Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for June 29, 2012

Medical Guidelines Reason for Update
Automated Percutaneous and Endoscopic Discectomy Title changed from Percutaneous Discectomy to Automated Percutaneous and Endoscopic Discectomy. Description section revised and information related to endoscopic discectomy added. "Endoscopic discectomy is considered investigational as a technique of intervertebral disc decompression in patients with back pain related to disc herniation in the lumbar, thoracic, or cervical spine." Removed the following codes from the Billing/Coding section; 0274T, 0275T, and S2348 as they are not specific to this policy. Medical Director review 3/30/2012. Notification given. Policy effective 7/1/2012.
Bioengineered Skin and Tissue C9368 and C9369 added to "Billing/Coding" section. Added new products to "When not Covered" section: Grafix® CORE and Grafix® PRIME.
Bone Morphogenetic Protein Significant revisions to policy. The "When Covered" section revised to state: "A:Use of recombinant human bone morphogenetic protein (rhBMP-2, InFUSE) may be considered medically necessary for the following indications for lumbar fusion in patients where there is a high risk of fusion failure (See Policy Guidelines): and when there are approved indications for lumbar spine fusion surgery (see medical policy titled, "Lumbar Spine Fusion Surgery"):1. As an adjunct to anterior lumbar interbody spinal fusion at one or more levels in skeletally mature patients with approved indications for lumbar spine fusion surgery. 2. For instrumented posterolateral intertransverse lumbar spinal fusion procedures, in conjunction with an FDA-approved device, at one or more levels in skeletally mature patients with degenerative disc disease. B: Use of recombinant human bone morphogenetic protein (rhBMP-2, InFUSE) may be considered medically necessary for the treatment of acute, open fracture of the tibial shaft. C: Use of recombinant human bone morphogenetic protein-7 (rhBMP-7, OP-1) may be considered medically necessary for noninstrumented revision posterolateral intertransverse lumbar spinal fusion in patients where there is a high risk of fusion failure (See Policy Guidelines) and when there are approved indications for lumbar spine fusion surgery (see medical policy titled, "Lumbar Spine Fusion Surgery"):. D: Use of recombinant human bone morphogenetic protein-7 (rhBMP-7, OP-1) may be considered medically necessary as an alternative to autograft in recalcitrant long bone nonunions where use of autograft is unfeasible and alternative treatments (e.g., electrical bone growth stimulation) have failed." The "When not Covered" section revised to state: "Bone Morphogenetic Proteins is considered not medically necessary when all of the above criteria are not met. The use of recombinant human bone morphogenetic protein-2 or recombinant human bone morphogenetic protein-7 is considered investigational for all other indications, including but not limited to: Cervical spinal fusion; Posterior or transforaminal lumbar interbody spinal fusion; As initial treatment or revision of noninstrumented posterolateral intertransverse spinal fusion that does not meet the criteria listed above; As an alternative or adjunct to bone grafting in other locations, including craniomaxillofacial surgeries." Policy Guidelines updated with the following clinical criteria listed as high risk for fusion failure: "one or more previous failed spinal fusion(s); grade III or worse spondylolisthesis; fusion to be performed at more than one level; current tobacco use; diabetes; renal disease; alcoholism; osteoporous; steroid use; when autologous bone and bone marrow harvest are not feasible or are not expected to promote fusion." The following statement was removed from the "Billing/Coding" section: "There is no specific CPT code for bone morphogenetic proteins. Services should be submitted in the form of an unlisted code (such as 20999, 22899, or 27899). Medical records for the explanation of the service rendered may be necessary." Added the following statement to "Billing/Coding" section: "In 2011, CPT code 20930 was revised to include BMP-type materials used in spine surgery." References updated. Medical Director review 2/2012. Specialty Matched Consultant Advisory panel review 2/2012. Policy noticed 3/30/2012 for effective date 7/1/2012.
