Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for September 4, 2012

Medical Guidelines Reason for Update
Accelerated Partial Breast Radiotherapy (Breast Brachytherapy) Specialty Matched Consultant Advisory Panel review 8/15/2012. No change to policy statement.
Balloon Sinuplasty for Treatment of Chronic Sinusitis Specialty Matched Consultant Advisory Panel review 8/15/12. Policy Guidelines updated. No change to policy statement.
Brachytherapy Treatment of Breast Cancer Specialty Matched Consultant Advisory Panel review 8/15/2012. No changes to policy statement. Reference added.
Cardiac Hemodynamic Monitoring in the Outpatient Setting References updated. Policy Guidelines updated. No changes to Policy Statements.
Carotid Intimal-Medial Thickness Study References updated. No changes to Policy Statements.
Cellular Immunotherapy for Prostate Cancer Specialty Matched Consultant Advisory Panel review August 15, 2012. Description section revised. Slight wording changes to the When and When Not Covered sections, no change to policy intent. Reference added.
Chemotherapy for Malignant Disease No change to policy. Continues to be consistent with North Carolina Mandate.
Use of Common Genetic Variants to Predict Risk of Nonfamilial Breast Cancer Specialty Matched Consultant Advisory Panel review 8/15/2012. Description section revised. Policy Guidelines section updated. No change to policy statement. Reference added.
Computed Tomography to Detect Coronary Artery Calcification References updated. No changes to Policy Statements.
Decompression of the Intervertebral Disc Using Laser Energy (Laser Discectomy) or Radiofrequency Coblation (Nucleoplasty) Reference added.
Diagnosis and Treatment of Chronic Cerebrospinal Venous Insufficiency in Multiple Sclerosis Description section revised. Policy Guidelines section updated. Reference added. Medical Director review 8/14/2012.
Epidermal Growth Factor Receptor (EGFR) Mutation Analysis for Patients with Non-Small Cell Lung Cancer (NSCLC) Specialty Matched Consultant Advisory Panel review 8/15/2012. No change to policy. Policy Guidelines section updated.
Extracorporeal Photopheresis after Solid-Organ Transplant and for Graft-versus-Host Disease, Autoimmune Disease, and Cutaneous T-Cell Lymphoma Specialty Matched Consultant Advisory Panel review 8/15/2012. No change to policy.
Gene-Based Tests for Screening, Detection, and/or Management of Prostate Cancer Specialty Matched Consultant Advisory Panel review 8/15/2012. No change to policy intent.
Genetic Testing for Breast and Ovarian Cancer Specialty Matched Consultant Advisory Panel review 8/15/2012. No change to policy intent. Reference added.
Genetic Testing for Colon Cancer Specialty Matched Consultant Advisory Panel review 8/15/2012. Description section revised. Added medical necessity criteria for EPCAM mutations in the When Covered section. Policy Guidelines updated. References added.
Genetic Testing for Long QT Syndrome References updated. Policy Guidelines updated. No changes to Policy Statements.
Hyperthermia Therapy Specialty Matched Consultant Advisory Panel review 8/15/2012. No change to policy statement.
