Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for May 14, 2013

Medical Guidelines Reason for Update
Allergy Immunotherapy (Desensitization) References updated. No changes to Policy Statements.
Assays of Genetic Expression to Determine Prognosis of Breast Cancer Specialty Matched Consultant Advisory Panel review March 30, 2013. Removed the following statement from the Policy Guidelines section; "Unfavorable features that may prompt testing in tumors greater than 0.5 cm in size include the following: angiolymphatic invasion, high histologic grade, or high nuclear grade."
Balloon Sinuplasty for Treatment of Chronic Sinusitis Billing/Coding section updated to include the following statement: "Balloon sinuplasty (codes 31295, 31296, 31297) performed in conjunction with functional endoscopic sinus surgery (FESS) is considered incidental to the major service and not eligible for separate reimbursement." The following statements were removed from the Billing/Coding section: "Beginning in 2011, there are specific CPT codes for Balloon Sinuplasty. These codes may be used to describe balloon sinuplasty when no other surgical intervention has been performed on the same sinus site. Prior to 2011, this procedure might be coded as an unlisted sinus procedure, 31299, and could be submitted alone or along with other nasal/sinus endoscopy codes. If balloon sinuplasty is performed in conjunction with cutting tools such as curettes and forceps, the procedure might be coded using the CPT codes 31256, 31276 or 31287. In this instance, the balloon dilation would be considered inclusive/incidental to the procedure."
Bundling Guidelines Added the following to Topics of Frequent Interest: "Balloon Sinuplasty - Balloon sinuplasty (codes 31295, 31296, 31297) performed in conjunction with FESS is considered incidental to the major service and not eligible for separate reimbursement. Refer to policy "Balloon Sinuplasty for Treatment of Chronic Sinusitis."
Cardiovascular Disease Risk Tests Specialty Matched Consultant Advisory Panel review 4/2013. This policy now consolidates the following policies: "Lipoprotein-associated Phospholipase A2", "Genotyping for 9p21 Genetic Polymorphisms to Predict Cardiovascular Disease Risk", "Genetic Testing for Lipoprotein (a) as a Decision Aid for Aspirin Treatment", and "KIF6 Genotyping for Predicting Cardiovascular Risk and/or Effectiveness of Statin Therapy." Added information regarding Measurement of lipoprotein-associated phospholipase A2 (Lp-PLA2), genotyping for 9p21 SNPs, testing for rs3798220 allele and KIF6 Trp719Arg variant to Description and Policy Guidelines. Added the following statements to the "When not Covered" section: "Measurement of lipoprotein-associated phospholipase A2 (Lp-PLA2)in the assessment of cardiovascular risk is considered investigational."; "The use of genotyping for 9p21 single nucleotide polymorphisms is considered investigational, including but not limited to, identification of patients who may be at increased risk of cardiovascular disease or its manifestations (e.g., MI, ischemic stroke, peripheral arterial disease, coronary artery calcification), or identification of patients who may be at increased risk for aneurysmal disease (abdominal aortic aneurysms, intracranial aneurysms, polypoidal choroidal vasculopathy)."; "The use of genetic testing for the rs3798220 allele (LPA-Aspirin Check®) is considered investigational in patients who are being considered for treatment with aspirin to reduce risk of cardiovascular events."; "KIF6 Genotyping is considered investigational for predicting cardiovascular risk and/or the effectiveness of statin therapy." Added CPT codes 83698 and 81479 to Billing/Coding section. References updated. Medical Director review 5/2013.
Chiropractic Services Changed the following statement in the When Not Covered section from: "Paraspinal surface electromyography is discussed under a separate policy. See BCBSNC medical policy entitled Paraspinal Surface Electromyography" to "Paraspinal surface electromyography is discussed under a separate evidence based guideline. See BCBSNC evidence based guideline entitled Paraspinal Surface Electromyography".
Continuous Monitoring of Glucose in the Interstitial Fluid Reference added. Policy statement added that artificial pancreases are considered investigational. Senior Medical Director review.
Electrodiagnostic Studies Changed "Related Policies" to "Related Evidence Based Guidelines" in the Description section. Removed the following from the When Not Covered section: "Surface Electromyography (SEMG). [See BCBSNC policy entitled, Paraspinal Surface Electromyography (EMG)]. Quantitative Sensory Tests, and Automated Nerve Conduction Tests."
Epithelial Cell Cytology and Breast Cancer Risk Assessment Medical Director review. Archive policy.
External Defibrillators References updated. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 4/2013. Medical Director review 4/2013.
Gene-Based Tests for Screening, Detection, and/or Management of Prostate Cancer Added the following to the description section; "There are a variety of gene-based biomarkers that have been associated with prostate cancer. These tests have the potential to improve the accuracy of risk prediction, diagnosis, staging, or prognosis of prostate cancer." Reference added.
