Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for November 8, 2011

Medical Guidelines Reason for Update
Acoustic Cardiography Specialty Matched Consultant Advisory Panel review 10/2011. No changes to Policy Statements.
Anesthesia Services Information under the "When Anesthesia Services Are Not Covered" revised. The following statements were deleted: "Monitoring of IV sedation by an anesthesiologist for gastrointestinal endoscopy, arteriograms, CT scans, MRIs, cardiac catherizations, and PTCA is generally considered not medically necessary except for children, acutely agitated patients, or, in some cases, for acutely ill patients who cannot have the procedure without sedation. Exceptions may be made for CT scans and MRIs for agitated patients. Examples include but are not limited to patients with: organic brain disease, senile dementia, delirium, claustrophobia, or uncooperative mentally retarded patients." The following statements were added; "See separate evidence-based guideline, "Monitored Anesthesia Care", for the evidence supporting use of Monitored Anesthesia for procedures including but not limited to: GASTROINTESTINAL ENDOSCOPY, ARTERIOGRAMS, CT SCANS, AND MRIS." AND "In accordance with the North Carolina Medical Board Position Statement entitled Office Based Procedures, "Anesthesia should be administered by an anesthesiologist or a CRNA supervised by a physician. The physician who performs the surgical or special procedure should not administer the anesthesia. The anesthesia provider should not be otherwise involved in the surgical or special procedure." "Policy Guidelines" revised. The following statements were removed: "The Office-Based Moderate Sedation/Analgesia (Conscious Sedation) Certification for endoscopic and other specified procedures never intended for the provider to use Propofol in the office setting. The package insert for Propofol (Diprivan®), AstraZeneca) indicates in the Warnings section; "For general anesthesia or monitored anesthesia care (MAC) sedation, Diprivan Injectable Emulsion should be administered only by persons trained in the administration of general anesthesia and not involved in the conduct of the surgical/diagnostic procedure. Sedated patients should be continuously monitored, and facilities for maintenance of a patent airway, providing artificial ventilation, administering supplemental oxygen, and instituting cardiovascular resuscitation must be immediately available.". Removed the following statement: "It is expected that the supervising anesthesiologist for any certified registered nurse anesthetist (CRNA) or anesthesiologist assistant (AA) must be on-site while the anesthesia is being administered. Services being rendered by a CRNA or AA should be filed under the supervising Anesthesiologist's provider number." Added the following reference: North Carolina Medical Board Position Statements (electronic version) retrieved 7/5/2011 from http://www.ncmedboard.org/position_statements/detail/office-based_procedures/. Removed the following reference: "FDA. (2007). Diprivan®), (propofol) injectable emulsion for IV administration. Retrieved 7/31/2007 from http://www.fda.gov/cder/foi/label/2007/019627s045lbl.pdf." Reviewed by Senior Medical Director 10/20/2011.
Ankle Replacement, Total References updated. No changes to policy statements.
Antiprothrombin Antibody Testing Specialty Matched Consultant Advisory Panel review 10/2011. No changes to Policy Statements.
Bioengineered Skin and Tissue Specialty Matched Consultant Advisory Panel review 9/2011. Updated "description" section. "When Covered" section re-formatted. Added new products to the "When not Covered" section and alphabetized product list. FDA indications provided for all products listed in policy. Added C9354 to "Billing/Coding" section. References updated.
Cardiac Hemodynamic Monitoring in the Outpatient Setting Specialty Matched Consultant Advisory Panel review 10/2011. No changes to Policy Statements.
Carotid Intimal-Medial Thickness Study Specialty Matched Consultant Advisory Panel review 10/2011. No changes to Policy Statements.
Computed Tomography to Detect Coronary Artery Calcification Specialty Matched Consultant Advisory Panel review 10/2011. References updated. No changes to Policy Statements.
Congenital Heart Defect, Repair Devices References updated. No changes to policy statements.
Dental, Criteria for use of Hospital Inpatient or Outpatient Facility Services or Ambulatory Surgery Center Facility Services Specialty Matched Consultant Advisory Panel review 10/26/2011. No changes to policy statement.
Dental, Reconstructive Services Specialty Matched Consultant Advisory Panel review 10/26/2011. No changes to policy statement.
Dermatoscopy References updated. No changes to Policy Statements.
Electrical Bone Growth Stimulation References updated. No changes to Policy Statements.
Electrocardiographic Body Surface Mapping References updated. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 10/2011. No changes to Policy Statements.
End Diastolic Pneumatic Compression Boot Specialty Matched Consultant Advisory Panel review 10/2011. No changes to Policy Statements.
Esophageal pH Monitoring Description section updated to include information regarding impedance-pH monitoring. The following statement was added to the Not Covered section: "24-hour catheter-based impedance-pH monitoring is considered not medically necessary." Billing/Coding section and Policy Guidelines updated.
Fecal Calprotectin Test Description section revised. Policy statement unchanged. When Fecal Calprotectin is Not Covered section revised to read: "Testing for fecal calprotectin is considered investigational in the diagnosis and management of intestinal conditions, including the diagnosis and management of inflammatory bowel disease." Specialty Mathced Consultant Advisory Panel review 10/26/11. Policy accepted as written.
Fecal Pancreatic Elastase-1 Test Description section updated. Specialty Matched Consultant Advisory Panel review 10/26/11. No change to policy, remains investigational.
