Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for October 1, 2013

Medical Guidelines Reason for Update
Analysis of Proteomic Patterns for Early Detection of Cancer Regulatory information updated. Policy archived due to no utilization of this test. (btw)
Ankle Replacement, Total Description section updated. References updated. No changes to Policy Statements.
Chelation Therapy Under "When Covered" section: added extreme conditions of metal toxicity; treatment of chronic iron overload due to blood transfusions (transfusional hemosiderosis) and due to nontransfusion-dependent thalassemia (NDTD); lead poisoning. Under "When Not Covered" section: added: " secondary prevention in patients with myocardial infarction" as investigational indication to 2nd bullet Atherosclerosis. Updated Regulatory status. Reference updated. Notification date 7/16/13 for effective date 10/1/13.
Chiropractic Services Specialty Matched Consultant Advisory Panel review 9/18/2013. No change to policy intent.
Cord Blood as a Source of Stem Cells Added diagnosis code, V30.2 to Billing/Coding section. Added Z38.1 to ICD10 codes listed in the Billing/Coding section.
Cranial Electrotherapy Stimulation (CES) and Auricular Electrostimulation Reference added.
Cytochrome p450 Genotyping Removed "Genetic Testing Treatment of Helicobacter pylori Infection (CYP2C19)" from Related Policies. Incorporated information regarding CYP450 genotyping for the purpose of managing tamoxifen treatment for women with high risk for or with breast cancer. Description section updated. Policy Statement and Policy Guidelines updated to include information on CYP450 genotyping and tamoxifen management. Medical Director review 9/2013.
Digital Breast Tomosynthesis References added. Description and Policy Guidelines sections extensively revised. Medical Director review. No change to Policy statement.
Electrocardiographic Body Surface Mapping References updated. Policy Guidelines updated. No changes to Policy Statements.
External Defibrillators Policy Guidelines updated. References updated.
Genetic Testing for Tamoxifen Treatment Information regarding genetic testing for tamoxifen treatment transferred to the policy, Cytochrome p450 Genotyping. This policy to be archived.
Hematopoietic Stem-Cell Transplantation for Plasma Cell Dyscrasias, Including Multiple Myeloma and POEMS Policy name changed from "Hematopoietic Stem-Cell Transplantation for Multiple Myeloma" to "Hematopoietic Stem-Cell Transplantation for Plasma Cell Dyscrasias, Including Multiple Myeloma and POEMS Syndrome". Description section updated to include information regarding POEMS syndrome. Policy section changed from "BCBSNC will provide coverage for Hematopoietic Stem-Cell Transplantation for Multiple Myeloma when it is determined to be medically necessary because the medical criteria and guidelines shown below are met." to "BCBSNC will provide coverage for Hematopoietic Stem-Cell Transplantation for Plasma Cell Dyscrasias when it is determined to be medically necessary because the medical criteria and guidelines shown below are met." The following statement was added to the When Covered section; "Autologous hematopoietic stem-cell transplantation may be considered medically necessary to treat disseminated POEMS syndrome. (see Policy Guidelines)" Added "Allogeneic and tandem hematopoietic stem-cell transplantation are considered investigational to treat POEMS syndrome." to the When Not Covered. Policy Guidelines section updated. Senior Medical Director review 9/14/2013. Reference added.
MRI-Guided Focused Ultrasound (MRgFUS) Specialty Matched Consultant Advisory Panel review 6/19/13. No change to policy statement.
Multigene Expression Assay for Predicting Recurrence in Colon Cancer Reference added.
Non-BRCA Breast Cancer Risk Assessment Policy name changed from "Non-BRCA Breast Cancer Risk Assessment (Oncovue)" to "Non-BRCA Breast Cancer Risk Assessment". Added information to policy related to the BREVAGenTM breast cancer risk test. "BREVAGenTM breast cancer risk tests are considered investigational as a method of estimating individual patient risk for developing breast cancer." No change to policy intent. Senior Medical Director review 9/14/2013. Reference added.
Prolotherapy References updated.
Retinal Prosthesis Added HCPCS code C1841 to Billing/Coding section for coding update.
