Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for November 13, 2012

Medical Guidelines Reason for Update
Acute and Maintenance Tocolysis Related policy added. Specialty Matched Consultant Advisory Panel review 9/19/12. No change to policy statement.
Allogeneic Hematopoietic Transplant for Genetic Diseases and Acquired Anemia Reference added.
Ankle Replacement, Total References updated. Added two new devices to Description section: Bologna and Oxford Universities (BOX) Ankle (MAT Ortho), CCI Evolution Ankle (Van Straten.) No changes to Policy Statements.
Artificial Intervertebral Disc Specialty Matched Consultant Advisory Panel review 10/17/2012. Revised Description section. Updated Policy Guidelines section. No change to policy intent. References added.
Axial Lumbosacral Interbody Fusion Specialty Matched Consultant Advisory Panel review 10/17/2012. No change to policy intent.
Botulinum Toxin Injection Specialty Matched Consultant Advisory Panel review 10/17/2012. No change to policy intent. The definition of "chronic migraine" was updated in the Policy Guidelines to include "with greater than or equal to 8 meeting criteria for migraines; provided there is no medication overuse." Reference added.
Bronchial Thermoplasty Reference update. No change to policy statement.
Bundling Guidelines Revisions made to "Surgical Supplies" section under Topics of Frequent Interest for clarity. The following statements were added: "Supplies are not covered when they do not require a prescription and can be purchased by the member over-the-counter or when they are given to the member as take-home supplies. Medical and/or surgical supplies, such as dressings and packings, used during the course of an office visit are generally considered incidental to the office visit. Compression/pressure garments, elastic stockings, support hose, foot coverings, leotards, knee supports, surgical leggings, gauntlets, and pressure garments for the arms and hands are examples of items that are not ordinarily covered."
Capsule Endoscopy, Wireless Reference added. Summary statement added. No change to policy intent. Medical director review.
Chemotherapy for Malignant Disease Removed deleted CPT code, 96445, from Billing/Coding section.
Chromosomal Microarray (CMA) Analysis for Genetic Evaluation of Developmental Delay/Autism Spectrum Disorder Description section updated. When Covered and When Not Covered sections updated. The following investigational statement was added: "Chromosomal microarray analysis is considered investigational in all other cases of suspected genetic abnormality in children with developmental delay/intellectual disability or autism spectrum disorder." The following not medically necessary statement was added: "Chromosomal microassay analysis to confirm the diagnosis of a disorder or syndrome that is routinely diagnosed based on clinical evaluation alone is not medically necessary." Policy guidelines updated. Specialty Matched Consultant Advisory Panel Review 7/18/12. Notification given 8/7/12 for policy effective date of 11/13/12.
CT Perfusion Imaging Reference added. Description section updated. No change to policy statement.
Decompression of the Intervertebral Disc Using Laser Energy (Laser Discectomy) or Radiofrequency Coblation (Nucleoplasty) Specialty Matched Consultant Advisory Panel review 10/17/2012. No change to policy.
Dental, Reconstructive Services Specialty Matched Consultant Advisory Panel review 10/17/2012. No change to policy statement or intent. Under Policy Guidelines: 1) revised page 3 II B #8 from "Non-odontogenic keratocysts to non-keratocystic odontogenic tumor"; 2)revised page 4 IV 4th bullet to add "Keratocystic Odontogenic tumor with parenthetical (Odontogenic keratocysts)".
Electroencephalograms Specialty Matched Consultant Advisory Panel review 10/17/2012. No change to policy statement. Removed requirement to have ambulatory cassette EEG prior to video EEG in Policy Guidelines section.
Facet Joint Denervation Specialty Matched Consultant Advisory Panel review 10/17/2012. No change to policy intent.
Functional Endoscopic Sinus Surgery (FESS) Specialty Matched Consultant Advisory Panel review 8/15/12. Additional pediatric information added to Policy Guidelines. No change to policy statement.
Genetic Testing for Cutaneous Malignant Melanoma References updated. No changes to Policy Statements
Genetic Testing for FMR1 Mutations Including Fragile X Syndrome New policy developed. Genetic testing for FMR1 mutations may be considered medically necessary for the following patient populations: Individuals of either sex with mental retardation, developmental delay, or autism spectrum disorder, Individuals seeking reproductive counseling who have a family history of fragile X syndrome or a family history of undiagnosed mental retardation, Prenatal testing of fetuses of known carrier mothers, Affected individuals or their relatives who have had a positive cytogenetic fragile X test result who are seeking further counseling related to the risk of carrier status among themselves or their relatives. Genetic testing for FMR1 mutations is considered investigational in the absence of the above clinical indications. Medical Director review 7/2012. Policy noticed on 8/7/12 for effective date of 11/13/12.
