Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for May 1, 2012

Medical Guidelines Reason for Update
Allergy Immunotherapy (Desensitization) References updated. No changes to policy statements.
Capsule Endoscopy, Wireless Patient Selection Criteria added to Policy Guidelines. Policy statement revised. No change to policy intent. Specialty Matched Consultant Advisory Panel review 4/18/12.
Carotid Artery Angioplasty/Stenting (CAS) "When not Covered" section revised to state: "Carotid angioplasty with or without associated stenting and embolic protection is considered investigational for all other indications, including but not limited to, patients with carotid stenosis who are suitable candidates for CEA and patients with carotid artery dissection." Description section updated. Policy Guidelines updated. References updated. Medical Director review 4/2012.
Catheter Ablation of the Pulmonary Veins as a Treatment for Atrial Fibrillation References updated. No changes to policy statements.
Esophageal pH Monitoring CPT code 91037 removed from policy as it is not a monitoring code. Specialty Matched Consultant Advisory Panel review 4/18/12.
Extracorporeal Photopheresis after Solid-Organ Transplant and for Graft-versus-Host Disease, Autoimmune Disease, and Cutaneous T-Cell Lymphoma Policy Guidelines updated. Reference added. Medical Director review 4/12/12.
Extracorporeal Shock Wave Treatment for Musculoskeletal Conditions and Wound Healing "When not Covered" section updated to include treatment of spasticity. Policy Guidelines updated. References updated. Medical Director review 4/2012.
Fecal Analysis in the Diagnosis of Intestinal Dysbiosis Summary statement added to Policy Guidelines. No change to policy intent. Specialty Matched Consultant Advisory Panel review 4/18/12.
Gastric Electrical Stimulation Code 43999 added. Policy Guidelines section revised. Specialty Matched Consultant Advisory Panel review 4/18/12. No change to policy statement or criteria.
Gene-Based Tests for Screening, Detection, and/or Management of Prostate Cancer Revised "Description" section. Added "and prognosis" to the second bullet under the "When Not Covered" section. No change to policy intent. Policy Guidelines updated. Reference added. Medical Director review 4/18/2012.
Gene Expression Testing to Predict Coronary Artery Disease Specialty Matched Consultant Advisory Panel review 4/2012 References updated.
Genetic Testing for Helicobacter pylori Treatment Specialty Matched Consultant Advisory Panel review 4/18/12. No change to policy statement or criteria.
Hematopoietic Stem-Cell Transplantation for Waldenstrom Macroglobulinemia Reference added.
Hematopoietic Stem-Cell Transplantation for Primary Amyloidosis Policy Guidelines updated. Reference added. Medical Director review 4/17/12.
Hematopoietic Stem-Cell Transplant for Non-Hodgkin Lymphomas Clarification that peripheral T-cell lymphomas encompass mature T-cell and NK-cell neoplasms in the When and When Not Covered sections. Policy Guidelines updated. Reference added. Medical Director review 4/11/2012.
Idiopathic Environmental Intolerance (i.e. Clinical Ecology) Policy status changed to active and will receive annual review. Description section updated. Policy Statement revised to state: "The diagnosis and management of Idiopathic Environmental Intolerance is considered investigational. BCBSNC does not cover investigational services." Policy Guidelines updated. References updated. Medical Director review 4/2012.
Meniscal Allografts and Collagen Meniscus Implants References updated. No changes to policy statements.
Neurostimulation, Electrical Reference added.
Pancreas Transplant No change in policy statement or coverage criteria. Information that was previously in the Not Covered section (list of contraindications) was moved to the Policy Guidelines section. Specialty Matched Consultant Advisory Panel review 4/18/12.
Progenitor Cell Therapy for the Treatment of Damaged Myocardium Due to Ischemia Policy status changed to active and will undergo routine literature review. Policy re-titled from "Autologous Cell Therapy for the Treatment of Damaged Myocardium" to "Progenitor Cell Therapy for the Treatment of Damaged Myocardium Due to Ischemia." Description section updated. Policy Guidelines updated. References updated. Medical Director review 4/2012.