Intravascular Ultrasound Imaging (IVUS) and Intracoronary Doppler Ultrasonography Policy status changed to active and will receive annual review. Policy re-titled to "Intravascular Ultrasound Imaging (IVUS) and Intracoronary Doppler Ultrasonography." Description section updated. New policy statement added: "BCBSNC will provide coverage for Intracoronary Doppler Ultrasonography when it is determined to be medically necessary because the medical criteria shown below are met." "When Covered" section extensively revised as follows: "IVUS is considered medically necessary when ONE of the following conditions is met: a. Assessment of the adequacy of deployment of coronary stents, including the extent of stent apposition and determination of the minimum luminal diameter within the stent, b. Determination of the mechanism of coronary stent re-stenosis and to enable selection of appropriate therapy, c. Evaluation of coronary obstruction at a location difficult to image by angiography in a patient with a suspected flow-limiting stenosis, d. Assessment of a suboptimal angiographic result following PCI, e. Establishment of the presence and distribution of coronary calcium in patients for whom adjunctive rotational atherectomy is contemplated, f. Determination of plaque location and circumferential distribution for guidance of directional coronary atherectomy, g. Determination of the extent of atherosclerosis in patients with characteristic anginal symptoms and a positive functional study with no focal stenoses or mild CAD on angiography, h. Pre-interventional assessment of lesional characteristics and vessel dimensions as a means to select an optimal coronary revascularization device, i. Diagnosis of coronary disease after cardiac transplantation. Intracoronary Doppler ultrasonography may be considered medically necessary as an integral component of either an angiogram or PTCA for the following: a. to determine the clinical significance of an intermediate stenosis; OR b. to determine the target lesion for revascularization in a patient with multiple lesions." "When not Covered" section revised to include following statement: "4. The routine use of intracoronary Doppler ultrasound with either pre- or post-angiogram perfusion PET, SPECT, or stress echocardiography is considered not medically necessary." Policy Guidelines updated. CPT codes 93571, 93572 added to Billing/Coding section. References updated. Medical Director review 8/2012.
Microarray-based Gene Expression Testing for Cancers of Unknown Primary Specialty Matched Consultant Advisory Panel review 8/15/2012. Description revised. No change to policy intent.
Mutation Analysis in Fine Needle Aspirates of the Thyroid Specialty Matched Consultant Advisory Panel review 8/15/2012. No change to policy.
Reverse Shoulder Arthroplasty Policy archived. Medical Director review.
Rhinoplasty Reference added. Specialty Matched Consultant Advisory Panel review 8/15/12. No change to policy statement or coverage criteria.
Rituximab for the Treatment of Rheumatoid Arthritis Added ICD-9 code 714.89 to the Billing/Coding section for 2012 code update.
Salivary Hormone Tests Medical Director review. Replaced the word testosterone with the word androgens in the Description, Policy, and When Salivary Hormone Tests are not covered sections of the Policy.
Surgery for Obstructive Sleep Apnea and Upper Airway Resistance Syndrome References updated. Specialty Matched Consultant Advisory Panel review 8/15/12. No change to policy statement or coverage criteria.
Systems Pathology for Predicting Risk of Recurrence in Prostate Cancer CPT code 88232 replaced with CPT code 88323 in Billing/Coding section.
Laboratory Testing to Allow Area Under the Curve (AUC) Targeted 5-Fluorouracil (5-FU) Dosing for Patients Administered 5-FU for Cancer Specialty Matched Consultant Advisory Panel review 8/15/2012. No change to policy.
Tinnitus Treatment Policy Guidelines updated. No change to coverage criteria. Specialty Matched Consultant Advisory Panel review 8/15/12.
Total Facet Arthroplasty Regulatory Status section updated. Reference added.
Transtympanic Micropressure Applications as a Treatment of Meniere's Disease Specialty Matched Consultant Advisory Panel review 8/15/12. No change to policy statement.
Evidence Based Guidelines
Auditory Brainstem Implant Evidence Based Guideline reactivated. Related Policies added. Added the following indications to the Not Recommended section "Bilateral use of an auditory brainstem implant is not recommended. Penetrating electrode auditory brainstem implant (PABI) is not recommended." Specialty Matched Consultant Advisory Panel review 8/15/12.
KRAS and BRAF Mutation Analysis in Cancer Policy name changed from "KRAS Mutation Analysis in Cancer" to "KRAS and BRAF Mutation Analysis in Cancer." Specialty Matched Consultant Advisory Panel review 8/15/2012. Description section revised. No change to evidence based guideline.
Photodynamic Therapy for Treatment of Specific Cancers Specialty Matched Consultant Advisory Panel review 8/15/2012. No change to policy intent. Reference added.
Septoplasty Specialty Matched Consultant Advisory Panel Review 8/15/12. No change to policy statement or coverage criteria.