Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for September 13, 2011

Medical Guidelines Reason for Update
Accelerated Partial Breast Radiotherapy (Breast Brachytherapy) Description section extensively revised. Under "When Not Covered" added Accelerated partial breast irradiation using an electronic radiotherapy device is considered investigational. Specialty Matched Consultant Advisory Panel review 8/31/2011.
Assays of Genetic Expression to Determine Prognosis of Breast Cancer "Description" section revised. Examples of other gene expression assays updated in the "When Not Covered" section. "Policy Guidelines" section updated. References added. Medical Director review 8/16/2011.
Balloon Sinuplasty for Treatment of Chronic Sinusitis Description section updated. Policy Guidelines with rationale updated. No change in policy statement, remains Investigational. Specialty Matched Consultant Advisory Panel review 8/31/11.
Decompression of the Intervertebral Disc Using Laser Energy (Laser Discectomy) or Radiofrequency Coblation (Nucleoplasty) "Description" section updated. "Policy Guidelines" updated. No change to policy intent. Medical Director review 8/27/2011. Reference added.
Functional Endoscopic Sinus Surgery (FESS) Specialty Matched Consultant Advisory Panel review 8/31/11. No change to policy statement or medical criteria.
Intensity Modulated Radiation Therapy (IMRT) of Breast and Lung Specialty Matched Consultant Advisory Panel review 8/31/2011. No changes to the policy statement.
Intensity Modulated Radiation Therapy for Tumors of the Central Nervous System Specialty Matched Consultant Advisory Panel review 8/31/2011. No changes to policy statement.
Ipilimumab (Yervoy) "Notification" Notification policy updated to include the following statements: "Ipilimumab is not covered in combination with Vemurafenib (Zelboraf) unless the member is enrolled in a clinical trial. Some patients may be eligible for coverage under Clinical Trials. Refer to the policy on Clinical Trial Services for Life-Threatening Conditions." Updated Policy Guidelines.
Rhinoplasty Specialty Matched Consultant Advisory Panel review 8/31/11. No change to policy statement or coverage criteria.
Tinnitus Treatment Description section updated. The following were added to the list of non-covered treatments for tinnitus: tinnitus coping therapy, transcutaneous electrical stimulation and sound therapy. References updated. Specialty Matched Consultant Advisory Panel review 8/31/11.
Total Facet Arthroplasty "Description" section updated. "Policy Guidelines" updated. Medical Director review 8/27/2011. Reference added.
Transtympanic Micropressure Applications as a Treatment of Meniere's Disease Rationale in the Policy Guidelines section updated. Specialty Matched Consultant Advisory Panel review 8/31/11.
Evidence Based Guidelines
External Insulin Pumps Description section updated. The following statement added to the medical criteria: "the patient with diabetes must be insulinopenic per the updated fasting C-peptide testing requirement, or must be beta cell autoantibody positive." Also added information regarding the fasting C-peptide testing requirements. References updated. Added codes A4230, A4231, A4232 and S9145 to Billing/Coding section. Specialty Matched Consultant Advisory Panel review 7/27/11.
High-Sensitivity C-Reactive Protein in Cardiac Disease Risk Assessment Evidence Based Guideline archived.
Septoplasty Specialty Matched Consultant Advisory Panel Review 8/31/11. Deleted statement in the Billing/Coding section regarding requirements for documentation of work or school absences. Medical Policy converted to Evidence Based Guideline.