Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for November 27, 2012

Medical Guidelines Reason for Update
Anterior Cruciate Ligament Allograft Medical Director review 10/2012. Policy archived.
Carotid Intimal-Medial Thickness Study Specialty Matched Consultant Advisory Panel review 10/2012. Description section updated. Policy Guidelines updated.
Chemoembolization of the Hepatic Artery, Transcatheter Approach Reference added. No change to Policy statement.
Code Bundling Rules Not Addressed in ClaimCheck® or Correct Coding Initiative The following was added to the Code Bundling Rules section; "Health Risk Assessment Instrument: A health risk assessment instrument (99420) is not reimbursed separately. It is considered incidental to the associated evaluation and management services. 99420 should not be used for developmental screening or testing. See policy entitled, Developmental Delay Screening and Testing Guidelines". "Real-time Intra-fraction Target Tracking: Radiation therapy techniques requiring use of real-time intra-fraction target tracking (0197T) will be considered incidental to radiation treatment. Payment for new technology is based on the procedure rendered rather than the "technology" involved in the procedure. Separate reimbursement is not allowed for real-time intra-fraction target tracking." Notification given 9/18/12. Policy Effective date 11/27/12.
Cord Blood as a Source of Stem Cells Revised Description section. Removed "but without a hematopoietic stem cell donor with the same or better HLA (Human Leukocyte Antigen) matching characteristics." from the first statement in the When Covered section. Reference added.
Cytochrome p450 Genotyping Policy statement in "When Covered" revised. "CYP450 genotyping for CYP2C19 *2 and *3 alleles may be considered medically necessary in patients with cardiovascular disease undergoing treatment with clopidogrel (Plavix®) in order to identify those who are poor metabolizers of the drug (patients with CYP2C19*2/2,*3/3, and *2/3 genotypes) and who are, therefore, likely to exhibit poor response to the drug." revised to state: "CYP450 genotyping for the purpose of aiding in the choice of clopidogrel versus alternative anti-platelet agents, or in decisions on the optimal dosing for clopidogrel, may be considered medically necessary." Policy statements in "When not Covered" revised. "dose of atomoxetine HCl (approved for treatment of attention-deficit/hyperactivity disorder)" changed to state "selection and dosing of selective norepinephrine reuptake inhibitors." The following clinical indication added to "When not Covered" section: "selection and dosing of tricyclic antidepressants." Added CPT code 81225 to Billing/Coding section. Policy Guidelines updated. Medical Director review 11/2012.
Electrodiagnostic Studies Specialty Matched Consultant Advisory Panel review 10/17/2012. No change to policy statement.
Gastric Electrical Stimulation Reference added. "Post-surgical" added to investigational statement on gastroparesis. Policy Guidelines updated. Medical director review.
Genetic Testing for Familial Alzheimer's Disease Specialty Matched Consultant Advisory Panel review 10//17/2012. No change to policy intent. Reference added. Description section revised. Policy Guidelines updated.
Genetic Testing for Rett Syndrome New policy developed. Genetic testing for Rett syndrome may be considered medically necessary to confirm a diagnosis of Rett syndrome in a female child with developmental delay and signs/symptoms of Rett syndrome, but when there is uncertainty in the clinical diagnosis. All other indications for mutation testing for Rett syndrome, including prenatal screening and testing of family members, are considered investigational. Medical Director review 7/2012. Notification given August 21, 2012 for effective date of November 27, 2012.
Hyperthermic Intraperitoneal Chemotherapy Reference added.
Injectable Clostridial Collagenase for Fibroproliferative Disorders References updated. No changes to policy statements.
Interspinous Fixation (Fusion) Devices New policy. "Interspinous fixation (fusion) devices are considered investigational for any indication, including but not limited to use: in combination with interbody fusion, or alone for decompression in patients with spinal stenosis."
Intravenous Antibiotic Therapy for Lyme Disease Reference added. Related policy added. Medical director review. No change to policy statement.
Quantitative Assay for Measurement of HER2 Total Protein Expression and HER2 Dimers Reference added.
Respiratory Syncytial Virus Prophylaxis Updated Description section. Added the following statement to Policy Guidelines: "Palivizumab may interfere with RSV diagnostic tests that are immunologically-based (e.g., some antigen detection-based assays)". Medical Director review. No change to policy statement.
Small Bowel, Small Bowel with Liver, or Multivisceral Transplant Reference added. No change to Policy Statement.
Subtalar Arthroereisis Policy Guidelines updated. References updated. No changes to Policy Statement.
Transtympanic Micropressure Applications as a Treatment of Meniere's Disease Reference added. Policy Guidelines updated. No change to policy statement. Medical Director review.
Evidence Based Guidelines
Balloon Dilatation of the Prostatic Urethra Medical Director review 10/2012. Evidence Based Guideline archived.
Biochemical Markers of Alzheimer's Disease Specialty Matched Consultant Advisory Panel review 10/17/2012. Description section revised. No change to guideline intent.
Bone Allotransplantation Medical Director review 10/2012. Evidence based guideline archived. Deleted CPT code 90962 and added 20962 to Policy Implementation/Update Information section.
Free Vascularized Fibular Graft for Avascular Necrosis Medical Director review 10/2012. Evidence Based Guideline archived.
Ilizarov Bone Lengthening Procedure Medical Director review 10/2012. Evidence Based Guideline archived.
Prostate Cancer Treatment with Brachytherapy In "Not Recommended" section added "Focal or subtotal prostate brachytherapy is not recommended." Specialty Matched Consultant Advisory Panel review 8/15/2012.
Tissue Pressure Measurement Medical Director review 10/2012. Evidence Based Guideline archived.
Transrectal Ultrasound Medical Director review 10/2012. Evidence Based Guideline archived.
Transurethral Radiofrequency Needle Ablation of the Prostate Medical Director review 11/2012. Evidence Based Guideline archived.
Water Induced Thermotherapy for Treatment of Benign Prostatic Hypertrophy Medical Director review 11/2012. Evidence Based Guideline archived.