Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for December 31, 2012

Medical Guidelines Reason for Update
Allergy Testing Specialty Matched Consultant Advisory Panel review 11/2012. References updated. Deleted CPT codes 95010, 95015, 95075 and added 95017, 95018, 95076, 95079 to Billing/Coding section.
Antiprothrombin Antibody Testing CPT code 0030T deleted and CPT code 86849 added to Billing/Coding section.
Automated Nerve Conduction Tests Removed the following statement from the Billing/Coding section; "Based on CPT Assistant, December 2008/Volume 18, Issue 12; CPT codes 95900, 95903 or 95904 should not be used for this service."
Axial Lumbosacral Interbody Fusion Added new CPT codes effective 1/1/2013, 0309T and 22586 to Billing/Coding section. Reference added.
Bioengineered Skin and Tissue Description section updated to remove non-covered product information. Non-covered product information is now specifically addressed in the "When not Covered" section. "When not Covered" section updated to include new products: hMatrix®, C-QUR EdgeTM, C-QUR V-PatchTM and C-QUR LiteTM V-Patch. Also added the following statement to the "When not Covered" section: "With the exception of products used within the scope of FDA indications for treatment of burns and rare skin conditions such as recessive dystrophic epidermolysis bullosa, FDA approval for a specific use does not define that product as non-investigational." Deleted C9366, C9368, C9369 and added Q4131, Q4132, Q4133, Q4134, Q4135, Q4136 to Billing/Coding section. Medical Director review 12/2012.
Botulinum Toxin Injection Effective 1/1/2013, new CPT codes, 52287 and 64615, added to Billing/Coding section.
Bronchial Thermoplasty Added CPT codes 31660 and 31661 to the Billing/Coding section and deleted CPT codes 0276T and 0277T for effective date 1/1/2013.
Capsaicin (Qutenza®) Added the following diagnoses to the Billing/Coding section 053.10, 053.11, and 053.12. Added the following comment to the Billing/Coding section. CPT code 64614 should not be used for the administration of capsaicin.
Cardiovascular Disease Risk Tests Evidence Based Guideline converted to Corporate Medical Policy. Policy re-titled from "Novel Lipid Risk Factors in Risk Assessment of Cardiovascular Disease" to "Cardiovascular Disease Risk Tests." Measurement of cardiovascular risk factors, (i.e., apolipoprotein B, apolipoprotein A-I, apolipoprotein E, LDL subclass, HDL subclass, lipoprotein[a], long chain fatty acids,) is considered investigational as an adjunct to LDL cholesterol in the risk assessment and management of cardiovascular disease. References updated. Description and Policy Guidelines sections updated. Medical Director review 8/2012. Notification given 10/1/12 for effective date 1/1/2013.
Catheter Ablation of the Pulmonary Veins as a Treatment for Atrial Fibrillation Added new CPT codes to Billing/Coding section: 93653, 93654, 93655, 93656, 93657. Deleted CPT code 93651 and information regarding use of unlisted code for these services from the Billing/Coding section. Added related policy to Description section. No changes to Policy Statements.
Chemoembolization of the Hepatic Artery, Transcatheter Approach CPT codes 75896 and 75898 added to Billing/Coding section.
Chiropractic Services Removed deleted codes, 95900, 95903, and 95904 from Billing/Coding section. Added new 2013 codes, 95907, 95908, 95909, 95910, 95911, 95912, and 95913.
Code Bundling Rules Not Addressed in ClaimCheck® or Correct Coding Initiative New code added for 2013. Physician documentation of face-to-face visit for durable medical equipment determination performed by nurse practitioner, physician assistant or clinical nurse specialist (G0454) is considered incidental to the evaluation and management service and is not eligible for separate reimbursement.
Use of Common Genetic Variants to Predict Risk of Nonfamilial Breast Cancer Removed the following statement from the Billing/Coding section; "Providers may use the following CPT codes for this service: 83894, 83898, 83900, 83909, and/or 83912." Added the following codes to the Billing/Coding section; 81599 and G0452.
Detection of Circulating Tumor Cells Added new 2013 CPT codes, 86152 and 86153 to Billing/Coding section. Deleted codes 0279T and 0280T.
