Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for April 1, 2013

Medical Guidelines Reason for Update
Composite Allotransplantation of the Hand and Face New policy developed. Composite allotransplantation of the hand and/or face is investigational. Medical Director review 3/2013.
Cough Stimulating Device Specialty Matched Consultant Advisory panel review meeting 3/20/13. No change to policy statement. Policy archived. Reviewed by medical director 3/2013.
Electroencephalograms Senior Medical Director review 3/27/13. Archive policy.
Extracorporeal Shock Wave Treatment for Musculoskeletal Conditions and Wound Healing References updated. Policy Guidelines updated. No changes to Policy Statement.
Gait Analysis Reference added. No change to policy statement.
Hematopoietic Stem-Cell Transplantation for Waldenstrom Macroglobulinemia Reference added.
Hematopoietic Stem-Cell Transplantation for Primary Amyloidosis Reference added
Hematopoietic Stem-Cell Transplant for Non-Hodgkin Lymphomas Reference added.
Immunization Guidelines ZOSTAVAX® (Zoster Vaccine Live), has FDA approval for use in prevention of herpes zoster (shingles) in individuals 50 years of age and older.
Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence Policy re-titled from "Periurethral Bulking Agents for Treatment of Urinary Incontinence" to "Injectable Bulking for the Treatment of Urinary and Fecal Incontinence." Description section extensively revised. New Policy Statement as follows: "The use of perianal bulking agents to treat fecal incontinence is considered investigational. BCBSNC does not provide coverage for investigational services or procedures." Added new code C9735 to Billing/Coding section. References updated. Policy Guidelines updated. Medical Director review 3/2013.
JAK2 and MPL Mutations in Myeloproliferative Neoplasms Reference added.
Keratoprosthesis References updated. No changes to policy statements.
Light Therapy for Dermatologic Conditions References updated.
Microwave Tumor Ablation Reference added.
Monoclonal Antibody Imaging for Prostate Cancer Reference added.
Multianalyte Assays for Predicting Risk of Type 2 Diabetes New policy developed. The use of multianalyte panels with algorithmic analysis (MAAA) for the prediction of type 2 diabetes is considered investigational. Medical Director review 3/2013.
Optical Coherence Tomography (OCT) Anterior Segment of the Eye Reference added. No change to policy statement.
Proteomics-based Testing for the Evaluation of Ovarian (Adnexal) Masses Description section and Policy Guidelines section updated. Policy statement changed to investigational for all indications. New coding information added to Billing/Coding section. Reviewed by Senior Medical Director 12/19/12. Notification given 01/01/13. Policy effective 4/1/13.
Radiofrequency Tissue Remodeling for Urinary Stress Incontinence References updated. Medical Director review. Policy archived.
Retinal Prosthesis Revised Description section and Policy Guidelines section. Reference added. No change to policy statement. Medical director review 3/2013.
Sexual Dysfunction Treatment, Female Medical Director review. Policy archived.
Suprachoroidal Delivery of Pharmacologic Agents Reference added. No change to policy statement.
Urinary Tumor Markers for Bladder Cancer Specialty Matched Consultant Advisory Panel review 12/2012. Removed the following statement from the "When not Covered" section: "Urinary bladder tumor markers are considered investigational for screening for bladder cancer in asymptomatic patients." Revised statement in the "When Covered" section: "The following urinary bladder tumor markers may be considered medically necessary as an adjunct in the diagnosis of bladder cancer only in conjunction with current standard diagnostic procedures for patients who have an atypical or equivocal cytology..." Revised headers in "When Covered" from "Bladder cancer monitoring" to "Bladder cancer surveillance" and "Initial Diagnosis" to "Initial Evaluation." Medical Director review 3/2013.
Varicose Veins, Treatment for Added diagnosis codes 454.0 - 454.9 to Billing/Coding section.
Evidence Based Guidelines
Genetic Testing for PTEN Hamartoma Tumor Syndrome New Evidence Based Guideline developed. Genetic testing for a PTEN mutation is recommended to confirm the diagnosis when a patient has clinical signs of a PTEN hamartoma tumor syndrome. Genetic testing for a PTEN mutation is recommended in a first -degree relative of a proband with a known PTEN mutation. Genetic testing for a PTEN mutation is not recommended for all other indications, including, but not limited to, prenatal testing. Medical Director review 3/2013.
Glaucoma, Evaluation by Ophthalmologic Techniques References updated. Added Regulatory Status to description section. No change to guideline statement.
Transpupillary Thermotherapy for Treatment of Choroidal Neovascular Conditions Medical policy retitled "Transpupillary Thermotherapy for Treatment of Choroidal Neovascular Conditions." Description section revised. Added the phrase "secondary to ocular conditions,including but not limited to age-related macular degeneration" to the current statement in "Not Recommended" section. Reference added. Medical director review 3/2013.
Ventricular Assist Devices and Total Artificial Hearts Description section updated. "When Recommended" section revised to state: "Ventricular assist devices with FDA approval or clearance, including humanitarian device exemptions, are recommended as a bridge to heart transplantation in children 16 years old or younger who are currently listed as heart transplantation candidates and not expected to survive until a donor heart can be obtained, or are undergoing evaluation to determine candidacy for heart transplantation." Deleted Q0505 and added Q0507, Q0508, and Q0509 to Billing/Coding section. References updated. Medical Director review 3/2013.