Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for June 21, 2011

Medical Guidelines Reason for Update
Automated Nerve Conduction Tests Specialty Matched Consultant Advisory Panel review 5/25/11. Revised "Description" section. No change to policy statement. "Policy Guidelines" updated with rationale. References added.
Bundling Guidelines Further defined "When a lumbar laminectomy, facetectomy or foraminotomy is performed in conjunction with a lumbar spinal fusion procedure, the lumbar laminectomy, facetectomy or foraminotomy will be considered incidental to the lumbar spinal fusion." Notification 3/15/2011 with an Effective date of 6/19/2011. Policy implementation information from 3/30/2006-05/05/2008 restored.
Cerebellar Stimulator-Pacemaker Policy archived. No claim activity.
Durable Medical Equipment (DME) Removed references to IC (individual consideration) under "When Covered" section and Policy Guidelines section. Removed statement "low intensity" under Policy Guidelines section: "DME may be purchased" under 3rd bullet b. Under Billing/Coding section added HCPCS codes K0743-K0746. Reviewed by medical director.
Electrical Stimulators, Neuromuscular Added HCPCS code, E0744 to "Billing/Coding" in the NMES section. "Description" section related to Threshold Electrical Stimulation revised. Removed reference to "Threshold Electrical Stimulation from the investigational policy statement. Added the following in the "Policy" section; "Threshold Electrical Stimulation is considered not medically necessary. BCBSNC does not provide coverage for services or procedures that are not medically necessary." Changed the statement in the "When Not Covered" section to indicate; "Threshold electrical stimulation as a treatment of motor disorders, including but not limited to cerebral palsy, is considered not medically necessary." "Policy Guidelines" revised. Reviewed with Medical Director 6/6/2011. References added.
End Diastolic Pneumatic Compression Boot New policy implemented. End diastolic pneumatic compression boots are considered investigational as a treatment of peripheral vascular disease or lymphedema and its associated complications, including but not limited to ischemic lesions, claudication pain, necrotizing cellulitis, venous stasis ulcers, stasis dermatitis, chronic lymphedema, or thrombophlebitis.
Endovascular Procedures for Intracranial Arterial Disease Policy title changed from "Cerebral Angioplasty" to "Endovascular Procedures for Intracranial Arterial Disease". Specialty Matched Consultant Advisory Panel review 5/25/2011. Revised "Description" section to include information regarding endovascular procedures for aneurysm. Changed the "Policy" statement; "BCBSNC will provide coverage for Endovascular Procedures (Angioplasty and/or Stenting) for Intracranial Arterial Disease (Atherosclerosis and Aneurysms) when it is determined to be medically necessary because the medical criteria and guidelines shown below are met." Added the following statement to the "When Covered" section; "Intracranial stent placement may be considered medically necessary as part of the endovascular treatment of intracranial aneurysms for patients when surgical treatment is not appropriate and standard endovascular techniques do not allow for complete isolation of the aneurysm, e.g., wide-neck aneurysm (4 mm or more) or sack-to-neck ratio less than 2:1." Revised the "When Not Covered" section to; "Intracranial stent placement is considered investigational in the treatment of intracranial aneurysms except as noted above. Intracranial percutaneous transluminal angioplasty with or without stenting is considered investigational in the treatment of atherosclerotic cerebrovascular disease." Updated "Policy Guidelines" section. References added.
Extracorporeal Photopheresis after Solid-Organ Transplant and for Graft-versus-Host Disease, Autoimmune Disease, and Cutaneous T-Cell Lymphoma Added "Solid Organ Transplant" to policy name. "Description" section updated to include section regarding use in solid organ transplantation rejection. Added the following statement to the "When Covered" section; "Extracorporeal photopheresis may be considered medically necessary to treat cardiac allograft rejection, including acute rejection, that is either recurrent or that is refractory to standard immunosuppressive drug treatment." Added the following information to the "When Not Covered" section; "Extracorporeal photopheresis is considered investigational in all other situations related to treatment or prevention of rejection in solid-organ transplantation." Added "autoimmune bullous disorders" to the "Autoimmune Disease" statement as another example of when extracorporeal photopheresis is not covered. Reviewed by Medical Director 3/23/11. References added.
Functional Intracellular Analysis New policy implemented. Functional Intracellular Analysis is not covered. It is considered investigational. There is no published scientific evidence to support the benefit or the validity of micronutrient testing. Medical Director review 6/2011.
Hematopoietic Stem-Cell Transplantation for Solid Tumors of Childhood Reference added.
Hyperhidrosis, Treatment of Medical Director review 6/2011. Policy Guidelines revised. The following statement added to Policy Guidelines: "In the absence of evidence to the contrary, botulinum toxin products are considered to have a class effect. This approach is consistent with the BCBSNC policy titled "Botulinum Toxin Injection." Therefore, all references to OnabotulinumtoxinA and RimabotulinumtoxinB replaced with the general term, Botulinum Toxin. RimabotulinumtoxinB removed as an investigational treatment for primary axillary hyperhidrosis. Medically necessary and investigational treatments for primary hyperhidrosis revised into a table format. Description section updated. References updated.
