™. These products have been added to the "What is not Covered" section. Updated references. Specialty Matched Consultant Advisory Panel review 9/2010. Added HCPCS codes C9358, C9360, C9363 and C9364 to Billing/Coding section.
Chemoembolization of the Hepatic Artery, Transcatheter Approach Added diagnoses codes to the "Billing/Coding" section.
Collagen Implantation Added new codes to policy: G0429, Q2026, Q2027, C9800.
Cosmetic and Reconstructive Surgery Specialty Matched Consultant Advisory Panel review 9/2010. Replaced "vaccination" with "asymptomatic" under "Repair/revision of scars" in Cosmetic Examples table. References updated. Reformatted the Billing/Coding section.
EMDR (Eye Movement Desensitization and Reprocessing) Description section extensively revised. The following was added to the EBG Statement: "The techniques of EMDR are considered tools within the framework of comprehensive treatment in which application of an evidenced-based psychotherapeutic method is the primary treatment." The statement in the Not Recommended section was deleted and replaced with the following: "EMDR would not be considered appropriate for the treatment of other psychiatric and behavioral disorders including phobias, eating disorders, and panic and anxiety disorders other than PTSD because its effectiveness for these indications has not been established." References updated. Specialty Matched Consultant Advisory Panel review 9/30/10. Draft policy accepted as written. Policy Archived.
Gastric Electrical Stimulation Description section revised. Specific diagnoses added to Billing/Coding section. Policy Guidelines and References updated. No change to policy statement or criteria.
Genetic Testing for Breast and Ovarian Cancer Added the following information to the "Description" section; "CHEK2 (cell cycle checkpoint kinase2) is also involved with DNA repair and human cancer predisposition like BRCA1 and BRCA2. CHEK2 is normally activated in response to DNA double-stranded breaks. CHEK2 regulates the function of BRCA1 protein in DNA repair and also exerts critical roles in cell cycle control and apoptosis. The CHEK2 mutation, 1100delC in exon 10 has been associated with familial breast cancers." Added "fallopian tube and primary peritoneal cancer" as additional BRCA-associated malignancies to assess when obtaining the family history throughout policy as appropriate. Reformatted the "When Covered" and "When Not Covered" section. Added "C. Testing for genomic rearrangements of the BRCA1 and BRCA2 genes may be considered medically necessary when: criteria for BRCA testing are met, and testing for point mutations is negative, and there are 3 or more family members (one lineage) affected with breast, ovarian, fallopian tube, or primary peritoneal cancer, or there is a risk of a BRCA mutation of at least 10%. (See Policy Guidelines)" to the "When Covered" section. Added "C. Testing for CHEK2 genetic abnormalities (mutations, deletions, etc.) is considered investigational in patients with breast cancer regardless of the family history." To the "When Not Covered" section. Added the following to the "Policy Guidelines" section; "For the purposes of this policy, an individual with a history of breast, ovarian, fallopian tube, or primary peritoneal cancer is considered to be from a "family with a high risk of BRCA1 or BRCA2 mutation" when one or more of the high risk criteria below are met." "Please Note: The US Preventative Services Task Force (USPSTF) recommendations for identifying families at high risk for mutation in the BRCA1 and BRCA2 gene applies to women without breast, ovarian, fallopian tube, or primary peritoneal cancer. In situations where the woman has breast, ovarian, fallopian tube, or primary peritoneal cancer, the family is considered at high risk for mutation if the overall family history (one lineage) including the affected individual meets the criteria below." "7. Comprehensive mutation analysis currently includes sequencing the coding regions and intron/exonsplice sites as well as tests to detect common large deletions and rearrangements that can be missed with sequence analysis alone. However, current routine laboratory testing for genomic rearrangement is more limited than the criteria noted in the policy statement; automatic testing is specified for those with a risk of BRCA mutation of at least 30%. In addition, prior to August 2006, testing for large deletions and rearrangements was not performed, thus some patients with familial breast cancer who had negative BRCA testing prior to this time may consider repeat testing for the rearrangements." "8.Based on data available at this time, there is no compelling evidence to justify routine clinical testing for CHECK2 to guide the management of families affected with breast cancer." Reviewed with Senior Medical Director 9/27/10. References added.
Hematopoietic Stem-Cell Transplantation for CNS Embryonal Tumors and Ependymoma Policy name changed from "Bone Marrow Transplant for Neuroectodermal Tumors and Ependymoma" to "Hematopoetic Stem-Cell Transplantation for CNS Embryonal Tumors and Ependymoma". "Description" section entirely revised. . Removed the statement in the "Benefit Application" section that indicated "Services for or related to the search for a donor are not covered." Removed reference to "Bone Marrow Transplant, high dose chemotherapy and stem cell support" and inserted "hematopoietic stem-cell transplantation" throughout policy as appropriate. Changed wording in the "When Covered" section to indicate; "Autologous hematopoietic stem-cell transplantation may be considered medically necessary as consolidation therapy for previously untreated embryonal tumors of the central nervous system (CNS) that show partial or complete response to induction chemotherapy, or stable disease after induction therapy (see Policy Guidelines). Autologous hematopoietic stem-cell transplantation may be considered medically necessary to treat recurrent embryonal tumors of the CNS." Revised the "When Not Covered" section to indicate; "Allogeneic hematopoietic stem-cell transplantation is investigational to treat embryonal tumors of the CNS. Tandem autologous hematopoietic stem-cell transplant is investigational to treat embryonal tumors of the CNS." No change to policy intent. "Policy Guidelines" section updated. References added. Reviewed by Medical Director 9/27/10.
