Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for November 12, 2013

Medical Guidelines Reason for Update
Acoustic Cardiography Specialty Matched Consultant Advisory Panel review 10/2013. No changes to Policy Statements.
Antiprothrombin Antibody Testing Specialty Matched Consultant Advisory Panel review 10/2013. References updated. Policy Guidelines updated. Medical Director review 9/2013.
Axial Lumbosacral Interbody Fusion Specialty Matched Consultant Advisory Panel review 10/16/2013. Additional Related Policies added to the Description section. Policy Guidelines updated. No change to policy intent.
Cardiac Hemodynamic Monitoring in the Outpatient Setting Specialty Matched Consultant Advisory Panel review 10/2013. No changes to Policy Statements.
Carotid Intimal-Medial Thickness Specialty Matched Consultant Advisory Panel review 10/2013. Medical Director review 10/2013. Removed the word "Study" from the policy title. Policy Statement revised to state: "Carotid Intimal-Medial Thickness measurement is considered investigational for all applications. BCBSNC does not provide coverage for investigational services or procedures." Policy intent is unchanged.
Chromoendoscopy as an Adjunct to Colonoscopy Specialty Matched Consultant Advisory Panel review 10/16/2013. No change to policy statement.
Computed Tomography to Detect Coronary Artery Calcification Specialty Matched Consultant Advisory Panel review 10/2013. Medical Director review 10/2013. No changes to Policy Statements.
Confocal Laser Endomicroscopy Specialty Matched Consultant Advisory Panel review 10/16/13. No change to policy statement.
Continuous Monitoring of Glucose in the Interstitial Fluid Specialty Matched Consultant Advisory Panel review 7/17/13. Information added about MiniMed 530G artificial pancreas system. No change to Policy statement.
Decompression of the Intervertebral Disc Using Laser Energy (Laser Discectomy) or Radiofrequency Coblation (Nucleoplasty) Specialty Matched Consultant Advisory Panel review 10/16/2013. No change to policy intent.
Dental Criteria for use of Hospital Inpatient or Outpatient Facility Services or Ambulatory Surgery Center Facility Services Specialty Matched Consultant Advisory Panel review 10/21/2013. No changes to policy statement.
Dental Reconstructive Services Specialty Matched Consultant Advisory panel review 10/21/2013. No change to policy statement.
Electrocardiographic Body Surface Mapping Specialty Matched Consultant Advisory Panel review 10/2013. No changes to Policy Statements.
Electrodiagnostic Studies Specialty Matched Consultant Advisory Panel review 10/16/2013. No change to policy.
End Diastolic Pneumatic Compression Boot Specialty Matched Consultant Advisory Panel review 10/2013. No changes to Policy Statements.
Endothelial Keratoplasty Revised Description and Policy Guidelines sections. Under "When Covered" section added the following statements as medically necessary: "Descemet's membrane endothelial keratoplasty (DMEK) and Descemet's membrance automated endothelial keratoplasty (DMAEK); ruptures in Descemet's membrane, endothelial dystrophy, iridocorneal endothelial (ICE) syndrome and corneal edema attributed to endothelial failure." Under "When Not Covered" section added the following statement: Femtosecond laser-assisted corneal endothelial keratoplasty (FLEK) or femtosecond and excimer lasers-assisted endothelial keratoplasty (FELEK) are considered investigational." Reference added.
Functional Endoscopic Sinus Surgery (FESS) Reference added. Existing references updated. Specialty Matched Consultant Advisory Panel review 8/21/13. Medical Director review. No change to policy statement.
Genetic Testing for Familial Alzheimer's Disease Description section updated to include information related to TREM2. TREM2 added to investigational policy statement. Specialty Matched Consultant Advisory Panel review 10/16/2013. Reference added.
Genetic Testing for Predisposition to Inherited Hypertrophic Cardiomyopathy References updated. Specialty Matched Consultant Advisory panel review 10/2013. No changes to Policy Statements.
Interferential Stimulation Specialty Matched Consultant Advisory Panel review 10/16/2013. No change to policy.
Lysis of Epidural Adhesions Specialty Matched Consultant Advisory Panel review 10/16/2013. No change to policy intent.