Radiofrequency Tissue Remodeling for Urinary Stress Incontinence Description section updated. Policy statement revised to state: "Transvaginal and Transurethral Radiofrequency Tissue Remodeling for Urinary Stress Incontinence are considered investigational. BCBSNC does not cover investigational services." Policy Guidelines updated. References updated. Medical Director review 4/2012.
Small Bowel, Small Bowel with Liver, or Multivisceral Transplant Potential contraindications added to Policy Guidelines section. Criteria for transplantation for HIV'positive patients added to Policy Guidelines section. CPT codes 44120 and 44121 added to Billing Section. Specialty Matched Consultant Advisory Panel review 4/18/12.
Surgical Interruption of Pelvic Nerve Pathways for Dysmenorrhea Specialty Matched Consultant Advisory Panel review. Added Related Guideline. Updated Policy Guidelines. No change to policy intent 3/21/12.
Systems Pathology for Predicting Risk of Recurrence in Prostate Cancer Description section updated. "When not Covered" section revised to state: "Systems pathology testing that determines cellular and biologic features of a tumor is considered investigational, including use for predicting risk of prostate cancer recurrence. BCBSNC does not cover investigational services." Policy Guidelines updated. Billing/Coding section updated. References updated. Medical Director review 4/2012.
Laboratory Testing to Allow Area Under the Curve (AUC) Targeted 5-Fluorouracil (5-FU) Dosing for Patients Administered 5-FU for Cancer Reference added.
Evidence Based Guidelines
Cardiac Rehabilitation Evidence Based Guideline changed to active status and will undergo routine literature review. Guidelines updated. References updated. Information regarding visit limitations removed. Medical Director review 4/2012.
Diagnosis and Treatment of Sacroiliac Joint Pain Guideline titled changed from "Sacroiliac Joint Arthroscopy and Injection" to "Diagnosis and Treatment of Sacroiliac Joint Pain." Description section updated. "Not Recommended" section updated. The following statement added to the Evidence Based Guidelines: "Radiofrequency ablation of the sacroiliac joint is not recommended as a treatment for sacroiliac pain." References updated. Medical Director review 4/2012.
Homocysteine Testing in Cardiac Disease Risk Assessment Specialty Matched Consultant Advisory Panel review 4/2012. "When not Recommended" section updated. References updated.
Intra Articular Hyaluronan Injections for Treatment of Osteoarthritis of the Knee Description section updated. "Not Recommended" section updated. References updated. Medical Director review 4/2012.
Lithotripsy, Extracorporeal, for Gallstones Medical Director Review 4/12/12. Policy archived.
Novel Lipid Risk Factors in Risk Assessment of Cardiovascular Disease Specialty Matched Consultant Advisory Panel review 4/2012. Policy Guidelines updated. References updated. CPT code 83695 added to "Billing/Coding" section. Medical Director review 4/2012.
Partial Left Ventriculectomy Guideline status revised to "active" and will undergo routine literature review. "Description" section updated. "Not Recommended" section updated. References updated. Medical Director review 4/2012.
Prothrombin Time Monitoring in the Home CPT codes 99363 and 99364 added to "Billing/Coding" section. Description section updated. "When Recommended" section revised to state: "At-home monitoring of chronic warfarin therapy is recommended in patients who require continuous anticoagulation for chronic medical conditions. These conditions include, but are not limited to, patients with mechanical heart valves and chronic atrial fibrillation." References updated. Medical Director review 4/2012.
Serologic Diagnosis of Celiac Disease Guideline updated. Related policy added. Rationale section updated. Policy statement that serologic measurement of a combination of tests is not medically necessary removed. Specialty Matched Consultant Advisory Panel review 4/18/12.
Transcoronary Ablation of Septal Hypertrophy (TASH) Evidence Based Guideline archived. Medical Director review.
Trastuzumab Title changed from "Herceptin" to "Trastuzumab". Specialty Matched Consultant Advisory Panel review 3/21/2012. Removed "esophageal and gastric" from the When Not Recommended section. No change to guideline intent.