Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for September 10, 2013

Medical Guidelines Reason for Update
Biofeedback Reference updated. No change to policy statement.
Cellular Immunotherapy for Prostate Cancer Specialty Matched Consultant Advisory Panel review 8/21/2013. Policy Guidelines updated. No change to policy intent. Reference added.
Chemotherapy for Malignant Disease Specialty Matched Consultant Advisory Panel review 8/21/2013. No change to policy. Policy continues to be consistent with North Carolina Mandate.
Use of Common Genetic Variants to Predict Risk of Nonfamilial Breast Cancer Specialty Matched Consultant Advisory Panel review 8/21/2013. Policy Guidelines updated. Reference added.
Dopamine Transporter Imaging with Single Photon Emission Computed Tomography Reference added. No change to Policy guideline.
Epidermal Growth Factor Receptor (EGFR) Mutation Analysis for Patients with Non-Small Cell Lung Cancer (NSCLC) Specialty Matched Consultant Advisory Panel review 8/21/2013. No change to policy.
Extracorporeal Photopheresis Specialty Matched Consultant Advisory Panel review 8/21/2013. No change to policy.
Gene-Based Tests for Screening, Detection, and/or Management of Prostate Cancer Specialty Matched Consultant Advisory Panel review 8/21/2013. No change to policy.
Genetic Testing for Breast and Ovarian Cancer Removed "epithelial ovarian, fallopian tube, or primary peritoneal" from A.5. in the When Covered section. Updated Policy Guidelines section. Updated NCCN testing criteria based on the current 2013 version. Specialty Matched Consultant Advisory Panel review 8/21/2013. No change to policy intent. Reference added.
Genetic Testing for Colon Cancer Updated Policy Guidelines section. The 6th bullet under the Amsterdam II Clinical Criteria, "Tumors, if available, should be verified by pathologic examination." Specialty Matched Consultant Advisory Panel review 8/21/2013. No change to policy intent.
Hyperthermia Therapy Specialty Matched Consultant Advisory Panel review 8/21/2013. No change to policy statement. Reference added.
Intradiscal Electrothermal (IDET) Annuloplasty and Percutaneous Intradiscal Radiofrequency Annuloplasty Policy Guidelines section updated. Removed HCPCS code S2348 from Coding/Billing section as it does not pertain to this policy. Senior Medical Director review 8/29/2013. Reference added.
Microarray-Based Gene Expression Profile Testing for Multiple Myeloma Risk Stratification New policy. "Microarray-based gene expression profile testing for multiple myeloma is considered investigational for all indications." Senior Medical Director review 8/29/2013.
Microarray-based Gene Expression Testing for Cancers of Unknown Primary Specialty Matched Consultant Advisory Panel review 8/21/2013. No change to policy.
Molecular Markers in Fine Needle Aspirates of the Thyroid Specialty Matched Consultant Advisory Panel review 8/21/2013. No change to policy intent.
Occipital Nerve Stimulation ICD-10 diagnosis code corrected from "G13.901" to "G43.901".
Percutaneous Electrical Nerve Stimulation (PENS) or Neuromodulation Therapy Description and Policy Guidelines sections updated. Senior Medical Director review 8/29/2013. Reference added.
Serum Holo-Transcobalamin as a Marker of Vitamin B12 Status Reference added. Policy archived.
Surgery for Morbid Obesity Added the following to the General Criteria for Adults and Adolescents in the Policy Guidelines section; "5. To determine whether or not patients have responded to conservative measures for weight reduction, patients must have been active participants in non-surgical weight reduction programs that include frequent, e.g., monthly, documentation of weight, dietary regimen, and exercise, for at least 6 months prior to consideration for bariatric surgery. These conservative attempts must be reviewed by the practitioner seeking approval for the surgical procedure." Notification given 7/1/2013, policy effective 9/10/2013.
Temporomandibular Joint Dysfunction (TMJD) Updated Regulatory Status. Under "When Not Covered" section #2 Diagnostic Procedures : added joint vibration analysis as investigational indication for diagnostic procedure. Under "When Covered" section B. Non-Surgical Treatments: added Intra-oral removable prosthetic devices/appliances (encompassing fabrication, insertion, and adjustment) as medically necessary indication. Removed reference to low level laser therapy under Policy Guidelines section. Reference updated. Medical director review 7/2013.
Laboratory Testing to Allow Area Under the Curve (AUC) Targeted 5-Fluorouracil (5-FU) Dosing for Patients Administered 5-FU for Cancer Specialty Matched Consultant Advisory Panel review 8/21/2013. No change to policy.
Vertebroplasty, Kyphoplasty, and Sacroplasty Percutaneous Description and Policy Guidelines updated. Added the following statement to the When Not Covered section; "Percutaneous mechanical vertebral augmentation using any other device, in-cluding but not limited to Kiva®, is considered investigational." Specialty Matched Consultant Advisory Panel review 5/15/2013. References added. Notification given 7/1/2013. Policy effective 9/10/2013.
Viscocanalostomy and Canaloplasty Reference updated. No change to guideline statement.
Evidence Based Guidelines
Ado-Trastuzumab Emtansine (Trastuzumab-DM1) for Treatment of HER-2 Positive Malignancies Specialty Matched Consultant Advisory Panel review 8/21/13. No change to guideline.
BCR-ABL1 Testing for Diagnosis, Monitoring, and Drug Resistance Mutation Detection in Chronic Myelogenous Leukemia Specialty Matched Consultant Advisory Panel review 8/21/2013. No change to guideline.
Intraoperative Radiation Therapy Reference updated. No change to guideline statement.
Monoclonal Antibodies for Non-Hodgkin Lymphoma, including Chronic Lymphocytic, & Acute Myeloid Leukemia In the Non-Hematopoietic Stem Cell Transplant Setting Added the following statement to the When Not Recommended section; "Ofatumumab (Arzerra®) is not recommended for the treatment of malignancies other than B-cell CLL." Senior Medical Director review 8/29/2013. Reference added.
Photodynamic Therapy for Treatment of Specific Cancers Specialty Matched Consultant Advisory Panel review 8/21/2013. No change to guideline intent. Reference added.
Radiofrequency Ablation of Primary or Metastatic Liver Tumors Reference added. No change to Guideline statement.
Uterine Artery Occlusion in the Treatment of Uterine Fibroids References updated. No change to Guideline statement.