Small Bowel, Small Bowel with Liver, or Multivisceral Transplant References added. Added the following indication, "A small bowel/liver transplant or multivisceral retransplant may be considered medically necessary after a failed primary small bowel/liver transplant or multivisceral transplant." Medical Director review.
Surgical Deactivation of Headache Trigger Sites Policy name changed from "Surgical Deactivation of Migraine Headache Trigger Sites" to "Surgical Deactivation of Headache Trigger Sites". Description section updated to include information regarding surgical deactivation of other types of headache. Policy statement changed from "Surgical Deactivation of Migraine Headache Trigger Sites is considered investigational for all applications." to "Surgical Deactivation of Headache Trigger Sites is considered investigational for all applications." "Surgical deactivation of trigger sites is considered investigational for the treatment of migraine and non-migraine headache." Senior Medical Director review 9/14/2013. Reference added.
Surgical Ventricular Restoration References updated. No changes in Policy Statements.
Tumor-Treatment Fields Therapy for Glioblastoma New policy. Tumor treatment fields therapy to treat glioblastoma is considered investigational. Senior Medical Director review 8/30/2013. Specialty Matched Consultant review 9/18/2013.
Evidence Based Guidelines
Biochemical Markers of Alzheimer's Disease Included information related to the findings of the "Alzheimer’s Disease Neuroimaging Initiative" to the When Not Recommended section. Reference added.
Genetic Testing for Alpha Thalassemia New Evidence Based Guideline developed. Preconception (carrier) testing for alpha thalassemia in prospective parents may be appropriate when both parents have evidence of alpha thalassemia based on biochemical testing. Genetic testing to confirm a diagnosis of alpha thalassemia is not recommended. Genetic testing for alpha thalassemia in other clinical situations (recognizing that prenatal testing is not addressed in this policy) is not recommended. Medical Director review 9/2013.
Genetic Testing for CHARGE Syndrome New Evidence Based Guideline developed. Genetic testing for CHARGE syndrome may be appropriate to confirm a diagnosis in a patient with signs/symptoms of CHARGE syndrome when a definitive diagnosis cannot be made with clinical criteria. Genetic testing for CHARGE syndrome is not recommended when a definitive diagnosis can be made with clinical criteria, as listed above. Medical Director review 9/2013.
Genetic Testing for Facioscapulohumeral Muscular Dystrophy New Evidence Based Guideline developed. Genetic testing for facioscapulohumeral muscular dystrophy may be appropriate to confirm a diagnosis in a patient with clinical signs of the disease. Medical Director review. Medical Director review 9/2013.
Human Leukocyte Antigen (HLA) Testing for Celiac Disease New guideline adopted. HLA testing may be appropriate to rule out celiac disease in patients with discordant serologic and histologic findings or if persistent symptoms warrant testing despite negative serology and histology. HLA testing for celiac disease is not recommended in all other situations. Senior Medical Director review.
Low Density Lipid Apheresis References updated. No changes to guideline statements.
Ocriplasmin for Symptomatic Vitreomacular Adhesion New evidence based guideline issued. A single intravitreal injection of ocriplasmin may be appropriate for treatment of an eye with symptomatic vitreomacular adhesion (VMA). Medical director review 8/2013.
Serum Biomarker Human Epididymis Protein 4 (HE4) Revised the dates and statistical figures in the Description section. Removed the following statement from the Evidence Based Guideline section; "The available data on the diagnostic test performance are in FDA documents; the reported studies were small, retrospective and may have included duplicate data on the same women, and used different cut-offs for identifying a recurrence." Removed the When not recommended section and included the information in the Evidence Based Guideline section. Senior Medical Director review 9/14/2013. Reference added.
Transmyocardial Revascularization References updated. No changes to Evidence Based Guideline.
Transurethral Microwave Thermotherapy for Benign Prostatic Hyperplasia "Prostatic lengths of 35-50 mm" removed from guideline statement. Revised "Not Recommened" section to state: "For technical reasons, transurethral microwave thermotherapy is not suitable for patients who have median lobe enlargement, bladder neck stenosis, or in whom the prostate gland does not meet the size recommendations for the particular device used, including prostatic urethra length and gland volume." Description section updated. References updated.