Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for December 20, 2011

Medical Guidelines Reason for Update
Allergy Immunotherapy (Desensitization) Specialty Matched Consultant Advisory Panel review. No changes to Policy Statements. Deleted code 0168T, and added 30999 to "Billing/Coding" section.
Artificial Intervertebral Disc Specialty Matched Consultant Advisory Panel review 11/30/2011 Updated "Description" section. Updated "Policy Guidelines" section. No change to policy intent. References added.
Bioimpedance Devices for Detection of Lymphedema Rationale in the Policy Guidelines section updated. References updated. No change in policy statement: Devices using bioimpedance (bioelectrical impedance spectroscopy) are considered investigational for use in the diagnosis, surveillance, or treatment of patients with lymphedema, including use in subclinical secondary lymphedema. Specialty Matched Consultant Advisory Panel review 11/30/11.
Botulinum Toxin Injection Specialty Matched Consultant Advisory Panel review 11/30/2011. Added the following indications to the "When Not Covered" section for clarification: prevention of pain associated with breast reconstruction after mastectomy, Hirschsprung's disease, and gastroparesis. Changed wording in number 6 to "Examples include but are not limited to patients with any of the following:". No change to policy intent. Added 2012 HCPCS code, J0588, to "Billing/Coding" section and deleted Q2040 and C9278. References added.
Cryoablation or Radiofrequency Ablation of Renal Cell Cancer Archive policy. See policies entitled Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate, or Dermatologic Tumors or Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors.
Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate, or Dermatologic Tumors Policy name changed from "Cryosurgical Ablation of Solid Tumors of the Breast and Pancreas". Policy updated to include information regarding cryosurgical treatment of the lung and renal cell carcinoma. Updated "Description" section." Medical Director review 11/23/2011. References added.
Decompression of the Intervertebral Disc Using Laser Energy (Laser Discectomy) or Radiofrequency Coblation (Nucleoplasty) Specialty Matched Consultant Advisory Panel review 11/30/2011. No change to policy.
Electrostimulation and Electromagnetic Therapy for Wounds Policy Guidelines and References updated. No change to policy statement of coverage criteria. Electrostimulation and electromagnetic therapy are considered investigational for treatment of wounds. Specialty Matched Consultant Advisory Panel review 11/30/11.
Endothelial Keratoplasty Removed HCPCS code C9732 from Billing/Coding section (only 1U allowed for implantation in one eye only.)
Growth Factors in Wound Healing Added coding instructions to Billing/Coding section. No change to policy statement or coverage criteria. Specialty Matched Consultant Advisory Panel review 11/30/10.
Intraepidermal Nerve Fiber Density Specialty Matched Consultant Advisory Panel review 11/30/2011. "Description" section revised. Policy statement changed from investigational to "BCBSNC will provide coverage for Intraepidermal Nerve Fiber Density when it is determined to be medically necessary because the medical criteria and guidelines shown below are met." The "When Covered" section updated to indicate; "Skin biopsy with epidermal nerve fiber density measurement for the diagnosis of small-fiber neuropathy may be considered medically necessary when all of the following conditions are met: 1. Individual presents with symptoms of painful sensory neuropathy; AND 2. There is no history of a disorder known to predispose to painful neuropathy (e.g., diabetic neuropathy, toxic neuropathy, HIV neuropathy, celiac neuropathy, inherited neuropathy); AND 3. Physical examination shows no evidence of findings consistent with large-fiber neuropathy, such as reduced or absent muscle-stretch reflexes or reduced proprioception and vibration sensation; AND 4. Electromyography and nerve-conduction studies are normal and show no evidence of large-fiber neuropathy." The "When Not Covered" section updated to indicate; "Skin biopsy with epidermal nerve fiber density measurement is considered investigational for all other conditions, including, but not limited to, the monitoring of disease progression or response to treatment." References added.
Lysis of Epidural Adhesions Specialty Matched Consultant Advisory Panel review 11/30/2011. "Description" section revised. No change to policy intent.
Non-Contact Ultrasound Treatment for Wounds Description section and Policy Guidelines section updated. No change in policy statement, the use of non-contact ultrasound is considered investigational for wound treatment. Specialty Matched Consultant Advisory Panel review 11/30/11.
Pelvic Floor Stimulation as a Treatment of Urinary Incontinence Specialty Matched Consultant Advisory Panel review 11/2011. No changes to Policy Statements.
Periurethral Bulking Agents for the Treatment of Urinary Incontinence Specialty Matched Consultant Advisory Panel review 11/2011. Revised the following statement in the "When not Covered" section: "Periurethral Teflon® injection for the treatment of urinary incontinence is considered investigational and is not covered." To "The use of any other periurethral bulking agent, including, but not limited to Teflon®, to treat stress urinary incontinence is considered investigational." References updated.