Genetic Testing for Lipoprotein (a) as a Decision Aid for Aspirin Treatment Information regarding genetic testing for the rs3798220 allele (LPA-Aspirin Check®)has been incorporated into the policy titled, "Cardiovascular Disease Risk Tests." Medical Director review 5/2013. Policy archived.
Genotyping for 9p21 Genetic Polymorphisms to Predict Cardiovascular Disease Risk Information regarding genetic testing for Genotyping for 9p21 single nucleotide polymorphisms has been incorporated into the policy titled, "Cardiovascular Disease Risk Tests." Medical Director review. Policy archived.
Ingestible pH and Pressure Capsule Reference added. Related policies added. Senior Medical Director review. No change to policy statement.
Intradialytic Parenteral Nutrition Specialty Matched Consultant Advisory panel review 4/2013. Medical Director review 3/2013. References updated. "When Covered" section revised as follows: "Intradialytic parenteral nutrition may be considered medically necessary when the following criteria are met: A) The patient is currenly receiving dialysis for End Stage Renal Disease AND 1) The patient has an albumin less than 3.2 g/dl and a Prealbumin less than 30 mg/dl AND 2) The patient has an adequate dialysis prescription (single pool KT/V of at least 1.25) and their acidosis has been corrected (serum tC02 of greater than or equal to 22 mmol/l). AND 3)The patient cannot tolerate full nutrition with an oral supplement, but can comsume at least 50% of their necessary caloric and protein intake (diabetic gastroparesis) OR 4)The patient has failed or is unable to tolerate adequate nasogastic tube feedings or PEG tube feedings with enteral nutritional supplements. B) After an intial 3 month trial, continued therapy will depend on the demonstration of a significant rise in the Pre Ablumin level to greater than 30mg/dl and continued documented compliance with critera 2-4 above. C) Approval will only be for 9 months after the intial trial." "When not Covered" section revised to state: "Intradialytic parenteral nutrition is considered not medically necessary when offered in addition to regularly scheduled infusions of TPN. Intradialytic parenteral nutrition is considered not medically necessary in patients who are suffering from an Acute Kidney Injury and are not felt to have End Stage Renal Disease. In patients who cannot tolerate any oral/ enteral feedings, TPN is the appropriate therapy and IDPN is considered investigational as a single therapy." Policy Guidelines updated.
KIF6 Genotyping for Predicting Cardiovascular Risk and/or Effectiveness of Statin Therapy Information regarding genetic testing to determine the KIF6 Trp719Arg variant status has been incorporated into the policy titled, "Cardiovascular Disease Risk Tests." Medical Director review. Policy archived.
Lipoprotein-associated Phospholipase A2 Information regarding measurement of lipoprotein-associated phospholipase A2 (Lp-PLA2) in the assessment of cardiovascular risk has been incorporated into the policy titled, "Cardiovascular Disease Risk Tests." Medical Director review. Policy archived.
Meniscal Allografts and Other Meniscal Implants Policy re-titled from "Meniscal Allografts and Collagen Meniscus Implants" to Meniscal Allografts and Other Meniscal Implants." References updated. Description section and Policy Guidelines updated. Policy statement and "When not Covered" statement revised to state: "Use of other meniscal implants incorporating materials such as collagen and polyurethane are considered investigational. BCBSNC does not cover investigational services." Medical Director review 4/2013.
Microprocessor-Controlled Prostheses for the Lower Limb Description section updated. References updated. No changes to Policy Statements.
Noninvasive Respiratory Assist Devices Medical Director review.
Optical Coherence Tomography for Imaging of Coronary Arteries Policy title changed from "Optical Coherence Topography" to "Optical Coherence Tomography for Imaging of Coronary Arteries" No changes to policy statement.
Orthotics Specialty Matched Consultant Advisory Panel review. Medical Director review. References updated. Policy Guidelines updated. Deleted code E1824 and added E1801 to Billing/Coding section. Removed references to JAS splints as spring-loaded devices. Added product information for Low - load Prolonged - duration Stretch/Spring-loaded Devices, Static Progressive Stretch Devices and Patient-actuated Serial Stretch (PASS) Devices in the Description section and the Policy Guidelines section. Added the following statements to the "When Covered" section: "Static progressive stretch devices are eligible for coverage when the patient is not responding favorably to conventional methods for restoring joint motion such as exercise and/or physical therapy. Continued coverage for orthotic devices is eligible when significant measurable improvement in joint range of motion is being made while using the device, but not to exceed three months (see "When Not Covered" section below.)" Revised the following statements to the "When not Covered"section: "2.Spring-loaded orthotics and static progressive stretch devices are not covered when conventional methods of treating a stiff or contracted joint have not been attempted. 3. Spring-loaded orthotics and static progressive stretch devices are not covered for longer than 3 months of use."
Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention Description section updated. Policy Guidelines updated. References updated. No changes to Policy Statement.
Radiofrequency Ablation of the Renal Nerves as a Treatment of Hypertension Specialty Matched Consultant Advisory Panel review 4/2013. Medical Director review 3/2012. New product information added to Description section. References updated.
