Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for October 25, 2011

Medical Guidelines Reason for Update
Cosmetic and Reconstructive Surgery Removed ear piercing from section of policy titled, "Examples of Cosmetic and Reconstructive Surgery." Under Reconstructive section for Otoplasty, added "congenital absence." The following information was removed from the section titled, "Telangiectasis or spider veins" and is now a distinct category: "Laser treatment of port wine stains in the presence of functional impairment related to the port wine stain may be considered medically necessary. Refer to Medical Policy entitled, Laser Treatment of Port Wine Stain for policy guidelines." Removed "dry eye" from the Reconstructive section of lower lid blepharoplasty and added the following conditions: "disease due to ectropion, entropion or trichiasis." Specialty Matched Consultant Advisory Panel review 9/2011. References updated.
Denosumab (Prolia, XGeva) When Denosumab Is Covered section revised to clarify requirement for oral biphosphonate.
Immunization Guidelines Revised description. Added the following codes to the Billing/Coding section: G0008, G0009, G0010, G9141, G9142. Information regarding appropriate coding of administration of vaccines also added to Billing/Coding section.
Orthotics Revised (i.e, JAS splints) to read (e.g., JAS splints) throughout the policy. Description section reformatted. Medical Director review 10/2011.
Rehabilitative Therapies Revised statement #11 under Billing/Coding Section to remove reference to plan of care recertification requirements by physician every 30 days. Reviewed with medical director (JM).
Tyrosine Kinase Mutations in Myeloproliferative Neoplasms New policy. "JAK2 tyrosine kinase and MPL mutation testing may be considered medically necessary in the diagnosis of patients presenting with clinical, laboratory, or pathological findings suggesting classic forms of myeloproliferative neoplasms (MPN), that is, polycythemia vera (PV), essential thrombocythemia (ET), or primary myelofibrosis (PMF). JAK2 tyrosine kinase and MPL mutation testing may be considered investigational in all other circumstances" Notification given July 19, 2011. Policy effective October 25, 2011.