Medical Policy Updates

Table Of Contents

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

Medical Guidelines Reason for Update
Accelerated Partial Breast Radiotherapy (Breast Brachytherapy) Updated the Description section. Specialty Matched Consultant Advisory Panel review 5/15/2013. Reference added. No change to policy statement.
Allergy Testing Revised "When Covered" section for Patch Testing as follows: "More comprehensive patch testing (greater than 42 patch tests) may be considered medically necessary when both a.) and b.) are met: a. The patient has persistent allergic contact dermatitis (ACD) after being previously evaluated and treated (including 6 weeks of avoidance of any allergens that were positive on initial patch testing, and use of topical steroid products if appropriate) OR Patient has any of the following: --At least 8 weeks of dermatitis without resolution with treatment, --Has a dermatitis that may be implanted device-related, --Is undergoing pre-testing for medical or dental device placement, --Requires extensive patch testing to determine if persistent dermatitis is allergic contact dermatitis, --Has seen at least one other physician who has requested specialty patch testing; AND b. The dermatitis interferes with the patient's normal activities of daily living, such as occupational or work activities (use of hands), sleep patterns (due to itching), bathing or social interactions." References updated. Medical Director review 6/2013.
Automated Percutaneous and Endoscopic Discectomy Specialty Matched Consultant Advisory Panel review 5/15/2013. Updated Description section. Added 0274T and 0275T back to Billing/Coding section since percutaneous discectomy is a component of these codes. Added "and/or radiculopathy" to both When Not Covered statements for clarification. No change to policy intent. Reference added.
Brachytherapy Treatment of Breast Cancer Updated Description section. Under When Covered section 3rd bullet: added technically clear and removed the word "negative" from the statement ending in surgical margins. Specialty Matched Consultant Advisory panel meeting 5/15/2013. Reference added. No change to policy statement.
Capsaicin (Qutenza®) ICD-10 diagnosis codes added to Billing/Coding section
Chemoembolization of the Hepatic Artery, Transcatheter Approach ICD-10 diagnosis codes added to Billing/Coding section.
Chiropractic Services Updated Billing/Coding section to add 97760 and 97761. Changed the statement under Applicable codes from "Constant Attendance Modalities, 97010-97039, and Therapeutic Procedures, 97110-97542, will be limited to a maximum 4 therapeutic modalities per treatment session, not to exceed one hour (4 units) for the combinations of codes submitted." to "Constant Attendance Modalities (97010-97039), Therapeutic Procedures (97110-97542), Orthotic Management (97760, 97762), and the unlisted Physical Medicine code (97799) will be limited to a maximum 4 therapeutic modalities per treatment session, not to exceed one hour (4 units) for the combinations of codes submitted."
Code Bundling Rules Not Addressed in ClaimCheck® or Correct Coding Initiative Removed code 95941 from Continuous intraoperative neurophysiology monitoring. This section was revised to read: "codes 95940 and G0453 are considered incidental to the surgeon's or anesthesiologist's primary service and not eligible for separate reimbursement when performed and billed by the surgeon or anesthesiologist. Continuous intraoperative neurophysiology monitoring of more than one case simultaneously, or when attention is not directed exclusively to one patient, is not eligible for reimbursement."
Cord Blood as a Source of Stem Cells ICD-10 diagnosis codes added to Billing/Coding section.
Cranial Electrotherapy Stimulation (CES) and Auricular Electrostimulation Specialty Matched Consultant Advisory Panel review 5/15/2013. No change to policy.
Diagnosis and Treatment of Chronic Cerebrospinal Venous Insufficiency in Multiple Sclerosis Specialty Matched Consultant Advisory Panel review 5/15/2013. No change to policy.
DNA Based Testing for Adolescent Idiopathic Scoliosis Deleted unlisted CPT code 81599 and added CPT code 0004M to Billing/Coding section
Dopamine Transporter Imaging with Single Photon Emission Computed Tomography ICD-10 diagnosis codes added to Billing/Coding section.
Durable Medical Equipment (DME) Added HCPCS code K0900 to "Billing/Coding" section for July 1, 2013 code update.
Endovascular Procedures for Intracranial Arterial Disease Specialty Matched Consultant Advisory Panel review 5/15/2013. No change to policy.
