Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for December 6, 2011

Medical Guidelines Reason for Update
Belimumab (Benlysta) Deleted statement: "who are not immunocompromised" under When Covered section. Added statement: "Serious and sometimes fatal infections have been reported in patients receiving immunosuppressive agents, including Benlysta. Caution should be exercised when considering use in patients with a history of chronic infections. Patients receiving therapy for a chronic infection should not receive Benlysta" to Policy Guidelines section. Reviewed with medical director. Removed HCPCS code Q2044 from the Billing/Coding section and added J0490 effective 1/1/2012.
Diagnosis and Treatment of Chronic Cerebrospinal Venous Insufficiency in Multiple Sclerosis New policy. The identification and subsequent treatment of chronic cerebrospinal venous insufficiency (CCSVI) in patients with multiple sclerosis is considered investigational. Medical Director review 8/6/11. Notification given 8/30/11. Policy effective 12/6/11.
Facet Joint Denervation Policy name changed from "Radiofrequency Facet Joint Denervation" to "Facet Joint Denervation". "Description" section updated. Added the following statement to the "When Not Covered" section; "All other techniques of facet joint denervation for the treatment of chronic back pain are considered investigational including, but not limited to: Laser; Cryodenervation." Reworded #2 under "Policy Guidelines" to indicate; "Non-radicular low back (lumbosacral) or neck (cervical) pain, suggestive of facet joint origin as documented in the medical record on history, physical and radiographic evaluations. Radiographic evidence is necessary to exclude other causes of cervical or lumbar pain prior to treatment with spinal injections and to document the presence of facet disease;" #3 "Pain has failed to respond to three (3) months of conservative management which must consist of therapies, including oral analgesics (e.g., nonsteroidal anti-inflammatory medications, acetaminophen), and manipulation or physical therapy, and a home exercise program;" and Added the following to #5 "Repeat blocks are not necessary after 6 months since prior RF treatment, if symptoms and treatment are at the same location(s) or spinal level(s), and presentation is similar to that of initial or prior treatment." #6 "If no prior diagnostic medial branch blocks have ever been done, even if the patient responded well to prior RF ablations, those ablations are NOT a substitute for an initial trial of nerve blocks, and, therefore, medial branch nerve blocks would be necessary before repeat RF ablation is done." Medical Director review 7/18/2011. Notification given 8/30/2011. Policy effective 12/6//2011.References added."
Laser Treatment of Port Wine Stains "When Covered" section revised. Bullet #1 changed to state: "Lesions located where there is potential compromise or actual compromise, (see numbers 3 and 4 below) of vital structures (e.g. nose, eyes, ears, lips, tongue or larynx)" and bullet #3 changed to state: "Lesions which involve the eyelids or periorbital tissue and result in impaired vision or strabismus." Medical Director review 12/2011.
Minimally Invasive Coronary Artery Bypass Graft Surgery Policy archived. Medical director review 11/2011.
Serum Holo-Transcobalamin as a Marker of Vitamin B12 Status References updated. No change to criteria.
Subtalar Arthroereisis Policy Statement revised. "for treatment of flatfoot deformity" removed. New policy statement as follows: "BCBSNC will not provide coverage for subtalar arthroereisis. It is considered investigational. BCBSNC does not cover investigational services." "When not Covered" section revised to state: "Subtalar arthroereisis is not covered. It is considered investigational for all clinical applications." Medical Director review 11/2011.
Ultrasonographic Evaluation of Skin Lesions Description section revised. References updated. No changes to Policy Statements.
Vertebral Axial Decompression (VAD-X) References updated. No changes to Policy Statement.
Evidence Based Guidelines
Anti-CCP Testing for Rheumatoid Arthritis References updated. No changes to guideline.