Medical Policy Updates
Blue Cross and Blue Shield of North Carolina Medical Policy Update for March 29, 2011
| Medical Guidelines | Reason for Update |
|---|---|
| Automated Nerve Conduction Tests | Removed deleted HCPCS code, "S3905", from "Billing/Coding" section. (btw) |
| Bone Turnover Markers for the Diagnosis and Management of Osteoporosis | The following statement was added to the Billing/Coding section: There is no specific CPT code for bone-specific alkaline phosphatase (ALK), but several laboratory websites identify CPT 84080 for the Ostase test. (adn) |
| Botulinum Toxin Injection | Added new HCPCS code, Q2040 to "Billing/Coding" section. Removed deleted code, C9278. (btw) |
| Cervicography | Description section and Policy Guidelines section updated. No change to policy statement or medical coverage/noncoverage criteria. Policy status changed to "Active policy, no longer scheduled for routine literature review." (adn) |
| Cough Stimulating Device | Policy status changed to "Active policy, no longer scheduled for routine literature review." References updated. (mco) |
| Endobronchial Valves | New policy issued. Endobronchial valves are considered investigational as a treatment of prolonged air leaks. Endobronchial valves are considered investigational as a treatment for patients with COPD or emphysema. Notice given 12/21/2010 with effective date 3/29/11.(lpr) |
| Implantable Bone Conduction Hearing Aids | Description section revised. Coverage criteria in the When Covered section was changed to read: "Unilateral or bilateral implantable bone-conduction (bone-anchored) hearing aid(s) may be considered medically necessary as an alternative to an air-conduction hearing aid in patients 5 years of age and older with a conductive or mixed hearing loss who also meet at least one of the following medical criteria: Congenital or surgically induced malformations (e.g., atresia) of the external ear canal or middle ear; or Chronic external otitis or otitis media; or Tumors of the external canal and/or tympanic cavity; or Dermatitis of the external canal; and meet the following audiologic criteria: A pure tone average bone-conduction threshold measured at 0.5, 1, 2, and 3 kHz of better than or equal to 45 dB (OBC and BP100 devices), 55 dB (Intenso device) or 65 dB (Cordele II device). For bilateral implantation, patients should meet the above audiologic criteria, and have a symmetrically conductive or mixed hearing loss as defined by a difference between left and right side bone conduction threshold of less than 10 dB on average measured at 0.5, 1, 2 and 3 kHz, or less than 15 dB at individual frequencies. An implantable bone-conduction (bone-anchored) hearing aid may be considered medically necessary as an alternative to an air-conduction CROS hearing aid in patients 5 years of age and older with single-sided sensorineural deafness and normal hearing in the other ear. The pure tone average air conduction threshold of the normal ear should be better than 20 dB measured at o.5, 1, 2 and 3 kHz." Information in the When Not Covered section was replaced with the following: "An implantable bone conduction hearing aid is not covered for indications other than those listed above. The use of bilateral bone-anchored hearing aids in patients with bilateral sensorineural hearing loss is considered investigational." Policy Guidelines updated. Added CPT codes 69710 and 69711 to the Billing/Coding section. Specialty Matched Consultant Advisory Panel 2/23/11. (adn) |
| Infertility Diagnosis and Treatment | No change to coverage/non-coverage criteria. Policy status changed to "Active policy, no longer scheduled for routine literature review." (adn) |
| Myolysis of Uterine Fibroids | Policy status changed to "Active policy, no longer scheduled for routine literature review." (adn) |
| Natalizumab (Tysabri) | New medical policy issued. Natalizumab (Tysabri) may be considered medically necessary for the treatment of multiple sclerosis and Crohn's disease when the medical criteria and guidelines are met. Notification date 1/1/2011 for effective date 4/1/2011. (lpr) |
| Prosthetic Appliances | Removed deleted HCPCS code, Q1003, from "Billing/Coding" section. (btw) |
| Pulmonary Hypertension, Drug Management | Under Description section under Advanced Therapy and Prostacyclin Analogues-added Tyvaso as approved inhalation treatment. Moved PAH (Who Group I) statement paragraph that begins "The diagnosis of PAH requires confirmation with a complete right heart catheterization" from the Description section to Policy Guidelines. Also moved non-pulmonary arterial hypertension PH (Who Groups 2-5) statement paragraph that begins "PH associated with elevated left heart filling pressures are more prevalent than PAH" from the Description section to Policy Guidelines. Moved statement paragraph that begins "Treatment with epoprostenol requires three steps as follows" from Policy Guidelines to Description section. Under When Covered section, added Tadalafil (ADCIRCA), oral as medically necessary oral therapy for PAH conditions. Under When Not Covered section, added Tadalafil as investigational for the treatment of non-PAH PH conditions. Added new HCPCS code J7686 for 2011. HCPCS codes J1325, J3285, J7686, Q4074 will be PPA as of 4/1/2011. Notification given 1/1/2011 for effective date 4/1/2011. (lpr) |
| Respiratory Syncytial Virus Prophylaxis | Description section updated. No change to medical necessity criteria in the When RSV Prophylaxis Is Covered/Not Covered sections. Specialty Matched Consultant Advisory Panel review 2/23/11. (adn) |
| Sexual Dysfunction Treatment, Female | No changes to medical coverage/non-coverage criteria. Policy status changed to "Active policy, no longer scheduled for routine literature review." (adn) |
| Smoking Cessation Therapies | Policy archived. Investigational services for tobacco cessation no longer appear to be an issue. Medical director review/approval 3/2011. (lpr) |
| Hematopoietic Stem-Cell Transplantation for CLL and SLL | References updated. (btw) |
| Spinal Cord Stimulation | References updated. (btw) |
| Vagus Nerve Stimulation | References updated. (btw) |
| Evidence Based Guidelines | |
| Human Papillomavirus (HPV) Vaccine | Specialty Matched Consultant Advisory Panel review 2/23/11. No change to Guidelines. (adn) |
| Laboratory Testing for HIV Tropism | Specialty Matched Consultant Advisory Panel review. No change to Guidelines. (adn) |
| Treatment for Age Related Macular Degeneration | Removed the following sentence from the "Billing/Coding" section: "There is no specific code for Ranibizumab injection (Luncentis)". Added code J2778 to "Billing/Coding" section. (mco) |
| Intracardiac Electrophysiologic Studies | 3/29/11 Guideline removed from archives and will undergo routine review. Electrophysiologic studies may be appropriate for patients with: Coronary artery disease and symptoms suggestive of ventricular tachycardia or fibrillation, Coronary artery disease, nonsustained ventricular tachycardia, and left-ventricular ejection fraction less than 40%, Unexplained recurrent syncope in the presence of structural heart disease' In preparation for, or as part of, catheter ablation procedures and for severe, unexplained symptoms suggestive of an undocumented arrhythmia, where noninvasive clinical testing has failed to adequately diagnose, localize, or fully characterize the arrhythmia. References updated. (mco) |
| PUVA (Psoralens with Ultraviolet A) Therapy | Policy returned to active status and changed to Evidence Based Guideline. Description section updated. References updated. Senior Medical Director review 2/2011. (mco) |
| Isolated Limb Perfusion/Infusion | No change to policy statement. References added. (btw) |