Epiretinal Radiation Therapy for Age-Related Macular Degeneration Added investigational indication to When Not Covered section regarding proton beam therapy: "Intraocular proton beam therapy for the treatment of choroidal neovascularization is considered investigational." Updated Policy Guidelines section. Reference added. Medical director review 3/2013. Notification given 4/1/2013 for effective date 7/1/2013.
Gastric Electrical Stimulation ICD-10 diagnosis codes added to Billing/Coding section
Gender Reassignment Surgery ICD-10 diagnosis codes added to Billing/Coding section
Genetic Testing for Helicobacter pylori Treatment Medical Director review. Archive policy.
Growth Factors in Wound Healing Medical Director review. Reference added. Summary statement added. Codes G0460 and P9020 added to Billing/Coding section. No change to policy statement.
Hormone Pellet Implantation for Hormone Replacement Therapy in Women ICD-10 diagnosis codes added to Billing/Coding section.
Image-Guided Minimally Invasive Lumbar Decompression (IG-MLD) for Spinal Stenosis Specialty Matched Consultant Advisory Panel review 5/15/2013. No changes to policy intent. Reference added.
Immune Globulin Therapy Medical Director review. Added "Sural nerve biopsy may be optional in selective cases in which there is no evidence of demyelination on the electrodiagnostic studies" to the Chronic Inflammatory Demyelinating Polyneuropathy (CIDP) section of the Appendix. No change to policy statement.
Infusion Therapy in the Home ICD-10 diagnosis codes added to "Billing/Coding" section.
Intensity Modulated Radiation Therapy (IMRT) of the Abdomen and Pelvis Specialty Matched Consultant Advisory Panel 8/2012 and 5/2013. Extensive revisions made to entire policy. Under "When Covered" section policy statement changed to state that IMRT is considered medically necessary for all anal cancers as well as when dosimetric planning with standard 3-D conformal radiation predicts that the radiation dose to an adjacent organ would result in unacceptable normal tissue toxicity, intensity-modulated radiation therapy (IMRT) may be considered medically necessary for the treatment of cancer of the abdomen and pelvis. Also added #3 a-e under "When Covered" section. Under "When Not Covered" section added a policy statement that IMRT would be considered investigational for all other uses in the abdomen and pelvis. Medical director review 5/2013.
Interspinous Fixation (Fusion) Devices Specialty Matched Consultant Advisory Panel review 5/15/2013. No change to policy
Intradiscal Electrothermal (IDET) Annuloplasty and Percutaneous Intradiscal Radiofrequency Annuloplasty Specialty Matched Consultant Advisory Panel review 5/15/2013. Policy Guidelines updated. No change to policy intent.
Laser Treatment of Onychomycosis New policy developed. Laser treatment of onychomycosis is considered investigational. There is no specific CPT code for this treatment. Medical Director review 6/2013.
Laser Treatment of Port Wine Stains ICD-10 diagnosis code added to "Billing/Coding" section.
Maximum Units of Service Blood glucose test or reagent strips (A4253) is limited to 20 units (boxes) per quarter for patients with insulin dependent diabetes, and 6 units (boxes) per quarter for patients with non-insulin dependent diabetes.
Molecular Markers in Fine Needle Aspirates of the Thyroid ICD-10 diagnosis codes added to Billing/Coding section.
Natalizumab (Tysabri) Specialty Matched Consultant Advisory Panel review 5/15/2013. No change to policy statement. References added.
Non-Pharmacologic Treatment of Rosacea ICD-10 diagnosis codes added to "Billing/Coding" section.
Occipital Nerve Stimulation Specialty Matched Consultant Advisory Panel review 5/15/2013. No change to policy intent. ICD-10 diagnosis codes added to Billing/Coding section.
Ovarian and Internal Iliac Vein Embolization Reference added. Updated Billing/Coding section, adding code 36012. No change to Policy statement. ICD-10 diagnosis codes added to Billing/Coding section.
Radiosurgery, Stereotactic Approach Entire policy extensively revised. Under When Covered section: added policy statement that craniopharyngiomas, glomus jugulare tumors, and spinal or vertebral metastases that are radioresistant are medically necessary indications and fractionation is medically necessary if all indications under When Covered section are met. Under "When Covered" also added B.2. a-d Prostate indications, B.3. a-d Hepatocellular indications and B.6 oligometastases indications. Added CPT codes 77301, 77338, 77295 to Billing/Coding section. Specialty Matched Consultant Advisory Panel meeting 5/15/2013. Added Karnofsky performance status scale (KPS) under Policy Guidelines section. Medical director review 5/2013.
