Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for August 7, 2012

Medical Guidelines Reason for Update
Acoustic Cardiography References updated. No change to Policy Statement.
Ankle Replacement, Total Specialty Matched Consultant Advisory Panel review 7/2012. No changes to Policy Statements.
Autologous Chondrocyte Implantation Specialty Matched Consultant Advisory Panel review 7/2012. References updated. No changes to Policy Statements.
Automated Nerve Conduction Tests Information related to "Brevio® from Neurotron Medical" added to Description section. Reference added.
Computer Assisted Surgical Navigational Orthopedic Procedures Specialty Matched Consultant Advisory Panel review 7/2011. References updated. Policy Guidelines updated. No changes to Policy Statement.
Continuous Monitoring of Glucose in the Interstitial Fluid Related guideline added. Information on OmniPod Insulin Management System added. Policy Guidelines section updated. No change in coverage criteria. Specialty Matched Consultant Advisory Panel review 7/18/12.
Continuous Passive Motion in the Home Setting Specialty Matched Consultant Advisory Panel review 7/2012. References updated. No changes to Policy Statements.
Electrical Bone Growth Stimulation Specialty Matched Consultant Advisory Panel review 7/2012. No changes to Policy Statements.
Electrothermal Arthroscopic Capsulorrhaphy Removed the following statement from the Billing/Coding section: "It is incorrect to use 23466, 29806 or 29999 for electrothermal arthroscopic capsulorrhaphy." CPT code 29999 added as applicable code for thermal capsulorrhaphy. References updated. Specialty Matched Consultant Advisory Panel review 7/2012.
Extracorporeal Shock Wave Treatment for Musculoskeletal Conditions and Wound Healing Specialty Matched Consultant Advisory Panel review 7/2012. No changes to Policy Statement.
Growth Hormone Policy archived.
Hyperhidrosis, Treatment of Description section updated to include the miraDry System, a microwave device designed to heat tissue at the dermal-hypodermal interface, the location of the sweat glands. "When Covered" section revised to include the following statement: "Treatment of primary hyperhidrosis may be considered medically necessary for functional impairment or with the following medical complications: acrocyanosis of the hands; OR history of recurrent skin maceration with bacterial or fungal infections; OR history of recurrent secondary infections; OR history of persistent eczematous dermatitis in spite of medical treatments with topical dermatological or systemic anticholinergic agents." "When not Covered" section updated to include "microwave treatment" as a procedure considered investigational for all focal areas. CPT code J0588 and 96999 added to Billing/Coding section. Benefit Application section updated to include following statements: "Please refer to the Member's Benefit Booklet for availability of benefits and for the definition of cosmetic and reconstructive services. Services or procedures performed for psychological or emotional reasons are considered cosmetic, and therefore are typically excluded by the member's health benefit plan.." The following statement added to Policy Guidelines: "Functional impairment refers to the inability to perform activities of daily living and/or manual tasks in a professional setting." References updated. Medical Director review 7/2012.
Insulin Therapy, Chronic Intermittent Intravenous (CIIIT) Policy Guidelines updated. No change to policy statement. Specialty Matched Consultant Advisory Panel review 7/18/12.
Islet Cell Transplantation Added Related Policy. Policy Guidelines Section revised. Specialty Matched Consultant Advisory Panel Review 7/18/12. No change to policy statement.
Laser Treatment of Port Wine Stains Policy Guidelines updated. References updated. No changes to Policy Statements.
Lung Volume Reduction Surgery Reference updated. No change in policy statement.
Mechanical Embolectomy for Treatment of Acute Stroke Policy converted from Evidence Based Guideline to Corporate Medical Policy. Mechanical embolectomy is considered investigational in the treatment of acute stroke. Medical Director review 4/17/12. Notification given 5/1/2012. Policy effective 8/7/2012.
Melanoma Vaccines Reference added.
Meniscal Allografts and Collagen Meniscus Implants Specialty Matched Consultant Advisory Panel review 7/2012. No changes to Policy Statements.
Osteochondral Grafting in the Treatment of Articular Cartilage Lesions Description section updated to include new minimally processed osteochondral allograft Chondrofix®. References updated. Specialty Matched Consultant Advisory Panel review 7/2012. Revised the following statement in "When Covered" section: "(Osteochondral allografting may be considered medically necessary as a technique to repair large (e.g., 10 cm2) full thickness chondral defects of the knee caused by acute or repetitive trauma." New statement: "Osteochondral allografting may be considered medically necessary as a technique to repair large (> 2.5 cm2) full thickness chondral defects of the knee caused by acute or repetitive trauma." Policy Guidelines updated. Medical Director review.
PathFinderTG® Molecular Testing Reference added.
Prolotherapy Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 7/2012. References updated.
Rapid Opioid Detoxification Specialty Matched Consultant Advisory Panel review 7/18/12. No change to policy.
Residential Treatment for Chemical Dependence Specialty Matched Consultant Advisory Panel review 7/18/12. No changes to policy statement. Policy returned to Active status.
Sensory Integration Therapy Specialty Matched Consultant Advisory Panel review 7/18/12. Removed Related Policy entitled Cognitive Rehabilitation. No changes to policy.
Surgery for Femoroacetabular Impingement Specialty Matched Consultant Advisory Panel review 7/2012. No changes to Policy Statements.
Transcranial Magnetic Stimulation The following statement was added to the Description section: "TMS is also being tested as a treatment for a variety of other disorders including alcohol dependence, Alzheimer's disease, neuropathic pain, obsessive-compulsive disorder (OCD), post-partum depression, depression associated with Parkinson's disease, Tourette’s syndrome, schizophrenia, migraine, spinal cord injury, fibromyalgia, and tinnitus." Related policies were added. Policy guidelines updated. Specialty Matched Consultant Advisory Panel Review 7/18/12.
Treatment for Severe Primary IGF-1 Deficiency Specialty Matched Consultant Advisory Panel review 7/18/12. References updated. No change to policy statement.
Vertebral Axial Decompression (VAD-X) Specialty Matched Consultant Advisory Panel review 7/2012. No changes to Policy Statement.
Evidence Based Guidelines
Blood Glucose Monitors for Use in the Home Specialty Matched Consultant Advisory Panel review 7/18/12. Guideline returned to Active review status. "Patients with severe hypoglycemia" added to Evidence Based Guideline statement.
Cardiac Rehabilitation References updated. No changes to Guideline Recommendations.
Deep Brain Stimulation Reference added.
Diagnosis and Treatment of Sacroiliac Joint Pain Specialty Matched Consultant Advisory Panel review 7/2012. No changes to guideline statements.
External Insulin Pumps Reference added. Specialty Matched Consultant Advisory Panel review 7/18/12. No change to policy guidelines.
Intra Articular Hyaluronan Injections for Treatment of Osteoarthritis of the Knee Specialty Matched Consultant Advisory Panel review. No changes to Guideline Statements.
Pharmacogenomic and Metabolite Markers for Treatment with Thiopurines Added code 81401 to Billing/Coding/Physician Documentation Information Section. No change to Guideline statement. Specialty Matched Consultant Advisory Panel review 4/18/12.
Psychoanalysis Specialty Matched Consultant Advisory Panel review 7/18/12. No changes to Guideline.