Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for March 30, 2012

Medical Guidelines Reason for Update
Bronchial Thermoplasty Specialty Matched Consultant Advisory Panel review meeting 3/21/2012. No change to policy statement.
Cervicography Medical Director review 3/10/12. Archive policy
Cough Stimulating Device Specialty Matched Consultant Advisory Panel review 3/21/2012. Extensively revised the description section and policy guidelines section. Active archive policy converted back to active policy. No change to policy statement.
Electromagnetic Navigation Bronchoscopy Specialty Matched Consultant Advisory Panel review 3/21/2012. Updated references and policy guidelines. No change to policy statement.
Exhaled Nitric Oxide Measurement Specialty Matched Consultant Advisory Panel review 3/2012. Added references and updated policy guidelines. No change to policy statement.
Facet Joint Denervation Specialty Matched Consultant Advisory Panel review 11/30/2011. "Description" section revised. "Chemical denervation" added to the "When Not Covered" section. "All other techniques of facet joint denervation for the treatment of chronic back pain are considered investigational including, but not limited to: Pulsed radiofrequency denervation; Laser; Cryodenervation; and Chemical denervation." "Therapeutic (as opposed to diagnostic) medial branch blocks are considered investigational." "Policy Guidelines" updated. Added the following new 2012 CPT codes to the "Billing/Coding" section: 64633, 64634, 64635, and 64636. Deleted CPT codes: 64622, 64623, 64626, and 64627. Notification given 1/1/2012. Policy effective date 4/1/2012.
Gene-Based Tests for Screening, Detection, and/or Management of Prostate Cancer Added HCPCS code S3721 to the Billing/Coding section.
Genetic Testing for Breast and Ovarian Cancer Deleted HCPCS codes S3818, S3819, S3820, S3822, S3823 from Billing/Coding Section.
Genetic Testing for Colon Cancer Deleted HCPCS codes S3828, S3829, S3830, and S3831from Billing/Coding section.
Genetic Testing for Familial Alzheimer's Disease Policy converted from Evidence Based Guideline to Corporate Medical Policy. Specialty Matched Consultant Advisory Panel review 11/30/2011. "Genetic testing for the diagnosis or risk assessment of Alzheimer's disease is considered investigational. Genetic testing includes, but is not limited to, testing for the apolipoprotein E epsilon 4 allele, presenilin genes, or amyloid precursor gene." Added new CPT code effective 1/1/2012, 81401, to "Billing/Coding" section. Notification given 1/1/2012. Policy effective 4/1/2012.
Genetic Testing for Long QT Syndrome Deleted the following codes from the "Billing/Coding" section: S3860, S3862.
Genetic Testing for Non-Malignant Inherited Disorders Deleted the following codes from the "Billing/Coding" section: S3828, S3829, S3835, S3837, S3843, S3847, S3848, and S3851. Added the following codes to the "Billing/Coding" section: 81292, 81295.
Genetic Testing for Tamoxifen Treatment Evidence Based Guideline converted to Corporate Medical Policy. "Genotyping to determine Cytochrome p450 (CYP2D6) genetic polymorphisms is considered investigational for the purpose of managing treatment with Tamoxifen for women at high risk for or with breast cancer." Added new 2012 CPT code, 81226 to "Billing/Coding" section. Notification given 1/1/2012. Policy effective 4/1/2012.
Immune Globulin Therapy Description section updated. Related policies and Evidence-based guidelines added. Added the following indications to When Immune Globulin Therapy is Covered: Ataxia telangiectasia; X-linked hyper-IgM syndrome; Acute Humoral Rejection; Autoimmune Mucocutaneous Blistering Diseases; and Eaton-Lambert myasthenic syndrome. Added Appendix B Diagnostic Criteria for Diagnosis of Multifocal Motor Neuropathy (MMN) Added new reference. Specialty Matched Consultant review 2/29/12.
Implantable Bone Conduction Hearing Aids Specialty Matched Consultant Advisory Panel 2/29/12. Policy guidelines updated.
Intravenous Antibiotic Therapy for Lyme Disease Added the following to the Description section under Polymerase Chain Reaction (PCR): (but may not be indicated with recent history of tick bite or exposure). Added C6 peptide ELISA to the list of investigational diagnostic testing. Added "Patients with symptoms consistent with chronic fatigue syndrome or fibromyalgia, in the absence of objective clinical or laboratory evidence for Lyme disease" to When Intravenous Antibiotic Therapy and Testing for Lyme Disease is not covered. Policy Guidelines section extensively revised. Added reference. Specialty Matched Consultant review 2/29/12.