Image-Guided Minimally Invasive Lumbar Decompression (IG-MLD) for Spinal Stenosis Specialty Matched Consultant Advisory Panel review 5/25/2011. No changes to policy. References added. Added new CPT code, "0275T" to "Billing/Coding" section effective 7/1/2011.
In Vitro Chemoresistance and Chemosensitivity Assays Reference added.
Intradiscal Electrothermal (IDET) Annuloplasty and Percutaneous Intradiscal Radiofrequency Annuloplasty Combined Intradiscal Electrothermal annuloplasty and Percutaneous Intradiscal Radiofrequency annuloplasty. Renamed "Intradiscal Electrothermal (IDET) Annuloplasty and Percutaneous Intradiscal Radiofrequency Annuloplasty". Specialty Matched Consultant Advisory Panel review 5/25/2011. Updated "Description" and "Policy" statements to reflect these services. No change to policy intent. "Intradiscal annuloplasty (e.g., intradiscal electrothermal annuloplasty, percutaneous intradiscal radiofrequency thermocoagulation, or intradiscal biacuplasty) for the treatment of chronic discogenic back pain is considered investigational for all applications. BCBSNC does not provide coverage for investigational services or procedures." References added.
Lumbar Spine Fusion Surgery Specialty Matched Consultant Advisory Panel review 5/25/2011. No change to policy statement. References added.
Modifier Guidelines Added Modifier -59 will not allow additional payment when appended to CPT4 codes 63005, 63012, 63017, 63030, 63035, 63042, 63044, 63047 and 63048 and when performed in conjunction with 22630 and 22632. Lumbar laminectomy, facetectomy and foraminotomy procedures are typically considered incidental to the lumbar arthrodesis, posterior interbody technique; and therefore are not eligible for separate reimbursement. Changes to policy reviewed by Senior Medical Director 3/10/2011. Notification given 3/15/2011. Policy effective 6/19/2011. Added "same group practice" to modifier 24. Further clarification of Modifier -59; added the following statements: "Based on the most common clinical scenario, it is expected that when a lumbar laminectomy, facetectomy, and/or foraminotomy is billed with a posterior lumbar interbody fusion, the procedures are being performed on the same level. In the unusual clinical circumstance when the procedures are performed at different vertebral levels, clinical information will be required to be submitted on appeal"
Natalizumab (Tysabri) Specialty Matched Consultant Advisory Panel review 5/25/2011. No change to policy statement.
Orthopedic Applications of Stem Cell Therapy Medical Director review 6/2011. References updated. No changes to policy statements. (mco)
Oxygen and Oxygen Supplies Added HCPCS codes K0741 and K0742 to Billing/Coding section.
Paraspinal Surface Electromyography (EMG) Specialty Matched Consultant Advisory Panel review 5/25/2011. "Description" section revised. "Policy Guidelines" updated. No change to policy intent. References added.
Pelvic Floor Stimulation as a Treatment of Urinary Incontinence Medical Director review 6/2011. References updated. No changes to policy statements.
Percutaneous Lumbar Discectomy Specialty Matched Consultant Advisory Panel review 5/25/2011. "Description" revised. No changes to policy intent. References added.
Quantitative Sensory Testing Specialty Matched Consultant Advisory Panel review 5/25/2011. "Description" section revised. "Policy Guidelines" updated. No change to policy intent. References added.
Spinal Surgery Using Interspinous Distraction Technology Specialty Matched Consultant Advisory Panel review 5/25/2011. "Description" section revised. "Policy Guidelines" updated. No change to policy intent. References added.
Surgery for Femoroacetabular Impingement Billing/Coding section updated to state the following: "Code 29914 and 29915 cannot be reported with the hip arthroscopy codes for chondroplasty (29862) or synovectomy (29863). Code 29916 cannot be reported with 29915 (acetabuloplasty and labral repair represent overlapping services when reported together); and 29916 cannot be reported with 29862 or 29863."
Systems Pathology for Predicting Risk of Recurrence in Prostate Cancer Medical Director review 6/2011. References updated. Revised policy statement as follows: "Systems pathology testing for predicting risk of recurrence of prostate cancer is considered investigational. BCBSNC does not provide coverage for investigational services or procedures." Intent of policy is unchanged.
Evidence Based Guidelines
Deep Brain Stimulation Specialty Matched Consultant Advisory Panel review 5/25/11. "Description" section updated. No change to "Evidence Based Guideline" References added.
Genetic Testing for Tamoxifen Treatment Reference added.
Herceptin Reference added.