Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for

Medical Guidelines Reason for Update
Abdominoplasty, Panniculectomy and Lipectomy New policy developed. Abdominoplasty and Lipectomy are considered cosmetic and not medically necessary for all applications. BCBSNC does not provide coverage for not medically necessary services or procedures. BCBSNC will provide coverage for Panniculectomy when it is determined to be medically necessary because the medical criteria and guidelines are met. Medical Director review 8/2012. Specialty Matched Consultant Advisory Panel review 9/2012.
Air Fluidized Beds Specialty Matched Consultant Advisory Panel 9/21/2012. Policy changed to "Active" status. Under "When Covered" #3: removed reference to egg crate mattresses and added "Dynamic" to air mattress reference. No change to policy statement.
Baroreflex Stimulation Devices Description section updated. References updated. No changes to Policy Statement.
Bioengineered Skin and Tissue Specialty Matched Consultant Advisory Panel review 9/2012. Added new products to the "When not Covered" section: AmnioFix®, Axogen/AxioGuard, DermaCellTM, DuraGen®, NeoxTM1K/NeoxTM100, NuCellTM/NuShieldTM, Restore Orthobiologic Soft Tissue Implant, SpinalMendTM, TissueMend, Unite®Biomatrix, XCM Biologic, DermaSpanTM and DuraGen® Dural Graft and DuraGen® Plus.
Biofeedback Under "When Not Covered" section added as investigational: autism, Raynaud’s disease, back pain, muscle re-education or muscle tension, hypertension, asthma, anxiety disorders, insomnia, sleep bruxism, tinnitus, movement disorders, Bell's palsy, motor function after stroke, injury or lower limb surgery, orthostatic hypotension with spinal cord injury, and temporomandibular joint dysfunction (TMJD) for consistency with BCBSA. Policy guidelines extensively revised. Deleted the statement "Limitations and Exclusions for investigational services for use of Biofeedback with Attention Deficit Disorder" from Benefits Application section. Specialty Matched Consultant Advisory Panel review meeting 3/21/12. References added. Notification given 7/10/12 for effective date 10/16/12. Reviewed with medical director. Under "Not Covered" section: added pain management during labor as investigational; also added to the end of statement 1) "but not limited to" following "included". These additions do not change the intent of the medical policy. Reference added. Reviewed with medical director.
Breast Surgeries Specialty Matched Consultant Advisory Panel review 9/2012. No changes to Policy Statements.
Children's Mobility and Positioning Equipment Revised wording Under "When Not Covered" section for statements 1-3 related to benefit exclusions. Changed language from "not medically necessary" to "not considered durable medical equipment since they do not serve a medical purpose." Also removed reference to standing frames since this is now a standard benefit exclusion. Specialty Matched Consultant Advisory Panel review 9/21/2012. No change to policy statement.
Chiropractic Services Specialty Matched Consultant Advisory Panel review 9/21/2012. No change to policy intent.
Collagen Implantation Policy archived. Collagen and dermal fillers are addressed in the BCBSNC policy titled, "Cosmetic and Reconstructive Surgery." Medical Director review.
Corneal Collagen Cross-linking New policy issued. Corneal collagen cross-linking is considered investigational. BCBSNC does not provide coverage for investigational services or procedures. Medical director review 6/2012. Specialty Matched consultant advisory panel review meeting 6/20/12. Notification given 7/10/12. Effective date 10/16/2012.
Cosmetic and Reconstructive Surgery Policy extensively revised. The following related BCBSNC policies are referenced in the Description section: Reconstructive Eyelid Surgery and Brow Lift, Rhinoplasty, Septoplasty, Non-Pharmacologic Treatment of Rosacea, Hyperhidrosis, Treatment of, Prosthetic Appliances, Breast Surgeries, Varicose Veins, Treatment for, Surgical Treatment of Chest Wall Deformities, Laser Treatment of Port Wine Stain, Abdominoplasty, Panniculectomy and Lipectomy, Orthognathic Surgery, Gender Reassignment Surgery, Botulinum Toxin Injection, Ultrasonographic Evaluation of Skin Lesions. Information regarding procedures specific to the related policies has been deleted from this policy. Deleted the table titled, "Examples of Cosmetic and Reconstructive Surgery." Examples of surgical and dermatological reconstructive procedures have been relocated to the "When Covered" section. Examples of surgical and dermatological cosmetic procedures have been relocated to the "When not Covered" section. Medical Director review 8/2012. Specialty Matched Consultant Advisory Panel review 9/2012.
Durable Medical Equipment (DME) Specialty Matched Consultant Advisory Panel review 9/21/2012. No change to policy statement.
Electrical Stimulation for the Treatment of Arthritis Policy retitled, "Electrical Stimulation for the Treatment of Arthritis" for consistency with BCBSA. Converted to active policy from active archive status. Description section revised. Medical director review 9/2012. No change to policy statement.
Functional Capacity Assessment and Work Hardening Specialty Matched Consultant Advisory Panel review 9/21/2012. No change to policy statement.
Gait Analysis Specialty Matched Consultant Advisory Panel review 9/21/2012. Reference added. No change to policy statement.
Guidelines for Global Maternity Reimbursement Description section revised. In the "Billing for Maternity Care" section, modifier 51 was changed to modifier 59.
Laser Treatment of Port Wine Stains Specialty Matched Consultant Advisory Panel review 9/2012. No changes to Policy Statements.
Magnetic Esophageal Ring to Treat Gastroesophageal Reflux Disease (GERD) New policy issued. An implantable magnetic esophageal ring to treat gastroesophageal reflux disease (GERD) is considered investigational.
Otoplasty Policy archived. Otoplasty is addressed in the BCBSNC policy titled, "Cosmetic and Reconstructive Surgery." Medical Director review 8/2012.
Power Operated Vehicle (Scooter) Specialty Matched Consultant Advisory Panel review 9/21/2012. Added the following additional HCPCS codes to the Billing/Coding section: K0800, K0801, K0802, K0806, K0807, K0808, K0812.
Pressure Reducing Support Surfaces Specialty Matched Consultant Advisory Panel review 9/21/2012. No change to policy statement.
Reconstructive Eyelid Surgery and Brow Lift Specialty Matched Consultant Advisory Panel review 9/2012. Medical Director review 8/2012. No changes to Policy Statements.
Speech Generating Devices Revised "Not Covered" section to address updated technology/software/devices. Added the statement "augmentative communication equipment" to "Covered" and description section. Statement in Policy Guidelines section changed to "Only one device or software application is considered medically necessary per member" from "Only one device or software application at a time is considered medically necessary per member." Specialty Matched Consultant Advisory panel review 9/21/12.
Surgical Treatment of Chest Wall Deformities (Congenital or Acquired) References updated. Medical Director review 8/2012. Specialty Matched Consultant Advisory Panel review 9/2012. No changes to Policy Statements.
Surgical Ventricular Restoration References updated. No changes in Policy Statements.
Wheelchairs Specialty Matched Consultant Advisory Panel review 9/21/2012. No change to policy statement. Removed HCPCS codes: K0800, K0801, K0802, K0806, K0807, K0808, K0812 due to more appropriate setting in POV policy. Added the codes to the POV(Scooter) corporate medical policy.
Evidence Based Guidelines
Anti-CCP Testing for Rheumatoid Arthritis Reviewed by Medical Director. Archive.
Serum Biomarker Human Epididymis Protein 4 (HE4) Description section updated. Reference added.
TENS (Transcutaneous Electrical Nerve Stimulator) Reference added.