Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for May 15, 2012

Medical Guidelines Reason for Update
Allogeneic Hematopoietic Transplant for Genetic Diseases and Acquired Anemia Specialty Matched Consultant Advisory Panel review 4/18/2012. No change to policy intent.
Allogeneic Stem-Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms Specialty Matched Consultant Advisory Panel review 4/18/2012. No change to policy intent. Policy Guidelines updated.
Ambulance and Medical Transport Services Revised statement #5 under "When Covered" section from "Transportation from a hospital, skilled nursing facility or rehabilitation facility to a patient's residence when the patient's condition is such that any other form of transportation would be medically contraindicated" to "Transportation from a hospital, skilled nursing facility or rehabilitation facility to a patient's residence when the patient's condition requires skilled monitoring during transport with the services of an EMT attendant or other licensed healthcare practitioner." Reviewed with medical director 4/2012.
Ambulatory Event Monitors Specialty Matched Consultant Advisory Panel review 4/2012. No changes to policy statements.
Baroreflex Stimulation Devices Specialty Matched Consultant Advisory Panel review 4/2012. Policy Guidelines updated.
Computerized 2-Lead Resting Electrocardiogram (Multifunction Cardiogram) Specialty Matched Consultant Advisory Panel review 4/2012. Policy Guidelines updated. Medical Director review 4/2012.
Cosmetic and Reconstructive Surgery Removed information regarding treatment of vitiligo from section titled "Examples of Cosmetic and Reconstructive Surgery" Please see separate BCBSNC policy titled, "Light Treatment for Dermatologic Conditions." Medical Director review.
Enhanced External Counterpulsation (EECP) Removed the word "congestive" from all references for "heart failure" throughout policy. Added "erectile dysfunction" and "ischemic stroke" to "When not Covered" section. References updated. Specialty Matched Consultant Advisory Panel review 4/2102.
External Defibrillators Specialty Matched Consultant Advisory Panel review 4/2012. References updated. No changes to Policy Statements.
Genetic Testing for Long QT Syndrome Specialty Matched Consultant Advisory Panel review 4/2012. Medical Director review 3/2012. Policy Guidelines updated.
Genetic Testing for Tamoxifen Treatment Specialty Matched Consultant Advisory Panel review 4/18/2012. Description revised. No change to policy intent.
Hematopoietic Stem-Cell Transplantation for Breast Cancer Specialty Matched Consultant Advisory Panel review 4/18/2012. No change to policy intent. Reference added. Single or tandem autologous hematopoietic stem-cell transplantation changed from investigational to not medically necessary.
Hematopoietic Stem-Cell Transplantation for Acute Lymphoblastic Leukemia Specialty Matched Consultant Advisory Panel review 4/18/2012. Description section updated for format consistency. No change to policy intent. References added.
Autologous Hematopoietic Stem-Cell Transplantation for Malignant Astrocytomas and Gliomas Specialty Matched Consultant Advisory Panel review 4/18/12. No change to policy intent.
Hematopoietic Stem-Cell Transplantation for Acute Myeloid Leukemia Specialty Matched Consultant Advisory Panel review 4/18/2012. Changed the "When Not Covered" section from "investigational" to "Hematopoietic stem-cell transplantation for acute myeloid leukemia is considered not medically necessary when the medical criteria listed above are not met." Policy Guidelines updated. Reference added.
In Vitro Chemoresistance and Chemosensitivity Assays Specialty Matched Consultant Advisory Panel review 4/18/2012. Updated Policy Guidelines. No change to policy intent. Reference added.
KIF6 Genotyping for Predicting Cardiovascular Risk and/or Effectiveness of Statin Therapy Specialty Matched Consultant Advisory panel review 4/2012. References updated. Policy Guidelines updated. Description section updated.
Laboratory Tests for Heart Transplant Rejection Specialty Matched Consultant Advisory Panel review 4/2012. Description section updated. Policy Guidelines updated. References updated.
