Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for April 16, 2013

Medical Guidelines Reason for Update
Adoptive Immunotherapy Specialty Matched Consultant Advisory Panel review 3/20/2013. Description section and Policy Guidelines updated. Added "cytokine-induced killer (CIK) cells" to the When Not Covered section, no change to policy intent. Reference added.
Bone Turnover Markers for the Diagnosis and Management of Osteoporosis and Diseases Associated with High Bone Turnover Specialty Matched Consultant Advisory Panel review 3/20/13. No change to policy statement.
BRAF Gene Mutation Testing to Select Melanoma Patients for BRAF Inhibitor Therapy Specialty Matched Consultant Advisory Panel review 3/20/2013. Regulatory Status added to Description section. No change to policy intent.
Bronchial Thermoplasty Description section updated. Specialty Matched Consultant Advisory panel review meeting 3/20/13. Reference updated. No change to policy statement.
Computer-Aided Evaluation of Malignancy with MRI of the Breast Reference added. No change in policy statement.
Convection-Enhanced Delivery of Therapeutic Agents to the Brain Specialty Matched Consultant Advisory Panel review 3/20/2013. No change to policy. References added.
Cord Blood as a Source of Stem Cells Specialty Matched Consultant Advisory Panel review 3/20/2013. Added CPT code 38243 to Billing/Coding section. No change to policy intent.
Corneal Collagen Cross-linking Reference added. No change to policy statement.
Detection of Circulating Tumor Cells Specialty Matched Consultant Advisory Panel review 3/20/2013. Policy Guidelines updated. No change to policy intent.
Electromagnetic Navigation Bronchoscopy Revised Policy Guidelines section. Specialty Matched Consultant Advisory panel review 3/20/2013. Reference added. No change to policy statement.
Endobronchial Valves Updated Policy Guidelines section. Specialty Matched Consultant Advisory Panel review meeting 3/20/13. References added. No change to policy statement.
Exhaled Nitric Oxide Measurement Specialty Matched Consultant Advisory Panel review meeting 3/20/13. Reference added. No change to policy statement.
Fetal Surgery for Malformations Specialty Matched Consultant Advisory Panel review 3/20/13.
Genetic Testing for Breast and Ovarian Cancer Revised Policy Guidelines in regards to NCCN testing criteria; From "7. Family history only: • Close blood relative meeting any of the above criteria in #2 above" to "7. Family history only: • Close blood relative meeting any of the criteria in #1-6 above."
Home Uterine Activity Monitoring Specialty Matched Consultant Advisory Panel Review 3/20/13. No change to Policy statement.
Hormone Pellet Implantation for Hormone Replacement Therapy in Women References added. Specialty Matched Consultant Advisory Panel review 3/20/13. No change to policy statement.
Hyperthermic Intraperitoneal Chemotherapy Specialty Matched Consultant Advisory Panel review 3/20/2013. No change to policy statement.
Immune Cell Function Assay Specialty Matched Consultant Advisory Panel review 3/20/2013. No change to policy statement.
Intravitreal Implant Reference added. No change to policy statement.
Ipilimumab (Yervoy) Specialty Matched Consultant Advisory Panel review 3/20/2013. No Change to policy.
Lung and Lobar Lung Transplantation Under "When Covered" section added statement: A lobar lung transplant from a living or deceased donor may be considered medically necessary for carefully selected patients with end-stage pulmonary disease including but not limited to one of the conditions listed below-also added emphysema as a condition under this list. Specialty Matched Consultant Advisory panel review meeting 3/20/2013. Reference added. No change to policy statement.
Lung Volume Reduction Surgery Specialty Matched Consultant Advisory panel review meeting 3/20/13. Reference updated. No change to policy statement.
MRI-Guided Focused Ultrasound (MRgFUS) References added. Policy title changed from MRI-Guided High Intensity Ultrasound Ablation of Uterine Fibroids and Other Tumors to MRI-Guided Focused Ultrasound (MRgFUS). Description and Background sections updated to include information on palliative treatment of bony metastases. Regulatory Status section updated to include FDA information from 2012. HCPCS code C9734 added to Billing/Coding section. No change to policy statement.
Neurostimulation, Electrical Description section updated and reformatted. Added "congenital disorders (e.g., cerebral palsy) or" to the third bullet under the When Not Covered section. Updated the Policy Guidelines. Reference added. Senior Medical Director review 4/1/2013.
Non-BRCA Breast Cancer Risk Assessment (OncoVue) Specialty Matched Consultant Advisory Panel review 3/20/2013. No change to policy statement.
Oscillatory Devices for the Treatment of Respiratory Conditions Specialty Matched Consultant Advisory Panel review meeting 3/20/13. Reference added. No change to policy statement.
