Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for October 15, 2013

Medical Guidelines Reason for Update
Abatacept (Orencia®) Added trial of Simponi Aria (golimumab) to statement #2 under "When Covered" section. Medical director review 10/2013.
Abdominoplasty, Panniculectomy and Lipectomy Specialty Matched Consultant Advisory Panel review 9/2013. Medical Director review 9/2013. References updated. Revised statement 3C under "When Covered" to remove the 6 month time requirement for development of fibrosis and thickening of the pannus with discoloration and/or lymphedema or peau d'orange effect.
Air Fluidized Beds Specialty matched consultant advisory panel review 9/18/2013. Updated CMS reference.
Autologous Fat Grafting to the Breast Specialty Matched Consultant Advisory Panel review 9/2013. Medical Director review 9/2013.
Bioengineered Skin and Tissue Specialty Matched Consultant Advisory Panel review 9/2013. Medical Director review 9/2013. References updated. New products added to the "When not Covered" section.
Breast Surgeries Added related policies to Description section. Added the following syndromes associated with TP53 and PTEN mutations: (Li-Fraumeni syndrome, Cowden syndrome, Bannayan-Riley-Ruvalcaba syndrome) to the "Prophylactic Mastectomy" section. References updated. Specialty Matched Consultant Advisory Panel review 9/2013. Medical Director review 9/2013.
Bundling Guidelines The following statement was added to the subsection regarding New Visit Frequency: "BCBSNC will replace a code billed for a subsequent office or other outpatient consultation within 6 months of the initial office or other outpatient consultation by the same provider for the same member with the appropriate level of established office visit." Code equivalents for crosswalk also added. Notification given 8/13/13 for effective date 10/15/13.
Children's Mobility and Positioning Equipment Specialty matched consultant advisory panel review 9/18/2013. Added the word "safely" to statement #2 under "When Covered" section.
Cochlear Implant Reference added. Medical Director review. Policy statement added that cochlear implantation as a treatment for patients with unilateral hearing loss with or without tinnitus is considered investigational. Summary statement added. Notification given 8/13/13 for policy effective date 10/15/13.
Composite Allotransplantation of the Hand and Face Specialty Matched Consultant Advisory Panel review 9/2013. Medical Director review 9/2013.
Cosmetic and Reconstructive Surgery Specialty Matched Consultant Advisory Panel review 9/2013. Revised "When not Covered": section A2 to state: "Hairplasty for any form of alopecia not related to a deformity resulting from accidental injury, trauma, or previous therapeutic process." Medical Director review 9/2013. References updated.
Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate, or Dermatologic Tumors Reference added. Policy guidelines updated. Metastases added to investigational policy statement. Medical Director review 9/2013.
Durable Medical Equipment (DME) Specialty matched consultant advisory panel review 9/18/2013.
Functional Capacity Assessment and Work Hardening Specialty matched consultant advisory panel review 9/18/2013.
Gait Analysis Specialty matched consultant advisory panel review 9/18/2013.
Gastric Electrical Stimulation Reference added. ICD-10 diagnosis codes E13.43 and E13.49 added to Billing/Coding section. No change to policy statement or guidelines.
Genetic Testing for the Diagnosis of Inherited Peripheral Neuropathy New policy implemented. Genetic testing to confirm a clinical diagnosis of an inherited peripheral neuropathy is considered investigational. Genetic testing for an inherited peripheral neuropathy is considered investigational for all indications. Medical Director review 7/2013. Notification given August 13, 2013 for effective date October 15, 2013.
Hematopoietic Stem-Cell Transplantation for Acute Myeloid Leukemia Description updated. No change to policy intent. Senior Medical Director review 9/14/2013. Reference added.
Hyperhidrosis, Treatment of Revised "When Covered" section. Coverage for endoscopic transthroacic sympathectomy (ETS) for axillary and palmer hyperhidrosis is considered medically necessary if conservative treatment (i.e., aluminum chloride and botulinum toxin, individually or in combination) has failed. Medical Director review 10/2013.
Laser Treatment of Port Wine Stains Specialty Matched Consultant Advisory Panel review 9/2013. Medical Director review 9/2013. No changes to Policy Statements.