Genotyping for 9p21 Genetic Polymorphisms to Predict Cardiovascular Disease Risk Specialty Matched Consultant Advisory Panel review 10/2012. No changes to Policy Statements.
H-Wave Electrical Stimulation Specialty Matched Consultant Advisory Panel review 10/17/2012. No change to policy intent.
Autologous Hematopoietic Stem-Cell Transplantation for Malignant Astrocytomas and Gliomas Reference added.
Implantation of Intrastromal Corneal Ring Segments Specialty Matched Consultant Advisory Panel review 10/17/2012. Reference added. Description section updated. No change to policy statement.
Insulin Therapy, Chronic Intermittent Intravenous (CIIIT) Reference added. Related policy removed. No change to policy statement.
Intensity Modulated Radiation Therapy for Tumors of the Central Nervous System Extensively revised the Description and Policy Guidelines sections. Deleted table for radiation tolerance doses. Under "When Covered" section: added statement 3)IMRT dosimetry demonstrates reduced toxicity of non-target areas. No change to policy statement. Specialty Matched Consultant Advisory Panel review 8/15/12.
Intensity Modulated Radiation Therapy (IMRT) of Breast and Lung Extensive revisions to entire policy including Description, When Not Covered, When Covered and Policy Guidelines sections. Policy statement under "When Covered" section on breast and lung IMRT changed from not medically necessary to may be considered medically necessary. Under "When Not Covered" section: policy statement added indicating chest wall IMRT routine adjuvant post-mastectomy is investigational. Partial breast irradiation remains investigational. Reference added. Specialty Matched Consultant Advisory Panel review 8/15/12.
Intensity Modulated Radiation Therapy (IMRT) of Head and Neck Description section extensively revised. Policy statement on thyroid tumors changed. Under "When Covered" section: added "Intensity modulated radiation therapy may be considered medically necessary for the treatment of thyroid cancers in close proximity to organs at risk (esophagus, salivary glands, and spinal cord) and 3-D CRT planning is not able to meet dose volume constraints for normal tissue tolerance." Specialty Matched Consultant Advisory Panel review meeting 8/15/12. Reference added.
Intensity-Modulated Radiation Therapy (IMRT) of the Prostate Description section and Policy Guidelines extensively revised. Under "When Covered" added new indications: In conjunction with permanent transperineal implantation of radioactive seeds when 3D-CRT planning is not able to meet dose volume constraints for normal tissue tolerance and In conjunction with high-dose rate temporary brachytherapy when 3D-CRT planning is not able to meet dose volume constraints for normal tissue tolerance. Specialty Matched Consultant Advisory Panel review 8/15/2012.
Interferential Stimulation Specialty Matched Consultant Advisory Panel review 10/17/2012. Policy Guidelines updated. No change to policy intent.
Intraepidermal Nerve Fiber Density Minor revisions in the Description section. The When Not Covered statement revised from "Skin biopsy with epidermal nerve fiber density measurement is considered investigational for all other conditions, including, but not limited to, the monitoring of disease progression or response to treatment." to "Skin biopsy with epidermal nerve fiber density measurement is considered investigational for all other clinical situations not specified above, including, but not limited to, the monitoring of disease progression or response to treatment." for clarification. No change to policy intent. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 10/17/12.
Lipoprotein-associated Phospholipase A2 Specialty Matched Consultant Advisory panel review 10/2012. No changes to Policy Statements.
Lysis of Epidural Adhesions Specialty Matched Consultant Advisory Panel review 10/17/2012. No change to policy statement.
Magnetoencephalography/Magnetic Source Imaging Reference added. No change to policy guideline.
Mechanical Embolectomy for Treatment of Acute Stroke Description section revised. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 10/17/2012. Reference added. No change to policy intent.
Microprocessor-Controlled Prostheses for the Lower Limb Added HCPCS codes L5848, L7274, L7367, L7368 to the Billing/Coding section. These codes were previously located in the Prosthetic Appliances policy which was archived.
