Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for December 30, 2011

Medical Guidelines Reason for Update
Ambulatory Event Monitors New product information added to "Description" section. New codes effective 1/1/2012: 0295T, 0296T, 0297T, 0298T added to "Billing/Coding" section. "When Covered" section revised to include the following statement: "The use of auto-activated external ambulatory event monitors may be considered medically necessary in patients treated for atrial fibrillation to monitor for asymptomatic episodes in order to evaluate treatment response." The "When not Covered" section revised to include the following statement: "The use of long-term ambulatory monitoring, i.e., ZioTM Patch, ZioTM Event Card and the Zeus ECG Utilization Service, is considered not medically necessary because the clinical (health) outcomes and cost effectiveness of extended monitoring have not been shown to be superior to other available approaches." Policy Guidelines updated. References updated. Medical Director review 12/2011.
Bioengineered Skin and Tissue Deleted the following codes from "Billing/Coding" section: 15170, 15171, 15175, 15176, 15330, 15331, 15335, 15336, , 15340, 15341, 15360, 15361, 15365, 15366, 15400, 15401, 15420, 15421, 15430, 15431, C9365, G0440, G0441. Added the following codes to "Billing/Coding" section: 15271, 15272, 15273, 15274, 15275, 15276, 15277, 15278, 15777, C9366, Q4122, Q4123, Q4124, Q4125, Q4126, Q4127, Q4128, Q4129, Q4130. New codes will be effective 1/1/2012. Added new product "Epifixo®" "When not Covered" section.
Bone Mineral Density Studies CPT codes 77079 and 77083 deleted from Billing/Coding section.
Bronchial Thermoplasty Added HCPCS code C1886 to billing/coding section for effective date 1/1/2012.
Cardiac Hemodynamic Monitoring in the Outpatient Setting Added new codes to "Billing/Coding" section: 0293T and 0294T. Effective date 1/1/2012. Added information on Left Atrial Hemodynamic Monitor, HeartPODTM System, to "Description" section. Added "left atrial hemodynamic monitoring" to the "When not Covered" section. Medical Director review 12/2011.
Children's Mobility and Positioning Equipment Added E0638 to Billing/Coding section for 2012 code update. Standing frames are benefit exclusion.
Denosumab (ProliaTM, XGEVATM) Code C9272 deleted and replaced with J0897 in the Billing/Coding section.
Detection of Circulating Tumor Cells Added new 2012 CPT codes, 0279T and 0280T to "Billing/Coding" section.
Extracorporeal Shock Wave Treatment for Musculoskeletal Conditions and Wound Healing Policy re-titled to "Extracorporeal Shock Wave Treatment for Musculoskeletal Conditions and Wound Healing." "Description" section updated to include information on dermaPACE®, new ESWT for treatment of diabetic foot ulcers. "When not Covered" section updated to include wound healing as an investigational clinical condition. 0299T and 0300T added to "Billing/Coding" section. New codes to be effective 1/1/2012. "Policy Guidelines" section updated. References update. Medical Director review 12/2011.
Gastric Electrical Stimulation CPT code 43659 added to Billing/Coding section. Deleted codes 0155T, 0156T, 0157T and 0158T.
Gene-Based Tests for Screening, Detection, and/or Management of Prostate Cancer Evidence Based Guideline converted to Corporate Medical Policy. "Description" section updated. "Policy" statement added indicating "Genetic tests for the screening, detection, and management of prostate cancer are considered investigational for all applications. BCBSNC does not provide coverage for investigational services or procedures." Specialty Matched Consultant Advisory Panel review 8/31/2011. References added. Notification given 9/30/2011 Policy effective 1/1/2012.
Gene Expression Testing to Predict Coronary Artery Disease New policy developed. Gene expression testing to predict coronary artery disease is considered investigational. Medical Director review 9/2011. Notice given 9/30/2011 for effective date December 30, 2011.
Genetic Testing for Colon Cancer Added the following 2012 CPT codes to the "Billing/Coding" section: 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81301, 81315, 81316, 81317, 81318, and 81319.
Genetic Testing for Helicobacter pylori Treatment CPT code 81225 added to Billing/Coding section.
Genetic Testing for Long QT Syndrome Added new codes 81280, 81281, 81282 to "Billing/Coding" section. Effective date 1/1/2012.
Genetic Testing for Non-Malignant Inherited Disorders The following CPT codes added to the "Billing/Coding" section and will be effective 1/1/2012: 81200, 81205, 81209 , 81240, 81241, 81242, 81243, 81244, 81250, 81251, 81255, 81256, 81257, 81260,81265, 81266, 81268, 81290, 81291, 81302, 81303, 81304, 81330, 81332,81350, 81402, 81403, 81404, 81405, 81406, 81407, 81408
Immune Globulin Therapy Coding update. Deleted code C9270 and replaced with J1557.
