Medical Policy Updates

Blue Cross and Blue Shield of North Carolina Medical Policy Update for November 09, 2010

Medical Guidelines	Reason for Update
Intensity-Modulated Radiation Therapy (IMRT) of the Prostate	Under "When Covered" section added the following statements: Intensity-modulated radiation therapy (IMRT) may be considered medically necessary in the treatment of prostate cancer when the following criteria are met: A. In patients with localized prostate cancer who will receive definitive dose escalated external beam radiation therapy at prescribed radiation doses of 75 to 80 Gy. B. In patients who are status-post prostatectomy with evidence of local recurrence, who will be receiving salvage radiation therapy at a prescribed dose of 66Gy or more to the prostate bed. C. In patients who are status-post prostatectomy who are at high risk for recurrence due to extracapsular extension, pathologic T3 disease, seminal vesicle invasion, positive margins and/or positive nodes, who will receive adjuvant Y(post-operative) radiation therapy at a prescribed dose of at least 66Gy to the prostate bed and/or pelvis. Under "When Not Covered" section deleted the statement "post-prostatectomy patients." Reviewed with medical director.
Occipital Nerve Stimulation	Removed CPT 64555 from "Coding/Billing" section. It does not seem to apply to this policy. Added "Diagnosis codes that are subject to medical necessity review: " to the "Billing/Coding" section.
Radioembolization for Primary and Metastatic Tumors of the Liver	Description section extensively revised. Policy statement changed to indicate that selective cases of hepatocelluar carcinoma and metastatic neuroendocrine tumors may be considered medically necessary. Under "When Covered" section: added Radioembolization may be considered medically necessary for the following: to treat primary hepatocellular carcinoma that is unresectable and limited to the liver,in primary hepatocellular carcinoma as a bridge to liver transplantation,to treat hepatic metastases from neuroendocrine tumors (carcinoid and noncarcinoid) with diffuse and symptomatic disease when systemic therapy has failed to control symptoms. Under "When Not Covered" section added Radioembolization is considered investigational to treat unresectable hepatic metastases from colorectal carcinoma and Radioembolization is considered investigational for all other hepatic metastases except for metastatic neuroendocrine tumors as noted above. Policy name changed from Selective Internal Radiation Therapy for Tumors of the Liver to Radioembolization for Primary and Metastatic Tumors of the Liver for consistency with BCBSA policy. References added. Reviewed with medical director.
Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Vein	Added cryoablation technology information to Description section and Policy Guidelines section. References updated. Added the following statement to When Not Covered section: "Transcatheter cryoablation of the pulmonary veins as a treatment for atrial fibrillation is considered investigational."
Evidence Based Guidelines
Transurethral Microwave Thermotherapy for Benign Prostatic Hyperplasia	Evidence Based Guideline returned to active status for routine review. Description section updated. Added the following statements to the "Not Recommended" section: "For technical reasons, transurethral microwave thermotherapy is not suitable for patients who have median lobe enlargement, bladder neck stenosis, or in whom the prostate gland exceeds 50 mm in length or 70 g in volume. Microwave thermotherapy is not to be confused with an earlier technique of microwave treatment, microwave hyperthermia, which has largely been abandoned." Senior Medical Director review 9/2010. References updated.