Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for March 15, 2011

Medical Guidelines Reason for Update
Abatacept Specialty Matched Consultant Advisory Panel review 2/2011. Medical definitions removed. Moved the following statement from the "When not Covered" section to "Policy Guidelines" section: "Orencia® (abatacept) may be used alone or in combination with methotrexate."
Cochlear Implant Specialty Matched Consultant Advisory Panel review 2/23/11. No change to policy statement or coverage criteria.
Dynamic Posturography Policy Statement changed from "not medically necessary" to "investigational." Rationale in the Policy Guidelines section extensively rewritten. Specialty Matched Consultant Advisory Panel review 2/23/11. No change in medical coverage/non-coverage criteria.
H-wave Electrical Stimulation "Description" section revised. Added "Post-operative treatment to improve function and/or range of motion." to the "When Not Covered" section. Updated the "Policy Guidelines" section. References added. Reviewed by Medical Director 2/17/11.
Hematopoietic stem-cell transplantation for solid tumors of childhood Revised the Retinoblastoma information in the "Description" section. Updated the "When Not Covered" section to indicate that "tandem autologous-autologous" HSCT is considered investigational and that "allogeneic (myeloablative or nonmyeloablative)" HSCT is considered investigational in treatment of pediatric solid tumors." Reviewed with Medical Director 2/17/2011. References added.
Inflixumab Specialty Matched Consultant Advisory Panel review 2/2011. Removed medical term definitions. References added.
Injectable Clostridial Collagenase for Fibroproliferative Disorders Specialty Matched Consultant Advisory Panel review 2/2011. References updated.
Intravascular Ultrasound Imaging (IVUS) References updated. Policy status changed to "Active policy, no longer scheduled for routine literature review."
Intravitreal Implant Deleted CPT code C9256. Removed the P from Ozurdex since that P was dropped during the drug approval process and the product is only available as Ozurdex.
Microprocessor-controlled prostheses for the lower limb Specialty Matched Consultant Advisory Panel review 2/2011. No changes to policy statement.
Myoelectric prosthetic components for the upper limb Specialty Matched Consultant Advisory Panel review 2/2011. Added L7180, L7181, L7190, L7191 to "Billing /Coding" section. References updated.
Noninvasive Respiratory Assist Devices Specialty Matched Consultant Advisory Panel review 2/23/11. No change to policy statement or coverage criteria.
Orthopedic Applications of Stem Cell Therapy Specialty Matched Consultant Advisory Panel review 2/2011. Added new product titled, "AlloStem Stem Cell Bone Growth Substitute" in the Policy Guidelines section
Partial Hip Resurfacing Specialty Matched Consultant Advisory Panel review 2/2011. References updated.
Rituximab for the treatment of rheumatoid arthritis Specialty Matched Consultant Advisory Panel review 2/2011. Under "When Covered" section, moved #5 "Subsequent courses of Rituxan (rituximab) should be administered every 24 weeks or based on clinical evaluation, but not sooner than every 16 weeks" to Policy Guidelines section since this refers to continuation of treatment and not initial approval. Under "When Not Covered" section, added phrase "not medically necessary" to statement #1 "Rituximab for the treatment of rheumatoid arthritis is considered not medically necessary when the criteria stated above are not met.
Semi-implantable middle ear hearing aid Specialty Matched Consultant Advisory Panel review 2/23/11. No changes to policy statement or coverage criteria.
Subtalar Arthroereisis Specialty Matched Consultant Advisory Panel review 2/2011. Description section updated. Policy Guidelines updated. References updated.
Tocilizumab (Actemra®) Specialty Matched Consultant Advisory Panel Review 2/2011. Added "these infections" to end of last bullet statement which reads "who have resided or traveled in areas of endemic tuberculosis or endemic mycoses; or with underlying conditions that may predispose them to these infections."
Total Hip resurfacing Specialty Matched Consultant Advisory Panel review 2/2011. References updated.
Ultrasound Accelerated Fracture Healing Device Specialty Matched Consultant Advisory Panel review 2/2011. Revised Policy Statement from "BCBSNC will provide coverage for Sonic Accelerated Fracture Healing system when it is determined to be medically necessary because the medical criteria and guidelines shown below are met." to "BCBSNC will provide coverage for Ultrasound Accelerated Fracture Healing Device when it is determined to be medically necessary because the medical criteria and guidelines shown below are met." References updated.
Evidence Based Guidelines
Aerosolized antibiotic treatment for chronic sinusitis Specialty Matched Consultant Advisory Panel review 2/23/2011. No changes to criteria. Evidence Based Guideline status changed to Active Archive, no longer scheduled for routine literature review.
Anti-CCP testing for rheumatoid arthritis Specialty Matched Consultant Advisory Panel review 2/2011.
Arthroscopic debridement and lavage as treatment of knee osteoarthritis Specialty Matched Consultant Advisory Panel review 2/2011. References updated.
Interventions for progressive scoliosis Specialty Matched Consultant Advisory Panel review 2/2011. References updated