Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for August 13, 2013

Medical Guidelines Reason for Update
Autografts and Allografts in the Treatment of Focal Articular Cartilage Policy re-titled from "Osteochodral Grafting in the Treatment of Articular Cartilage Lesions" to "Autografts and Allografts in the Treatment of Focal Articular Lesions." Description section updated. Added the following statements to the "When not Covered" section as follows: "Treatment of focal articular cartilage lesions with autologous minced cartilage is considered investigational. Treatment of focal articular cartilage lesions with allogeneic minced cartilage is considered investigational." Autologous and allogenic minced cartilage was formerly addressed in the BCBSNC policy titled, "Autologous Chondrocyte Implantation." Policy Guidelines updated. References updated. Specialty Matched Consultant Advisory Panel review 7/2013
Autologous Chondrocyte Implantation References to "minced cartilage" and "allogenic chondrocytes" deleted from this policy and can now be referenced in the BCBSNC policy titled, "Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions." Description section updated. The following statement removed from the "When not Covered" section: "Treatment of focal articular cartilage lesions with autologous or allogeneic minced cartilage is considered investigational." Policy Guidelines updated. References updated. Specialty Matched Consultant Advisory Panel review 7/2013. Medical Director review 7/2013.
Biofeedback References updated. No change to policy statement.
Bronchial Thermoplasty Description section updated. Reference updated. No change to policy statement.
Cardiovascular Disease Risk Tests "6/11/13 Policy statement revised to state: ""Measurement of cardiovascular risk factors (i.e., apolipoprotein B, apolipoprotein A-I, apolipoprotein E, LDL subclass, HDL subclass, lipoprotein[a], lipoprotein-associated phospholipase A2 [Lp-PLA2], genomic markers including genotyping for 9p21 SNPs, rs3798220 allele, and KIF6 , hereditary hypercoagulability factors, long chain fatty acids, fibrinogen, cystatin C) is considered investigational as an adjunct to LDL cholesterol in the risk assessment and management of cardiovascular disease. BCBSNC does not provide coverage for investigational services or procedures."" ""When not Covered"" section updated to include the following statements: ""Measurement of cardiovascular risk factors (i.e., apolipoprotein B, apolipoprotein A-I, apolipoprotein E, LDL subclass, HDL subclass, lipoprotein[a], long chain fatty acids, fibrinogen, genomic markers, cystatin C) is considered investigational as an adjunct to LDL cholesterol in the risk assessment and management of cardiovascular disease."" and ""Measurement of hereditary hypercoagulability factors is considered investigational for predicting cardiovascular disease risk."" Description section updated. Policy Guidelines updated. Added the following CPT codes to the Billing/Coding section: 81250, 81241, 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408. Medical Director review 5/2013. Notification given June 11, 2013 for effective date August 13, 2013. 7/1/13 ICD-10 diagnosis codes added to ""Billing/Coding"" section. Policy remains on notification for effective date August 13, 2013."
Chemoembolization of the Hepatic Artery, Transcatheter Approach Specialty Matched Consultant Advisory Panel review 7/17/2013. No change to Policy statement.
Computer Assisted Surgical Navigational Orthopedic Procedures Specialty Matched Consultant Advisory Panel review 7/2013. References updated. Medical Director review 7/2013.
Continuous Passive Motion in the Home Setting Specialty Matched Consultant Advisory Panel review 7/2013. References updated. Medical Director review 7/2013. No changes to Policy Statements.
Cosmetic and Reconstructive Surgery References updated. Added related policy to Description section: "Composite Allotransplantation of the Hand and Face." Added the following service to the "When Not Covered" section: "Chemical exfoliation for active acne and acne scarring." Medical Director review 4/2013. Notification given 5/14/13 for effective date of 8/13/13.
Electrothermal Arthroscopic Capsulorrhaphy Revised statement in section "When Not Covered" as follows: "Electrothermal arthroscopic capsulorrhaphy is considered not medically necessary as a treatment of joint instability, including, but not limited to the shoulder, knee, and elbow." References updated. Specialty Matched Consultant Advisory Panel review 7/2013. Medical Director review 7/2013.
Endovascular Procedures for Intracranial Arterial Disease Policy Guidelines updated. Reference added. Senior Medical Director review 7/26/2013.
Genetic Testing for Statin-induced Myopathy New policy developed. Genetic testing for the presence of variants in the SLCO1B1 gene for the purpose of identifying patients at risk of statin-induced myopathy is considered not medically necessary. Medical Director review 7/2013.
Group Visit (Shared Medical Appointment) Guidelines Reviewed by Medical Director. No change to current policy.
Intensity Modulated Radiation Therapy (IMRT) of Head and Neck Reference updated. No change to policy statement.
Lung Volume Reduction Surgery Reference updated. No change to policy statement.
Meniscal Allografts and Other Meniscal Implants Specialty Matched Consultant Advisory Panel review 7/2013. Medical Director review 7/2013. No changes to Policy Statements.
Myocardial Sympathetic Innervation Imaging Removed codes 0031T and 0032T from Billing/Coding section. Added codes 0331T and 0332T to Billing/Coding section.
Myoelectric Prosthetic Components for the Upper Limb Specialty Matched Consultant Advisory Panel review 7/2013. References updated. Medical Director review 7/2013. No changes to Policy Statements.
Orthopedic Applications of Stem Cell Therapy Added new product to Description section: InQuTM (ISTO Technologies): A combination of poly(lactide-co-glycolide) (PLGA) a ceramic bone void filler with hyaluronic acid.
Radioembolization for Primary and Metastatic Tumors of the Liver Policy effective 7/30/13. Web link was corrected.
Sleep Apnea: Diagnosis and Medical Management Medical Director review. Added information on the WinxTM Sleep Therapy System to the Description section. Added "Single pressure, oral airway devices without forced nasal air are not considered CPAP and are considered investigational in the treatment of OSA" to the When Not Covered section. Reference added. Notification given 5/14/13 for policy effective date of 8/13/13.
Evidence Based Guidelines
Intra Articular Hyaluronan Injections for Treatment of Osteoarthritis of the Knee Description section updated. References updated. Specialty Matched Consultant Advisory Panel review 7/2013. Medical Director review 7/2013.