DNA Based Testing for Adolescent Idiopathic Scoliosis Deleted the following statement from the Billing/Coding section: "There is no specific CPT code for this test. A series of molecular diagnostic codes such as 83891, 83898, 83903, 83012 would likely be used." Added code 81599, G0452 to Billing/Coding section.
Electrodiagnostic Studies Removed deleted codes, 95900, 95903, and 95904 from Billing/Coding section. Added the following new 2013 codes, 95907, 95908, 95909, 95910, 95911, 95912, and 95913.
Electrostimulation and Electromagnetic Therapy for Wounds Reference added. Specialty Matched Consultant Advisory Panel review 12/4/12. No change to Policy Statement.
Endobronchial Valves Added CPT codes 31647, 31648, 31649, 31651 to the Billing/Coding section for effective date 1/1/2013. Deleted CPT codes 0250T, 0251T, 0252T.
Epidermal Growth Factor Receptor (EGFR) Mutation Analysis for Patients with Non-Small Cell Lung Cancer (NSCLC) Added 81235 and G0452 to Billing/Coding section. Removed the following statement with deleted codes: "This laboratory test would likely be coded using a series of nonspecific genetic testing codes. Providers may use a series of the following CPT codes: 83891, 83896, 83898, 83901, 83907, 83912, 88313, 88323, and/or 88381."
External Defibrillators Removed information regarding Implantable Cardioverter Defibrillators from Policy Guidelines. Please refer to new policy titled "Implantable Cardioverter Defibrillators" effective 1/1/2012. Medical Director review 10/1/12.
Gender Reassignment Surgery Reference added. Specialty Matched Consultant Advisory Panel review 12/4/12. No change to policy statement.
Gene Expression Testing to Predict Coronary Artery Disease Added the following new codes to the Billing/Coding section: G0452, 81599.
Genetic Testing for Cutaneous Malignant Melanoma Codes added to Billing/Coding section: G0452, 81404.
Genetic Testing for Familial Alzheimer's Disease Added the following codes to the Billing/Coding section: 81405, 81406, and G0452.
Genetic Testing for Lipoprotein (a) as a Decision Aid for Aspirin Treatment Deleted the following codes from the Billing/Coding section: 83891, 83892, 83896, 83898, 83903, 83912. Added new codes to Billing/Coding section: G0452, 81479.
Genetic Testing for Non-Malignant Inherited Disorders Updated Related Policies in the Description section. Added the following codes to Billing/Coding section: 81161, 81252, 81253, 81254, 81321, 81322, 81323, 81324, 81325, 81326, 81479, 81599, G0452. Deleted the following codes from the Billing/Coding section: 83890-83894, 88384, 88385, and 88386. Added "whole exome sequencing" to the "What is not Covered" section. Updated Policy Guidelines to include information regarding "whole exome sequencing." References updated. Medical Director review 12/2012.
Genetic Testing for Predisposition to Inherited Hypertrophic Cardiomyopathy Added codes to Billing/Coding section: 81405, 81406, 81407, 81479, G0452.
Genotyping for 9p21 Genetic Polymorphisms to Predict Cardiovascular Disease Risk Deleted codes 83891, 83892, 83896, 83898, 83912 from Billing/Coding section. Added codes 81404, 81479, G0452 to Billing/Coding section.
Growth Factors in Wound Healing Reference added. Specialty Matched Consultant Advisory Panel review 12/4/12. No change to policy statement.
Guidelines for Global Maternity Reimbursement Item C in the "Billing for Maternity Care" section dealing with multiple births has been extensively revised. Added Item D. Notification 10/16/12 for effective date 12/28/12
Hematopoietic Stem-Cell Transplantation for Multiple Myeloma Specialty Matched Consultant Advisory Panel review 12/4/2012. No change to policy intent. Added new 2013 CPT code, 38243 to Billing/Coding section.
Hematopoietic Stem-Cell Transplantation for Waldenstrom Macroglobulinemia Specialty Matched Consultant Advisory Panel review 12/4/2012. No change to policy intent. Added new 2013 CPT code, 38243 to Billing/Coding section.
Hematopoietic Stem-Cell Transplantation for Primary Amyloidosis Specialty Matched Consultant Advisory Panel review 12/4/2012. No change to policy intent. Added new 2013 CPT code, 38243 to Billing/Coding section.
