Medical Policy Updates

Blue Cross and Blue Shield of North Carolina Medical Policy Update for April 26, 2011

Medical Guidelines	Reason for Update
Chemonucleolysis	Policy reviewed by medical director. Chemonucleolysis appears to no longer be utilized. Archive policy.
Continuous Passive Motion in the Home Setting	In the "References" section, BCBSA Medical Policy Reference Manual date corrected.
Convection-Enhanced Delivery of Therapeutic Agents to the Brain	Specialty Matched Consultant Advisory Panel review March 30, 2011. No changes to policy. References added.
Cord Blood as a Source of Stem Cells	Policy reactivated from "Active policy, no longer scheduled for routine literature review. Specialty Matched Consultant Advisory Panel review March 30, 2011. "Description" section revised. Removed statement indicating "Services for or related to the search for a donor is not covered. Reformatted statements for consistency, no change in policy intent. References added.
Corneal Topography	Under "when not covered" section: changed policy statement to not medically necessary from investigational for consistency with BCBSA and deleted the statement "Non-computer assisted corneal topography is considered part of the evaluation and management services of general ophthalmological services (CPT codes 92002-92014), and therefore this service should not be billed separately. There is no separate CPT code for this type of corneal topography" since this statement is already listed under the "Billing/Coding" section. Reference added.
Cryosurgical Ablation of Solid Tumors of the Breast or Pancreas	Policy statement reworded to read: "Cryosurgical ablation is considered investigational as a treatment of benign or malignant breast tumors or for pancreatic cancer." No change in noncoverage criteria. References and rationale updated.
Detection of Circulating Tumor Cells	Specialty Matched Consultant Advisory Panel review March 30, 2011. "Description" section revised. No change to policy statement. "Policy Guidelines" updated. References added.
ECG Reimbursement Issues	Added the following statements to the "criteria for reimbursement" section: "Please note: In light of the recent advances in information technology, specifically the development of electronic health records (EHR), BCBSNC will accept documentation of the above criteria in EHR format. This includes the physician's interpretation and electronic signature."
Epithelial Cell Cytology and Breast Cancer Risk Assessment	Updated description section. No change in Policy Statement or noncoverage criteria. Reference updated.
Extracorporeal Shock Wave Treatment for Musculoskeletal Conditions	Description section updated. References updated. Policy guidelines updated. No change to policy statement.
HIV Genotyping and Phenotyping	Specialty Matched Consultant Advisory Panel review 2/23/2011. No change to policy statement of coverage criteria. Policy status changed to "ARCHIVED."
Hyperbaric Oxygen Pressurization	Acute carbon monoxide poisoning and chronic refractory osteomyelitis added to the When HBO Is Covered section. Policy Guidelines sections updated with rationale.
Hyperthermic Intraperitoneal Chemotherapy	Specialty Matched Consultant Advisory Panel review March 30, 2011. "Description: revised. New indication for "When Covered" states the following: "Cytoreduction and hyperthermic intraperitoneal chemotherapy for the treatment of pseudomyxoma peritonei may be considered medically necessary." The "When Not Covered" section was revised to indicate; "Cytoreduction and hyperthermic intraperitoneal chemotherapy is considered investigational for peritoneal carcinomatosis from colorectal cancer." "Policy Guidelines" updated. References added.
Immune Cell Function Assay in Solid Organ Transplantation	Specialty Matched Consultant Advisory Panel review March 30, 2011. No change to policy statement. "Policy Guidelines" updated. References added.
Keratoprosthesis	References updated. No changes to policy statements.
Minimally Invasive Coronary Artery Bypass Graft Surgery	New policy implemented. BCBSNC will provide coverage for minimally invasive direct coronary artery bypass graft surgery (MIDCAB) procedure as medically necessary. Other techniques of minimally invasive coronary artery bypass graft surgery, including but not limited to PACAB, hybrid CABG, or TECAB techniques, are considered investigational. Notice given on 1/18/2011 for effective date of 4/26/2011.
Non-BRCA Breast Cancer Risk Assessment (OncoVue)	Specialty Matched Consultant Advisory Panel review March 30, 2011. "Description" section revised. "Policy guidelines" updated. No change to policy intent. References added.
PathFinderTG® Molecular Testing	Specialty Matched Consultant Advisory Panel Review March 30, 2011. No change to policy intent. References added.
T-Wave Alternans	Description section updated. Policy guidelines updated. References updated.
Wheelchairs	Specialty Matched Consultant Advisory Panel review meeting 12/2010.