Breast Surgeries Policy revised and status changed to active. Policy will undergo yearly scheduled review. Revisions of Section I titled "Reconstructive Breast Surgery after Mastectomy" include: Description section updated. Following statement added to "When Covered" section: "Reconstruction may be performed by an implant based approach or through the use of autologous tissue." Section II re-titled from "Mastectomy for Gynecomastia" to "Surgical Treatment of Gynecomastia." Description section updated, otherwise no changes to policy statements. Section III re-titled from "Reduction Mammaplasty" to "Reduction Mammaplasty for Breast Related Symptoms." "When Covered" section revised. B#2 rephrased to state: "physical exam indicates obvious breast hypertrophy (pictures are not necessary) that is consistent with symptoms precipitating request for reduction mammaplasty." B#4 statement deleted. Revisions to Section IV titled "Prophylactic Mastectomy" include Description section update, "When Covered" section revised to allow coverage when one or more criteria are met. New clinical criteria for Prophylactic Mastectomy are: "Two or more first-degree relatives with breast cancer or ovarian cancer, One first-degree relative and two or more second-degree or third-degree relatives with breast cancer, One first-degree relative with breast cancer before the age of 45 years and one other relative with breast cancer, One first-degree relative with breast cancer and one or more relatives with ovarian cancer, Two second-degree or third-degree relatives with breast cancer and one or more with ovarian cancer, One second-degree or third-degree relative with breast cancer and two or more with ovarian cancer, Three or more second-degree or third-degree relatives with breast cancer, One first-degree relative with bilateral breast cancer, Presence of a BRCA1 or BRCA2 mutation in the patient consistent with a BRCA1 or 2 mutation in a family member with breast or ovarian cancer, Presence of a TP53 or PTEN mutation, Received radiation therapy to the chest between the ages of 10 and 30 years. Moderately increased risk based on family history with or without breast lesions associated with an increased risk, including, but not limited to, atypical hyperplasia or breast cancer diagnosed in the opposite breast, Patients with such extensive mammographic abnormalities (i.e., calcifications) that adequate biopsy or excision is impossible." Policy Guidelines updated. Section V re-titled from "Insertion and Removal of Breast Implants" to "Surgical Management of Breast Implants." The following statement added to Description section: "This policy only addresses internal prosthetic breast implants. For information regarding external breast prosthetics see policy titled, "Prosthetic Appliances." Otherwise, no changes to Policy Statements. References updated. Medical Director review 6/2012.
Chemoembolization of the Hepatic Artery, Transcatheter Approach Description section revised. Added the following statement to the When Not Covered section to indicate; "Transcatheter hepatic arterial chemoembolization is considered investigational to treat unresectable cholangiocarcinoma." No change to policy intent. Policy Guidelines updated. Reference added. Medical Director review 5/2012.
Detection of Circulating Tumor Cells Reference added.
Endovascular Procedures for Intracranial Arterial Disease Description section revised. Policy Guidelines section updated. Medical Director review 6/14/2012. Reference added.
Functional Endoscopic Sinus Surgery (FESS) Code S1090 added to policy. "The use of a propel sinus implant may be considered medically necessary when the following criteria are met. 1. Implanted at the time of approved functional endoscopic sinus surgery, and 2. Implanted in the ethmoid sinus only" added to the when covered section. "Use of the Propel sinus implant is considered not medically necessary if inserted at any surgical setting other than the FESS procedure, or for any sinus cavities other than the ethmoid" added to the When Not Covered section.
Genetic Testing for Lipoprotein (a) as a Decision Aid for Aspirin Treatment Description section updated. References updated. No changes to Policy Statement.
Hematopoietic Stem-Cell Transplantation for Multiple Myeloma Reference added.
Hematopoietic Stem-Cell Transplantation for Solid Tumors of Childhood Added the following statement to the When Covered section; "Tandem autologous hematopoietic stem-cell transplantation may be considered medically necessary for high-risk neuroblastoma." Removed the following statement from the When Not Covered section; "Tandem autologous-autologous hematopoietic stem-cell transplantations are considered investigational for treatment of pediatric solid tumors." And added; "Tandem autologous hematopoietic stem-cell transplantation is considered investigational for the treatment of all other types of pediatric solid tumors except high-risk neuroblastoma, as noted above." Policy Guidelines updated. Reference added. Medical Director review 6/10/2012.
