Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for February 12, 2013

Medical Guidelines Reason for Update
Alefacept Injection (Amevive) Medical Director review. Alefacept (Amiveve) is no longer available in the United States. Manufacturer information regarding discontinuation and website added to policy.
Children's Mobility and Positioning Equipment Deleted HCPCS code E1340 from the Billing/Coding section.
Chromosomal Microarray (CMA) Analysis for Genetic Evaluation of Developmental Delay/Autism Spectrum Disorder Specialty Matched Consultant Advisory Panel review 1/2013. References updated. Description section updated with new commercially available tests. Policy Guidelines updated to include information on prenatal CMA analysis. No changes to Policy Statements.
Cytochrome p450 Genotyping Specialty Matched Consultant Advisory Panel review 1/2013. No changes to Policy Statements.
Dermatologic Applications of Photodynamic Therapy Specialty Matched Consultant Advisory Panel review 1/2013. References updated. No changes to Policy Statements.
Dopamine Transporter Imaging with Single Photon Emission Computed Tomography Added diagnosis codes 331 - 333.99 to Billing/Coding section.
Genetic Testing for Alpha-1 Antitrypsin Deficiency Specialty Matched Consultant Advisory Panel review 1/2013. No changes to Policy Statements.
Genetic Testing for Cutaneous Malignant Melanoma Specialty Matched Consultant Advisory Panel review 1/2013. No changes to Policy Statements.
Genetic Testing for FMR1 Mutations Including Fragile X Syndrome Specialty Matched Consultant Advisory Panel review 1/2013. No changes to Policy Statements.
Genetic Testing for Helicobacter pylori Treatment CPT codes deleted in 2012 removed from Billing/Coding section.
Genetic Testing for Hereditary Hemochromatosis Specialty Matched Consultant Advisory Panel review 1/2013. No changes to Policy Statements.
Genetic Testing for Non-Malignant Inherited Disorders Specialty Matched Consultant Advisory Panel review 1/2013. No changes to Policy Statements.
Genetic Testing for Rett Syndrome Specialty Matched Consultant Advisory Panel review 1/2013. Added related policy to Description section. No changes to Policy Statements.
Hematopoietic Stem-Cell Transplantation for Chronic Myelogenous Leukemia Reference added.
Hyperhidrosis, Treatment of Specialty Matched Consultant Advisory Panel review 1/2013. No changes to Policy Statements.
Interferential Stimulation Description and Policy Guidelines sections updated. No change to policy intent. Reference added.
Intracellular Micronutrient Analysis Specialty Matched Consultant Advisory Panel review 1/2013. No changes to Policy Statements.
Light Therapy for Dermatologic Conditions Specialty Matched Consultant Advisory Panel review 1/2013. No changes to Policy Statements.
Lysis of Epidural Adhesions Reference added.
Mohs' Micrographic Surgery Specialty Matched Consultant Advisory Panel review 1/2013. No changes to Policy Statements.
Non-Pharmacologic Treatment of Rosacea References updated. Added "Related Policies' to Description section. Specialty Matched Consultant Advisory Panel review 1/2013.
NOTCH3 Genotyping for Diagnosis of CADASIL Specialty Matched Consultant Advisory Panel review 1/2013. No changes to Policy Statements.
Spinal Surgery Using Interspinous Distraction Technology Reference added.
Surgical Deactivation of Migraine Headache Trigger Sites New policy. "Surgical deactivation of trigger sites is considered investigational for the treatment of migraine headache." Notification given 11/13/12. Effective date 2/12/13.
Transcatheter Heart Valve Implantation Added code 0262T to Billing/Coding section.
Ustekinumab (Stelara®) References updated. Updated related policies. Specialty Matched Consultant Advisory Panel review 1/2013. Trademark symbol TM replaced throughout policy with Registered trademark symbol®.
Wheelchairs Deleted HCPCS code E1340 from the Billing/Coding section.
Evidence Based Guidelines
Erythropoiesis-Stimulating Agents (ESAs) Information regarding Peginesatide (Omontys®) added to Description section. Under Evidence Based Guideline added; "The use of an ESA may be appropriate for treatment of patients with hepatitis C and anemia related to ribavirin treatment." "The use of peginesatide may be appropriate for: treatment of anemia associated with chronic kidney disease in adults on dialysis." Medical Director review 1/15/2013. Reference added.
Intraoperative Neurophysiologic Monitoring (sensory-evoked potentials, motor-evoked potentials, EEG monitoring) Reference added.
KRAS and BRAF Mutation Analysis in Cancer Reference added.
Pertuzumab for Treatment of HER2-Positive Malignancies New Evidence Based Guideline. "The use of pertuzumab may be appropriate in the treatment of breast cancer when all of the following conditions are met: Patient has HER2–positive metastatic breast cancer and Pertuzumab is used in combination with trastuzumab and a taxane (e.g., docetaxel, paclitaxel)." "The use of pertuzumab is not recommended for all other indications, including but not limited to locally advanced breast cancer, local recurrences of breast cancer following treatment, HER2-positive gastric cancers, and HER2-positive cancers of the gastro-esophageal junction." Senior Medical Director review 1/15/13.
Serologic Diagnosis of Celiac Disease Medical Director review 1/10/13. Archive policy.
Total Body Photography References updated. Added "Related Policy" to Description section. Specialty Matched Consultant Advisory Panel review 1/2013.