Medical Policy Updates

Table Of Contents

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

Medical Guidelines Reason for Update
Aqueous Shunts and Devices for Glaucoma Specialty Matched consultant advisory panel review 6/19/2013. No changes to policy statement.
Cardiac (Heart) Transplantation Specialty Matched Consultant Advisory Panel review 6/2013. Medical Director review 6/2013. References updated.
Carotid Artery Angioplasty/Stenting (CAS) Description section updated. References updated. Specialty Matched Consultant Advisory Panel review 6/2013. Medical Director review 6/2013.
Catheter Ablation of the Pulmonary Veins as a Treatment for Atrial Fibrillation Specialty Matched Consultant Advisory Panel review 6/2013. Medical Director review 6/2013. References updated. Description section updated. Policy Guidelines updated.
Congenital Heart Defect, Repair Devices Specialty Matched Consultant Advisory Panel review 6/2013. Medical Director review 6/2013. References updated.
Corneal Collagen Cross-linking Specialty matched consultant advisory panel review 6/19/2013. No change to policy statement.
Corneal Topography Specialty Matched consultant advisory panel review 6/19/13. No change to policy statement. Reference added.
Denosumab (ProliaTM, XGEVATM) Medical Director review. References updated. Added the following clinical indication to the "When Covered" section: "Xgeva may be considered medically necessary for treatment of adults and skeletally mature adolescents with giant cell tumor of bone that is unresectable or where surgical resection is likely to result in severe morbidity."
Dental, Reconstructive Services Under "Policy Guidelines" section: IV. 3rd bullet Dentigerous, added (intrabony <= 2.5cm); and 4th bullet was deleted (Keratocystic Odontogenic tumor (Odontogenic keratocysts). Under "When Covered" section: II. B. 8 deleted non-keratocystic and kept keratocystic, then added "or other" to the statement. Also deleted (non-odontogenic keratocysts). Under "When Covered" section: II. A. added "for reasons other than for preparation for dentures" to the statement. Medical director review 6/27/13.
Detection of Circulating Tumor Cells Description section revised. Reference added.
Diagnosis and Treatment of Chronic Cerebrospinal Venous Insufficiency in Multiple Sclerosis ICD-10 diagnosis code added to "Billing/Coding" section.
Endothelial Keratoplasty Updated Policy Guidelines section. Specialty Matched consultant review panel 6/19/2013. No change to policy statement.
Fundus Photography Specialty matched consultant advisory panel review 6/19/2013. No change to policy statement.
Heart-Lung Transplantation Specialty Matched Consultant Advisory Panel review 6/2013. Medical Director review 6/2013. References updated.
Hematopoietic Stem-Cell Transplantation for Acute Lymphoblastic Leukemia "Allogeneic HSCT is considered medically necessary to treat relapsing ALL after a prior autologous HSCT." added to the When Covered section for both children and adults. Reference added.
Hyperhidrosis, Treatment of Added the follow treatment for Palmer Hyperhidrosis under the "When not Covered" section: "Radiofrequency Ablation." References updated. Policy Guidelines updated. Medical Director review 6/2013.
Implantable Cardioverter Defibrillator Specialty Matched Consultant Advisory Panel 6/2013. Medical Director review 6/2013.
Implantation of Intrastromal Corneal Ring Segments Specialty Matched consultant advisory panel review 6/19/2013. No change to policy statement.
Intravitreal Implant Specialty matched consultant advisory panel review 6/19/2013. No change to policy statement.
Keratoprosthesis Specialty matched consultant advisory panel review 6/19/2013. No change to policy statement.
Lumbar Spine Fusion Surgery Specialty Matched Consultant Advisory Panel review 5/15/2013. No change to policy. References added.
Melanoma Vaccines Policy Guidelines updated. Reference added.
Optical Coherence Tomography (OCT) Anterior Segment of the Eye Specialty matched consultant advisory panel review meeting 6/19/2013. No change to policy statement. Reference added.
PathFinderTG® Molecular Testing Reference added.
Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention Specialty Matched Consultant Advisory Panel review 6/2012. References updated. Description section and Policy Guidelines updated.
Posterior Tibial Nerve Stimulation for Voiding Dysfunction Policy Guidelines updated. References updated. Medical Director review 6/2013.
Refractive Surgery Specialty Matched Consultant Advisory panel review meeting 6/19/2013. No change to policy statement.
Retinal Prosthesis Specialty Matched consultant advisory panel review 6/19/2013. No change to policy statement.