Renal (Kidney) Transplantation Added the following statement to "When Covered" section: "Kidney re-transplant after a failed primary kidney transplant may be considered medically necessary." References updated. Medical Director review 6/2013.
Repository Corticotropin (H.P. Acthar Gel) Specialty Matched Consultant Advisory Panel review 5/15/2013. No change to policy intent. References added.
Rituximab for the Treatment of Rheumatoid Arthritis Added ICD-10 codes to the "Billing/Coding" section.
Sacroiliac Joint Fusion Specialty Matched Consultant Advisory Panel meeting 5/2013. No change to policy intent. Added new July 2013 CPT code, 0334T, to Billing/Coding section. Reference added.
Sequencing Based Tests to Determine Trisomy 21 from Maternal Plasma DNA New policy issued. Nucleic acid sequencing-based testing of maternal plasma for trisomy 21 may be considered medically necessary in women with high-risk singleton pregnancies undergoing screening for trisomy 21. Nucleic acid sequencing-based testing of maternal plasma for trisomy 21 is considered investigational for all other applications. Medical Director review 1/2013.
Spinal Surgery Using Interspinous Distraction Technology Description section and Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 5/15/2013. No change to policy intent.
Surgery for Femoroacetabular Impingement Description section updated. "When Covered" section revised. The statement: "Adult patients should be too young to be considered an appropriate candidate for total hip arthroplasty or other reconstructive hip surgery (e.g., younger than 55 years)" has been deleted. References updated. Medical Director review 6/2013.
Surgery for Morbid Obesity Medical Director review. Removed the following statement from the When Covered section "Morbid obesity (BMI > 35 associated with at least one of the problems listed in A.2. or BMI > 40) has been present for at least the previous two years". Clarified Revision Bariatric Surgery criteria in Section IV. Added "erosion" and "and band slippage that cannot be corrected with manipulation or adjustments" to the statement in IV.A. Added "or dilation proximal to an adjustable gastric band" to IV.B. Deleted "and the patients still meets criteria (BMI) for bariatric surgery" in IV.B. Under the When Not Covered section deleted the following statement; "If it is determined that the surgery for morbid obesity is not medically necessary or investigational, and the gallbladder is removed during the same operative session, the removal of the gallbladder would not be covered.". Clarified General Criteria for Adults and Adolescents in the Policy Guidelines. Statements added to clarify guideline; "Patients with a BMI greater than or equal to 50 kg/m2 need a bariatric procedure to achieve greater weight loss. Thus, use of adjustable gastric banding, which results in less weight loss, should be most useful as one of the procedures used for patients with BMI less than 50 kg/m2. Malabsorptive procedures, although they produce more dramatic weight loss, potentially result in nutritional complications, and the risks and benefits of these procedures must be carefully weighed in light of the treatment goals for each patient." and "Patients who undergo adjustable gastric banding and fail to achieve weight loss must show evidence of post-operative compliance with diet and regular bariatric visits prior to consideration of a second bariatric procedure." Updated the paragraph that begins with the US. Food and Drug Administration (FDA) premarket approval statement for the LAP-Band.
Surgery for Obstructive Sleep Apnea and Upper Airway Resistance Syndrome Medical Director review. References updated. No change to policy statement or coverage criteria.
Systems Pathology for Predicting Risk of Recurrence in Prostate Cancer ICD-10 diagnosis code added to "Billing/Coding" section.
Tinnitus Treatment Reference added. Related Policies added. Policy Guidelines updated. Medical Director review. No change to Policy statement.
Vagus Nerve Stimulation Specialty Matched Consultant Advisory Panel review 5/15/2013. No change to policy statement. ICD-10 diagnosis codes added to Billing/Coding section. References added.
Varicose Veins, Treatment for ICD-10 diagnosis codes added to Billing/Coding section.
Evidence Based Guidelines
Deep Brain Stimulation Specialty Matched Consultant Advisory Panel review 5/15/2013. No changes to guideline.
Hip Resurfacing Corporate Medical Policy changed to Evidence Based Guideline. Medical Director review 6/2013.
Intraoperative Neurophysiologic Monitoring (sensory-evoked potentials, motor-evoked potentials, EEG monitoring) Specialty Matched Consultant Advisory Panel review 5/15/2013. No changes to guideline.
Therapeutic Apheresis Removed "Idiopathic thrombocytopenic purpura; refractory or non-refractory" from the "Not Recommended" section.