Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for January 15, 2013

Medical Guidelines Reason for Update
Allergy Immunotherapy (Desensitization) Specialty Matched Consultant Advisory Panel review 12/2012. Deleted "Atopic dermatitis" from the "When not Covered" section. Policy Guidelines updated. References updated.
Allogeneic Hematopoietic Transplant for Genetic Diseases and Acquired Anemia Add new 2013 CPT code, 38243 to Billing/Coding section.
Allogeneic Stem-Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms Added new 2013 CPT code, 38243, to Billing/Coding section. Reference added.
Ambulatory Event Monitors Description section extensively revised. "When Covered" revised to state: "The use of patient-activated or auto-activated external ambulatory event monitors and long-term ambulatory monitoring may be considered medically necessary as a diagnostic alternative to Holter monitoring in: Patients who experience infrequent symptoms (less frequently than every 48 hours) suggestive of cardiac arrhythmias (i.e., palpitations, dizziness, presyncope, or syncope);Patients with atrial fibrillation who have been treated with catheter ablation, and in whom discontinuation of systemic anticoagulation is being considered; Patients treated for atrial fibrillation to monitor for asymptomatic episodes in order to evaluate treatment response." "When not Covered" section revised to state: "Other uses of ambulatory event monitors, including outpatient cardiac telemetry, are considered investigational, including but not limited to monitoring effectiveness of antiarrhythmic therapy, for patients with cryptogenic stroke, and detection of myocardial ischemia by detecting ST segment changes." References updated. Medical Director review 12/2012.
Analysis of Proteomic Patterns for Early Detection of Cancer Specialty Matched Consultant Advisory Panel review 12/4/2012. No change to policy intent. Added G0452 to Billing/Coding section.
Autologous Fat Grafting to the Breast New policy developed. The use of autologous fat grafting and adipose-derived stem cells for augmentation or reconstruction of the breast is considered investigational. Ninety day notice given 10/16/2012 for effective date of 01/15/2013.
Balloon Sinuplasty for Treatment of Chronic Sinusitis Removed statement See also policy titled "Bundling Guidelines" from Billing/Coding section.
Bioimpedance Devices for Detection of Lymphedema Specialty Matched Consultant Advisory Panel review 12/4/12. References updated. No change in policy statement.
Computerized 2-Lead Resting Electrocardiogram (Multifunction Cardiogram) References updated. No changes to Policy Statement.
Dopamine Transporter Imaging with Single Photon Emission Computed Tomography New policy issued. Dopamine transporter imaging with single photon emission computed tomography (DAT-SPECT) is investigational for all indications, including but not limited to, aiding in the diagnosis of patients with clinically uncertain parkinsonian syndromes, essential tremor, or dementia with Lewy bodies, and for the monitoring of disease progression. Medical Director review 10/2012. Notification given 10/16/12 for policy effective date of 1/15/13.
Dynamic Posturography Reference added. No change to policy statement.
Gastroesophageal Reflux Disease, Transendoscopic Therapies Reference added. Information on transesophageal (or transoral) incisionless fundoplication added to Description section. Related Policies and Related Guideline added. Coding section updated. No change to policy statement. Medical Director review.
Genetic Testing for Breast and Ovarian Cancer Removed the following deleted codes from the Billing/Coding section; 83890, 83891, 83892, 83893, 83894, 83896, 83897, 83898, 83901, 83902, 83903, 83904, 83905, 83906, 83912. Added HCPCS code G0452 to Billing/Coding section. Description section updated. Under the When Covered section, A#2, removed "with both breast cancer and either" from statement. A#3 reworded from "Women who do not have a known family history of breast, epithelial ovarian, fallopian tube, or primary peritoneal cancer..." Changed A#3d. from "epithelial ovarian/fallopian tube/primary peritoneal cancer at any age," to "two or more close blood relatives with pancreatic cancer any age" Removed "and either" from C#2. Removed C#3 "(a) there are 3 or more family members (one lineage) affected with breast, ovarian, fallopian tube, primary peritoneal cancer, or (b) there is a risk of a BRCA mutation of at least 10%. (See Policy Guidelines)" Updated Policy Guidelines. Reference added. Medical Director review 12/18/2012.