Gastroesophageal Reflux Disease, Transendoscopic Therapies Description section updated. When It Is Not Covered section was revised to read: "Transesophageal endoscopic gastroplasty is considered investigational as a treatment of gastroesophageal reflux disease (e.g., the EndoCinchTM, NDO PlicatorTM, or EsophyXTM procedures). Transesophageal radiofrequency to create submucosal thermal lesion of the gastroesophageal junction (i.e., the Stretta procedure) is considered investigational as a treatment of gastroesophageal reflux disease. Endoscopic submucosal implantation of a prosthesis or injection of a bulking agent (e.g., biocompatible liquid polymer, polymethylmethacrylate beads, zirconium oxide spheres) is considered investigational as a treatment of gastroesophageal reflux disease." Rationale updated in the Policy Guidelines section.
Genetic Testing for Colon Cancer Extensive revisions to Description section and Policy Guidelines section. No change in medical coverage criteria. Specialty Matched Consultant Advisory Panel review 10/26/11.
Genetic Testing for Lipoprotein (a) as a Decision Aid for Aspirin Treatment Specialty Matched Consultant Advisory Panel review 10/2011. No changes to Policy Statement.
Genotyping for 9p21 Genetic Polymorphisms to Predict Cardiovascular Disease Risk Specialty Matched Consultant Advisory Panel review 10/2011. No changes to Policy Statement.
Ingestible pH and Pressure Capsule Routine annual review. No changes to policy.
Intradialytic Parenteral Nutrition Description section revised. Policy Guidelines section updated. No change in policy statement or medical coverage criteria. Specialty Matched Consultant Advisory Panel review 10/26/11.
Lipoprotein-associated Phospholipase A2 References updated. Specialty Matched Consultant Advisory Panel review10/2011. No changes to Policy Statements.
Orthognathic Surgery Specialty Matched Consultant Advisory panel review 10/26/2011. No changes to policy statement. Under Benefits Application removed statement under Orthodontic treatment prior to orthognathic surgery: "Orthognathic surgery requires prior review before pre-surgical orthodontic treatment. The interim occlusion that is achieved by orthodontic treatment may be dysfunctional prior to the completion of the orthognathic surgical phase of the treatment plan. Therefore, all requests for orthognathic surgery must be reviewed/precertified by BCBSNC prior to the initiation of pre-surgical orthodontic care. Failure to precertify the orthognathic surgical request prior to orthodontic care may result in the denial of benefits." Under When Covered section: added statement "and/or failure to thrive to D.2.a."
Pharmacogenetic Testing for Warfarin Dose Specialty Matched Consultant Advisory Panel review. Evidence Based Guideline revised to Corporate Medical Policy. Genotyping to determine cytochrome p450 2C9 (CYP2C9) and vitamin K epoxide reductase subunit C1 (VKORC1) genetic polymorphisms is considered investigational for the purpose of managing the administration and dosing of warfarin, including use in guiding the initial warfarin dose to decrease time to stable INR and reduce the risk of serious bleeding. References updated. Policy Guidelines updated.
Signal-Averaged ECG Specialty Matched Consultant Advisory Panel review 10/2011. References updated. Policy Guidelines updated. No changes to Policy Statements.
Stem-cell Therapy for Peripheral Arterial Disease Specialty Matched Consultant Advisory Panel review 10/2011.No changes to Policy Statements.
Subtalar Arthroereisis References updated. No changes to Policy Statements.
T-Wave Alternans Specialty Matched Consultant Advisory Panel review 10/2011. No changes to Policy Statement.
Temporary Prostatic Stent References updated. Description section updated to include product information for the MemokathTM 028, a new non-FDA approved temporary prostatic stent. No changes to Policy Statement.
Transanal Radiofrequency Treatment of Fecal Incontinence Routine annual review. Description section and Policy Guidelines section updated. No change in policy statement.
Ultrasound Accelerated Fracture Healing Device Policy Statement updated. New statement in section "When Covered" states: "Low-intensity ultrasound treatment may be considered medically necessary as a treatment of delayed union of bones, (defined as a decelerating healing process as determined by serial x-rays), excluding the skull and vertebra." Revised statement in section "When not Covered" to state: "Other applications of low intensity ultrasound treatment are investigational, including but not limited to, congenital pseudoarthroses, open fractures, or stress fractures." Removed "delayed unions of bones" from the "When not Covered" section. Policy Guidelines updated to include information regarding delayed unions. References updated. Reviewed by Medical Director 10/2011.
Evidence Based Guidelines
Endoscopic Radiofrequency Ablation or Cryoablation for Barrett's Esophagus Routine annual review. No change to guideline
Mechanical Embolectomy for Treatment of Acute Stroke "Not Recommended" section updated. References updated. No changes to guideline statements.
Monitored Anesthesia Care (MAC) New evidence based guideline implemented. Reviewed by Senior Medical Director 10/2011. "Use of monitored anesthesia care may be appropriate for gastrointestinal endoscopy, bronchoscopy, and interventional pain procedures, when there is documentation by the proceduralist and anesthesiologist that specific risk factors or significant medical conditions are present." "Use of monitored anesthesia care is considered a matter of patient choice when used for gastrointestinal endoscopic, bronchoscopic, or interventional pain procedures in patients at average risk related to use of anesthesia and sedation. Shared decision-making is recommended such that the patient and their physician discuss the risks and benefits of the use of monitored anesthesia care in these patients."
Prothrombin Time Monitoring in the Home Specialty Matched Consultant Advisory Panel review 10/2011. No changes to Guideline Statements.
Ventricular Assist Devices and Total Artificial Hearts Description section extensively revised to include information regarding Percutaneous Ventricular Assist Devices. Device regulatory information updated. References updated. No changes to guideline statements.