Evidence Based Guidelines
Glaucoma, Evaluation by Ophthalmologic Techniques	"Description" section revised and updated. The "Evidence Based Guideline" section revised, removed the following statements; "Techniques to evaluate the retinal nerve fiber layer (scanning laser ophthalmoscopy, scanning laser polarimetry and optical coherence tomography) will be referred to as scanning laser glaucoma tests (SLGT). SLGT may be appropriate when performed for the evaluation of individuals at high risk for developing glaucoma and for the monitoring of patients with a diagnosis of glaucoma." Added the following statement; "Analysis of the optic nerve (retinal nerve fiber layer) using scanning laser ophthalmoscopy, scanning laser polarimetry, and optical coherence tomography may be appropriate when performed for the diagnosis and evaluation of patients with glaucoma or glaucoma suspects." Revised the wording in the "When Not Recommended" section from; "When the above medical criteria are not met. The use of SLGT to screen for glaucoma. The use of optic nerve head analyzers (i.e. Glaucoma Scope), the measurement of pulsatile ocular blood flow or blood flow velocity with Doppler ultrasonography are not recommended for the diagnosis and follow up of patients with glaucoma." to "The measurement of ocular blood flow, pulsatile ocular blood flow or blood flow velocity with Doppler ultrasonograpy is not recommended for the diagnosis and follow up of patients with glaucoma." "A literature review did not identify any studies that demonstrate the clinical utility for use of pulsatile ocular blood flow or blood flow velocity in patients with glaucoma. These techniques are used in evaluating various glaucoma treatments. A recent publication reported on color doppler imaging (CDI) in normal and glaucomatous eyes. Using data from reported studies, a weighted mean was derived for the peak systolic velocity, end diastolic velocity and Pourcelot's resistive index in the ophthalmic, central retinal and posterior ciliary arteries. Data from 3,061 glaucoma patients and 1,072 controls were included. The mean values for glaucomatous eyes were within 1 SD of the values for controls for most CDI parameters. Methodologic differences created inter-study variance in CDI values, complicating the construction of a normative database and limiting its utility. The authors noted that because the mean values for glaucomatous and normal eyes have overlapping ranges, caution should be used when classifying glaucoma status based on a single CDI measurement. Measurement of ocular blood flow has also been studied as a technique for evaluating patients with glaucoma. While reports of use have been longstanding, the clinical impact of this technique is not known. Reports have commented on the complexity of these parameters and have noted that these technologies are not commonly used in clinical settings. The impact on health outcomes is not known." Added 0198T to "billing/coding" section and removed deleted CPT code, 92135. References added.
Herceptin	Specialty Matched Consultant Advisory Panel review March 30, 2011. No changes made to guideline.
Intra Articular Hyaluronan Injections for Treatment of Osteoarthritis of the Knee	References updated. No changes to guideline statements.
Intrahepatic Arterial Chemotherapy	Specialty Matched Consultant Advisory Panel review March 30, 2011. No changes to guideline. References added.
Radioimmunotherapy in the Treatment of Non-Hodgkin Lymphoma	Specialty Matched Consultant Advisory Panel review March 30, 2011. The following statements were added to the "Evidence Based Guideline" section: "The use of tositumomab (Bexxar®) or ibritumomab tiuxetan (Zevalin®) for the initial treatment of follicular lymphoma may be appropriate in patients who are unable to tolerate standard chemotherapy, e.g., elderly or frail patients." "The use of tositumomab (Bexxar®) or ibritumomab tiuxetan (Zevalin®)* for consolidation after chemotherapy in non-Hodgkin lymphoma patients who achieve a partial or complete response may be appropriate." "Multiple studies have shown that the use of radioimmunotherapy in treating relapsed or refractory non-Hodgkin lymphoma can induce remissions in 50-80% of patients, with 15-50% achieving complete remission." "For patients with previously untreated non-Hodgkin lymphoma, achievement of a complete remission with consolidation after induction chemotherapy has been associated with longer progression-free and overall survival rates and is a prerequisite for cure in diffuse large cell lymphoma. Radioimmunotherapy as consolidation following induction therapy in previously untreated patients with advanced follicular lymphoma has demonstrated high overall response rates, complete remission rates, and prolonged progression-free survival in one Phase III and several Phase II trials." The following was removed from the "When Not Recommended" section; "The use of tositumomab (Bexxar®) or ibritumomab tiuxetan (Zevalin®) for the initial treatment of NHL is not recommended." Added the following information the section; "The data on the use of radioimmunotherapy as part of the conditioning regimen prior to hematopoietic stem-cell transplant are promising but evolving. Preliminary data suggest there may be a role for radioimmunotherapy, particularly in patients who may not be able to tolerate potentially curative high-dose chemotherapy and/or total body irradiation because of the risk of excessive treatment-related morbidity and mortality. Several Phase III trials are underway examining the role of radioimmunotherapy in both autologous and reduced-intensity allogeneic hematopoietic stem-cell transplants." References added.
Sacroiliac Joint Arthrography and Injection	References updated. No changes to guideline statements.