Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for February 26, 2013

Medical Guidelines Reason for Update
Bioengineered Skin and Tissue References updated. Added the following statement to the Description section and to the "When not Covered" section: "Dermagraft had been FDA approved by a Humanitarian Device Exemption (HDE) for the treatment of dystrophic epidermolysis bullosa. The manufacturer has since withdrawn Dermagraft from HDE status."
Botulinum Toxin Injection Added "urgency, and frequency" and the "*" indicating FDA approval to number 10 under the When Covered section. Medical Director review 2/2/2013.
Breast Surgeries Added the following statement to the "When not Covered" section: "Autologous fat grafting using liposuction technique for breast reconstruction is not covered. Please see policy titled, "Autologous Fat Grafting to the Breast." Added Related Policy to the Description section.
Bundling Guidelines CPT code removed from list in the section on "Pathologists." CPT 83912 was deleted as of 12/31/12.
Chelation Therapy Revised description section. Changed status of policy to active from active archive. Added autism, alzheimer's disease and rheumatoid arthritis as investigational indications under "When Not Covered" section. Reference added. Notification given 11/27/12 for effective date 2/26/13. Medical director review 11/2012.
Code Bundling Rules Not Addressed in ClaimCheck® or Correct Coding Initiative Immunization Administration: Evaluation and Management services will not be reimbursed separately when billed with immunization administration codes 90460 - 90474. If a significant, separately identifiable evaluation and management service is performed in addition to immunization administration, the -25 modifer must be used. The -25 modifier is not required with Preventive Medicine Services 99381 - 99397. (See also Corporate Medical Policy titled "Immunization Guidelines").
Cranial Electrotherapy Stimulation (CES) and Auricular Electrostimulation New policy. Cranial electrotherapy stimulation (also known as cranial electrostimulation therapy or CES) is considered investigational. Electrical stimulation of auricular acupuncture points is considered investigational. Reviewed by Senior Medical Director 11/3/12. Notification given 11/27/12. Policy effective 2/26/13.
Cytochrome p450 Genotyping Added CPT codes 81226, 81227, 81401, 81402, 81404, 81405 to Billing/Coding section. Medical Director review 2/2013.
Electrical Bone Growth Stimulation Added related policy to Description section. Revised the following statement in the "When not Covered" section: "2.Investigational applications of electrical bone growth stimulation in the appendicular skeleton include, but are not limited to, immediate post-surgical treatment., and treatment of fresh fractures, delayed union or failed arthrodesis. Delayed union is defined as a decelerating fracture healing process, as identified by serial x-rays. 3. Semi-invasive electrical bone growth stimulators are considered investigational as an adjunct to lumbar fusion and for failed lumbar fusion." References updated. Medical Director review. Policy noticed on 11/27/12 for effective date 2/26/13.
End Diastolic Pneumatic Compression Boot References updated. Policy Guidelines updated. CPT code 93799 added to Billing/Coding section. No changes to Policy Statements.
Epidermal Growth Factor Receptor (EGFR) Mutation Analysis for Patients with Non-Small Cell Lung Cancer (NSCLC) Updated policy guidelines. Reference added. Senior Medical Director review 2/8/2013.
Hematopoietic Stem-Cell Transplantation for Breast Cancer Reference added.
Hematopoietic Stem-Cell Transplantation for CLL and SLL Reference added.
Identification of Microorganisms Using Nucleic Acid Probes New policy developed. BCBSNC will provide coverage for identification of microorganisms using nucleic acid probes when it is determined to be medically necessary because the medical criteria and guidelines are met. Medical Director review 10/2012. Policy noticed on 11/27/12 for effective date 2/26/13.
Immunization Guidelines Codes G9141 and G9142 deleted.
Liver Transplant Reference added. Description section revised. Non-alcoholic steatohepatitis cirrhosis added to the medically necessary policy statement; a statement added that retransplantation may be considered medically necessary; a statement added that extrahepatic peri-hilar or hilar cholangiocarcinoma may be considered medically necessary. Information on other intrahepatic or extrahepatic malignancies including non-peri-hilar or non-hilar cholangiocarcinoma and recurrent hepatocellular carcinoma salvage treatment added to the Policy guidelines. Medical Director review.
