Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for April 30, 2013

Medical Guidelines Reason for Update
Allogeneic Hematopoietic Transplant for Genetic Diseases and Acquired Anemia Specialty Matched Consultant Advisory Panel review 4/17/2013. Removed the last statement under Policy Guidelines that indicated "as outlined in the clinical trial section under each disease type." No other changes to policy.
Allogeneic Stem-Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms Specialty Matched Consultant Advisory Panel review 4/17/2013. No change to policy.
Ambulatory Event Monitors Specialty Matched Consultant Advisory panel review 4/2013. Medical Director review 4/2013. No changes to Policy Statements.
Baroreflex Stimulation Devices Specialty Matched Consultant Advisory Panel review 4/2013. Medical Director review 4/2013. No changes to Policy Statement.
Capsule Endoscopy, Wireless Specialty Matched Consultant Advisory Panel review 4/17/13.
Computerized 2-Lead Resting Electrocardiogram (Multifunction Cardiogram) Specialty Matched Consultant Advisory Panel review 4/2013. Policy Guidelines updated. Medical Director review. No changes to Policy Statements.
Enhanced External Counterpulsation (EECP) Specialty Matched Consultant Advisory Panel review 4/2013. Description section updated. References updated. Medical Director review 4/2013.
Esophageal pH Monitoring Specialty Matched Consultant Advisory Panel review 4/17/13. No change to policy statement.
Extracorporeal Photopheresis Name changed from "Extracorporeal Photopheresis after Solid Organ Transplant and for Graft versus Host Disease, Autoimmune Disease, and Cutaneous T-Cell Lymphoma" to "Extracorporeal Photopheresis". Description section revised to add information regarding Peripheral T-Cell Lymphoma (PTCL). Added the following statement to the When Not Covered section; "Other - Extracorporeal photopheresis is considered investigational for all other indications." Senior Medical Director review 4/4/2013. Reference added.
Fecal Pancreatic Elastase-1 Test Medical Director review. Archive policy.
Gastric Electrical Stimulation Specialty Matched Consultant Advisory Panel review 4/17/13. No change to policy statement or criteria.
Gene Expression Testing to Predict Coronary Artery Disease Specialty Matched Consultant Advisory Panel review 4/2013. Medical Director review 4/2013. References updated. No changes to Policy Statements.
Genetic Testing for Long QT Syndrome Specialty Matched Consultant Advisory Panel review 4/2013. No changes to Policy Statements.
Genetic Testing for Tamoxifen Treatment Specialty Matched Consultant Advisory Panel review 4/17/2013. Minor changes to Description section. No change to policy intent.
Hematopoietic Stem-Cell Transplantation for Breast Cancer Specialty Matched Consultant Advisory Panel review 4/17/2013. No change to policy.
Hematopoietic Stem-Cell Transplantation for Acute Lymphoblastic Leukemia Specialty Matched Consultant Advisory Panel review 4/17/2013. Removed the word "support" from #2 under Children in the When Covered section. No change to policy intent.
Autologous Hematopoietic Stem-Cell Transplantation for Malignant Astrocytomas and Gliomas Specialty Matched Consultant Advisory Panel review 4/17/2013. No change to policy.
Hematopoietic Stem-Cell Transplantation for Acute Myeloid Leukemia Specialty Matched Consultant Advisory Panel review 4/17/2013. Policy Guidelines updated. No change to policy intent.
In Vitro Chemoresistance and Chemosensitivity Assays Specialty Matched Consultant Advisory Panel review 4/17/2013. No change to policy.
Intravascular Ultrasound Imaging (IVUS) and Intracoronary Doppler Ultrasonography Specialty Matched Consultant Advisory Panel review 4/2013. No changes to Policy Statements.
KIF6 Genotyping for Predicting Cardiovascular Risk and/or Effectiveness of Statin Therapy Specialty Matched Consultant Advisory Panel review 4/2013. CPT code 81599 deleted from Billing/Coding section. Policy Guidelines updated. References updated. No changes to Policy Statements.
Laboratory Tests for Heart Transplant Rejection References updated. Specialty Matched Consultant Advisory Panel review 4/2013. No changes to Policy Statements.
Melanoma Vaccines Specialty Matched Consultant Advisory Panel review 4/17/2013. Policy Guidelines updated. No change to policy statement.
Monoclonal Antibody Imaging for Prostate Cancer Specialty Matched Consultant Advisory Panel review 4/17/2013. No change to policy.
Multigene Expression Assay for Predicting Recurrence in Colon Cancer Specialty Matched Consultant Advisory Panel review 4/17/2013. No change to policy.
