Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for April 17, 2012

Medical Guidelines Reason for Update
Adoptive Immunotherapy Specialty Matched Consultant Advisory Panel review 3/21/2012. Description section revised. Updated Policy Guidelines section. No change to policy intent. Reference added.
Bone Turnover Markers for the Diagnosis and Management of Osteoporosis Related policy and related guideline added. Added "bone turnover marker levels may be independently associated with osteoporosis and fracture risk in groups of individuals" and added revision "In addition, there is insufficient evidence from controlled studies that bone turnover marker measurement improves adherence to treatment or improves health outcomes such as reducing fracture rates" in Policy Guidelines section. No change to policy intent. Specialty Matched Consultant Advisory Panel review 3/21/12
Convection-Enhanced Delivery of Therapeutic Agents to the Brain Specialty Matched Consultant Advisory Panel review 3/21/2012. No change to policy.
Cord Blood as a Source of Stem Cells Description section revised. "with a diagnosis that is consistent with the possible need for allogeneic transplant" added to the second statement under the When Covered section. New 2012 CPT code, 38232, added to Billing/Coding section. References added. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 3/21/2012.
Cryosurgical Ablation of Primary or Metastatic Liver Tumors Policy Guidelines revised. Reference added. Medical Director review 3/21/2012.
Detection of Circulating Tumor Cells Specialty Matched Consultant Advisory Panel review 3/21/2012. No change to policy, Deleted HCPCS code S3711 from Billing/Coding section.
Endobronchial Valves Specialty Matched Consultant Advisory Panel review 3/21/2012. References and Policy Guidelines updated. No change to policy statement.
Epidermal Growth Factor Receptor (EGFR) Mutation Analysis for Patients with Non-Small Cell Lung Cancer (NSCLC) Reference added.
Fetal Surgery for Malformations Added references. Specialty Matched Consultant Advisory Panel review 3/21/12.
Hematopoietic Stem-Cell Transplantation for Chronic Myelogenous Leukemia Reference added.
Hematopoietic Stem-Cell Transplantation for CLL and SLL Reference added.
Home Uterine Activity Monitoring Related policies added. Policy guidelines updated. No change to Policy statement. Specialty Matched Consultant Advisory Panel Review 3/21/12.
Hormone Pellet Implantation for Hormone Replacement Therapy in Women Reference added. Specialty Matched Consultant Advisory Panel review No change to policy statement 3/21/12.
Hyperthermic Intraperitoneal Chemotherapy Specialty Matched Consultant Advisory Panel review 3/21/2012. No change to policy intent.
Infusion Therapy in the Home Specialty Matched Consultant Advisory Panel review meeting 2/29/2012. Under "When Covered" section C: removed bullet #4, indication for IV antibiotics." Also under "When Covered" section, statement 1. and "When Not Covered" statement 2. changed "licensed physician (MD, DO) to "a provider who has a current (DEA) Drug Enforcement Agency licensure." Moved the following statement from the Description section to Policy Guidelines: "Home infusion therapy includes all of the components related to such therapy, such as, but not limited to, nursing services, durable medical equipment, supplies, Prescription and non-Prescription Legend Drugs and solutions, pharmacy compounding and dispensing, specimen collection, patient and family education, delivery of drugs and supplies, and management of emergencies arising from said therapy."
Insulin Potentiation Therapy Medical Director review 3/19/2012. Archive policy.
Interferential Stimulation Reference added.
Intravitreal Implant Added CPT code 67028 to the Billing/Coding section for consistency with BCBSA. Reviewed by medical director.
JAK2 and MPL Mutations in Myeloproliferative Neoplasms Policy name changed from "Tyrosine Kinase Mutation Analysis in Myeloproliferative Neoplasms" to "JAK2 and MPL Mutation Analysis in Myeloproliferative Neoplasms". MPL is not a tyrosine kinase. No change to policy intent. Policy Guidelines updated. Medical Director review 3/29/12. Reference added.
