Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for August 27, 2013

Medical Guidelines Reason for Update
BRAF Gene Mutation Testing to Select Melanoma Patients for BRAF Inhibitor Therapy Statement in the When Not Covered section changed from "Testing for the BRAFV600E mutation for all other indications, including but not limited to, use in patients with lesser stage melanoma, or with non-melanoma tumors, is considered investigational." to "Testing for the BRAFV600 mutation for all other patients with melanoma, including but not limited to, use in patients with lesser stage melanoma, is considered investigational."
Cardiac Hemodynamic Monitoring in the Outpatient Setting Policy Guidelines updated. References updated. No changes to Policy Statements.
Carotid Intimal-Medial Thickness Study References updated. No changes to Policy Statements.
Decompression of the Intervertebral Disc Using Laser Energy (Laser Discectomy) or Radiofrequency Coblation (Nucleoplasty) Reference added.
DNA Based Testing for Adolescent Idiopathic Scoliosis References update. No changes to Policy Statement.
General Approach to Evaluating the Utility of Genetic Panels New policy developed. Genetic panels that use next-generation sequencing or chromosomal microarray, and are classified in one of the test categories, may be considered medically necessary when all criteria are met for each category, as outlined in the Policy Guidelines Section. Medical Director review 7/2013.
General Approach to Genetic Testing New policy developed. Genetic testing classified in one of the following categories may be considered medically necessary when all criteria are met for each category. Diagnostic testing, Risk assessment, Prognostic testing, Genetic variants that alter response to treatment or to an environmental factor. Medical Director review 7/2013.
Genetic Cancer Susceptibility Panels Using Next Generation Sequencing New policy. "Genetic cancer susceptibility panels using next generation sequencing are considered investigational." Senior Medical Director review 8/6/2013.
Genetic Testing for Non-Malignant Inherited Disorders Policy archived. Medical Director review. Please see new policies titled, "General Approach to Evaluating the Utility of Genetic Panels" and "General Approach to Genetic Testing."
Genetic Testing for Tamoxifen Treatment Policy Guidelines updated. Reference added. Senior Medical Director review 8/12/2013.
Autologous Hematopoietic Stem-Cell Transplantation for Malignant Astrocytomas and Gliomas Reference added. Policy archived.
Insulin Therapy, Chronic Intermittent Intravenous (CIIIT) Reference added. No change to policy statement.
Intensity Modulated Radiation Therapy (IMRT) of Abdomen and Pelvis Added endometrial to "When Covered" statement #3 d. for gynecological indications when treatment includes inguinal and/or pelvic nodes. Medical director review 8/2013.
Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers) Policy name changed from "Spinal Surgery Using Interspinous Distraction Technology" to "Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers)". Description section updated. Policy statement updated to indicate: "Interspinous distraction devices and interlaminar stabilization devices are considered investigational for all applications." Added new statement under the When Not Covered section; "Use of an interlaminar stabilization device following decompressive surgery is considered investigational for all applications." Senior Medical Director review 8/6/2013. Reference added.
Intracellular Micronutrient Analysis References updated. No changes to Policy Statement.
Outpatient Use of Limb Pneumatic Compression Devices for Venous Thromboembolism Prophylaxis New policy adopted. Outpatient use of limb pneumatic compression devices after major orthopedic surgery is considered medically necessary in patients with a contraindication to pharmacological agents i.e., at high-risk for bleeding. Outpatient use is considered medically necessary after major non-orthopedic surgery in patients who are at moderate or high risk of venous thromboembolism with a contraindication to pharmacological agents. Other outpatient uses are investigational and outpatient use beyond 30 days post-surgery is not medically necessary. Senior Medical Director review. Notification given 5/28/13 for policy effective date 8/27/13.
Sacroiliac Joint Fusion Removed CPT code 0334T from Billing/Coding section. Code implementation delayed.
Total Facet Arthroplasty Reference added.
Evidence Based Guidelines
Automated Nerve Conduction Tests Specialty Matched Consultant Advisory Panel review 5/15/2013. No changed to guideline. Reference added.
Deep Brain Stimulation Reference added.
Endovascular Stent Grafts for Thoracic Aortic Aneurysm The following statement added as a recommendation: "Endovascular stent grafts may be appropriate for the treatment of rupture of the descending thoracic aorta." The "Not Recommended" statement revised as follows: "Endovascular stent grafts are not recommended for the treatment of thoracic aortic lesions that do not meet the above criteria, including but not limited to thoracic aortic arch aneurysms." Description section updated. References updated.
Pharmacogenomic and Metabolite Markers for Treatment with Thiopurines Reference added. No change to Guideline statement.
TENS (Transcutaneous Electrical Nerve Stimulator) Reference added.