Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for November 26, 2013

Medical Guidelines Reason for Update
Acute and Maintenance Tocolysis Reference added. Specialty Matched Consultant Advisory Panel review 9/18/13. Policy statement changed to read "Maintenance tocolytic therapy (beyond 48-72 hours) with any medication is considered not medically necessary". Statement added to Policy Guidelines that maintenance tocolytic therapy is "not medically necessary, as the treatment is ineffective in prolonging gestation after acute tocolysis".
Children's Mobility and Positioning Equipment Under Description section 2nd bullet: relocated the word "prone" and placed in parentheses with "supine, upright and dynamic" as other examples of standers. Medical director review 11/2013.
Denosumab (ProliaTM, XGEVATM) Specialty Matched Consultant Advisory Panel review 9/18/13. No change to Policy statement.
Electrical Bone Growth Stimulation References updated. No changes to Policy Statements.
Epidermal Growth Factor Receptor (EGFR) Mutation Analysis for Patients with Non-Small Cell Lung Cancer (NSCLC) Added "of nonsquamous cell type" to the When Covered statement.
Facet Joint Denervation Specialty Matched Consultant Advisory Panel review 10/16/2013. Added "(e.g., alcohol, phenol, or high-concentration local anesthetics)" as examples of chemical denervation. Policy Guidelines updated. No change to policy intent.
Genetic Testing for Cutaneous Malignant Melanoma Specialty Matched Consultant Advisory Panel review 10/16/2013. Added "(e.g., alcohol, phenol, or high-concentration local anesthetics)" as examples of chemical denervation. Policy Guidelines updated. No change to policy intent.
Hyperthermic Intraperitoneal Chemotherapy Description and Policy Guidelines sections updated. No change to policy intent. Reference added.
Implantable Cardioverter Defibrillator Description section updated. Policy Guidelines updated. References updated.
Infertility Diagnosis and Treatment Policy returned to active review. Senior Medical Director review. AIDS removed from list of contraindications to AI in both females and males. Statement related to dollar limits removed. Added the statements that "Indications for AI related to male infertility are eligible for 3 cycles of AI per pregnancy attempt" and "Members meeting the medically necessary criteria related to female infertility listed above are eligible for 3 cycles of AI using sperm from the male partner per pregnancy attempt".
Infliximab (Remicade) Reference updated. No change to policy statement.
Injectable Clostridial Collagenase for Fibroproliferative Disorders Description section updated. References updated. No changes to Policy Statements.
Magnetoencephalography/Magnetic Source Imaging Reference added. No change to Policy statement.
Optical Diagnostic Devices for Evaluating Skin Lesions Suspected of Malignancy Policy Guidelines updated. References updated. No changes to Policy Statements.
Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors Reference added. No change to Policy statement.
Sacroiliac Joint Fusion Added CPT code 0334T to Billing/Coding section, code effective 7/1/2013.
Total Facet Arthroplasty Specialty Matched Consultant Advisory Panel review 10/16/2013. No change to policy.
Transanal Radiofrequency Treatment of Fecal Incontinence Reference added. Specialty Matched Consultant Advisory Panel review 10/16/13. No change to policy statement.
Vertebral Axial Decompression (VAD-X) References updated. No changes to Policy Statements.
Wheelchairs Replaced the word "electrical" with "power" throughout the document. Added full reclining and tilt in space wheelchair to Table 1 page 4. Under "When Not Covered" section a. Trays: added "used solely for convenience purposes." and deleted d. "patient lifts,ceiling lifts, access ramp." Under " When Covered" section: 1.d.vi. added "complex fracture of single to bilateral lower extremity," added 1.d.vii. Amputee; added 2.d.iii. "other neurological conditions that seriously compromise functional status, such as, but not limited to, CHF Class 3 and 4, COPD, spinal cord injury, stroke with dense hemiplegia, severe Parkinson's disease, and ALS."; 3.i. added "custom cushions such as Roho"; 3.iv. added "other straps that may be required to secure the patient"; added 3.vii "altered controls such as hand, mouth/head controls." Medical director review 11/2013.
Evidence Based Guidelines
Bone Turnover Markers for the Diagnosis and Management of Osteoporosis and Diseases Associated with High Bone Turnover Reference added. No change to Policy statement.
Diabetic Retinopathy Telescreening Reference updated. No change to guideline statement.
Endoscopic Radiofrequency Ablation or Cryoablation for Barrett's Esophagus Specialty Matched Consultant Advisory Panel review 10/16/13. No change to the Evidence Based Guideline.
Fecal Calprotectin Test Specialty Matched Consultant Advisory Panel review 10/16/13. No change to Guideline statement.
Inhaled Nitric Oxide Reference updated. No change to guideline statement.
Pertuzumab for Treatment of HER2-Positive Malignancies Changed the range for Equivocal in Table 1. Testing for HER2 Overexpression and/or Amplification in the Description section from "Ratio of HER2/CEP 17 is between 1.8 and 2.2" to "Ratio of HER2/CEP 17 is between 1.8 and 2.0" based on Specialty Matched Consultant review.
Quantitative Sensory Testing Specialty Matched Consultant Advisory Panel review 5/28/2013. Added the following statement to the Description section; "In addition, to get reliable results, examinations need to be standardized with standardized instructions to the patients, and stimuli must be applied in a consistent manner by trained staff." Reference added.
TENS (Transcutaneous Electrical Nerve Stimulator) Specialty Matched Consultant Advisory Panel review 10/16/2013. No change to guideline.