Myoelectric Prosthetic Components for the Upper Limb Added HCPCS codes L6611, L6621, L6638, L6646, L6647, L6648, L6881, L6882, L6884, L6885, L6920, L6930, L6940, L6950, L6960, L6970, L7185, L7186, L7261, L7272, L7274, L7367, L7368 to the Billing/Coding section. These codes were previously located in the Prosthetic Appliances policy which was archived.
Neurostimulation, Electrical Specialty Matched Consultant Advisory Panel review 10/17/2012. Policy Guidelines updated under the Functional Neuromuscular Electrical Stimulation section. No change to policy intent.
Patient Lifts Specialty Matched Consultant Advisory Panel review 9/21/12. No change to policy statement.
Pharmacogenetic Testing for Warfarin Dose Specialty Matched Consultant Advisory Panel review 10/2012. No changes to Policy Statements.
Progenitor Cell Therapy for the Treatment of Damaged Myocardium Due to Ischemia Specialty Matched Consultant Advisory Panel review 10/2012. No changes to Policy Statements.
Progesterone Therapy in High Risk Pregnancies Specialty Matched Consultant Advisory Panel review 9/19/12. No change to policy statement.
Prosthetic Appliances Moved HCPCS codes L5848, L7274, L7367, L7368 to the Billing/Coding section of the Microprocessor-Controlled Prostheses for the Lower Limb medical policy. Moved HCPCS codes L6611, L6621, L6638, L6646, L6647, L6648, L6881, L6882, L6884, L6885, L6920, L6930, L6940, L6950, L6960, L6970, L7040, L7170, L7185, L7186, L7261, L7272, L7274, L7367, L7368 to the Billing/Coding section of the Myoelectric Prosthetic Components for the Upper Limb medical policy. Policy previously was in active archive status. Policy archived. Reviewed by medical director 10/2012.
Quantitative Sensory Testing Reference added.
Real-Time Intra-Fraction Target Tracking During Radiation Therapy Specialty Matched Consultant Advisory Panel review 5/16/2012. Revised related policy section under Description. No change to policy statement. This procedure is now addressed under medical policy entitled "Code Bundling Rules Not Addressed in Claim Check." Policy archived. Reviewed by medical director.
Refractive Surgery Specialty Matched Consultant Advisory Panel review meeting 10/17/2012. Reference updated. No change to policy statement.
Serum Holo-Transcobalamin as a Marker of Vitamin B12 Status References updated. No change to policy statement.
Signal-Averaged ECG Specialty Matched Consultant Advisory Panel review 10/2012. References updated. Policy Guidelines updated. No changes to Policy Statements.
Spinal Cord Stimulation Specialty Matched Consultant Advisory Panel review 10/17/2012. Added "in the epidural space" to A. in the When Covered section for clarification. No change to policy intent.
Stem-cell Therapy for Peripheral Arterial Disease Specialty Matched Consultant Advisory Panel review 10/2012. No changes to Policy Statements.
Surgery for Morbid Obesity Reference added. Description Section updated with information about type II diabetes mellitus following bariatric surgery. Added Related Policy. Criteria for Adolescents revised. Policy Guidelines updated to include information on Adolescents. Medical Director review.
T-Wave Alternans Specialty Matched Consultant Advisory Panel review 10/2012. No changes to Policy Statements.
Total Facet Arthroplasty Specialty Matched Consultant Advisory Panel review 10/17/2012. Policy Guidelines updated. No change to policy intent.
Viscocanalostomy and Canaloplasty Specialty Matched Consultant Advisory Panel Review 10/17/2012. Reference updated. No change to policy statement.
Evidence Based Guidelines
Biventricular Pacemakers/Cardiac Resynchronization Therapy for Heart Failure New statement added to the "Not Recommended" section as follows: "Biventricular pacemakers, with or without an accompanying implantable cardiac defibrillator (i.e., a combined biventricular pacemaker/ICD), are not recommended as a treatment for heart failure in patients with atrial fibrillation." References updated. Medical Director review 9/2012.
Diabetic Retinopathy Telescreening Specialty Matched Consultant Advisory Panel review 10/17/2012. Reference added. No change to guideline statement.
Dynamic Spinal Visualization Description section updated. Related policy added. Reference added. No change to guideline statement.
Inhaled Nitric Oxide New Evidence Based Guideline issued. Inhaled nitric oxide may be appropriate as a component of treatment of hypoxic respiratory failure in neonates born at more than 34 weeks of gestation.
Prothrombin Time Monitoring in the Home Specialty Matched Consultant Advisory Panel review 10/2012. No changes to Guideline.