Plugs for Fistula Repair Removed code 0170T from Billing/Coding section. Specialty Matched Consultant Advisory Panel review 11/30/11.
Posterior Tibial Nerve Stimulation for Voiding Dysfunction Specialty Matched Consultant Advisory Panel review 11/2011. References updated. BCBSA 2010 TEC Assessment information added to Policy Guidelines. No changes to Policy Statement.
Radiofrequency Ablation of Pulmonary Tumors Archive policy. See policy entitled, Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors.
Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors The following policies/EBGs were combined for this policy: Radiofrequency Ablation of Osteoid Osteomas and Bone Metastases, Radiofrequency Ablation of Pulmonary Tumors, and Cryosurgical or Radiofrequency Ablation of Renal Cell Cancer. Policy statements changed to indicate medically necessary options for primary and metastatic pulmonary tumors. "Radiofrequency ablation is considered investigational as a technique for ablation of tumors of the breast, lung cancer not meeting the criteria above, renal cell cancer not meeting the criteria above, and all other tumors outside the liver including, but not limited to, the head and neck, adrenal gland, ovary, and pelvic/abdominal metastases of unspecified origin and for the treatment of osteoid osteomas that can be managed with medical treatment and for initial treatment of painful bony metastases." Medical Director review 12/2/2011. References added.
Radiofrequency Tissue Remodeling for Urinary Stress Incontinence Specialty Matched Consultant Advisory Panel review 11/2011. References updated. No changes in Policy Statements.
Sacral Nerve Neuromodulation/Stimulation for Pelvic Floor Dysfunction Specialty Matched Consultant Advisory Panel review 11/2011. References updated. Policy Guidelines updated.
Saturation Biopsy for Diagnosis and Staging of Prostate Cancer Specialty Matched Consultant Advisory Panel review 11/2011. References updated. No changes to Policy Statement.
Systems Pathology for Predicting Risk of Recurrence in Prostate Cancer Specialty Matched Consultant Advisory Panel review 11/2011. Policy Guidelines updated. No changes to Policy Statement.
Temporary Prostatic Stent Specialty Matched Consultant Advisory Panel review 11/2011. No changes to Policy statement.
Topical Negative Pressure Therapy for Wounds Description section updated to include information on non-powered (mechanical) NPWT systems. Updated FDA link. The word "powered" was added to "NPWT" where applicable. The following statement was added to the When NPWT is Not Covered section: "Use of nonpowered NPWT systems for the treatment of acute or chronic wounds is considered investigational." Codes A7000, A7001, A9272, K0743, K0744, K0745, K0746 added to Billing/Coding section. Noted in the Billing/Coding section that there is no specific code for the disposable NPWT system. Specialty Matched Consultant Advisory Panel review 11/30/11.
Total Facet Arthroplasty Specialty Matched Consultant Advisory Panel review 11/30/2011. No change to policy intent.
Varicose Veins, Treatment for Routine annual review. Added additional covered indication to bulleted list under "Symptomatic Varicose Tributaries. "Ligation, division, and/or excision" is also covered. Specialty Matched Consultant Advisory Panel review 11/30/11.
Vesicoureteral Reflux, Treatment with Periureteral Bulking Agents Specialty Matched Consultant Advisory Panel review 11/2011. References updated. No changes to Policy Statements.
Xolair® (Omalizumab) Specialty Matched Consultant Advisory Panel review 11/2011. Revised following statement from "Description" section: "It has been shown to be beneficial as adjunctive therapy in patients whose symptoms are inadequately controlled despite the regular use of maximum dose inhaled corticosteroids." to "It has been shown to be beneficial as adjunctive therapy in patients whose symptoms are inadequately controlled despite appropriate therapy for moderate to severe asthma." Removed the following statement from the "When Covered" section: "Depending on the length of time the patient has been receiving Xolair® therapy, documentation may be necessary to verify that criteria for continuing therapy are met (under B. and/or C. above.)" Revised the following statement in the "When not Covered" section: "Xolair® (Omalizumab) is not covered when the conditions listed above have not been met." to "Xolair® (Omalizumab) is considered not medically necessary when the conditions listed above have not been met." Removed "twin-ject" from Policy Guidelines and replaced with "or similar device." References updated.
Evidence Based Guidelines
Biochemical Markers of Alzheimer's Disease Specialty Matched Consultant Advisory Panel review 11/30/2011. "Description" section revised. No change to guideline intent.
Prostate Cancer Treatment with Brachytherapy Specialty Matched Consultant Advisory Panel review 11/2011. References updated. No changes to Guideline.
Radiofrequency Ablation of Osteoid Osteomas and Bone Metastases Archive policy. See policy entitled, Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors.
Transurethral Microwave Thermotherapy for Benign Prostatic Hyperplasia Specialty Matched Consultant Advisory Panel review 11/2011. No changes to Guideline statement.