Multiple Surgical Procedure Guidelines for Professional Providers Description section revised for clarity. Previous version of this policy contained guidelines for Section 1 (Blue Advantage, Blue Care, Blue Choice, Blue Options and Classic Blue) and Section II (Preferred Care, Preferred Select, CMM). These were combined into one section titled, "Guidelines for Reimbursement of Multiple Surgical Procedures." Determination of the primary procedure will be based on the most appropriate CPT code as defined by the editing software utilized by BCBSNC at the time of receipt of the claim. The primary procedure will be considered the service with the highest charge. Reimbursement for the primary procedure will be based on 100% of the BCBSNC allowance. Procedures performed in conjunction with the primary surgical procedure considered by BCBSNC to be incidental to that primary procedure will not receive additional reimbursement. Incidental procedures are defined as procedures requiring little additional provider resources and/or are clinically integral to the performance of the primary procedure. No additional benefits will be provided for procedures which are considered to be incidental, integral or mutually exclusive to the covered primary or secondary procedure. Procedure codes identified as "add-on" and "modifier -51 exempt" codes are not subject to multiple surgical procedure reductions. Multiple procedure reductions may apply when a single code is submitted with multiple units.
Patient Lifts Specialty matched consultant advisory panel review 9/18/2013.
Power Operated Vehicle (Scooter) Specialty matched consultant advisory panel review 9/18/2013.
Pressure Reducing Support Surfaces Added HCPCS code E0277 to Billing/Coding section. Specialty matched consultant advisory panel review 9/18/2013.
Pricing and Adjudication Principles for Professional Providers Policy was reviewed and the following changes were made: This policy does not apply to contractual reimbursement methodologies outside fee-for-service, such as bundled payment for episodic care or care management, or quality-based reimbursement. Item 5 in the Principles section added clarification: "For example, the use of modifier -22 will not affect claims processing adjudication." Item 11 in the Principles section-deleted "governmental program limitations." The last statement following Item 11 was revised to read: This policy applies to BCBSNC commercial business and Inter-Plan Programs.
Progesterone Therapy in High Risk Pregnancies References added. Specialty Matched Consultant Advisory Panel review 9/18/13. Policy Guidelines updated. No change to policy statement.
Reconstructive Eyelid Surgery and Brow Lift Specialty Matched Consultant Advisory Panel review 9/2013. Medical Director review 9/2013. References updated.
Rehabilitative Therapies Specialty matched consultant advisory panel review 9/18/2013.
Rituximab for the Treatment of Rheumatoid Arthritis Added trial of Simponi Aria (golimumab) to statement #2 under When Covered section. Added ICD-10 diagnosis code M05.319 to Billing/Coding section. Medical director review 10/2013.
Sequencing Based Tests to Determine Trisomy 21 from Maternal Plasma DNA Information regarding Natera's Panorama prenatal test added to Regulatory Status section. Specialty Matched Consultant Advisory Panel review 9/18/13. No change to Policy statement.
Speech Generating Devices Specialty matched consultant advisory panel review 9/18/2013.
Surgical Treatment of Chest Wall Deformities (Congenital or Acquired) References updated. Specialty Matched Consultant Advisory Panel review 9/2013. Medical Director review 9/2013. No changes to Policy Statements.
Tocilizumab (Actemra) Added trial of Simponi Aria(golimumab) to statement # 1 under When Covered section. Medical director review 10/2013.
Ustekinumab (Stelara®) FDA presecribing information updated 9/2013. Decscription section updated. "When Covered" section updated to include the following statement: "Ustekinumab (Stelara®) may be considered medically necessary for the treatment of active psoriatic arthritis in patients who are 18 years of age or older. Ustekinumab (Stelara®) may be used alone or in combination with methotrexate for the treatment of active psoriatic arthritis." References updated. Medical Director review 10/2013.
Wheelchairs Specialty matched consultant advisory panel review 9/18/2013.
Whole Exome Sequencing New policy developed. Whole exome sequencing is considered investigational. Medical Director review 10/2013.
Evidence Based Guidelines
Intrauterine Ablation or Resection of the Endometrium Reference added. Removed the following statement from the contraindications for microwave ablation section: "Essure contraceptive micro inserts are in place in the Fallopian tubes". Added February 2013 FDA information regarding Essure inserts. Specialty Matched Consultant Advisory Panel review 9/18/13. No change to Guideline statement. Medical Director review.