Medical Policy Updates

Table Of Contents

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

Medical Guidelines Reason for Update
Acoustic Cardiography References updated. No change to Policy Statement.
Ankle Replacement, Total Medical Director review 7/2013. Specialty Matched Consultant Advisory Panel review 7/2013. No changes to Policy Statements.
Charged Particle Radiotherapy (Proton or Helium Ion) Revised Policy Guidelines section. Under When Covered; added medically necessary indication for pediatric CNS tumors. Under When Not Covered section: added investigational statements for pediatric non-CNS tumors and for tumors of the head and neck, other than skull based chordoma or chondrosarcoma. Added HCPCS code S8030 to the Billing/Coding section. Reference added. Medical director review 3/2013. Notification given 4/30/13 for effective date 7/30/13.
Computed Tomography to Detect Coronary Artery Calcification Description section updated. References updated. No changes to Policy Statement.
Computer-Aided Evaluation of Malignancy with MRI of the Breast Specialty Matched Consultant Advisory Panel review 7/17/13. No change to policy statement.
CT Perfusion Imaging Specialty Matched Consultant Advisory Panel review 7/17/13. No change to policy statement.
Digital Breast Tomosynthesis Reference added. Paragraph added to Regulatory Status regarding GE Healthcare. Policy guidelines updated. Specialty Matched Consultant Advisory Panel review 7/17/13. No change to policy statement.
Electrical Bone Growth Stimulation Specialty Matched Consultant Advisory Panel review 7/2013. Medical Director review 7/2013. No changes to Policy Statements.
Extracorporeal Shock Wave Treatment for Musculoskeletal Conditions and Wound Healing Specialty Matched Consultant Advisory panel review 7/2013. Medical Director review 7/2013. No changes to Policy Statements.
Gene Expression Testing to Predict Coronary Artery Disease References updated. Policy Guidelines updated. No changes to Policy Statements.
Genetic Testing for FMR1 Mutations Including Fragile X Syndrome References updated. No changes to Policy Statements.
Infliximab (Remicade) Under "When Covered" section, added UVB therapy to statement 1.e. "as treatment of severe plaque type psoriasis (as evidenced by psoriatic plaques covering at least 10% of the body surface) that has failed prior treatment with psoralen-UVA,or UVB light therapy, or conventional systemic therapies(methotrexate,cyclosporine, Soriatane), or patient has contraindication to these treatments." Medical director review 6/2013. Added HCPCS codes E0691-E0694 to the Billing/Coding section.
Insulin Therapy, Chronic Intermittent Intravenous (CIIIT) Specialty Matched Consultant Advisory Panel review 7/17/13. No change to policy statement.
Intradialytic Parenteral Nutrition References updated. No changes to Policy Statements.
Islet Cell Transplantation Medical Director review. CPT code 48999 added to Policy Guidelines. References updated. Specialty Matched Consultant Advisory Panel Review 7/17/12. No changes to policy statement.
Laser Treatment of Port Wine Stains Description section updated. References updated. No changes to Policy Statements.
Magnetic Resonance Spectroscopy Specialty Matched Consultant Advisory Panel review 7/17/13. No change to policy statement.
Magnetoencephalography/Magnetic Source Imaging Specialty Matched Consultant Advisory Panel review 7/17/13. No change to policy statement.
Myocardial Sympathetic Innervation Imaging New policy developed. Myocardial sympathetic innervation imaging with 123Iodine meta-iodobenzylguanidine (MIBG) is considered investigational for patients with heart failure. Medical Director review 7/2013.
Natalizumab (Tysabri) Added "Aubagio® and TecfideraTM" to 3.A. Relapsing form of Multiple Sclerosis, in the When Covered section based on CAP review.
Progenitor Cell Therapy for the Treatment of Damaged Myocardium Due to Ischemia Description section updated. References updated. No changes to Policy Statements.
Prolotherapy Specialty Matched Consultant Advisory Panel review 7/2012. Medical Director review 7/2013. References updated. No changes to Policy Statements.
Radioembolization for Primary and Metastatic Tumors of the Liver Policy Guidelines and Description sections revised. Under When Not Covered section added investigational indication "Radioembolization is considered investigational to treat primary intrahepatic cholangiocarcinoma." Reference added. Medical director review 3/2013. Notification given 4/30/13 for effective date 7/30/13.
Rapid Opioid Detoxification Specialty Matched Consultant Advisory Panel review 7/17/13. No change to policy.
Repository Corticotropin (H.P. Acthar Gel) Added "Lack of venous access for the administration of intravenous steroids" to the When Covered section based on CAP review.
Sensory Integration Therapy Specialty Matched Consultant Advisory Panel review 7/17/13. No changes to policy.
Surgery for Femoroacetabular Impingement Specialty Matched Consultant Advisory Panel review 7/2013. Medical Director review 7/2013. No Changes to Policy Statements.
Transcranial Magnetic Stimulation Specialty Matched Consultant Advisory Panel Review 7/17/13. No change to Policy statement.
Treatment for Severe Primary IGF-1 Deficiency Specialty Matched Consultant Advisory Panel review 7/17/13. References updated. Information regarding 2013 interruption of supply added to Description section. No change to policy statement.
Ultraviolet Light Therapy in the Home Setting(UVB) Policy returned to active status and changed from Evidence Based Guideline to Corporate Medical Policy. Policy re-titled from "Ultraviolet Light Box Therapy in the Home Setting" to "Ultraviolet Light Therapy in the Home Setting." Policy Guidelines updated. References updated. Medical Director review 6/2013.
Vertebral Axial Decompression (VAD-X) Specialty Matched Consultant Advisory Panel review 7/2013. References updated. Medical Director review 7/013. No changes to Policy Statements.
Evidence Based Guidelines
Cardiac Rehabilitation References updated. No changes to Guideline Recommendations.
Screening for Vertebral Fracture with Dual X-ray Absorptiometry (DEXA) Specialty Matched Consultant Advisory Panel review 7/17/13. No changes to guideline statement.
Thermography Reference added. Specialty Matched Consultant Advisory Panel review 7/17/13. No change to guideline statement.