Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for July 10, 2012

Medical Guidelines Reason for Update
Aqueous Shunts and Devices for Glaucoma Specialty Matched Consultant Advisory Panel review meeting 6/20/12. Removed CPT codes 66174 and 66175 from Billing/Coding section. Removed canaloplasty references under When Covered section since new Canaloplasty policy addresses. Revised description section and policy guidelines. No changes to policy statement.
Bioengineered Skin and Tissue Revised the FDA information for product EZ Derm™ to state: "FDA 510(k) approved xenograft for the treatment of partial-thickness burns and venous, diabetic, and pressure ulcers."
Cardiac (Heart) Transplantation Specialty Matched Consultant Advisory Panel review 6/2012. No changes to Policy Statements or clinical criteria.
Carotid Artery Angioplasty/Stenting (CAS) Specialty Matched Consultant Advisory Panel review 6/2012. No changes to Policy Statements.
Catheter Ablation of the Pulmonary Veins as a Treatment for Atrial Fibrillation Specialty Matched Consultant Advisory Panel review 6/2011. No changes to Policy Statements.
Computer-Aided Evaluation of Malignancy with MRI of the Breast Policy Guidelines section updated with new information. No change in policy statement. Specialty Matched Consultant Advisory Panel review 6/20/12.
Congenital Heart Defect, Repair Devices Specialty Matched Consultant Advisory Panel review 6/2012. No changes to Policy Statements.
Corneal Topography Under Benefits Application, added "The use of computer-assisted corneal topography to correctly design/fit contact lenses for treatment of keratoconus is a benefit exclusion and is not covered. The preoperative use of computer-assisted corneal topography for purposes required to address changes to the cornea due to side effects and complications of non-covered services (e.g., Lasik surgery) is a benefit exclusion and is not covered." These statements added for clarification. No change in policy statement. Reference added. Specialty Matched Consultant Advisory Review panel meeting 6/20/2012.
CT Perfusion Imaging Descriptions added for subarachnoid hemorrhage/cerebral vasospasm and brain tumors. Policy guidelines updated. Specialty Matched Consultant Advisory Panel review 6/20/12. No change to policy statement.
Digital Breast Tomosynthesis Specialty Matched Consultant Advisory Panel review 6/20/12. Policy accepted as written.
Electroencephalograms Added #5 to When Covered section to indicate: "Video EEG monitoring in the pediatric or adult intensive care setting (ICU) is considered medically necessary for patients with altered levels of consciousness who are at risk of subclinical seizures based upon: a. Suspected clinical diagnosis of encephalitis, meningitis, stroke, intracranial hemorrhage, subarachnoid hemorrhage, or traumatic brain injury; OR b. Clinical findings of elevated intracranial pressure or cerebral edema." Added #3 to When Not Covered section to indicate: "Video EEG monitoring in the pediatric or adult intensive care setting is considered not medically necessary: a. When performed for more than 72 hours in the absence of electrical seizures; OR b. When the criteria under "when covered" above are not met." Policy Guidelines updated. Medical Director review 6/26/2012. References added.
Endovascular Stent Grafts for Abdominal Aortic Aneurysm Description section updated. Deleted the following statement from the "When Covered" section: "Endovascular Stent Grafts for Iliac Aneurysms are covered for iliac artery aneurysms greater than 3 cm in patients with appropriate aortoiliac anatomy." Endovascular repair of the iliac artery is not applicable to this medical policy. Deleted codes 0254T and 0255T from "Billing/Coding" section. CPT codes 75952 and 75953 added to Billing/Coding section. Policy Guidelines updated. References updated. Medical Director review 5/2012. Specialty Matched Consultant Advisory Panel review 6/2012.
Endovascular Stent Grafts for Thoracic Aortic Aneurysm Specialty Matched Consultant Advisory Panel review 6/2012. References updated.
Epiretinal Radiation Therapy for Age-Related Macular Degeneration Specialty Matched Consultant Advisory Panel review 6/20/2012. Policy guidelines updated. No change to policy statement. Reference added.
Genotyping for 9p21 Genetic Polymorphisms to Predict Cardiovascular Disease Risk Additional indications added to "When not Covered" section as investigational (peripheral vascular disease, coronary artery calcification, polypoidal choroidal vasculopathy.) Policy statement remains unchanged: "Genotyping for 9p21 Genetic Polymorphisms to Predict Cardiovascular Disease Risk is considered investigational for all applications." References updated. Medical Director review 6/2012.
Heart-Lung Transplantation Specialty Matched Consultant Advisory Panel review 6/2012. No changes to Policy Statements or clinical criteria.
