Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for March 20, 2012

Medical Guidelines Reason for Update
Abatacept (Orencia®) Deleted statement under "When Not Covered" which read: when criteria stated above not met. Also under "When Not Covered" changed statement 1. to read "is considered not medically necessary" and 2. to read "investigational". Specialty Matched Consultant Advisory Panel review meeting 2/29/2012. No change to policy statement.
Allergy Testing Specialty Matched Consultant Advisory Panel review 11/2011. Added "ImmunoCAP" as a Specific IgE In Vitro Test. Added the following tests to the "When not Covered" table: "Antigen Leukocyte Cellular Antibody (ALCAT) Automated Food Allergy Testing. There is insufficient evidence in the published peer-reviewed scientific literature to support the use of this testing in the diagnosis or management of allergic disease." "In Vitro Metal Allergy Testing. There is insufficient evidence that in vitro metal allergy testing improves patient management decisions or health outcomes for total joint replacement patients. No national organizations have issued recommendations regarding in vitro metal allergy testing and orthopedic implants." References updated. Added CPT code 86353 to "Billing/Coding" section. References updated. Notice given on 12/20/11 for effective date 03/20/12.
Belimumab (Benlysta) Under "When Not Covered" first two statements changed to read "not medically necessary" Instead of "investigational" and the last statement continues to read "investigational for all Other indications, including but not limited to use in children." Specialty Matched Consultant Advisory Panel review meeting 2/29/12. No change to policy statement.
Bioengineered Skin and Tissue New policy criteria as follows: "BCBSNC will provide coverage for Apligraf® bioengineered skin, Oasis® Wound Matrix and Dermagraft® for the treatment of skin ulcers when it is determined to be medically necessary because the medical criteria and guidelines shown below have been met." "When Covered' section revised to state, "A. The applications of Apligraf® and Dermagraft® Oasis Wound Matrix® are covered for the treatment of vascular ulcers when all of the following criteria are met: 1.When used in conjunction with standard therapy, 2. The ulcers have not healed by at least 50% after clinically appropriate therapy, 3.The ulcers intended for treatment are partial or full thickness venous stasis ulcers, and 4.The patient has adequate arterial blood supply to the involved limb, including restoration by vascular bypass grafting, stenting or other means." "When not Covered" section updated to include the following statements: "B. Oasis® Wound Matrix is contraindicated in the following situations: 1.The patient has a known allergy to porcine collagen 2.For any indications other than those listed above in the "When Covered" section of the policy." Added the following statement to the "When not Covered" section: "With the exception of products used within the scope of FDA indications for treatment of burns and rare skin conditions such as recessive dystrophic epidermolysis bullosa, FDA approval for a specific use does not define that product as non-investigational." References updated. Medical Director review 3/2012.
Cochlear Implant Specialty Matched Consultant Advisory Panel review 2/29/12. Description section revised and FDA approval Status table removed. Semi-Implantable and Fully Implantable Middle Ear Hearing Aid added to Related Policies. Additional information added to contraindications section "A cochlear implant is contraindicated for the following conditions: Deafness due to lesions of the eighth cranial (acoustic) nerve, central auditory pathway or brain stem, Active or Chronic infections of the external or middle ear and mastoid cavity or tympanic membrane perforation, Cochlear ossification may prevent electrode insertion, and the Absence of cochlear development as demonstrated on CT scans is an absolute contraindication." No change to policy intent. Reference added.
DNA Based Testing for Adolescent Idiopathic Scoliosis Specialty Matched Consultant Advisory Panel review 2/2012. No changes to policy statement.
Dynamic Posturography Specialty Matched Consultant Advisory Panel review 2/2012. No changes to policy statement. Specialty Matched Consultant Advisory Panel Review 2/29/12. No change in medical coverage/non-coverage criteria.
End Diastolic Pneumatic Compression Boot References updated. No changes to policy statements.
E-visits (Online Medical Evaluations) Specialty Matched Consultant Advisory Panel Review meeting 2/29/2012. No change to policy statement.
Hip Resurfacing Policy re-titled from "Total Hip Resurfacing" to "Hip Resurfacing." Policy will address both partial and total hip resurfacing procedures. Specialty Matched Consultant Advisory Panel review 2/2012. "Description" section updated to include product information. "When Covered" section revised to include criteria for partial hip resurfacing. "Policy Guidelines" updated. Added CPT code 27130 to "Billing/Coding" section. References updated. Medical Director review 3/2012.
Infliximab (Remicade) Added FDA approved indication for pediatric patients ages 6 years or older for the treatment of ulcerative colitis. Added the following indications to the investigation status under "When Not Covered" for consistency with BCBSA: age-related macular degeneration, alcoholic hepatitis, depression, diabetic macular edema, erythrodermic or exfoliative psoriasis, systemic sclerosis, Wegener's granulomatosis, cancer cachexia,endometriosis,giant cell arteritis, intraarticular injections, Kawasaki syndrome, gonarthritis, polymyalgia rheumatic, renal cell carcinoma, sacroiliitis, sclerosing cholangitis, Sjogren syndrome, systemic necrotizing vasculitides. Specialty Matched Consultant Advisory Panel review 2/29/2012. No change to policy statement.
Injectable Clostridial Collagenase for Fibroproliferative Disorders Specialty Matched Consultant Advisory Panel review 2/2012. No changes to Policy Statements.
Microprocessor-Controlled Prostheses for the Lower Limb Specialty Matched Consultant Advisory Panel review 2/2012. References updated. No changes to policy statements.