Hormone Pellet Implantation for Hormone Replacement Therapy in Women Policy Guidelines updated. Pertinent diagnoses codes added to Billing/Coding section. No change in policy statement.
Infusion Therapy in the Home Added diagnoses codes to the "Billing/Coding" section.
Intensity Modulated Radiation Therapy for Tumors of the Central Nervous System New policy implemented. Intensity Modulated Radiation Therapy (IMRT) may be considered medically necessary for the treatment of malignant (primary and secondary) and benign neoplasms of the Central Nervous System (CNS), including brain, brain stem, and spinal cord, when those lesions are in close proximity to the optic nerve or brain stem.
Laboratory Tests for Heart Transplant Rejection CPT code 86849 added to Billing/Coding section.
Progesterone Therapy in High Risk Pregnancies Description section revised. When Progesterone Therapy is Covered section revised to read: "Weekly injections of 17 alpha-hydroxyprogesterone caproate, performed in the office setting, between 16 and 36 weeks of gestation may be considered medically necessary for women with a singleton pregnancy and a prior history of spontaneous preterm birth before 37 weeks' gestation. Daily vaginal progesterone between 24 and 34 weeks of gestation may be considered medically necessary for women with a singleton pregnancy and a prior history of spontaneous preterm birth before 37 weeks' gestation." The When Progesterone Therapy is Not Covered section revised to read: "In the absence of a prior history of spontaneous preterm birth, progesterone therapy as a technique to prevent preterm labor is considered investigational in pregnant women with other risk factors for preterm delivery, including, but not limited to multiple gestations, short cervical length, or positive tests for cervicovaginal fetal fibronectin, cervical cerclage, or a uterine anomaly." Policy Guidelines updated. References updated.
Psychiatric Care Specialty Matched Consultant Advisory Panel review 9/30/10. No changes to policy. Policy to be Archived
Psychological Testing Description section extensively revised. When Psychological Testing Is Covered section was replaced with the following: "Psychological testing is medically appropriate when there is a strong indication that significant, useful information that would impact the patient's care and treatment would be generated from such testing. Psychological testing is medically appropriate following evaluation and recommendation by a psychologist, psychiatrist or clinical social worker for any one of the following reasons: To rule-in or rule-out the presence of a thought disorder or other serious psychiatric diagnosis; To make a psychiatric diagnosis which a provider has been unable to make by other methods; To differentiate between psychogenic and neurogenic syndromes. Neuropsychological testing is considered medically appropriate to establish or confirm the diagnosis of brain damage or brain disease when there has been a significant mental status change, behavior change, memory loss or organic brain disease. Neuropsychological testing is considered medically appropriate as part of a pre-operative evaluation prior to brain surgery to establish a baseline. Neuropsychological testing is considered medically appropriate when performed post-operatively to determine if it appears that cognitive dysfunction has occurred." The following was added to the Policy Guidelines section: "Psychological testing performed as simple self-administered or self-scored inventories or screening tests are considered inclusive of an Evaluation and Management service are not eligible for separate reimbursement as psychological testing." Specialty Matched Consultant Advisory Panel review 9/30/10. Draft policy accepted as written. Policy Archived.
Rapid Opioid Detoxification Policy statement reworded to read: Rapid opioid detoxification is considered investigational. BCBSNC does not provide coverage for investigational services or procedures. Statement under the When It Is Not Covered section was reworded to read: Opioid antagonists under heavy sedation or anesthesia are considered investigational as a technique for opioid detoxification (i.e., ultra-rapid detoxification). Rationale in the Policy Guidelines section was updated. Updated references. Specialty Matched Consultant Advisory Panel review 9/30/10. Policy accepted as written.
Real-Time Intra-Fraction Target Tracking During Radiation Therapy Added diagnoses codes to the "Billing/Coding" section. Under "When Not Covered" section added "in the treatment of prostate cancer" to Real-time intra-fraction target tracking during radiation therapy to adjust radiation doses or monitor target movement during individual radiation therapy treatment sessions is considered not medically necessary in the treatment of prostate cancer.
Reconstructive Eyelid Surgery and Brow Lift Reformatted and renumbered section "When Blepharoplasty is covered". Specialty Matched Consultant Advisory Panel review 9/2010. References updated.