Intravitreal Implant Specialty Matched Consultant Advisory Panel review 6/20/2012. Medically necessary policy statement on uveitis expanded to include intermediate and panuveitis. Policy guidelines updated. Reference added.
Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention Specialty Matched Consultant Advisory Panel review 6/2012. References updated. Policy title and policy statements revised to include "percutaneous." Description section updated.
Magnetic Resonance Spectroscopy Summary statement added. Specialty Matched Consultant Advisory Panel review 6/20/12. No change in policy statement.
Magnetoencephalography/Magnetic Source Imaging Specialty Matched Consultant Advisory Panel review 6/20/12.
Multigene Expression Assay for Predicting Recurrence in Colon Cancer Added the following statement to the Description section to indicate; "ColoPrint, an 18-gene signature test was launched by Agendia June 1, 2012 for predicting the risk of distant recurrence for stage II colon cancer. This test has not been FDA approved and is only available as a laboratory-developed assay service by Agendia." Medical Director review 6/25/12. Reference added.
Optical Coherence Tomography (OCT) Anterior Segment of the Eye Specialty Matched Consultant Advisory Panel review 6/20/2012. Policy title/name change from Anterior Eye Segment Optical Imaging to Optical Coherence Tomography (OCT) Anterior Segment of the Eye for consistency with BCBSA. Revised description section and policy guidelines section. No change to policy statement. Reference added.
Retinal Prosthesis Specialty Matched Consultant Advisory Panel review meeting 6/20/2012. Description section extensively revised. Policy guidelines updated. No change to policy statement.Reference added.
Suprachoroidal Delivery of Pharmacologic Agents Specialty Matched Consultant Advisory Panel review 6/20/2012. No change to policy statement. Reference added.
Surgical Ventricular Restoration Specialty Matched Consultant Advisory Panel review 6/2012. No changes to Policy Statement.
Thermography Description updated. References added. No change in Policy Statement. Specialty Matched Consultant Advisory Panel review 6/20/12.
Topical Negative Pressure Therapy for Wounds 2011 update information added to Policy Guidelines section. Related Policies added. Specialty Matched Consultant Advisory Panel review 5/16/12. No change to policy statements.
Transcatheter Closure of Ventricular Septal Defects Description section updated to include regulatory status of available FDA approved devices. References updated. Specialty Matched Consultant Advisory Panel review 6/2012.
Transcatheter Heart Valve Implantation
Evidence Based Guidelines
Biventricular Pacemakers/Cardiac Resynchronization Therapy for Heart Failure Guideline title changed from "Biventricular Pacemakers for CHF" to "Biventricular Pacemakers/Cardiac Resynchronization for Heart Failure." Description section updated. Removed the word "congestive" from all references of heart failure. "Not Recommended" section revised to state: "Biventricular pacemakers, with or without an accompanying implantable cardiac defibrillator (i.e., a combined biventricular pacemaker/ICD) are not recommended as a treatment for patients with NYHA class I heart failure." CPT codes 33208 and 33228 added to "Billing/Coding" section. References updated. Specialty Matched Consultant Advisory Panel review 6/2012.
Dynamic Spinal Visualization Specialty Matched Consultant Advisory Panel meeting 6/20/12. No change to guideline statement.
Maze Procedure for Atrial Fibrillation or Flutter Guideline status changed to "active" and will undergo routine literature review. Description section updated. "Evidence Based Guideline" section revised to state: "The maze procedure, performed on a non-beating heart during cardiopulmonary bypass with or without concomitant cardiac surgery may be appropriate for treatment of symptomatic, drug resistant atrial fibrillation or flutter." "Not Recommended" section revised to state: "Minimally invasive, off-pump maze procedures, including those done via mini-thoracotomy, are not recommended for treatment of drug-resistant atrial fibrillation or flutter." References updated. CPT code 33253 deleted. Specialty Matched Consultant Advisory Panel review 6/2012.
Partial Left Ventriculectomy Specialty Matched Consultant Advisory Panel 6/2012. No changes to Guideline statements.
Screening for Vertebral Fracture with Dual X-ray Absorptiometry (DEXA) Specialty Matched Consultant Advisory Panel review 6/20/12. No changes to guideline.
Thermotherapy, Transpupillary Specialty Matched Consultant Advisory Panel review meeting 6/20/2012. Description section extensively revised. References added.
Transmyocardial Revascularization Specialty Matched Consultant Advisory Panel review 6/2012. References updated.
Ultrafiltration in Decompensated Heart Failure Specialty Matched Consultant Advisory Panel review 6/2012. References updated.
Ventricular Assist Devices and Total Artificial Hearts Specialty Matched Consultant Advisory Panel review 6/2012. No changes to Guideline statements.