Hematopoietic Stem-Cell Transplant for Non-Hodgkin Lymphomas Specialty Matched Consultant Advisory Panel review 12/4/12. No change to policy intent. Added new 2013 CPT code, 38243 to Billing/Coding section.
Hematopoietic Stem-Cell Transplantation for Autoimmune Diseases Specialty Matched Consultant Advisory Panel review 12/4/2012. No change to policy statement. Reference added. Added new 2013 CPT code, 38243 to Billing/Coding section.
Hematopoietic Stem-Cell Transplantation for Chronic Myelogenous Leukemia Specialty Matched Consultant Advisory Panel 12/4/12. No change to policy intent. Added new 2013 CPT code, 38243 to Billing/Coding section.
Hematopoietic Stem-Cell Transplantation for CLL and SLL Specialty Matched Consultant Advisory Panel review 12/4/12. No change to policy intent. Added new 2013 CPT code, 38243 to Billing/Coding section.
Hematopoietic Stem-Cell Transplantation for Epithelial Ovarian Cancer Specialty Matched Consultant Advisory Panel review 12/5/2012. No change to policy intent. Added new 2013 CPT code, 38243 to Billing/Coding section. Reference added.
Hematopoietic Stem-Cell Transplantation for Hodgkin Lymphoma Specialty Matched Consultant Advisory Panel review 12/4/2012. No change to policy intent. Added new 2013 CPT code, 38243 to Billing/Coding section. Reference added.
Hematopoietic Stem-Cell Transplantation for Solid Tumors of Childhood Specialty Matched Consultant Advisory Panel review 12/4/2012. No change to policy intent. Added new 2013 CPT code, 38243 to Billing/Coding section.
Hematopoietic Stem-Cell Transplantation for Miscellaneous Solid Tumors in Adults Specialty Matched Consultant Advisory Panel review 12/4/2012. No change to policy. Reference added. Added new 2013 CPT code, 38243 to Billing/Coding section.
Hematopoietic Stem-Cell Transplantation in the Treatment of Germ Cell Tumors Specialty Matched Consultant Advisory Panel review 12/4/2012. No change to policy intent. Added new 2013 CPT code, 38243 to Billing/Coding section.
Implantable Cardioverter Defibrillator New policy developed to separate information regarding Internal Cardioverter Defibrillators (ICD) from the External Defibrillator policy. BCBSNC will provide coverage for implantable cardioverter defibrillators when it is determined to be medically necessary because the medical criteria and guidelines are met. Medical Director review 9/2012. Policy notified on 10/1/2012 for effective date of 1/1/2013. 11/13/12 Revised information regarding the FDA approval for subcutaneous ICD. Policy effective date remains 1/1/2013.
Ingestible pH and Pressure Capsule CPT code 0242T removed from policy. CPT code 91112 added to Billing/Coding section.
Intravenous Anesthetics for the Treatment of Chronic Pain Evidence based guideline converted to corporate medical policy. Intravenous infusion of anesthetics (e.g., ketamine or lidocaine) for the treatment of chronic pain, including, but not limited to chronic neuropathic pain and fibromyalgia, is considered investigational. Medical Director review 8/21/12. Notification given 9/18/2012 Policy effective 12/28/2012.
JAK2 and MPL Mutations in Myeloproliferative Neoplasms Specialty Matched Consultant Advisory Panel review 12/4/2012. No change to policy intent. Added CPT codes 81402, 81403, and G0452 to Billing/Coding section.
KIF6 Genotyping for Predicting Cardiovascular Risk and/or Effectiveness of Statin Therapy The following statement was deleted from the Billing/Coding section: "There is currently no specific CPT code for this testing. A combination of the molecular diagnostic CPT codes 83890-83912 would most likely be used." Added codes 81479, G0452, 81599 to Billing/Coding section.
Mechanical Embolectomy for Treatment of Acute Stroke Removed comment containing deleted codes, "and radiological supervision and interpretation (75660-75680)", from Coding/Billing section.
Measurement of Serum Antibodies to Infliximab New policy. Measurement of antibodies to infliximab in a patient receiving treatment with infliximab, either alone or as a combination test which includes the measurement of serum infliximab levels, is considered investigational. Medical director review 9/18/2012. Notification given10/1/12. Policy effective 1/1/13.