Optical Diagnostic Devices for Evaluating Skin Lesions Suspected of Malignancy Policy re-titled from "Dermatoscopy" to "Optical Diagnostic Devices for Evaluating Skin Lesions Suspected of Malignancy." Desciption section updated to include computer based optical imaging information. "When not Covered" section revised to state: "Dermatoscopy, using either direct inspection, digitization of images, or computer-assisted analysis, is considered investigational as a technique to evaluate or serially monitor pigmented skin lesions. Computer-based optical imaging devices e.g., multispectral digital skin lesion analysis, are considered investigational as a technique to evaluate or serially monitor pigmented skin lesions. Dermatoscopy and computer-based optical imaging devices are considered investigational for defining peripheral margins of skin lesions suspected of malignancy prior to surgical excision." Policy Guidelines updated. References updated. Medical Director review 11/2012. Policy noticed on 11/27/12 for effective date of 2/26/13.
Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers Reference added. Title changed to Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers. Statement on two-phase pumps deleted. Statement added that use of lymphedema pumps to treat the trunk or chest in patients with lymphedema limited to the upper and/or lower limbs is considered investigational. Statement added that use of lymphedema pumps to treat venous ulcers is considered investigational. Medical Director review. Notification given 11/27/12. Policy effective 2/26/13.
Pulmonary Hypertension, Drug Management Under "When Not Covered" section added: “"of other advanced therapies for the pharmacologic treatment of pulmonary arterial hypertension (PAH/WHO Group 1), including but not limited to imatinib and simvistatin, is considered investigational." Notification given 11/27/12 for effective date 2/26/13.
Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors Reference added. Information on thyroid tumors added to Description section. Thyroid tumors added to non covered indications. Policy Guidelines updated. Medical Director review. Notification given 11/27/12. Policy effective 2/26/13.
Rehabilitative Therapies Under "Benefits Application" section, added a disclaimer stating "Most certificates exclude cognitive rehabilitation therapy as a stand-alone therapy. Please check the Member's Benefit Booklet before applying this policy." Medical director review 2/2013.
Sacroiliac Joint Fusion New policy. "Sacroiliac joint fusion procedures may be considered medically necessary for any of the following indications: as an adjunct to sacrectomy or partial sacrectomy related to tumors involving the sacrum; or as an adjunct to the medical treatment of sacroiliac joint infection/sepsis; or severe traumatic injuries associated with pelvic ring fracture; or when multisegment spinal constructs extend to the sacrum/ilium, for covered lumbar spine fusion procedures (See medical policy, 'Lumbar Spine Fusion Surgery')." "When none of the above indications are present, the procedure is considered not medically necessary. Sacroiliac joint fusion surgery is considered investigational for the treatment of mechanical low back pain when the sacroiliac joint is the suspected cause." Senior Medical Director review 10/28/2012. Notification given 11/27/12. Policy effective 2/26/13.
Spinal Cord Stimulation Reference added.
Topical Negative Pressure Therapy for Wounds Reference added. No change to policy statement.
Transcranial Magnetic Stimulation Reference added. Additional disorders being tested for treatment with rTMS added to Description section. Added "For other psychiatric/neurologic conditions, the evidence is insufficient to determine whether rTMS leads to improved outcomes. The available clinical trials are small and report mixed results for a variety of conditions other than depression. There are no large, high-quality trials for any of these other conditions. Therefore, rTMS is considered investigational for other psychiatric/neurologic conditions" to the Summary section. Medical Director review. No change to Policy statement.
Ultrasound Accelerated Fracture Healing Device Revised following statement in the "When not Covered" section: "Other applications of low intensity ultrasound treatment are investigational, including but not limited to, congenital pseudoarthroses, open fractures, arthrodeses, or stress fractures." Policy Guidelines updated. Medical Director review 11/2012. Policy noticed 11/27/12 for effective date 2/26/2013.
Evidence Based Guidelines
Screening for Vertebral Fracture with Dual X-ray Absorptiometry (DEXA) Reference added. Not recommended section updated. Medical Director review. No change to guideline.