Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for October 1, 2012

Medical Guidelines Reason for Update
Ambulatory Event Monitors Revised the following statement in the "When Covered" section: "The use of patient-activated or auto-activated external ambulatory event monitors and long-term ambulatory monitoring may be considered medically necessary as a diagnostic alternative to Holter monitoring in patients who experience infrequent symptoms (less frequently than every 48 hours) suggestive of cardiac arrhythmias (i.e., palpitations, dizziness, presyncope, or syncope)." Deleted the following statement from the "When not Covered" section: "The use of long-term ambulatory monitoring, i.e., ZioTM Patch, ZioTM Event Card and the Zeus ECG Utilization Service, is considered not medically necessary because the clinical (health) outcomes and cost effectiveness of extended monitoring have not been shown to be superior to other available approaches." Removed 0296T, 0297T and 0298T from the Billing/Coding section. Medical Director review 8/2012.
Bone Mineral Density Studies Specialty Matched Consultant Advisory Panel review 9/21/12. Policy Statement unchanged.
Bundling Guidelines Topics of Frequent Interest. The following statement was deleted from the section regarding Surgical Supplies: "Supplies and materials furnished by the provider (drugs, trays, and materials) above and beyond those usually included with the procedure(s) performed are reported separately." HCPCS codes removed from description. The remaining statements in that section are unchanged.
Capsaicin (Qutenza®) New policy. "Capsaicin (Qutenza®) may be considered medically necessary when criteria are met. Medical Director review June 10, 2012. Notification given 6/29/2012. Policy effective 10/1/2012. 8/21/12 Notification updated for clarification. Changed the wording in #3 from "No more than 4 patches are to be applied every 90 days" to "3. No more than 4 patches are to be applied per treatment; AND 4. No more than one treatment session should occur within 90 days." in the When Covered section. No change to policy intent. (btw) 10/1/12 Added the following diagnoses to the Billing/Coding section: 053, 053.1, 053.13, 053.19, 053.7, 053.79, 053.8, 053.9.
Electrodiagnostic Studies Added the following to the Policy Guidelines section to indicate: "Electrodiagnostic studies may also be rendered by a Licensed Physical Therapist who is currently listed on the American Physical Therapy Association website as a Board Certified Clinical Electophysiologic Certified Specialist per the American Board of Physical Therapy Specialists. In North Carolina, appropriately qualified Physical Therapists can perform EMG studies and provide physical therapy interpretations but not medical diagnoses based on the results of such testing." Medical Director review 9/17/2012. Reference to "physician" changed to "provider" where appropriate throughout policy.
Genetic Testing for Alpha-1 Antitrypsin Deficiency New policy developed. Genetic testing for alpha-1 antitrypsin deficiency may be considered medically necessary when both of the following conditions are met: 1. Patient is suspected of having alpha-1 antitrypsin deficiency because of clinical factors and/or because the patient may be at high risk of having alpha-1 antitrypsin deficiency due to a first degree relative with AAT deficiency; AND 2. Patient has a serum alpha-1 antitrypsin level in the range of severe deficiency. Medical Director review 5/2012. Policy noticed on 6/29/2012 for effective date of 10/01/2012.
Genetic Testing for Hereditary Hemochromatosis New policy developed. Genetic testing for HFE gene mutations may be considered medically necessary in a patient with abnormal serum iron indices indicating iron overload. Genetic testing for HFE gene mutations may be considered medically necessary in individuals with a family history of hemochromatosis in a first degree relative. Genetic testing for hereditary hemochromatosis in screening of the general population is considered investigational. Medical Director review 6/2012. Policy noticed on 6/29/12 for effective date of 10/01/12.
Genetic Testing for Non-Malignant Inherited Disorders Added the following new genetic testing policies as references in the Description section. Genetic Testing for Rett Syndrome (effective 11/27/2012), Genetic Testing for FMR1 Mutations Including Fragile X Syndrome (effective 11/13/2012), NOTCH3 Genotyping for Diagnosis of CADASIL (effective 12/11/2012), Genetic Testing for Alpha-1 Antitrypsin Deficiency (effective date 10/01/2012), Genetic Testing for Hereditary Hemochromatosis (effective date 10/01/2012)
Multianalyte Assays for the Evaluation and Monitoring of Patients with Liver Disease New policy developed. Combined serum markers of hepatic fibrosis, evaluated with algorithms to produce a predictive score, are considered investigational in the diagnosis and monitoring of patients with chronic liver disease. Multianalyte assays with algorithmic analyses are considered investigational for the diagnosis or monitoring of patients with chronic liver disease. Medical Director review 8/2012.
Repository Corticotropin (H.P. Acthar Gel) New policy BCBSNC will provide coverage for repository corticotropin when it is determined to be medically necessary because the medical criteria and guidelines are met. Medical Director review 5/20/2012. Notification given 7/1/2012. Effective date 10/1/2012.
Treatment of Hereditary Angioedema New policy developed to address the FDA approved products used as treatment of Hereditary Angioedema. BCBSNC will provide coverage for Cinryze®, Berinert®, Kalbitor® (Ecallantide), and Firazyr® (Icatibant) when it is determined to be medically necessary because the medical criteria and guidelines are met. Medical Director review 6/2012. Notification given 6/29/12 for effective date 10/01/12. (mco) 8/7/12 Laryngeal Hereditary Angioedema added as a clinical indication for treatment with Berinert®.Policy remains on 90 day notification with effective date 10/01/2012.
Evidence Based Guidelines
Intrauterine Ablation or Resection of the Endometrium Reference added. Specialty Matched Consultant Advisory Panel review - 9/21/12. No change to policy guidelines.
Uterine Artery Occlusion in the Treatment of Uterine Fibroids "Treatment of postpartum uterine hemorrhage may be appropriate" added to evidence based guideline. "One repeat transcatheter embolization may be appropriate" added to evidence based guideline. Criteria for repeat procedure added to evidence based guideline. "Transcatheter embolization for the management of cervical ectopic pregnancy is not recommended" added to evidence based guideline. Rationale section updated. Specialty Matched Consultant Advisory Panel review 9/21/12.