Light Therapy for Dermatologic Conditions New policy developed to combine policies titled, "Targeted Phototherapy for Psoriasis", and "PUVA (Psoralens with Ultraviolet A) Therapy." This policy also addresses coverage for treatment of vitiligo. PUVA may be considered medically necessary for the treatment of severe, disabling psoriasis, severe refractory atopic dermatitis and severe refractory pruritus which is not responsive to other forms of conservative therapy (e.g., topical corticosteroids, coal/tar preparations, and ultraviolet light.) PUVA may be considered medically necessary for the treatment of Cutaneous T-Cell Lymphoma (e.g., mycosis fungoides and Sezary syndrome.) PUVA may be considered medically necessary for the treatment of vitiligo which is not responsive to other forms of conservative therapy (e.g., topical corticosteroids, coal/tar preparations, and ultraviolet light.) Targeted phototherapy may be considered medically necessary for the treatment of moderate to severe psoriasis (comprising less than 20% body area) for which NB-UVB or PUVA are indicated. Targeted phototherapy may be considered medically necessary for the treatment of mild to moderate localized psoriasis that is unresponsive to conservative treatment. Targeted phototherapy is considered investigational for the first-line treatment of mild psoriasis. Targeted phototherapy is considered investigational for the treatment of generalized psoriasis or psoriatic arthritis. Targeted phototherapy is considered investigational for the treatment of vitiligo. Medical Director review 4/2012.
Melanoma Vaccines Specialty Matched Consultant Advisory Panel review 4/18/2012. Policy Guidelines updated. No change to policy intent.
Monoclonal Antibody Imaging for Prostate Cancer Specialty Matched Consultant Advisory Panel review 4/18/2012. No change to policy intent. Description section revised. Policy Guidelines updated. Reference added.
Multigene Expression Assay for Predicting Recurrence in Colon Cancer Specialty Matched Consultant Advisory Panel review 4/18/2012. No change to policy intent.
Targeted Phototherapy for Psoriasis Policy archived. Indications for targeted phototherapy for psoriasis are now addressed in the policy titled, "Light Therapy for Dermatologic Conditions." Medical Director review 4/2012.
Telemedicine Added CPT codes 90801, 90862 to Billing/Coding section. (UHS Telepsychiatry).
Urinary Tumor Markers for Bladder Cancer Specialty Matched Consultant Advisory Panel review 4/18/2012. The When Not Covered section re-formatted, no change to policy intent.
Wound Therapy, Noncontact Radiant Heat Bandage Medical Director review 4/17/12. Archive policy.
Xolair® (Omalizumab) Deleted sections B1 and 2 from "When Covered" section addressing continuation of coverage after 6 months. Continuation of Xolair will be reviewed after 12 month interval. Medical Director review 4/2012.
Evidence Based Guidelines
Diagnosis and Treatment of Sacroiliac Joint Pain Information regarding radiofrequency ablation of the sacroiliac joint deleted. Description section updated to include reference for BCBSNC policy titled, "Facet Joint Denervation." Medical Director review 5/2012.
Monoclonal Antibodies for Non-Hodgkin Lymphoma, including Chronic Lymphocytic, & Acute Myeloid Leukemia In the Non-Hematopoietic Stem Cell Transplant Setting Specialty Matched Consultant Advisory Panel review 4/18/2012 No change to policy intent.
PUVA (Psoralens with Ultraviolet A) Therapy Guideline archived. Indications for PUVA treatments are addressed in the policy titled, "Light Therapy for Dermatologic Conditions." Medical Director review 4/2012.
Serum Biomarker Human Epididymis Protein 4 (HE4) Specialty Matched Consultant Advisory Panel review 4/18/2012. No change to guideline intent.
Transjugular Intrahepatic Portosystemic Shunt (TIPS) Medical Director review 4/17/12. Archive policy.
Ultraviolet Light Box Therapy in the Home (UVB) Policy archived. Medical Director review 4/2012.