Medical Policy Updates

Table Of Contents

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

Medical Guidelines Reason for Update
Abatacept (Orencia®) Specialty Matched Consultant Advisory panel review meeting 2/20/2013. No change to policy statement. Reference added.
Ambulance and Medical Transport Services Specialty Matched Consultant Advisory Panel review meeting 2/20/2013. No change to policy statement.
Aqueous Shunts and Devices for Glaucoma Revised the description and policy guidelines sections. Under "When Not Covered" section added investigational statement: "Use of a micro-stent is considered investigational." Notification given 12/11/12 for effective date 3/12/13.
Back School Medical Director review. References updated. Specialty Matched Consultant Advisory Panel review 2/2013. Policy archived.
Belimumab (Benlysta) Specialty Matched Consultant Advisory Panel review meeting 2/20/2013. No change to policy statement. Reference added.
Biofeedback Revised Description and Policy Guidelines sections. Under "When Covered"section added new constipation indication for adults. Added Appendix-Diagnostic Criteria section at the end of the policy. Specialty Matched Consultant Advisory Panel review meeting 2/20/2013. Reference added.
Bone Morphogenetic Protein Specialty Matched Consultant Advisory Panel review 2/2013. References updated. Policy Guidelines updated.
Chelation Therapy Specialty Matched Consultant Advisory panel review meeting 2/20/13. No change to policy statement.
Clinical Trial Services for Life-Threatening Conditions Specialty Matched Consultant Advisory panel review meeting 2/20/2013. No change to policy statement. References updated. Converted policy to active status from active archive status. Medical director review 2013.
Cochlear Implant Reference added. Specialty Matched Consultant Advisory Panel Review 2/20/13. No change to policy statement.
Complementary and Alternative Medicine Specialty Matched Consultant Advisory Panel review meeting 2/20/2013. No change to policy statement. References updated. Convert policy to active status from active archive status. Medical director review 2013.
DNA Based Testing for Adolescent Idiopathic Scoliosis Specialty Matched Consultant Advisory Panel review 2/2013. No changes to Policy Statement.
Dynamic Posturography Specialty Matched Consultant Advisory Panel review 2/20/2013. No change to Policy statement
Electrical Stimulation for the Treatment of Arthritis Specialty Matched Consultant Advisory Panel review meeting 2/20/2013. No change to policy statement.
E-visits (Online Medical Evaluations) Specialty Matched Consultant Advisory Panel review meeting 2/20/2013. No change to policy statement. References updated.
Hip Resurfacing Added FDA device approval information and related policies to Description section. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 2/2013. No changes to Policy Statements.
Infliximab (Remicade) Under "Not Covered" section, added Hidradenitis suppurativa as investigational indication. Reference added. Specialty Matched Consultant Advisory Panel review meeting 2/20/13.
Infusion Therapy in the Home Specialty Matched Consultant Advisory Panel review meeting 2/20/2013. No change to policy statement.
Injectable Clostridial Collagenase for Fibroproliferative Disorders References updated. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 2/2013. No changes to Policy Statements.
Intravenous Antibiotic Therapy for Lyme Disease Specialty Matched Consultant Advisory Panel review 2/20/13. No change to policy statement.
Measurement of Serum Antibodies to Infliximab Specialty Matched Consultant Advisory panel review meeting 2/20/2013. No change to policy statement.
Microprocessor-Controlled Prostheses for the Lower Limb Deleted code L7274 from Billing/Coding section. Revised Related Policies and added new devices to Description section. References updated. Specialty Matched Consultant Advisory Panel review 2/2013.
Monochromatic Infrared Energy Treatment (MIRE) Specialty Matched Consultant Advisory Panel review meeting 2/20/2013. Reference added. No change to policy statement.
Myoelectric Prosthetic Components for the Upper Limb Specialty Matched Consultant Advisory Panel review 2/2013. References updated. Added "Related Policy" to Description section.