Lysis of Epidural Adhesions Description section revised. Policy Guidelines updated. Medical Director review 3/29/12. Reference added.
Microwave Thermotherapy for Primary Breast Cancer Medical Director review 3/12/2012. Archive policy.
Non-BRCA Breast Cancer Risk Assessment (OncoVue) Specialty Matched Consultant Advisory Panel review. No change to policy.
Ovarian and Internal Iliac Vein Embolization Specialty Matched Consultant Advisory Panel review. Added Related Guideline. Updated Policy Guidelines. No change to policy intent 3/21/12.
PathFinderTG® Molecular Testing Specialty Matched Consultant Advisory Panel 3/21/2012. No change to policy.
Proteomics-based Testing for the Evaluation of Ovarian (Adnexal) Masses Related policies added. Reworded when covered section. No change to policy intent. Specialty Matched Consultant Advisory Panel review 3/21/12.
Refractive Surgery Added HCPCS code C1780 to Billing/Coding section for April 2012 code update.
Salivary Hormone Tests No change to policy statement. Specialty Matched Consultant Advisory Panel review 3/21/12.
Spinal Surgery Using Interspinous Distraction Technology Description section revised. Reworded the When Not Covered statement for consistency, no change to policy intent. Policy Guidelines updated. Reference added. Medical Director review 3/21/2012.
Evidence Based Guidelines
Balloon Valvuloplasty, Percutaneous Medical Director review 3/2012. Guideline archived.
Breast Lesion Localization, Stereotactic Approach Medical Director review 3/30/12. Archive policy.
Chronic Pulmonary Thromboendarterectomy Medical Director review 3/2012. Guideline archived.
Donor Leukocyte Infusion Policy returned to active review status. Description revised. Removed the following statement from the Evidence Based Guideline section; "Donor leukocyte infusion may be appropriate as treatment for a patient with a hematologic malignancy who has relapsed after a prior allogeneic bone marrow transplant for Acute Myelogenous Leukemia, Hodgkin's Disease, Chronic Myelogenous Leukemia, and Acute Lymphocytic Leukemia." Added the following statements to the Evidence Based Guideline section; "Donor lymphocyte infusion may be appropriate following allogeneic-hematopoietic stem cell transplantation (HSCT) that was originally considered medically necessary for the treatment of a hematologic malignancy that has relapsed or is refractory, to prevent relapse in the setting of a high risk of relapse, or to convert a patient from mixed to full donor chimerism. Settings considered high risk for relapse include T cell depleted grafts or nonmyeloablative (reduced-intensity conditioning) allogeneic HSCT" Removed the following statement from the When Not Recommended section; "Donor leukocyte infusion is not recommended as a treatment for other malignancies that have relapsed after prior allogeneic bone marrow (or stem cell) transplant." Added the following statements to the When Not Recommended section; "Donor lymphocyte infusion is not recommended following allogeneic-hematopoietic stem cell transplantation (HSCT) that was originally considered investigational for the treatment of a hematologic malignancy. Donor lymphocyte infusion is not recommended as a treatment of nonhematologic malignancies following a prior allogeneic HSCT." Specialty Matched Consultant Advisory Panel review 3/21/2012. Reference added.
Drug Eluting Coronary Stent Medical Director review 3/2012. Guideline archived.
KRAS Mutation Analysis in Cancer Added CPT code 81403 and HCPCS code S3713 to Billing/Coding section. Reference added.
Laboratory Testing for HIV Tropism Policy description updated to include information on sequencing the third variable (V3) loop. Added V3 population genotyping to Evidence Based Guideline. Added HIV V3 deep sequencing to not recommended section. Extensively revised Rationale Section. Specialty Matched Consultant Advisory Panel review.
Pulmonary Artery Balloon Angioplasty, Percutaneous Transluminal Approach Medical Director review 3/2012. Guideline archived.
Radioimmunotherapy in the Treatment of Non-Hodgkin Lymphoma Specialty Matched Consultant Advisory Panel review 3/21/2012. No change to guideline.