Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for October 30, 2012

Medical Guidelines Reason for Update
Acoustic Cardiography Specialty Matched Consultant Advisory Panel review 10/2012. No changes to Policy Statements.
Antiprothrombin Antibody Testing Specialty Matched Consultant Advisory Panel review 10/2012. No changes to Policy Statements.
Assays of Genetic Expression to Determine Prognosis of Breast Cancer Specialty Matched Consultant Advisory Panel review 3/21/2012. Added the following information to the When Covered section; item 5e. "tumor size is > 0.5cm". Removed "tumor size is 0.6 - 1cm with moderate/poor differentiation or unfavorable features, OR tumor size > 1cm." Added the following to item 6. "The test is being ordered by the treating surgeon who has discussed the patient's clinical situation with the oncologist to whom the patient will be referred, and that oncologist has agreed that the patient IS a candidate for systemic chemotherapy in addition to hormonal therapy if the Oncotype DxTM Test result indicates a high risk for recurrence. That discussion must be documented in the patient's clinical chart." Policy Guidelines section updated.
Cardiac Hemodynamic Monitoring in the Outpatient Setting Specialty Matched Consultant Advisory Panel review 10/2012. No changes to Policy Statements.
Cellular Immunotherapy for Prostate Cancer Reference added.
Chromoendoscopy as an Adjunct to Colonoscopy New policy issued. Chromoendoscopy and virtual chromoendoscopy are considered investigational as an adjunct to diagnostic or surveillance colonoscopy. Notification given 7/24/12 for policy effective date of 10/30/12.
Computed Tomography to Detect Coronary Artery Calcification Specialty Matched Consultant Advisory Panel review 10/2012. References updated. Policy Guidelines updated.
Denosumab (ProliaTM, XGEVATM) References updated. Specialty Matched Consultant Advisory Panel review 9/21/12. Added the following clinical indication to the "When Covered" section: "ProliaTM may also be considered medically necessary as a treatment to increase bone mass in men with osteoporosis at high risk for fracture."
Dental, Criteria for use of Hospital Inpatient or Outpatient Facility Services or Ambulatory Surgery Center Facility Services Specialty Matched Consultant Advisory Panel review 10/17/2012. No changes to policy statement.
DNA Based Testing for Adolescent Idiopathic Scoliosis References updated. No changes to Policy Statement.
Electrocardiographic Body Surface Mapping References updated. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 10/2012. No changes to Policy Statements.
End Diastolic Pneumatic Compression Boot Specialty Matched Consultant Advisory Panel review 10/2012. No changes to Policy Statements.
Endothelial Keratoplasty Updated Description section and reference added. Specialty Matched Consultant review panel meeting 10/17/2012. No change to policy statement.
Fundus Photography Specialty Matched Consultant Advisory Panel review 10/17/2012. No change to policy statement.
Gastroesophageal Reflux Disease, Transendoscopic Therapies Added CPT code 43219 to Billing/Coding section. Specialty Matched Consultant Advisory Panel review 10/17/12. No change to policy statement.
Genetic Testing for Lipoprotein (a) as a Decision Aid for Aspirin Treatment Specialty Matched Consultant Advisory Panel review 10/2012. No changes to Policy Statements.
Genetic Testing for Predisposition to Inherited Hypertrophic Cardiomyopathy References updated. Specialty Matched Consultant Advisory panel review 10/2012. No changes to Policy Statements.
Hematopoietic Stem-Cell Transplantation for Acute Myeloid Leukemia Reference added.
Hyperthermic Intraperitoneal Chemotherapy Removed deleted code, 96445, from Billing/Coding section.
Immune Globulin Therapy Coding update. Code C9270 replaced with Code J1557 in Billing/Coding section.
Ingestible pH and Pressure Capsule Added "In 2009, the FDA expanded the use of the SmartPill to determine colonic transit time for the evaluation of chronic constipation and to differentiate between slow versus normal transit constipation. When colonic transit time cannot be determined, small and large bowel transit times combined can be used instead. The SmartPill is not for use in pediatric patients" to the Description section. Changed the When Not Covered statement to read "Measurement of gastrointestinal transit times, including gastric emptying and colonic transit times, using an ingestible pH and pressure capsule is considered investigational for the evaluation of suspected gastroparesis, constipation, or other gastrointestinal motility disorders". Updated the Policy Guidelines. Specialty Matched Consultant Advisory Panel review 10/17/12.
Intradialytic Parenteral Nutrition Specialty Matched Consultant Advisory Panel review 10/17/12. No change to policy statement.
Keratoprosthesis Description section updated. Reference added. Specialty Matched Consultant Advisory Panel review 10/17/2012. No change to policy statement.
Multigene Expression Assay for Predicting Recurrence in Colon Cancer Description section revised. The When Not Covered statement changed from "The 12-gene expression test (Oncotype DX® colon cancer test) is considered investigational, including use for predicting the likelihood of disease recurrence for patients with stage II colon cancer following surgery." to "Gene expression assays for determining the prognosis of stage II colon cancer following surgery are considered investigational." Policy Guidelines updated. References added. Senior Medical Director review 10/14/12.
Non-BRCA Breast Cancer Risk Assessment (OncoVue) Reference added.
Orthognathic Surgery Specialty Matched Consultant Advisory panel review 10/17/2012. No change to policy statement.
Percutaneous Electrical Nerve Stimulation (PENS) or Neuromodulation Therapy Description section revised. Medical Director review 10/14/2012. Specialty Matched Consultant Advisory Panel review 10/17/12. Reference added.
Positional Magnetic Resonance Imaging (MRI) Added CPT 76498 to Billing/Coding section. Revised policy guidelines section. No change to policy statement. Converted policy from active archive status to active status.
Radiofrequency Ablation of the Renal Nerves as a Treatment of Hypertension New policy developed. Radiofrequency ablation of the renal sympathetic nerves is considered investigational for treatment of resistant hypertension. Medical Director review 10/2012.
Rehabilitative Therapies Extensive revision of description, "when covered" and "when not covered" sections as well as policy guidelines section. Specialty Matched Consultant Advisory Panel review 9/21/2012. No change to policy statement.
Transanal Endoscopic Microsurgery (TEMS) Specialty Matched Consultant Advisory Panel review 10/17/12. Policy Guidelines updated. No change to policy intent.
Transanal Radiofrequency Treatment of Fecal Incontinence Specialty Matched Consultant Advisory Panel review 10/17/12. No change to policy statement.
Evidence Based Guidelines
Endoscopic Radiofrequency Ablation or Cryoablation for Barrett's Esophagus Specialty Matched Consultant Advisory Panel review 10/17/12. Updated Description section. Added "Radiofrequency ablation may be appropriate for treatment of Barrett's esophagus with low-grade dysplasia, when the initial diagnosis of low-grade dysplasia is confirmed by two physicians" to the Evidence Based Guideline. Updated Medical Evidence section.
Glaucoma, Evaluation by Ophthalmologic Techniques Specialty Matched Consultant Advisory Panel review 10/17/2012. Reference updated. No change to guideline statement.
Partial Left Ventriculectomy References updated. Evidence Based Guideline archived. Medical Director review 10/2012.
Photodynamic Therapy, Ocular Revised description section. Added "chronic central serous chorioretinopathy, and choroidal hemangioma as recommended indications. Specialty Matched Consultant Advisory panel review 10/17/2012. Reference added.
Transmyocardial Revascularization References updated. No changes to Evidence Based Guideline.
Transurethral Microwave Thermotherapy for Benign Prostatic Hyperplasia References updated. No changes to Guideline statement.