Optical Coherence Topography Specialty Matched Consultant Advisory Panel review 4/2013. References updated. No changes to Policy Statements.
Pancreas Transplant Reference added. Specialty Matched Consultant Advisory Panel review 4/17/13. No change to policy statement.
Small Bowel, Small Bowel with Liver, or Multivisceral Transplant References added. Added Small Bowel Specific information to Policy Guidelines. Specialty Matched Consultant Advisory Panel review 4/17/13. No change to Policy Statement.
Evidence Based Guidelines
Automated Nerve Conduction Tests Corporate Medical Policy converted to Evidence Based Guideline. "Automated nerve conduction tests are not recommended."
BCR-ABL1 Testing for Diagnosis, Monitoring, and Drug Resistance Mutation Detection in Chronic Myelogenous Leukemia Evidence based guideline adopted. BCR/ABL1 qualitative testing for the presence of the fusion gene may be appropriate for diagnosis of chronic myeloid leukemia. BCR/ABL1 testing for messenger RNA transcript levels by quantitative real-time reverse transcription-polymerase chain reaction at baseline prior to initiation of treatment and at appropriate intervals during therapy may be appropriate for monitoring of chronic myeloid leukemia treatment response and remission. Evaluation of ABL kinase domain point mutations to evaluate patients for tyrosine kinase inhibitor resistance may be appropriate when there is inadequate initial response to treatment or any sign of loss of response; and/or when there is progression of the disease to the accelerated or blast phase. Evaluation of ABL kinase domain point mutations is not recommended for monitoring in advance of signs of treatment failure or disease progression. Senior Medical Director review 4/4/2013.
Bone Turnover Markers for the Diagnosis and Management of Osteoporosis and Diseases Associated with High Bone Corporate Medical Policy converted to Evidence Based Guideline. "Measurement of bone turnover markers in the diagnosis and management of osteoporosis is not recommended. Measurement of bone turnover markers in the management of patients with conditions associated with high rates of bone turnover, including but not limited to Paget's disease, primary hyperparathyroidism and renal osteodystrophy is not recommended".
Cardiac Rehabilitation Specialty Matched Consultant Advisory Panel review 4/2013. References updated. Medical Director review. No changes to Policy Statements.
Endovascular Stent Grafts for Abdominal Aortic Aneurysm Medical Policy changed to Evidence Based Guideline. References updated.
Endovascular Stent Grafts for Thoracic Aortic Aneurysm Medical Policy changed to Evidence Based Guideline.
Fecal Calprotectin Test Corporate Medical Policy converted to Evidence Based Guideline. "Testing for fecal calprotectin is not recommended in the diagnosis and management of intestinal conditions, including the diagnosis and management of inflammatory bowel disease."
Intravitreal Angiogenesis Inhibitors for Choroidal and Retinal Vascular Conditions Revised description section. Under When Recommended/may be appropriate section for retinal vascular conditions, added the following indications: injection of ranibizumab or bevacizumab may be appropriate for treatment of neovascular glaucoma and rubeosis; injection of bevacizumab may be appropriate for treatment of retinopathy of prematurity for any stage (removed 3+ requirement); injection of aflibercept may be appropriate for treatment of macular edema following central retinal vein occlusion. Reference added.
Paraspinal Surface Electromyography Corporate Medical Policy converted to Evidence Based Guideline. "Paraspinal surface electromyography (SEMG) is not recommended as a technique to diagnose or monitor back pain."
Pharmacogenomic and Metabolite Markers for Treatment with Thiopurines Removed genetic testing modifier 9A from Billing/Coding section. Specialty Matched Consultant Advisory Panel review 4/17/13. No change to Guideline statement.
Quantitative Sensory Testing Corporate Medical Policy converted to Evidence Based Guideline. "Quantitative sensory testing, including but not limited to current perception threshold testing, pressure-specified sensory device testing, vibration perception threshold testing, and thermal threshold testing is not recommended."
Serum Biomarker Human Epididymis Protein 4 (HE4) Specialty Matched Consultant Advisory Panel review 4/17/2013. Description section revised. The Evidence Based Guideline section updated to indicate; "There is no established cut-off for determining when an HE4 test is positive, when used for identifying disease progression or recurrence. Moreover, a survival advantage of early detection of ovarian cancer recurrence using HE4 levels or other biomarkers has not been established. No published studies were identified evaluating use of the HE4 test to screen asymptomatic women for ovarian cancer."
Thermography Medical Director review. Corporate Medical Policy converted to Evidence Based Guideline. "The use of thermography is not recommended for all indications."