Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for October 11, 2011

Medical Guidelines Reason for Update
Acute and Maintenance Tocolysis Description section revised. Policy Statement revised to read: "Acute tocolytic therapy with calcium channel blockers, magnesium sulfate, prostaglandin inhibitors and parenteral terbutaline may be considered medically necessary for the induction of tocolysis in patients with preterm (< 37 weeks' gestational age) labor. Maintenance tocolytic therapy (beyond 48-72 hours) with any medication is considered investigational." Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 9/28/11.
Bone Mineral Density Studies Added the following statement to the When Covered section: "Peripheral measurement of BMD may be considered medically necessary if the hip/spine or hip/hip cannot be done or the patient is over the table limit for weight; for hyperparathyroidism, where the forearm is essential for diagnosis." The When BMD Studies Are Not Covered section was revised to read: "Bone mineral density studies are considered not medically necessary if the criteria listed above are not met. Screening individuals who are at low risk for osteoporosis is considered not medically necessary. Ultrasound technology to measure and interpret bone density at peripheral sites by any method is considered investigational. Peripheral or appendicular bone density studies are considered not medically necessary except as noted above. Dual x-ray absorptiometry (DEXA) body composition studies are considered investigational." Rationale in the Policy Guidelines section updated. Added information from U.S. Preventive Services Task Force guidelines. The statement: The procedure must be ordered by a physician or qualified practitioner after a complete assessment of the patient's condition determines that a bone mass measurement is medically necessary. If diagnosis, frequency, or documentation does not support medical necessity, coverage will be denied" was added to the Billing/Coding section. Specialty Matched Consultant Advisory Panel review 9/28/11.
Bronchial Thermoplasty Added HCPCS codes C9730 and C9731 for effective date 7/1/2011 to the billing/coding section. Also added CPT codes 0276T and 0277T to the billing/coding section for effective date January 1, 2012. No change in policy statement. Reference added.
Children's Mobility and Positioning Equipment Specialty Matched Consultant Advisory Panel review 9/28/2011. Added benefit exclusion for standing frames to "Benefits Application" section.
Cognitive Rehabilitation Archive policy.
Denosumab (ProliaTM, XGEVATM) Specialty Matched Consultant Advisory Panel review 9/28/11. Policy accepted as written.
DNA Based Testing for Adolescent Idiopathic Scoliosis New policy developed. DNA based testing for adolescent idiopathic scoliosis is not covered. It is considered investigational. BCBSNC does not cover investigational services or procedures. Medical Director review 8/2011.
Durable Medical Equipment (DME) Specialty Matched Consultant Advisory Panel review 9/28/2011. No changes to policy statement.
Functional Capacity Assessment and Work Hardening Specialty Matched Consultant Advisory Panel review 9/28/2011. No changes to policy statement.
Gait Analysis Added to "When Not Covered" section: postoperative evaluation of surgical outcomes in patients with gait disorders associated with cerebral palsy; surgical planning for conditions other than gait disorders associated with cerebral palsy; rehabilitation planning and/or evaluation for all conditions; and gait analysis that does not include a quantitative assessment of coordinated muscle function in a dedicated laboratory is considered investigational. Revised the Description section and policy guidelines section. Specialty Matched Consultant Advisory Panel review 9/28/2011.
Hematopoietic Stem-Cell Transplantation for Acute Myeloid Leukemia Reference added.
Intravenous Histamine Therapy Senior Medical Director review 9/9/2011. Policy archived.
Laser Treatment of Port Wine Stains Re-worded policy statement to read: "Laser treatment of port wine stains causing functional impairment may be considered medically necessary." Specialty Matched Consultant Advisory Panel review 9/2011.
Medical Supplies and Surgical Dressings Archive policy.
Multigene Expression Assay for Predicting Recurrence in Colon Cancer "Policy Guidelines" updated. Reviewed by Senior Medical Director. Reference added.
Paternal or Fetal Antigen Immunotherapy for Recurrent Fetal Loss Senior Medical Director review 9/9/2011. Policy archived.
Patient Lifts Specialty Matched Consultant Advisory Panel review 9/28/2011. Under "Benefits Application" section added: "Devices and equipment used for environmental accommodation such as, but not limited to, chair lifts, stair lifts, home elevators, standing frames, and ramps are specifically excluded under most health benefit plans." Also added "Durable medical equipment that serves no medical purpose or that is primarily for comfort or convenience is also excluded under most health benefit plans." Removed references to items excluded by benefit under "Policy and When Not Covered".
