Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for September 18, 2012

Medical Guidelines Reason for Update
Analysis of Proteomic Patterns for Early Detection of Cancer Removed the following statement from the Description section: "Proteomic testing is not commercially available at this time." Added the following statement; "The OvaCheck test has been licensed exclusively to the reference laboratories LabCorp and Quest Diagnostics." Added the following statement to the Billing/Coding section: "CPT codes 83788, 83789, or 84999 may be used to report this test." Policy Guidelines updated. No change to policy intent. Medical Director 8/21/12. Reference added.
Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate, or Dermatologic Tumors Description section updated with additional information related to lung tumors. Medical Director review 9/1/12. References added.
Dermatologic Applications of Photodynamic Therapy Evidence Based Guideline converted to Corporate Medical Policy. Photodynamic therapy may be considered medically necessary as a treatment of: Non-hyperkeratotic actinic keratoses of the face and scalp, Superficial basal cell skin cancer only when surgery and radiation are contraindicated, Bowen's disease (squamous cell carcinoma in situ) only when surgery and radiation are contraindicated. Photodynamic therapy is considered investigational for other dermatologic applications, including, but not limited to, acne vulgaris, non-superficial basal cell carcinomas, hidradenitis suppurativa, or mycoses. Photodynamic therapy as a technique of skin rejuvenation, hair removal, or other cosmetic indications is considered not medically necessary. Photodynamic therapy is considered not medically necessary as a treatment of non-hyperkeratotic actinic keratoses in locations other than the face and scalp, including, but not limited to, the trunk and extremities. Medical Director review 5/2012. Notice given 6/12/12 for effective date 9/18/12.
Developmental Delay Screening and Testing Guidelines New policy implemented. Pediatric developmental screening is covered if the following criteria are met: 1.a validated screening tool is utilized, and 2.the tool must be used in its entirety; using a subset of items is not considered valid, and 3.medical records document the screening tool is scored and a separate report is prepared, and 4.screening occurs at 6, 12, 18 or 24, 36, 48, and 60 months of age or if concerns are raised by the parents during routine visits. Screening with the Modified Checklist for Autism in Toddlers (MCHAT) for autism is recommended to take place at 18 and 24 months. Pediatric developmental delay testing is covered if screening demonstrates the possibility of disability and further assessment is required. Pediatric developmental delay screening and/or testing is not covered if the above criteria are not met. Preventative counseling for risk factor reduction or the administration of a health risk assessment tool is not considered developmental delay screening or testing and is not covered. Medical Director review 8/2012.
Endovascular Stent Grafts for Thoracic Aortic Aneurysm Added the following statement to the "When Covered" section: "Endovascular stent grafts using devices approved by the U.S. Food and Drug Administration may also be considered medically necessary in the following situations: Treatment of acute, complicated (organ or limb ischemia or rupture) Type B thoracic aortic dissection." Policy Guidelines updated. References updated. Medical Director review 8/2012.
Esophageal pH Monitoring Reference added. Added wireless pH monitoring to the first medically necessary policy statement; third policy statement on 48- to 96-hour, catheter-free, wireless esophageal monitoring deleted. First policy statement under When Not Covered section deleted. Added monitoring must be done in accordance with FDA approved indications and age ranges to policy statement. Policy Guidelines updated. Medical Director review 9/1/12.
Gender Reassignment Surgery Added diagnosis codes 302.0, 302.5, 302.50 - 302.53, 302.6, 302.85, 302.9, 313.82, 752.7 to Billing/Coding section.
Intracellular Micronutrient Analysis Policy Guidelines and References updated. No changes to Policy Statements. Medical Director review 8/2012.
Intradiscal Electrothermal (IDET) Annuloplasty and Percutaneous Intradiscal Radiofrequency Annuloplasty Reference added.
Lumbar Spine Fusion Surgery Specialty Matched Consultant Advisory Panel review. No change to policy intent. References added.
Mohs' Micrographic Surgery Policy status changed to active and will undergo routine scheduled review. References updated. Medical Director review 8/2012.
Varicose Veins, Treatment for Added the following statement to When Covered section: "The greater or lesser saphenous veins were surgically treated at least 3 months prior to treatment of accessory saphenous veins, in cases where greater or lesser saphenous reflux is also present". Medical Director review.
Vertebroplasty, Kyphoplasty, and Sacroplasty Percutaneous Information regarding spineoplasty added to Description section. Policy Statement updated to indicate that spineoplasty is considered investigational for all applications. BCBSNC does not provide coverage for investigational services or procedures. The graft used in spineoplasty has not received FDA approval. Medical Director review 8/28/2012.
Evidence Based Guidelines
Colon Cancer Screening Archive policy. Colon cancer screening is benefit driven. Status changed from "Active guideline, no longer scheduled for routine literature review" to Archive status. Medical Director review 9/1/2012.