Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for October 29, 2013

Medical Guidelines Reason for Update
Allogeneic Hematopoietic Transplant for Genetic Diseases and Acquired Anemia Reference added.
Aqueous Shunts and Devices for Glaucoma Revised Description and Policy Guidelines sections. Under "When Covered" section added the statement "Implantation of a single FDA-approved micro-stent in conjunction with cataract surgery may be considered medically necessary in patients with mild to moderate open-angle glaucoma currently treated with ocular hypotensive medication." Reference added.
Congenital Heart Defect, Repair Devices Policy Guidelines updated. References updated. No changes to Policy Statements.
Consistency Guidelines Policy re-activated and reformatted. Description section updated for clarity. Guidelines reviewed and approved by Payment Policy Governance Committee.
Cord Blood as a Source of Stem Cells Description section updated. Reference added.
CT Perfusion Imaging of the Brain Reference added. "of the brain" added to title and policy statement. No change to policy intent. Medical director review.
Gender Reassignment Surgery Reference added. Replaced DSM-IV TR criteria with DSM-5TM criteria. Removed "Sex change surgical procedures other than breast augmentation surgery (mammoplasty) and mastectomy" from the When Not Covered section. Added "pelvic reconstruction" to the When Covered section. Applicable Service Codes removed from Billing/Coding section. Senior Medical Director review.
Genetic Testing for Rett Syndrome Description section updated. References updated. No changes to Policy Statements.
Identification of Microorganisms Using Nucleic Acid Probes "When Covered" section updated to include Candida species-Amplified Probe and Trichomonas vaginalis-Amplified Probe. Description section updated. References updated. Medical Director review 10/2013.
Implantation of Intrastromal Corneal Ring Segments Reference updated. No change to policy statement.
Interspinous Fixation (Fusion) Devices Reference added.
Intravenous Anesthetics for the Treatment of Chronic Pain Reference added.
Pulmonary Hypertension, Drug Management Added e.g. to indicate availability of epoprostenol and sildenafil generic formulations under "When Covered" section. Atorvastatin is investigational under "When Not Covered" section. Reference added.
Radiosurgery, Stereotactic Approach Reference updated. No change to policy statement.
Respiratory Syncytial Virus Prophylaxis Reference added. Senior Medical Director review. No change to Policy statement.
Subtalar Arthroereisis Description section updated. Policy Guidelines updated. References updated. No changes to Policy Statement.
Evidence Based Guidelines
Automated Nerve Conduction Tests The word "automated" was removed from the sentence in the Description section that indicated; "The Axon-IITM (PainDx) is an automated system that is being marketed for the detection of various sensory neurologic impairments caused by various pathologic conditions or toxic substance exposures, including signs of sympathetic dysfunction and detection of down-regulated A-delta function to locate injured nerve(s)." Information related to "The Neural-ScanTM NCS (Neuro Diagnostics) is a Class II diagnostic device" was revised from previous wording indicating it was a Class I device. The CPT code, 95999, was added to the Billing/Coding section. Senior Medical Director review 10/11/2013.
Genetic Testing for Nonsyndromic Hearing Loss New Evidence Based Guideline developed. Genetic testing to confirm the diagnosis of hereditary nonsyndromic hearing loss (NSHL) may be recommended to distinguish NSHL from other etiologies of hearing loss and facilitate the diagnostic workup. Preconception testing of parents (carrier testing) may be recommended under certain conditions. Medical Director review 9/2013.
Paraspinal Surface Electromyography (SEMG) Reference added.
Uterine Artery Occlusion in the Treatment of Uterine Fibroids Added related policy "Laparoscopic and Percutaneous Techniques for the Myolysis of Uterine Fibroids". Specialty Matched Consultant Advisory Panel review 9/18/13.