Medical Policy Updates

Blue Cross and Blue Shield of North Carolina Medical Policy Update for June 12, 2012

Medical Guidelines	Reason for Update
Allergy Testing	Allergy patch testing limitation increased from 36 to 42 units. Greater than 42 patch tests will be reviewed and documentation of medical necessity will be required.
Genetic Testing for Tamoxifen Treatment	Reference added.
Immunization Guidelines	Added code Q2034 to the code range in the Billing/Coding section for the July 1, 2012 update.
Nonpayment for Serious Adverse Events	Added "outpatient" to the statement in the Hospital Acquired Conditions section to read: Participating acute care inpatient hospitals will not be permitted to receive or retain reimbursement for inpatient or outpatient services related to Never Events. Also deleted "inpatient" from the statement that is revised to read: Members will be held harmless for any inpatient services related to Never Events. The following statement was added following the list of the 3 wrong surgeries: Any professional provider associated with a wrong surgery Never Event (surgeon, anesthesiologist, radiologist, etc.) is not eligible for reimbursement. Reimbursement is also not provided for any services in the operating or procedure room where the wrong surgery error occurs. Members will be held harmless for any services related to wrong surgery Never Events.
Orthopedic Applications of Stem Cell Therapy	References updated. No changes to policy statements.
Pelvic Floor Stimulation as a Treatment of Urinary Incontinence	Description section updated. Policy Guidelines updated. References updated. Medical Director review 5/2012.
Removal of Impacted Cerumen	The definition of impacted cerumen added to I. in the When Covered section for clarification. The following statement was added under the When Covered section to indicate; "II.5. A -25 modifier must be submitted with the E&M code for proper adjudication to indicate a significant, separately identifiable evaluation and management service was performed." No change to policy intent. Medical Director review 5/28/2012. Reference added.
Sacral Nerve Neuromodulation/Stimulation for Pelvic Floor Dysfunction	Description section updated. "When Covered" section revised. Medically necessary policy statement for urinary incontinence changed to 2-part statement as follows: A trial period of sacral nerve neuromodulation with either percutaneous nerve stimulation or a temporarily implanted lead may be considered medically necessary in patients who meet all of the following criteria: 1. There is a diagnosis of at least one of the following: a. Urge incontinence, b. Urgency-frequency, c. Non-obstructive urinary retention. 2. There is documented failure or intolerance to at least two conventional therapies (e.g., behavioral training such as bladder training, prompted voiding, or pelvic muscle exercise training, pharmacologic treatment for at least a sufficient duration to fully assess its efficacy, and/or surgical corrective therapy) 3. Incontinence is not related to a neurologic condition. Permanent implantation of a sacral nerve neuromodulation device may be considered medically necessary in patients who meet all of the following criteria: 1. All of the criteria in (1-3) above are met. 2. A trial stimulation period demonstrates at least 50% improvement in symptoms over a period of at least 2 weeks. Policy Guidelines updated. References updated. Medical Director review 5/2012.
Vagus Nerve Stimulation	Specialty Matched Consultant Advisory Panel review 5/16/2012. Description section revised. The When Not Covered section reformatted. Added treatment of heart failure and fibromyalgia to the list of investigational indications. No change to policy intent. Policy Added the following diagnoses to the Billing/Coding section: 428 - 428.9 and 729.1. Guidelines updated. Reference added.