Suprachoroidal Delivery of Pharmacologic Agents Under Description section: corrected diabetic retinopathy from diabetic neuropathy in second paragraph. Updated policy guidelines. Specialty Matched Consultant Advisory panel review 6/19/2013. No change to policy statement. Reference added.
Surgical Deactivation of Migraine Headache Trigger Sites Specialty Matched Consultant Advisory Panel review 5/15/2013. No change to policy.
Surgical Ventricular Restoration Specialty Matched Consultant Advisory Panel review 6/2013. Medical Director review. Description section updated. References updated.
Transcatheter Closure of Ventricular Septal Defects References updated. Specialty Matched Consultant Advisory Panel review 6/2013. Medical Director review 6/2013.
Transcatheter Heart Valve Implantation Specialty Matched Consultant Advisory Panel review 6/2013. Medical Director review 6/2013.
Ustekinumab (Stelara®) Added the following statement to the Policy Guidelines section: "After proper training in subcutaneous injection technique, a patient may self inject with STELARA® if a physician determines that it is appropriate. The first self-injection should be performed under the supervision of a qualified healthcare professional. If a patient or caregiver is to administer STELARA®, he/she should be instructed in injection techniques and their ability to inject subcutaneously should be assessed to ensure the proper administration of STELARA®. Refer to the FDA Medication Guide for Stelara® at http://www.accessdata.fda.gov/drugsatfda_docs/label/2013/125261s086lbl.pdf" References updated. Medical Director review 6/2013.
Viscocanalostomy and Canaloplasty Specialty Matched Consultant Advisory panel review 6/19/2013. No change to policy statement.
Evidence Based Guidelines
Ado-Trastuzumab Emtansine (Trastuzumab-DM1) for Treatment of HER-2 Positive Malignancies Added new HCPCS code, C9131, to Billing/Coding section.
Biventricular Pacemakers/Cardiac Resynchronization Therapy for Heart Failure New statement added to the "Not Recommended" section as follows: "Triple-site (triventricular) CRT, using an additional pacing lead, is not recommended." References updated. Description section updated. Medical Director review 6/2013. Specialty Matched Consultant Advisory Panel review 6/2013.
Diabetic Retinopathy Telescreening Specialty Matched Consultant Advisory Panel review 6/19/2013. No change to guideline statement.
Diagnosis and Treatment of Sacroiliac Joint Pain Specialty Matched Consultant Advisory Panel review 5/15/2013. No change to guideline.
Donor Lymphocyte Infusion Reference added.
Endovascular Stent Grafts for Abdominal Aortic Aneurysm Specialty Matched Consultant Advisory Panel review 6/2013. Medical Director review 6/2013.
Endovascular Stent Grafts for Thoracic Aortic Aneurysm Specialty Matched Consultant Advisory Panel review 6/2013. Medical Director review 6/2013.
Glaucoma, Evaluation by Ophthalmologic Techniques Specialty matched consultant advisory panel review 6/19/2013. No change to guideline statement.
Intravitreal Angiogenesis Inhibitors for Choroidal and Retinal Vascular Conditions Revised Description section. Under "When Appropriate" section: added indications for neovascular glaucoma and rubeosis; deleted 3+ requirement for retinopathy of prematurity. Specialty Matched Consultant Advisory panel review 6/19/2013. Reference added.
Maze Procedure for Atrial Fibrillation or Flutter Specialty Matched Consultant Advisory Panel review 6/2013. Medical Director review 6/2013. References updated.
Photodynamic Therapy, Ocular Specialty matched consultant advisory panel review 6/19/2013. No change to guideline statement. Reference added.
Prostate Cancer Treatment with Brachytherapy Specialty Matched Consultant Advisory Panel review 5/15/2013. Under "When Appropriate", the 1st bullet: added "low risk" prostate cancer when used as monotherapy, when the Gleason score is 5.6, PSA <10, T1-T2A). Medical director reviewed 5/2013. Reference added.
Transmyocardial Revascularization Specialty Matched Consultant Advisory Panel review 6/2013. Medical Director review 6/2013.
Transpupillary Thermotherapy for Treatment of Choroidal Neovascular Conditions Specialty Matched consultant advisory panel review 6/19/2013. No change to guideline statement.
Ultrafiltration in Decompensated Heart Failure Specialty Matched Consultant Advisory Panel review 6/2013. References updated. "Not Recommended" section updated. Medical Director review 6/2013.
Ventricular Assist Devices and Total Artificial Hearts Specialty Matched Consultant Advisory Panel review 6/2013. Medical Director review 6/2013. Added the following statement to the "Not Recommended" section: "Use of a percutaneous ventricular assist device (pVAD) is not recommended."