Rituximab for the Treatment of Rheumatoid Arthritis Added diagnoses codes to the "Billing/Coding" section.
Sensory Integration Therapy Description section revised. Specialty Matched Consultant Advisory Panel review 9/30/10. Policy accepted as written.
Surgical Treatment of Chest Wall Deformities (Congenital or Acquired) Specialty Matched Consultant Advisory Panel review 9/2010. Combined criteria numbers 4 through 6 under the "When covered" section for Pectus Excavatum , Pectus Carinatum and Poland syndrome. References updated.
Temporomandibular Joint Dysfunction (TMJD) CPT code 21116 (injection procedure for TMJ arthrography) added to "Billing/Coding" section. Additional information added to the Description section. Under "When Covered" Section B: MRI is considered medically necessary changed to may be considered medically necessary; Section C. TMJ Surgery added pharmacological treatment to criteria for medical necessity; Section D. Added arthroscopic coverage criteria. Under "When Not Covered" added Acupuncture as not covered/investigational. Also added Arthroscopy of the TMJ for purely diagnostic purposes is not covered. Specialty Matched Consultant Advisory Panel 1/2010. Reviewed with Senior Medical Director 8/2010. References added.
Tumor Markers Reworded "G." under the "When Covered" section to add additional test names. Statement changed from "Bladder Cancer Tumor antigen such as BTA stat, or NMP-22, may be medically necessary in the diagnosis and monitoring of bladder cancer only in conjunction with surveillance with cystoscopy in patients with a history of bladder cancer." to "Bladder Cancer Tumor antigen such as BTA stat®, BTA TRAK®, NMP22®, NMP22® BladderCHEK™, or UroVysion™ may be medically necessary as an adjunct in the initial diagnosis and monitoring of bladder cancer only in conjunction with current standard diagnostic procedures such as urine cytology and cystoscopy (with and without biopsy)." Reworded "H," from "ImmunoCyt™: The bladder tumor marker using immunohistochemistry test, ImmunoCyte, may be considered medically necessary in the monitoring of bladder cancer only when used in conjunction with cystoscopy and cytology." to "ImmunoCyt™: The bladder tumor marker using immunohistochemistry test, ImmunoCyt™, may be considered medically necessary as an adjunct in the monitoring of bladder cancer only when used in conjunction with current standard diagnostic procedures such as cystoscopy and urine cytology." Under "F" in the "When Not Covered" section added "and all other urinary bladder tumor markers" to the statement, NMP22® or BTA stat™ and all other urinary bladder tumor markers are considered investigational for screening for bladder cancer in asymptomatic persons." Medical Director review 10/4/10. References added.
Vagus Nerve Stimulation Revised "Description' section. Revised policy to indicate that VNS may be medically necessary in refractive seizures (not just in partial onset seizures). Added diagnoses codes to the "Billing/Coding" section. Reviewed by Medical Director 9/30/10. References added.
Varicose Veins, Treatment For Description section extensively revised. The sections for when treatment for varicose veins is and is not covered were reformatted. The following was added to the When Varicose Vein Treatment Is Covered section: "Surgical ligation (including subfascial endoscopic perforator surgery) or endovenous radiofrequency or laser ablation of incompetent perforator veins may be considered medically necessary as a treatment of leg ulcers associated with chronic venous insufficiency when the following conditions have been met: There is demonstrated perforator reflux; AND The superficial saphenous veins (greater, lesser, or accessory saphenous and symptomatic varicose tributaries) have been previously eliminated; AND Ulcers have not resolved following combined superficial vein treatment and compression therapy for at least 3 months; AND The venous insufficiency is not secondary to deep venous thromboembolism." The following statements were added to the When Varicose Vein Treatment Is Not Covered section: "Treatment of symptomatic varicose tributaries when performed either at the same time or following prior treatment of saphenous veins using any other techniques than noted above is considered investigational. Ligation or ablation of incompetent perforator veins performed concurrently with superficial venous surgery is not medically necessary." Also "Endovenous cryoablation of any vein" is investigational and not covered. Definition of "compressive therapy" moved to Policy Guidelines section. Rationale for coverage added to Policy Guidelines section. The following statements were added to the Billing/Coding section: "There is no specific CPT code for transilluminated powered phlebectomy. CPT codes 37765, 37766 or 37799 could be used.If CPT 76942 is used for ultrasound guidance of sclerotherapy of the varicose tributaries, it would be considered either not medically necessary or incidental to the injection procedure". References updated. Notification given 7/20/10 for effective date of 10/26/10.
Vertebroplasty, Kyphoplasty, and Sacroplasty Percutaneous Removed "Sacroplasty" from the title of the "When Covered" section.
Evidence Based Guidelines
Psychoanalysis Specialty Matched Consultant Advisory Panel review 9/30/10. Minor wording changes to guideline statements, but intent of EBG is unchanged. EBG approved as written.