Measurement of Serum Antibodies to Infliximab and Adalimumab Policy title changed to add "Adalimumab". Added the following statement to the "When Not Covered" section: Measurement of antibodies to adalimumab in a patient receiving treatment with adalimumab, either alone or as a combination test which includes the measurement of serum adalimumab levels, is considered investigational. Revised Description section .Reference added. Medical director review 10/2013.
Mechanical Embolectomy for Treatment of Acute Stroke Description section and Policy Guidelines section updated. Specialty Matched Consultant Advisory Panel review 10/16/2013. No change to policy intent.
Neurostimulation, Electrical Specialty Matched Consultant Advisory Panel review 10/16/2013. No change to policy.
Occipital Nerve Stimulation Added the following ICD10 codes to the Billing/Coding section; G43.821, G43.829, G43.831, G43.839, G43.B0, G43.C0, and G43.C1. Removed the following codes; G43.A09, G43.A19, G43.B09, G43.B19, G43.C09, G43.C19, G43.D01, G43.D09, G43.D11, and G43.D19.
Orthognathic Surgery Specialty Matched Consultant Advisory panel review 10/21/2013. No change to policy statement.
Percutaneous Electrical Nerve Stimulation (PENS) or Neuromodulation Therapy Specialty Matched Consultant Advisory Panel review 10/16/2013. No change to policy.
Peroral Endoscopic Myotomy for Treatment of Esophageal Achalasia New policy developed. Peroral endoscopic myotomy for treatment of esophageal achalasia is considered investigational. Medical Director review 9/2013.
Pharmacogenetic Testing for Warfarin Dose Specialty Matched Consultant Advisory Panel review 10/2013. References updated. No changes to Policy Statements.
Progenitor Cell Therapy for the Treatment of Damaged Myocardium Due to Ischemia Specialty Matched Consultant Advisory Panel review 10/2013. No changes to Policy Statements.
Signal-Averaged ECG Specialty Matched Consultant Advisory Panel review 10/2013. References updated. Medical Director review 10/2013. No changes to Policy Statements.
Spinal Cord Stimulation Specialty Matched Consultant Advisory Panel review 10/16/2013. No change to policy.
Stem-cell Therapy for Peripheral Arterial Disease Specialty Matched Consultant Advisory Panel review 10/2013. No changes to Policy Statements.
T-Wave Alternans Specialty Matched Consultant Advisory Panel review 10/2013. Medical Director review 10/2013. References updated. Policy archived.
Temporomandibular Joint Dysfunction (TMJD) Specialty Matched Consultant Advisory panel review 10/21/2013. No changes to policy statement.
Tinnitus Treatment Specialty Matched Consultant Advisory Panel review 8/21/13. No change to Policy guidelines.
Transanal Endoscopic Microsurgery (TEMS) Reference added. Specialty Matched Consultant Advisory Panel review 10/16/13. No change to policy intent.
Transcatheter Heart Valve Implantation Updated "When Covered" section to state "Severe aortic stenosis with a calcified aortic annulus as defined by one or more of the following criteria..." Removed statement "Severe aortic stenosis with a calcified aortic annulus defined as..."
Transtympanic Micropressure Applications as a Treatment of Meniere's Disease Specialty Matched Consultant Advisory Panel review 8/21/13. No change to policy statement.
Vagus Nerve Stimulation Added M60.872 and M60.879 to the ICD10 list in the Billing/Coding section.
Evidence Based Guidelines
Biochemical Markers of Alzheimer's Disease Specialty Matched Consultant Advisory Panel review 10/16/2013. No change to guideline.
Blood Glucose Monitors for Use in the Home Medical Director review. References added. Specialty Matched Consultant Advisory Panel review 7/17/13. No change to Guideline.
External Insulin Pumps Medical Director review. References added. Specialty Matched Consultant Advisory Panel review 7/17/13. No change to policy guidelines.
Hip Resurfacing References updated. No changes to Guideline Statements.
Prothrombin Time Monitoring in the Home References updated. Description section updated. Specialty Matched Consultant Advisory Panel review 10/2013. No changes to Guideline Statements.
Septoplasty Specialty Matched Consultant Advisory Panel Review 8/21/13. No change to policy statement or coverage criteria.
Transurethral Microwave Thermotherapy for Benign Prostatic Hyperplasia Medical Director review 10/2013. Guideline archived.