Renal (Kidney) Transplantation Specialty Matched Consultant Advisory Panel review 4/2013. Medical Director review 3/2013. References updated. Added the following statement to the "When not Covered" section: "Coverage is not provided if the procedure is expected to be futile due to co-morbid disease or if post-transplantation care is expected to significantly worsen co-morbid conditions."
Systems Pathology for Predicting Risk of Recurrence in Prostate Cancer References updated. No changes to Policy Statements.
Laboratory Testing to Allow Area Under the Curve (AUC) Targeted 5-Fluorouracil (5-FU) Dosing for Patients Administered 5-FU for Cancer Reference added.
Urinary Tumor Markers for Bladder Cancer Description section updated. References updated. No changes to Policy Statements.
Varicose Veins, Treatment for Senior Medical Director review. Information on endovenous mechanochemical ablation added to policy. Reference added. No change to policy intent.
Evidence Based Guidelines
Ambulatory Blood Pressure Monitoring Specialty Matched Consultant Advisory Panel review 4/2013. References updated. Medical Director review 3/2013. The following statement added to the "Not Recommended" section: "Use of ambulatory blood pressure monitoring is not recommended in patients who have not tried conventional intermittent home blood pressure monitoring to evaluate for the above conditions." The "When Recommended" section updated as follows: "Automated ambulatory blood pressure monitoring over a 24-hour period is recommended: To differentiate between 'white coat' hypertension and true hypertension; To rule out suspected Episodic Hypertension (eg. Pheochromocytoma); To monitor for hypertension resistant to increasing medications; To monitor for hypotensive symptoms while taking antihypertensive medications; To monitor for autonomic dysfunction; To evaluate whether antihypertensive therapy is moderating the early morning Blood pressure surge.
Apnea Monitor for Use in the Home Evidence Based Guideline returned to Active review. Reference added. CPT codes 94772, 94774, 94775, 94776, 94777 added to Billing/Coding Section. "Home cardiorespiratory monitoring (pneumogram) is not recommended in infants with any siblings with a history of sudden infant death syndrome (SIDS), but without at least one of the indications cited" and "Home cardiorespiratory monitoring (pneumogram) in all other conditions, including but not limited to the diagnosis of obstructive sleep apnea, is not recommended" added to Medical Evidence Section. Senior Medical Director review.
Genetic Testing for Duchenne and Becker Muscular Dystrophy New Evidence Based Guideline developed. Genetic testing for DMD gene mutations is recommended under the following conditions: 1.In a male with signs and symptoms of a dystrophinopathy in order to confirm the diagnosis and direct treatment. 2.For at-risk female relatives: a. To confirm or exclude the need for cardiac surveillance, b. For preconception testing to determine the likelihood of an affected offspring in a woman considering a pregnancy. Medical Director review 4/2013.
Low Density Lipid Apheresis New Evidence Based Guideline developed to separate information regarding low density lipid apheresis from the "Therapeutic Apheresis" Evidence Based Guideline. LDL apheresis may be appropriate in patients with homozygous familial hypercholesterolemia as an alternative to plasmapheresis. LDL apheresis may be appropriate in patients with heterozygous familial hypercholesterolemia who have failed a 6-month trial of diet therapy and maximum tolerated combination drug therapy AND who meet the following FDA approved indications: (All LDL levels represent the best achievable LDL level after a program of diet and drug therapy.) 1. Functional hypercholesterolemic heterozygotes with LDL > 300 mg/dL 2. Functional hypercholesterolemic heterozygotes with LDL > 200 mg/dL AND documented coronary artery disease. LDL apheresis is not recommended for all other uses, including use in preeclampsia. Medical Director review 3/2013. Specialty Matched Consultant Advisory Panel review 4/2013.
Monoclonal Antibodies for Non-Hodgkin Lymphoma, including Chronic Lymphocytic, & Acute Myeloid Leukemia In the Non-Hematopoietic Stem Cell Transplant Setting Specialty Matched Consultant Advisory Panel review 4/17/2013. Added the following statement to the Description section; "Labeling indications for alemtuzumab are as monotherapy for the treatment of CLL." Added "and previously treated" to 1.e. under Evidence Based Guideline section.
Pertuzumab for Treatment of HER2-Positive Malignancies Specialty Matched Consultant Panel review 4/17/2013. Changed Table 1, Positive Results from "Ratio of HER2 /CEP17 is >2.2." to "Ratio of HER2 /CEP17 is > or equal to 2.0".
Therapeutic Apheresis Specialty Matched Consultant Advisory Panel review 4/2013. Medical Director review 3/2013. References updated. Removed information regarding LDL apheresis. Added reference to new Evidence Based Guideline titled "Low Density Lipid Apheresis." Revised the "Recommended" section to include following items: Idiopathic thrombocytopenic purpura (ITP); Thrombotic thrombocytopenic purpura (TTP).