Genetic Testing for Colon Cancer Removed the following deleted codes from the Billing/Coding section; 83890, 83891, 83892, 83894, 83896, 83898, 83902, 83903, 83904, 83905, 83906, 83907, and 83912. Added the following new 2013 codes to the Billing/Coding section; 81201, 81202, 81203, 81401, 81402, 81406, and G0452. Removed the following comment; "There is no specific CPT code for genetic testing; testing is typically coded for using a series of CPT codes describing the individual steps in the testing process." Description section revised. Added new medically necessary statement that indicates "Genetic testing for MMR gene mutations is considered medically necessary in the following patients: Patients with endometrial cancer and one first-degree relative diagnosed with a Lynch-associated cancer (see Policy Guidelines), for the diagnosis of Lynch syndrome." Under Policy Guidelines the Revised Bethesda Guidelines 5th bullet changed from "CRC diagnosed in 2 or more first-degree or second-degree relatives with Lynch syndromeassociated tumors, regardless of age. Lynch-associated tumors include: endometrial, stomach, ovarian, cervical, esophageal, leukemia, thyroid, bladder, ureter, and renal pelvis, biliary tract, small bowel, breast, pancreas, liver, larynx, bronchus, lung, and brain (glioblastoma), sebaceous gland adenomas, and keratoacanthomas." To "CRC diagnosed with one or more first-degree relatives with an HNPCC-related tumor (colorectal, endometrial, stomach, ovarian, pancreas, bladder, ureter and renal pelvis, biliary tract, brain [usually glioblastoma as seen in Turcot syndrome], sebaceous bland adenomas and keratoacanthomas in Muir-Torre syndrome, and carcinoma of the small bowel), with one of the cancers being diagnosed at younger than age 50 years, OR CRC diagnosed in 2 or more first-or second-degree relatives with HNPCC-related tumor, regardless of age." Medical Director review 12/18/2012. Reference added.
Hematopoietic Stem-Cell Transplantation for Breast Cancer Added new 2013 CPT code, 38243, to Billing/Coding section.
Hematopoietic Stem-Cell Transplantation for Acute Lymphoblastic Leukemia Added new CPT code, 38243, to Billing/Coding section.
Autologous Hematopoietic Stem-Cell Transplantation for Malignant Astrocytomas and Gliomas Added new CPT code, 38243, to Billing/Coding section.
Hematopoietic Stem-Cell Transplantation for Acute Myeloid Leukemia Added new CPT code, 38243, to Billing/Coding section.
Hematopoietic Stem-Cell Transplantation for CNS Embryonal Tumors and Ependymoma 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. Description and Policy Guidelines sections updated. Medical Director review 12/18/2012.
Home Uterine Activity Monitoring Reference added. Policy guidelines updated. No change to Policy statement. Medical director review.
Idiopathic Environmental Intolerance (i.e. Multiple Chemical Sensitivities) Policy title revised from "Idiopathic Environmental Intolerance (i.e. Clinical Ecology)" to "Idiopathic Environmental Intolerance (i.e. Multiple Chemical Sensitivities.)" Description section updated. Specialty Matched Consultant Advisory Panel review. References updated.
Microarray-based Gene Expression Testing for Cancers of Unknown Primary Removed the following statement from the Billing/Coding section; "Preparation of the probes may be coded using a combination of the molecular diagnostic codes 83890 - 83913. The analysis of the probes may be coded using array-based evaluation of multiple molecular probes codes 88384 - 88386 based on the number of probes analyzed" Added codes 81479 and G0452 to Billing/Coding section. Description section updated. The When Not Covered section reworded from "Gene expression profiling using the Pathwork® Tissue of Origin test or the Pathwork® Tissue of Origin test kit-FFPE to evaluate the site of origin of a tumor of unknown primary, and to distinguish a primary from a metastatic tumor is considered investigational for all indications." to "Gene expression profiling is considered investigational to evaluate the site of origin of a tumor of unknown primary, or to distinguish a primary from a metastatic tumor." Policy Guidelines updated. Reference added. Medical Director review 12/18/2012.
Microwave Tumor Ablation Specialty Matched Consultant Advisory Panel review 12/4/2012. No change to policy intent.
Neurostimulation, Electrical Reference added.
Occipital Nerve Stimulation Description section updated. No change to policy intent. Reference added.
Paraspinal Surface Electromyography (SEMG) Reference added.
Pelvic Floor Stimulation as a Treatment of Urinary Incontinence Specialty Matched Consultant Advisory Panel review 11/2012. Added "Related Policies" to Description section. No changes to Policy Statements.