Injectable Clostridial Collagenase for Fibroproliferative Disorders Policy Statements revised as follows: "Injectable clostridial collagenase for the treatment of Dupuytren's contracture in adult patients with a palpable cord may be considered medically necessary, for up to three injections at intervals of at least thirty-days. Injectable clostridial collagenase is considered investigational for all other indications including, but not limited to, Peyronie's disease, and adhesive capsulitis." "When Covered" and "When not Covered" sections revised to reflect coverage criteria. CPT codes 20527 and 26341 added to "Billing/Coding" section and are effective 1/1/2012. CPT code 26989 deleted. "Policy Guidelines" section updated. References updated.
Interferential Stimulation Specialty Matched Consultant Advisory Panel review 11/30/11. "Description" revised. No change to policy intent. Rationale in "Policy Guidelines" updated. Added 2012 HCPCS codes S8130 and S8131 to the "Billing/Coding" section.
Ipilimumab (Yervoy) Deleted codes J3590, C9284 from "Billing/Coding" section and added J9228, which will be effective 1/1/2012.
Islet Cell Transplantation Coding update. CPT Codes 0141T, 0142T, 0143T deleted.
Left Atrial Appendage Closure Device for Stroke Prevention Coding update. 0281T added to "Billing/Coding" section. New code is effective 1/1/2012.
Lumbar Spine Fusion Surgery Added new 2012 CPT codes, 22633 and 22634 to "Billing/Coding" section.
Myoelectric Prosthetic Components for the Upper Limb Added new codes L6715 and L6880 to "Billing/Coding" section. Effective date 1/1/2012.
Optical Coherence Topography New policy developed. Optical coherence tomography is considered investigational in all situations, including but not limited to, as an adjunct to percutaneous coronary interventions with stenting, risk stratification of intracoronary atherosclerotic plaques and follow-up evaluation of stenting. Medical Director review 12/2011.
Pharmacogenetic Testing for Warfarin Dose CPT codes 81355 and 81227 added to "Billing/Coding" section and will be effective 1/1/2012. Policy Guidelines updated. References updated.
Progesterone Therapy in High Risk Pregnancies Code Q2042 deleted and replaced with code J1725 in Billing/Coding section.
Laboratory Testing to Allow Area Under the Curve (AUC) Targeted 5-Fluorouracil (5-FU) Dosing for Patients Administered 5-FU for Cancer Added new 2012 HCPCS code, S3722, to the "Billing/Coding" section
Transanal Radiofrequency Treatment of Fecal Incontinence CPT Codes 0288T and C9716 added to the Billing/Coding section.
Transcatheter Closure of Ventricular Septal Defects Deleted codes 0166T and 0167T from "Billing/Coding" section. Added code 33999.
Transcranial Magnetic Stimulation CPT code 90869 added to Billing/Coding section.
Tyrosine Kinase Mutations in Myeloproliferative Neoplasms Specialty Matched Consultant Advisory Panel review 11/30/11. No change to policy. Added new 2012 CPT code, 81275, to the "Billing/Coding" section.
Urinary Tumor Markers for Bladder Cancer Added new 2012 CPT code, 86386, to the "Billing/Coding" section.
Wheelchairs Added E0988, E2358-E2359 and E2626-E2633 to Billing/Coding section for 2012 code update.
Evidence Based Guidelines
Biventricular Pacemakers for CHF New codes added to "Billing/Coding" section: 33230, 33231, 33262, 33263, 33264, G0448. Effective date 1/1/2012.
Diabetic Retinopathy Telescreening Removed HCPCS code S0625 from Billing/Coding section for 2012 code update.
Evoked Otoacoustic Emissions Coding update. CPT code 92558 added to the Billing/Coding section. Guideline archived.
Intra Articular Hyaluronan Injections for Treatment of Osteoarthritis of the Knee New code J7326 added to "Billing/Coding" section. Effective date 1/1/2012.
KRAS Mutation Analysis in Cancer Added new 2012 CPT code, 81275, to "Billing/Coding" section.
Sacroiliac Joint Arthrography and Injection Deleted code 73542 from "Billing/Coding" section.
TENS (Transcutaneous Electrical Nerve Stimulator) Specialty Matched Consultant Advisory Panel review 11/30/11. "Evidence Based Guideline" reformatted. No change to guideline. Added 2012 CPT code, 0278T, to the "Billing/Coding" section.
Treatment for Age Related Macular Degeneration Added HCPCS code C1840 to Billing/Coding section for 2012 code update.