Microprocessor-Controlled Prostheses for the Lower Limb Added HCPCS code L5859 to Billing/Coding section.
Mutation Analysis in Fine Needle Aspirates of the Thyroid Removed the following statement from the Billing/Coding section; "According to the Asuragen website, the following CPT codes would be "sed to report miRInformTM Thyroid: 83913, 83907, 83891, 83902, 83896, 83898, 83909, 83912." Added the following codes 81401, 81404, 81405, 81406, and G0452 to Billing/Coding section.
Natalizumab (Tysabri) New 2013 code, 86711 added to Billing/Coding section.
Non-Contact Ultrasound Treatment for Wounds Reference added. Specialty Matched Consultant Advisory Panel review 12/4/12. No change to policy statement.
NOTCH3 Genotyping for Diagnosis of CADASIL Deleted the following statement from the Billing/Coding section: "There is not a specific code for this test; however, a series of molecular diagnostic codes such as 83891, 83898, 83904, 83909 and 83912 may be used." Added 81406, 81479, G0452 to Billing/Coding section.
Plugs for Fistula Repair Reference added. Specialty Matched Consultant Advisory Panel review 12/4/12. No change to policy statement.
Radiosurgery, Stereotactic Approach Added CPT code 32701 to Billing/Coding section for effective date 1/1/2013.
Sleep Apnea: Diagnosis and Medical Management CPT codes 95782 and 95783 added to Billing/Coding section.
Telemedicine Deleted CPT code 90862 from Billing/Coding section for effective date 1/1/13.
Tinnitus Treatment CPT codes 90804-90809 replaced with CPT codes 90832-90838 in Billing/Coding Section.
Topical Negative Pressure Therapy for Wounds Added HCPCS codes G0456 and G0457 to Billing/Coding Section.
Transcatheter Heart Valve Implantation Deleted CPT codes 0256T, 0257T, 0258T, 0259T, 0262T and added 0318T, 33361, 33362, 33363, 33364, 33365, 33367, 33368, 33369 to Billing/Coding section. No changes to Policy Statements. References updated.
Transcranial Magnetic Stimulation CPT code 0310T added to Billing/Coding section.
Treatment of Hereditary Angioedema Specialty Matched Consultant Advisory Panel review 11/2012. No changes to Policy Statements. New code added to Billing/Coding section: J1744.
Varicose Veins, Treatment for Reference added. Specialty Matched Consultant Advisory Panel review 12/4/12. No change to policy statement.
Evidence Based Guidelines
Biochemical Markers of Alzheimer's Disease Removed deleted code, 83912, from Billing/Coding section. Added HCPCS code, G0452 to Billing/Coding section.
Intravitreal Angiogenesis Inhibitors for Choroidal and Retinal Vascular Conditions Added HCPCS code J0178 to the Billing/Coding section and deleted HCPCS Q2046 for effective date 1/1/13.
KRAS and BRAF Mutation Analysis in Cancer Added codes, 81405, 81406, and G0452 to Billing/Coding section. Removed CPT code 81210 from Billing/Coding section.
Maternal and Fetal Diagnostics Policy changed to Active status and will undergo routine literature review. Added information regarding fetal nasal bone assessment to Section IV. Added statement that "First-trimester screening for detection of Down syndrome incorporating fetal nasal bone assessment is not recommended" to Not recommended section in Section IV. References updated. Added CPT codes 81508, 81509, 81510, 81511, and 81512 to Section IV Billing/Coding.
Prostate Cancer Treatment with Brachytherapy Added HCPCS code G0458 to Billing/Coding section for effective date 1/1/13.
Ventricular Assist Devices and Total Artificial Hearts Added information table to Description section for FDA approved devices. Revised statement regarding bridge to transplant as follows: "Total artificial hearts with FDA-approved devices are recommended as a bridge to heart transplantation for patients with biventricular failure who have no other reasonable medical or surgical treatment options, who are ineligible for other univentricular or biventricular support devices, and are currently listed as heart transplantation candidates, or are undergoing evaluation to determine candidacy for heart transplantation and not expected to survive until a donor heart can be obtained." References updated. Deleted CPT codes 0048T and 0050T. Added CPT codes 33990, 33991, 33992, 33993 to Billing/Coding section. Medical Director review 12/2012.