Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for January 24, 2012

Medical Guidelines Reason for Update
Allogeneic Hematopoietic Transplant for Genetic Diseases and Acquired Anemia Reference added.
Ambulance and Medical Transport Services Deleted statement #3 under "When Not Covered" section: Transportation from the member's home to a facility other than a hospital, skilled nursing facility or rehabilitation facility is not covered.Transportation from a facility other than a hospital, skilled nursing facility or rehabilitation facility to the member's home is not covered. Reviewed by medical director.
Chiropractic Services Specialty Matched Consultant Advisory Panel review September 2011. "Description" section revised. Added #13 to the "When Not Covered" section to indicate massage therapy as stand alone therapy is not covered. No change to policy intent. References added.
Chromosomal Microarray (CMA) Analysis for Genetic Evaluation of Developmental Delay/Autism Spectrum Disorder Added CPT code 81229 to "Billing/Coding" section.
Facet Joint Denervation Added new 2012 CPT codes, 64633,64634, 64635, and 64636 to Billing/Coding section. Removed the following deleted codes, 64622, 64623, 64626, and 64627. Also removed 77003 since this service is now reported as part of the new procedure codes.
Genetic Testing for Breast and Ovarian Cancer Specialty Matched Consultant Advisory Panel review August 29, 2011. No change to policy statement. "Policy Guidelines" updated to include NCCN guidelines. Added the following new 2012 CPT codes to the "Billing/Coding" section: 81211, 81212, 81213, 81214, 81215, 81216, and 81217.
Genetic Testing for Colon Cancer Removed 81315 and 81316 from Billing/Coding section as they do not apply to this policy. Reference added.
Genetic Testing for Non-Malignant Inherited Disorders Added new CPT code 81331 to "Billing/Coding" section.
Genetic Testing for Predisposition to Inherited Hypertrophic Cardiomyopathy New policy. "Genetic testing for predisposition to hypertrophic cardiomyopathy (HCM) may be considered medically necessary for individuals who are at risk for development of HCM, defined as having a first-degree relative with established HCM, when there is a known pathogenic gene mutation present in that affected relative. (See policy guidelines). Genetic testing for predisposition to HCM is considered not medically necessary for patients with a family history of HCM in which a first-degree relative has tested negative for pathologic mutations. Genetic testing for predisposition to HCM is considered investigational for all other patient populations, including but not limited to individuals who have a first-degree relative with clinical HCM, but in whom genetic testing is unavailable." Reviewed by Medical Director.
Autologous Hematopoietic Stem-Cell Transplantation for Malignant Astrocytomas and Gliomas New CPT code 38232 added to Billing/Coding section. Reference added.
Hematopoietic Stem-Cell Transplantation for Miscellaneous Solid Tumors in Adults Specialty Matched Consultant Advisory Panel review 11/30/2011. No change to policy statement. Changed wording in the "When Not Covered" section from "gastric" to "stomach". "Policy Guidelines" section updated. Added new CPT code 38232 to Billing/Coding section. References added.
Hyperthermic Intraperitoneal Chemotherapy "Description" section updated to include information related to Mesothelioma. The "When Covered" section updated to indicate; "Cytoreductive surgery and perioperative intraperitoneal chemotherapy for the treatment of pseudomyxoma peritonei may be considered medically necessary. Cytoreductive surgery and perioperative intraperitoneal chemotherapy for the treatment of diffuse malignant peritoneal mesothelioma may be considered medically necessary." The "When Not Covered" section updated to indicate; "Cytoreductive surgery and perioperative intraperitoneal chemotherapy is considered investigational for peritoneal carcinomatosis from colorectal cancer." "Policy Guidelines" updated. Medical Director review 12/24/11 References added.
Lumbar Spine Fusion Surgery CPT code 22624 corrected to 22634 in Billing/Coding section.
Neurostimulation, Electrical Policy name changed to Neurostimulation, Electrical. Specialty Matched Consultant Advisory Panel review 11/30/11. "Description" section updated under the "Functional Neuromuscular Electrical Stimulation" part of the policy. Section IV added to policy to address Peripheral Subcutaneous Field Stimulation. "Peripheral subcutaneous field stimulation is considered investigational for all applications. BCBSNC does not provide coverage for investigational services or procedures." New 2012 CPT codes added to "Billing/Coding" section: 0282T, 0283T, 0284T, 0285T. Reference added.
Non-BRCA Breast Cancer Risk Assessment (OncoVue) "Description" and "Policy Guidelines" sections updated. No change to policy intent. Medical Director review 12/14/2011. References added.
Percutaneous Discectomy Added HCPCS code S2348 to Billing/Coding section. Reference added.
Quantitative Sensory Testing "Description" section revised. "When Not covered" section updated to indicate the following; "Quantitative sensory testing, including but not limited to current perception threshold testing, pressure-specified sensory device testing, vibration perception threshold testing, and thermal threshold testing, is considered investigational for all applications. BCBSNC does not provide coverage for investigational services or procedures." No change to policy intent. "Policy Guidelines" updated. Medical Director review 12/14.2011. References added.
Rehabilitative Therapies Deleted HCPCS codes G9041-G9044 for 2012 code update.
Tyrosine Kinase Mutations in Myeloproliferative Neoplasms Removed 81275 from Billing/Coding section as it does not pertain to this policy. Added new 2012 CPT code, 81270 to Billing/Coding section.
Evidence Based Guidelines
KRAS Mutation Analysis in Cancer Added new 2012 CPT code, 81210, to Billing/Coding section