Lung and Lobar Lung Transplantation Specialty Matched Consultant Advisory Panel review 3/21/2012. Revised description section extensively as well as Policy Guidelines and When Not Covered sections. Reordered covered indications under When Covered section. Added references. No change to policy statement. (lpr)
Lung Volume Reduction Surgery Specialty Matched Consultant Panel review 3/21/2012. Converting active archive policy back to active policy. Updated the policy for consistency with BCBSA. Extensive revisions to Description and Policy Guidelines sections. Added the following updated information to "When Covered criteria section: Predominantly upper lobe emphysema with hyperinflation and heterogeneity; Forced expiratory volume in one second (FEV-1): 1) for patients who are younger than 70 years of age, the FEV must be no more than 45% of the predicted value; 2) for patients who are 70 years of age or older, the FEV-1 must be no more than 45% pf the [redacted value and greater than or equal to 15% of the predicted value; Marked restriction in activities of daily living despite maximal medical therapy; Age younger than 75 years; Acceptable nutrition status, i.e., 70-130% of ideal body weight; Ability to participate in a vigorous pulmonary rehabilitation program; No coexisting major medical problems that would significantly increase operative risk; Willingness to undertake risk of morbidity and mortality associated with LVRS; Abstinence from cigarette smoking for at least 4 months.
Mutation Analysis in Fine Needle Aspirates of the Thyroid New policy. "Mutation analysis in fine-needle aspirates of the thyroid that are cytologically considered to be indeterminate, atypical or suspicious for malignancy is considered to be investigational."
Myolysis of Uterine Fibroids Medical Director review 3/10/12. Archive policy.
Natural Killer Cell Assay for Habitual Spontaneous Abortions Medical Director review 3/10/12. Archive policy.
Oscillatory Devices for the Treatment of Respiratory Conditions Specialty Matched Consultant Advisory Panel review 3/21/2012. Updated Policy Guidelines section. No change to policy statement.
Oxygen and Oxygen Supplies Policy reviewed by medical director 3/10/12. Archived.
Pulmonary Hypertension, Drug Management Under Description section: Phosphodiesterase (PDE5) Inhibitors, added statement that Sildenafil (Revatio) and Tadalafil (Adcirca) should not be used in combination with nitrates. Extensively revised Policy Guidelines section. Specialty Matched Consultant Advisory Panel 3/21/2012.
Quantitative Assay for Measurement of HER2 Total Protein Expression and HER2 Dimers New policy. "The assessment of HER2 status by quantitative total HER2 protein expression and HER2 homodimer measurement is considered investigational." Medical Director review 12/14/11. Notification given 1/1/2012. Policy effective 4/1/2012.
Refractive Surgery Added HCPCS code S0596 to Billing/Coding section for April 2012 code update.
Rehabilitative Therapies Deleted the statement "Requests for more than one hour of treatment per day will be reviewed on an individual consideration basis." under Policy Guidelines section.
Respiratory Syncytial Virus Prophylaxis "Subsequently, AstraZeneca suspended Motavizumab development and requested the FDA withdraw its biological license application" added to Description. Removed "up to a maximum of 5 monthly doses" from When RSV Prophylaxis is Covered 1. Removed "born before 35 weeks of gestation" and "during the first year of life up to a maximum of 5 monthly doses" from When RSV Prophylaxis is Covered 4. Deleted "congestive" from "congestive heart failure" in policy statements. Policy Guidelines section updated. Specialty Matched Consultant Advisory Panel review 2/29/12.
Salivary Estriol as a Risk Predictor for Preterm Labor Medical Director review 3/10/12. Archive policy.
Spinal Cord Stimulation Reference added.
Transcatheter Heart Valve Implantation Added new coverage criteria for Transcatheter Aortic Valve Implantation (TAVI.) "When Covered" section revised to state: "Transcatheter pulmonary valve implantation (TPVI) may be considered medically necessary for patients with prior repair of congenital heart disease and right ventricular outflow tract (RVOT) dysfunction. Transcatheter aortic valve implantation (TAVI) is considered medically necessary for patients with aortic stenosis (AS) when all of the following conditions are present. Severe aortic stenosis with a calcified aortic annulus defined as: a. An aortic valve area of less than 0.8cm2, b.A mean aortic valve gradient greater than 40mmHg, c. A jet velocity greater than 4.0m/sec and 2. NYHA heart failure Class II, III or IV symptoms an 3. Patient is not an operable candidate for open surgery, as judged by at least two cardiovascular specialists (cardiologist and/or cardiac surgeon)" "Description" section and "Policy Guidelines" section updated. Reference updated. Medical Director review
Evidence Based Guidelines
External Cephalic Version Medical Director review 3/10/12. Archive policy.
Hysteroscopic Tubal Occlusion for Permanent Sterilization Medical Director review 3/10/12. Archive policy.
Intrauterine Ablation or Resection of the Endometrium Guideline returned to active review. References updated. "Dilation and curettage" removed from guideline statement and "would otherwise be considered a candidate for hysterectomy" added. A statement was added for clarification that endometrial ablation is not recommended for all other indications. No changes to guideline intent.
KRAS Mutation Analysis in Cancer Removed deleted HCPCS code S3713 from Billing/Coding section.
Pulmonary Rehabilitation Specialty Matched Consultant Advisory Panel review 3/21/2012. References updated. No change to guideline statement.
Secondary Physician Attendance at Delivery Medical Director review 3/10/12. Archive policy.
Treatment for Age Related Macular Degeneration Added HCPCS code C9291 to Billing/Coding section for 2012 code update.
Twin-Twin Transfusion Syndrome, Treatment Medical Director review 3/10/12. Archive policy.