Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for February 7, 2012

Medical Guidelines Reason for Update
Alefacept Injection (Amevive) Specialty Matched Consultant Advisory Panel review 1/2012. Medical Director review 1/2012. No changes to policy statements.
Allogeneic Stem-Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms Reference added.
Axial Lumbosacral Interbody Fusion Policy name changed from Percutaneous Axial Anterior Lumbar Fusion to Axial Lumbosacral Interbody Fusion. Description section revised. No change to policy intent. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 11/30/2011. References added.
BRAF Gene Mutation Testing to Select Melanoma Patients for BRAF Inhibitor Therapy New policy developed. Testing for the BRAFV600E mutation in tumor tissue of patients with stage IIIC or IV melanoma may be considered medically necessary to select patients for treatment with vemurafenib. Testing for the BRAFV600E mutation for all other indications, including but not limited to, use in patients with lesser stage melanoma, or with non-melanoma tumors, is considered investigational. Medical Director review 1/2012.
Cardiac (Heart) Transplantation Revised "When not Covered" section. Absolute and Relative contraindications have been combined and revised to delegate contraindications that are "subject to the judgment of the transplant center" or "policy specific." References updated. Policy Guidelines updated. Medical Director review.
Dermatoscopy Specialty Matched Consultant Advisory Panel review 1/2012. "Description" section updated. References updated. Medical Director review 1/2012.
Genetic Testing for Cutaneous Malignant Melanoma Specialty Matched Consultant Advisory Panel review 1/2012. No changes to Policy Statements.
H-Wave Electrical Stimulation Reference added.
Heart-Lung Transplantation Revised "When not Covered" section. Absolute and Relative contraindications have been combined and revised to "Potential contraindications subject to the judgment of the transplant center." References updated. Medical Director review.
Hematopoietic Stem-Cell Transplantation for CNS Embryonal Tumors and Ependymoma Added new 2012 CPT code, 38232 to Billing/Coding section. Reference added.
Hematopoietic Stem-Cell Transplantation for Epithelial Ovarian Cancer Added new 2012 CPT code, 38232 to Billing/Coding section. Reference added.
Hematopoietic Stem-Cell Transplantation for Hodgkin Lymphoma Added new 2012 CPT code, 39232 to Billing/Coding section. Reference added.
Hyperhidrosis, Treatment of Specialty Matched Consultant Advisory Panel review 1/2012. No changes to Policy Statements.
Ipilimumab (Yervoy) Specialty Matched Consultant Advisory Panel review 1/2012. No changes to Policy Statements.
Microarray-based Gene Expression Testing for Cancers of Unknown Primary Reference added.
Non-Pharmacologic Treatment of Rosacea Specialty Matched Consultant Advisory Panel review 1/2012. References updated. Policy Guidelines updated.
Occipital Nerve Stimulation Reference added.
Paraspinal Surface Electromyography (EMG) Reference added.
Targeted Phototherapy for Psoriasis Specialty Matched Consultant Advisory Panel review 1/2012. "Description" section updated. References updated.
Ultrasonographic Evaluation of Skin Lesions Specialty Matched Consultant Advisory Panel review 1/2012. References updated. No changes to Policy Statements.
Ustekinumab (Stelara) Specialty Matched Consultant Advisory Panel review 1/2012. References updated. No changes to Policy Statements.
Evidence Based Guidelines
Bevacizumab in Advanced Adenocarcinoma of the Pancreas Added 6th bullet to Description section to indicate; "November 2011: FDA approval withdrawn for breast cancer." Specialty Matched Consultant Advisory Panel review 11/30/2011. Reference added.
Brachytherapy, Intracoronary Evidence Based Guideline archived. Medical Director review 1/2012.
Dermatologic Applications of Photodynamic Therapy Specialty Matched Consultant Advisory Panel review 1/2012. References updated. Description section updated. Medical Director review 1/2012. No changes to Policy Statements.
ECMO Extracorporeal Membrane Oxygenation Evidence Based Guideline archived. Medical Director review 1/2012.
Electrophrenic Pacemaker Evidence Based Guideline archived. Medical Director review 1/2012.
PUVA (Psoralens with Ultraviolet A) Therapy Specialty Matched Consultant Advisory Panel review 1/2012. Added the following statement to the "Evidence Based Guidelines for PUVA Therapy": "PUVA is recommended for the treatment of Cutaneous T-Cell Lymphoma (e.g., mycosis fungoides and Sezary syndrome.)" References updated.
Tilt Table for Syncope Evidence Based Guideline archived. Medical Director review 1/2012.
Total Body Photography Specialty Matched Consultant Advisory Panel review 1/2012. No changes to Guideline Statements.