Ovarian and Internal Iliac Vein Embolization Specialty Matched Consultant Advisory Panel review 3/20/13. No change to Policy statement.
PathFinderTG® Molecular Testing Specialty Matched Consultant Advisory Panel review 3/20/2013. No change to policy statement.
Pulmonary Hypertension, Drug Management Specialty Matched Consultant Advisory panel review meeting 3/20/13. No change to policy statement.
Quantitative Assay for Measurement of HER2 Total Protein Expression and HER2 Dimers Specialty Matched Consultant Advisory Panel review 3/20/2013. No change to policy statement.
Sacroiliac Joint Fusion Added CPT code 27299 to Billing/Coding section.
Salivary Hormone Tests References added. Specialty Matched Consultant Advisory Panel review 3/20/13. No change to policy statement.
Surgical Interruption of Pelvic Nerve Pathways for Dysmenorrhea Policy guidelines updated. No change to Policy Statement. Specialty Matched Consultant Advisory Panel review 3/20/13.
Telemedicine Deleted CPT code 90801 from Billing/Coding section for 2013 coding update.
Evidence Based Guidelines
Diagnosis and Treatment of Sacroiliac Joint Pain References updated. Added "Sacral Joint Fusion" as a related policy.
Donor Lymphocyte Infusion Name changed from Donor Leukocyte Infusion to Donor Lymphocyte Infusion. Added the following statement to the When Not Recommended section; "Donor lymphocyte infusion is not recommended following allogeneic hematopoietic stem-cell transplantation (HSCT) that was originally considered investigational for the treatment of a hematologic malignancy." Specialty Matched Consultant Advisory Panel review 3/20/2013.
Erythropoiesis-Stimulating Agents (ESAs) Specialty Matched Consultant Advisory Panel review 3/20/2013. No change to evidence based guideline.
Intra Articular Hyaluronan Injections for Treatment of Osteoarthritis of the Knee Description section updated. References updated.
KRAS and BRAF Mutation Analysis in Cancer Added the following to the When Not Recommended section regarding KRAS Mutation Analysis in Non-small Cell Lung Cancer (NSCLC); "NCCN guidelines state that KRAS mutations are associated with intrinsic TKI resistance, and KRAS gene sequencing could be useful for the selection of patients as candidates for TKI therapy, but make no specific recommendations." "It remains unclear whether assessment of KRAS mutation status will be clinically useful with regard to anti-epidermal growth factor receptor (EGFR) therapy in the treatment of non-small-cell lung cancer (NSCLC). Data on the role of KRAS mutations in NSCLC and response to erlotinib are available from 2 Phase III trials that conducted non-concurrent subgroup analyses of the efficacy of TKIs in patients with wild-type (non-mutated) versus mutated KRAS lung tumors, Phase II trials, retrospective single-arm studies, and 2 meta-analyses." Senior Medical Director review 4/1/2013. Reference added.
Monitored Anesthesia Care (MAC) Added the last paragraph to the Description section. Changed the second bullet under Evidence Based Guideline from "Morbid obesity (BMI [body mass index] >50)" to "Morbid obesity (BMI [body mass index] >40)". Changed the third bullet from "Severe sleep apnea (oxygen and bi-pap required during sleep)" to "Documented sleep apnea". Changed the eighth bullet from "Patients of extreme age, i.e., younger than 12 years or age 70 years or older" to "Patients of extreme age, i.e., younger than 18 years or age 70 years or older". Senior Medical Director review 4/1/2013.
Pulmonary Rehabilitation Specialty Matched Consultant Advisory Panel review meeting 3/20/13. Reference updated. No change to guideline statement.
Radioimmunotherapy in the Treatment of Non-Hodgkin Lymphoma Specialty Matched Consultant Advisory Panel review 3/20/2013. Description section updated. Revised the following statement in the When Not Recommended section, from "2. The use of tositumomab (Bexxar®) or ibritumomab tiuxetan (Zevalin®) for consolidation after chemotherapy or as part of a preparatory regimen prior to hematopoietic stem-cell transplantation is not recommended." to "2. The use of tositumomab (Bexxar®) or ibritumomab tiuxetan (Zevalin®) as part of a preparatory regimen prior to autologous or allogeneic hematopoietic stem-cell transplantation in patients with non-Hodgkin lymphoma is not recommended. Added the following statement, "3. Radioimmunotherapy with tositumomab or ibritumomab tiuxetan for consolidation of a first remission following chemotherapy for de novo aggressive B-cell NHL is not recommended." Reference added.
Trastuzumab Specialty Matched Consultant Advisory Panel review 3/20/2013. Added "esophageal (except as noted above), gastric (except as noted above)" to the When Not Recommended statement.