Nerve Fiber Density Testing Name changed from Intraepidermal Nerve Fiber Density to Nerve Fiber Density Testing. Description section revised. New indication added to the When Not Covered section to state; "Measurement of sweat gland nerve fiber density is considered investigational." Policy Guidelines updated. Reference added. Senior Medical Director review 11/26/12. Notification given 12/11/12. Policy effective 3/12/13.
Noninvasive Respiratory Assist Devices Reference added. No change to Policy statement. Specialty Matched Consultant Advisory Panel review 2/20/13.
Observation Room Services Specialty Matched Consultant Advisory Panel review meeting 2/20/2013. No change to policy statement. References updated.
Orthopedic Applications of Stem Cell Therapy Specialty Matched Consultant Advisory Panel review 2/2013. References updated. Policy Guidelines updated. Added Related Policies to Description section.
Private Duty Nursing Services Specialty Matched Consultant Advisory panel review meeting 2/20/2013. No change to policy statement. References updated. Converted policy to active status from active archive status. Medical director review.
Respiratory Syncytial Virus Prophylaxis Specialty Matched Consultant Advisory Panel review 2/20/13. No change to policy statement.
Rituximab for the Treatment of Rheumatoid Arthritis Specialty Matched Consultant Advisory Panel review meeting 2/20/2013. No change to policy statement. Reference added.
Semi-Implantable and Fully Implantable Middle Ear Hearing Aid Reference added. Specialty Matched Consultant Advisory Panel review 2/20/13. No change to policy statement.
Serum Holo-Transcobalamin as a Marker of Vitamin B12 Status Specialty Matched Consultant Advisory Panel review meeting 2/20/2013. No change to policy statement.
Skilled Nursing Facility Care Specialty Matched Consultant Advisory review panel meeting 2/20/2013. No change to policy statement. Reference updated. Converted policy to active status from active archive status. Medical director review 2013.
Skilled Nursing Services Specialty Matched Consultant Advisory panel review meeting 2/20/2013. No change to policy statement. Reference updated. Converted policy to active status from active archive status. Added HCPCS code G0156 to billing/coding section. Medical director review 2013.
Subtalar Arthroereisis Specialty Matched Consultant Advisory Panel review 2/2013. No changes to Policy Statement.
Surgery for Morbid Obesity Added "Two-stage bariatric surgery procedures (e.g., sleeve gastrectomy as initial procedure followed by biliopancreatic diversion at a later time)" to the When Surgery for Morbid Obesity is Not Covered section. Added information related to 2-stage bariatric surgery procedures to the Policy Guidelines section. Notification given 12/11/12. Policy effective 3/12/13.
Tocilizumab (Actemra) Specialty Matched Consultant Advisory panel review meeting 2/20/2013. No change to policy statement. Reference added.
Ultrasound Accelerated Fracture Healing Device Specialty Matched Consultant Advisory Panel review 2/2013. References updated. No changes to Policy Statements.
Evidence Based Guidelines
Arthroscopic Debridement and Lavage as Treatment of Knee Osteoarthritis Related Policies added to Description section. Updated "When not Recommended" section. References updated. Specialty Matched Consultant Advisory Panel review 2/2013.
Interventions for Progressive Scoliosis References updated. Specialty Matched Consultant Advisory Panel review 2/2013.
Laboratory Testing for HIV Tropism Specialty Matched Consultant Advisory Panel review 2/20/13. No change to Guideline statement.
Prothrombin Time Monitoring in the Home Removed the following statement from the Benefits Application section: "Education or demonstration related to the use of the Prothrombin Time Monitoring is considered incidental to the office visit or the provision of the materials and equipment. Additional reimbursement is not warranted for these services."
Therapeutic Apheresis Specialty Matched Consultant Advisory Panel review meeting 2/20/2013. No change to guideline statement. Reference added.
Vertical Expandable Prosthetic Titanium Rib Specialty Matched Consultant Advisory Panel review 2/2013. No changes to Guideline Recommendations.