Monochromatic Infrared Energy Treatment (MIRE) Specialty Matched Consultant Advisory Panel review meeting 2/29/2012. Policy renamed from "Infrared Heating Pad System in the Home Setting" to "Monochromatic Infrared Energy Treatment (MIRE)." No change to policy statement.
Myoelectric Prosthetic Components for the Upper Limb Specialty Matched Consultant Advisory Panel review 2/2012. References updated. No changes to policy statements.
Noninvasive Respiratory Assist Devices References added. No change to Policy statement. Specialty Matched Consultant Advisory Panel review 2/29/11.
Orthopedic Applications of Stem Cell Therapy Specialty Matched Consultant Advisory Panel review 2/2012. References update. Policy Guidelines updated.
Partial Hip Resurfacing Specialty Matched Consultant Advisory Panel review 2/2012. References updated. Policy Guidelines updated. Medical Director review 3/2012. Policy archived. New policy titled "Hip Resurfacing" will address both partial and total hip resurfacing.
Posterior Tibial Nerve Stimulation for Voiding Dysfunction References updated. Policy Guidelines updated. No changes to policy statement.
Rituximab for the Treatment of Rheumatoid Arthritis Specialty Matched Consultant Advisory Panel review meeting 2/29/2012. Under "When Not Covered" statement 2. changed to not medically necessary. No change to policy statement.
Semi-Implantable and Fully Implantable Middle Ear Hearing Aid Specialty Matched Consultant Advisory Panel review 2/29/12. Policy Guidelines updated.
Serum Holo-Transcobalamin as a Marker of Vitamin B12 Status Specialty Matched Consultant Advisory Panel review meeting 2/29/2012. No change to policy statement.
Subtalar Arthroereisis Specialty Matched Consultant Advisory Panel review 2/2012. No changes to policy statements.
Telemedicine Specialty Matched Consultant Advisory Panel review meeting 2/29/2012. No change to policy statement.
Tocilizumab (Actemra) Added new approval guidelines from the FDA on use in patients 2 years old and older under "When Covered" and Policy Guidelines. Under "When Not Covered" changed first statement to read: Tocilizumab (Actemra) is considered not medically necessary patients when used for patients with an absolute neutrophil count (ANC) below 2000/mm3, platelet count below 100,000/mm3, or who have ALT or AST above 1.5 times the upper limit of normal. Changed the second statement under "When Not Covered" to read: Tocilizumab (Actemra) is considered not medically necessary for patients with an active infection, including localized infections and also added a fifth bullet that reads: "with recently active GI problems such as diverticulitis possibly placing them at risk of perforation." Added the following investigational statement under "When Not Covered" Tocilizumab (Actemra®) is considered investigational when used for conditions other than rheumatoid arthritis (RA) and active systemic juvenile idiopathic arthritis (sJIA). Specialty Matched Consultant Advisory Panel review 2/29/2012.
Topical Negative Pressure Therapy for Wounds Removed the following statement from the Billing/Coding section as there is now a specific code (A9272) for a disposable NPWT system: "There are no specific codes for a disposable NPWT system. It may be coded using an unlisted code such as A4649".
Ultrasound Accelerated Fracture Healing Device Removed "less than one month old" from "When not Covered" section. Statement now revised as follows: "Low-intensity ultrasound treatment may be considered medically necessary when used as an adjunct to conventional management (including, but not limited to, closed reduction and cast immobilization) for the treatment of fresh, closed fractures in skeletally mature individuals." Removed definition of delayed union "(defined as a decelerating healing process as determined by serial x-rays)" from "When Covered" section. Revised "Policy Guidelines." Specialty Matched Consultant Advisory Panel review 2/2012. Medical Director review 2/2012.
Evidence Based Guidelines
Ambulatory Blood Pressure Monitoring Description section updated. "When Recommended" section revised to state: "automated ambulatory blood pressure monitoring over a 24-hour period is recommended for patients with elevated office BP, when performed one time to differentiate between 'white coat' hypertension and true hypertension, and when the following conditions are met: office blood pressure elevation is in the mild to moderate range (<180/110), not requiring immediate treatment with medications; there is an absence of hypertensive end-organ damage on physical examination and laboratory testing." "When not Recommended" section revised to state: "Other than listed above, uses of ambulatory blood pressure monitoring for patients with elevated office BP, including but not limited to repeated testing in patients with persistently elevated office BP, is not recommended." References updated. Medical Director review 3/2012.
Anti-CCP Testing for Rheumatoid Arthritis Specialty Matched Consultant Advisory Panel review 2/29/2012. No change to policy statement. Added medical evidence statement under "When Not Recommended".
Arthroscopic Debridement and Lavage as Treatment of Knee Osteoarthritis Specialty Matched Consultant Advisory Panel review 2/2012. References updated. No changes to policy statement.
Human Papillomavirus (HPV) Vaccine Specialty Matched Consultant Advisory Panel review 2/29/12. Added "Human papillomavirus (HPV) vaccine (Gardasil®) may be appropriate for boys and men who are between the age of 9 and 26. It is recommended that it be routinely given to boys 11-12 years old to reduce the risk of anal cancer and genital warts. Gardasil® is given in three intramuscular injections over a 6 month period. The second dose should be given 2 months after the initial dose and the third dose should be administered 6 months after the first dose."
Interventions for Progressive Scoliosis Specialty Matched Consultant Advisory Panel review 2/2012. No changes to guideline statements.