Percutaneous Electrical Nerve Stimulation (PENS) or Neuromodulation Therapy Reference added.
Power Operated Vehicle (Scooter) Specialty Matched Consultant Advisory Panel review 9/28/2011. No change to policy statement.
Pressure Reducing Support Surfaces Specialty Matched Consultant Advisory Panel review 9/28/2011. No change in policy statement.
Progesterone Therapy in High Risk Pregnancies Description section updated. When Covered section was changed to read: "For women with a singleton pregnancy and prior history of spontaneous preterm birth before 37 weeks' gestation, the following may be considered medically necessary: Weekly injections of 17 alpha-hydroxyprogesterone caproate, performed in the office setting, initiated between 16 and 20 weeks of gestation and continued until 36 weeks 6 days, Daily vaginal progesterone between 24 and 34 weeks of gestation. For women with a singleton pregnancy and a short cervix (less than 20 mm), the following may be considered medically necessary: Daily vaginal progesterone initiated between 20 and 23 weeks 6 days of gestation and continue until 36 weeks 6 days." The first statement in the When Not Covered section was revised to read: "Progesterone therapy as a technique to prevent preterm labor is considered investigational in pregnant women with other risk factors for preterm delivery, including, but not limited to multiple gestations, or positive tests for cervicovaginal fetal fibronectin, cervical cerclage, or a uterine anomaly." Deleted CPT codes 90772 and 99506 from the Billing/Coding section and added code Q2042. Specialty Matched Consultant Advisory Panel review 9/28/11.
Reconstructive Eyelid Surgery and Brow Lift Specialty Matched Consultant Advisory Panel review 9/2011. Description section for "Blepharoplasty" and "Browlift" updated.
Rehabilitative Therapies Specialty Matched Advisory Panel 9/28/2011. Under "When Not Covered" section added benefit disclaimers and under B. #3 Gait motion: added reference to Gait Analysis medical policy. Under "When Covered" section D. Outpatient, Office or Home Therapy services: removed #5 "Goals of therapy are required and must be signed by a MD/DO/NP/PA prior to the start of treatment."
Speech Generating Devices Specialty Matched Consultant Advisory Panel review 9/28/2011. No change to policy statement
Surgical Treatment of Chest Wall Deformities (Congenital or Acquired) Removed information regarding the Haller Index from "Description" section, as it is also discussed in the "Policy Guidelines" section. Consolidated the "When Covered" section. Added the following requirements to the "When Covered" section: a. for treatment of Pectus Excavatum, the Haller Index is greater than or equal to 3.2, OR b. for treatment of Pectus Carinatum, the Haller Index is less than or equal to 2.0, OR c. for treatment of Poland syndrome, when rib formation is absent. Specialty Matched Consultant Advisory Panel review 9/2011.
Wheelchairs Specialty Matched Consultant Advisory Panel review 9/28/2011. Under "When Covered" deleted reference to IC (Individual Consideration). Under "Benefits Application" added benefit disclaimer. Under "When Not Covered" added not medically necessary statement to #3: Seat elevators for manually and electrically operated wheelchairs are considered not medically necessary when used solely for the convenience of the insured or the insured's family/caretaker.
Evidence Based Guidelines
Infrared Coagulation Senior Medical Director review 9/9/11. Guideline archived.
Intraoperative Transesophageal Echocardiography Senior Medical Director review 9/9/2011. Guideline archived.
Patient Controlled Analgesics Senior Medical Director review 9/9/2011. Guideline archived.
Phototherapy for Neonatal Jaundice in the Home Senior Medical Director review 9/9/2011. Guideline archived.
Radioimmunotherapy in the Treatment of Non-Hodgkin Lymphoma Reference added.
Serum Biomarker Human Epididymis Protein 4 (HE4) "Description" section updated. Medical Director review 9/21/2011. Reference added.
TENS (Transcutaneous Electrical Nerve Stimulator) Reference added.
Uterine Artery Occlusion in the Treatment of Uterine Fibroids Description section revised. No change to medical evidence in the guideline. Rationale updated. Specialty Matched Consultant Advisory Panel review 9/28/11.