Hematopoietic Stem-Cell Transplantation in the Treatment of Germ Cell Tumors Reference added.
High-Intensity Focused Ultrasound for Treatment of Prostate Cancer Medical Director review 5/28/12. Policy combined with policy entitled "MRI-guided High Intensity Ultrasound Ablation of Uterine Fibroids" and policy name changed to "MRI Guided High Intensity Ultrasound Ablation of Uterine Fibroids and Other Tumors". Policy archived.
Hip Resurfacing Description section updated. Policy Guidelines updated. References updated. No changes to Policy Statements. Medical Director review 6/2012.
Lung Cancer Screening, CT Scanning or Chest Radiographs Medical Director review 5/28/12. Policy archived due to Diagnostic Imaging Management program.
MRI-Guided High Intensity Ultrasound Ablation of Uterine Fibroids and Other Tumors Policy title changed to include "Other Tumors." Related Guideline added to Description section. "Magnetic resonance imaging (MRI)-guided ablation of other tumors, including but not limited to breast, brain, prostate cancer, and palliative treatment of bone metastases, is considered investigational" added to When Not Covered section. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 6/20/12.
Salivary Hormone Tests Removed Related Policy from Description section.
Stem-cell Therapy for Peripheral Arterial Disease References updated. No changes to Policy Statement.
Surgery for Femoroacetabular Impingement References updated. No changes to Policy Statements.
T-Wave Alternans Policy Guidelines updated. References updated. No changes to Policy Statement.
Evidence Based Guidelines
Donor Leukocyte Infusion Reference added.
External Breast Reconstruction (Prosthesis) Medical Director review. Evidence Based Guideline archived.
Interventions for Progressive Scoliosis References updated. Description section updated and added "Vertebral Expandable Prosthetic Titanium Rib" as a related Evidence Based Guideline. Medical Director review 6/2012.
Intravitreal Angiogenesis Inhibitors for Choroidal and Retinal Vascular Conditions New Evidence Based Guideline issued. "Anti-vascular endothelial growth factor therapies (anti-VEGF) are not appropriate for the treatment of chorioretinal scars; Intravitreal injection of aflibercept is not appropriate for treatment of retinal vascular disorders, including proliferative diabetic retinopathy and central or branch retinal vein occlusion; Intravitreal injection of pegaptanib is not appropriate for treatment of retinal vascular disorders, including proliferative diabetic retinopathy, diabetic macular edema, and central or branch retinal vein occlusion." Medical director review 5/2012. Specialty Matched Consultant Advisory Panel review meeting 6/20/12.
Monoclonal Antibodies for Non-Hodgkin Lymphoma, including Chronic Lymphocytic, & Acute Myeloid Leukemia In the Non-Hematopoietic Stem Cell Transplant Setting Reference added.
Trastuzumab Description section revised. No change to guideline intent. Policy Guidelines updated. Medical Director review 6/10/12. Reference added.
Treatment for Age Related Macular Degeneration Deleted HCPCS code C9291. Archive per medical director. See new evidence based guideline titled: Intravitreal Angiogenesis Inhibitors for Choroidal and Retinal Vascular Conditions.
Vertical Expandable Prosthetic Titanium Rib New Evidence Based Guideline developed. Use of the vertical expandable prosthetic titanium rib (VEPTR) is recommended in the treatment of progressive thoracic insufficiency syndrome (TIS) due to rib and/or chest wall defects in infants/children between 6 months of age and skeletal maturity. Use of the VEPTR in pediatric patients with scoliosis without TIS is an off-label indication and is not recommended. Use of the vertical expandable prosthetic titanium rib for all other conditions is not recommended. Medical Director review 6/2012.