Periurethral Bulking Agents for the Treatment of Urinary Incontinence Specialty Matched Consultant Advisory Panel review 11/2012. Description section updated. References updated. No changes to Policy Statements.
Posterior Tibial Nerve Stimulation for Voiding Dysfunction Added "Related Policies" to the Description section. Specialty Matched Consultant Advisory Panel review 11/2012. No changes to Policy Statement.
Radiofrequency Tissue Remodeling for Urinary Stress Incontinence Specialty Matched Consultant Advisory Panel review 11/2012. References updated. No changes to Policy Statements.
Sacral Nerve Neuromodulation/Stimulation for Pelvic Floor Dysfunction Specialty Matched Consultant Advisory Panel review 11/2012. No changes to Policy Statements.
Saturation Biopsy for Diagnosis and Staging of Prostate Cancer Updated Description section. Updated references. Specialty Matched Consultant Advisory Panel review 11/2012. No changes to Policy Statements.
Systems Pathology for Predicting Risk of Recurrence in Prostate Cancer Specialty Matched Consultant Advisory Panel review 11/2012. No changes to Policy Statements.
Temporary Prostatic Stent Description section updated. Related policy added. Policy Guidelines updated. References updated. Specialty Matched Consultant Advisory Panel review 11/2012. Medical Director review 12/2012. Policy archived.
Transanal Endoscopic Microsurgery (TEMS) Reference added. No change to policy statement.
Transanal Radiofrequency Treatment of Fecal Incontinence Reference added. Policy Guidelines section updated. No change to policy statement.
Ultrasonographic Evaluation of Skin Lesions References updated. Medical Director review. Archive policy.
Vesicoureteral Reflux, Treatment with Periureteral Bulking Agents Specialty Matched Consultant Advisory Panel review 11/2012. Description section updated. References updated. No changes to Policy Statements.
Xolair® (Omalizumab) Specialty Matched Consultant Advisory Panel review 11/2012. References updated. No changes to Policy Statements.
Evidence Based Guidelines
Bevacizumab in Advanced Adenocarcinoma of the Pancreas Specialty Matched Consultant Advisory Panel review 12/4/12. No change to policy intent. Reference added.
Cryoablation of Prostate Cancer Evidence Based Guideline re-titled from "Cryosurgery Ablation of the Prostate" to "Cryoablation of Prostate Cancer." Status changed to active. Guideline will undergo routine review. Description section updated. Added "Related Policies" to Description section. "When Recommended" section revised to state: "Cryoablation of the prostate is recommended as treatment of clinically localized (organ-confined) prostate cancer when performed: 1) as initial treatment or 2) as salvage treatment of disease that recurs following radiation therapy." "When not Recommended" section revised to state: "Subtotal prostate cryoablation is not recommended in the treatment of prostate cancer." Medical Director review 11/2012. Specialty Matched Consultant Advisory Panel review 11/2012. References updated.
Implantable Infusion Pumps Reference added. Primary epithelial ovarian cancer (intraperitoneal infusion as component of chemotherapy) added as recommended. Head/neck cancers (intra-arterial injection of chemotherapeutic agents) changed to not recommended. Medical Director review.
Intraoperative Neurophysiologic Monitoring (sensory-evoked potentials, motor-evoked potentials, EEG monitoring) New Evidence Based Guideline developed. "Intraoperative monitoring, which includes somatosensory-evoked potentials, motor-evoked potentials using transcranial electrical stimulation, brainstem auditory-evoked potentials, EMG of cranial nerves, EEG, and electrocorticography (ECoG), may be appropriate during spinal, intracranial, or vascular procedures. Intraoperative monitoring of visual-evoked potentials is not recommended. Due to the lack of FDA approval, intraoperative monitoring of motor-evoked potentials using transcranial magnetic stimulation is not recommended. Intraoperative EMG and nerve conduction velocity monitoring during surgery on the peripheral nerves is not recommended." Senior Medical Director review 10/14/12.
Pharmacogenomic and Metabolite Markers for Treatment with Thiopurines Replaced the word azathioprine with the word thiopurines throughout the entire document. Description section revised. Removed CPT codes 83890, 83891, 83892, 83896, 83898, 83900, 83909, 83912, and 83914 from Coding/Billing section. Added HCPCS G0452 to Billing/Coding section. No change to Guideline statement.
Transurethral Microwave Thermotherapy for Benign Prostatic Hyperplasia Specialty Matched Consultant Advisory Panel review 11/2012. No changes to Guideline Statements.