Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for December 10, 2013

Medical Guidelines Reason for Update
Air Fluidized Beds Added Stage V and VI pressure ulcers to Description and "When Covered" sections. Reference added. Medical director review 10/2013.
Ambulatory Event Monitors Description section updated. References updated. Policy Guidelines updated. Medical Director review 11/2013.
Continuous Monitoring of Glucose in the Interstitial Fluid Removed the phrase "with low glucose suspend (LGS) features" from the When Not Covered section.
Co-Surgeon, Assistant Surgeon, Team Surgeon and Assistant-at-Surgery Guidelines Routine policy review. No change to current policy.
Cytochrome p450 Genotyping The following clinical indication added to "When not Covered" section: "dosing and management of anti-tuberculosis medications." Medical Director review. References updated.
Durable Medical Equipment (DME) Changed the word "physician" to "licensed provider" under both "When Covered" section statement #2 and "Not Covered" section bullet #3. Medical director review 11/2013.
ECG Reimbursement Routine policy review. Name of policy changed from "ECG Reimbursement Issues" to "ECG Reimbursement."
Genetic Testing for CADASIL Syndrome Policy re-titled from "NOTCH3 Genotyping for CADASIL" to "Genetic Testing for CADASIL Syndrome". "When Covered" revised from "Not Applicable" to "Genetic testing to confirm the diagnosis of CADASIL syndrome may be considered medically necessary under the following conditions: 1)Clinical signs, symptoms, and imaging results are consistent with CADASIL, indicating that the pre-test probability of CADSIL is at least in the moderate to high range. 2) The diagnosis of CADASIL is inconclusive following alternate methods of testing, including MRI and skin biopsy. "When not Covered" revised to state: "Genetic testing for CADASIL syndrome in all other situations, including but not limited to testing of asymptomatic patients who have a first or second degree relative with CADASIL, is considered investigational." Policy Guidelines updated. References updated. Medical Director review 11/2013.
Genetic Testing for Hereditary Pancreatitis New policy developed. Genetic testing for hereditary pancreatitis is considered investigational. Medical Director review 9/2013. Notice given 10/1/13 for effective dated 12/10/13.
Guidelines for Global Maternity Reimbursement Routine policy review. No change to current policy.
Hematopoietic Stem-Cell Transplantation for Plasma Cell Dyscrasias, Including Multiple Myeloma and POEMS Syndrome Specialty Matched Consultant Advisory Panel review 11/20/2013. No change to policy intent.
Hematopoietic Stem-Cell Transplantation for Waldenstrom Macroglobulinemia Specialty Matched Consultant Advisory Panel review 11/20/2013. No change to policy intent.
Hematopoietic Stem-Cell Transplantation for Primary Amyloidosis Specialty Matched Consultant Advisory Panel review 11/20/2013. Policy Guidelines updated. No change to policy intent.
Hematopoietic Stem-Cell Transplant for Non-Hodgkin Lymphomas Specialty Matched Consultant Advisory Panel review 11/20/2013. No change to policy intent.
Hematopoietic Stem-Cell Transplantation for Autoimmune Diseases Specialty Matched Consultant Advisory Panel review 11/20/2013. Added "chronic inflammatory demyelinating polyneuropathy" as an investigational indication. Reference added.
Hematopoietic Stem-Cell Transplantation for Chronic Myelogenous Leukemia Specialty Matched Consultant Advisory Panel review 11/20/2013. Updated Policy Guidelines. No change to policy intent.
Hematopoietic Stem-Cell Transplantation for CLL and SLL Specialty Matched Consultant Advisory Panel review 11/20/2013. No change to policy intent.
Hematopoietic Stem-Cell Transplantation for CNS Embryonal Tumors and Ependymoma Specialty Matched Consultant Advisory Panel review 11/20/2013. Policy Guidelines updated. No change to policy intent.
Hematopoietic Stem-Cell Transplantation for Epithelial Ovarian Cancer Specialty Matched Consultant Advisory Panel review 11/20/2013. Description section updated. No change to policy intent.
Hematopoietic Stem-Cell Transplantation for Hodgkin Lymphoma Specialty Matched Consultant Advisory Panel review 11/20/13. No change to policy intent.
Hematopoietic Stem-Cell Transplantation for Solid Tumors of Childhood Specialty Matched Consultant Advisory Panel review. 11/20/2013. No change to policy intent.
Hematopoietic Stem-Cell Transplantation for Miscellaneous Solid Tumors in Adults Specialty Matched Consultant Advisory Panel review 11/20/2013. Policy Guidelines updated. No change to policy intent. Reference added.
Hematopoietic Stem-Cell Transplantation in the Treatment of Germ Cell Tumors Specialty Matched Consultant Advisory Panel review 11/20/2013. No change to policy intent.
Hyperbaric Oxygen Pressurization Added the following indications as investigational to the When Not Covered section: "Bisphosphonate-related osteonecrosis of the jaw, motor dysfunction associated with stroke, herpes zoster and vascular dementia". Senior Medical Director review 9/14/2013. Reference added. Notification given 10/1/2013. Policy effective 12/10/2013.
Idiopathic Environmental Intolerance (i.e. Multiple Chemical Sensitivities) Specialty Matched Consultant Advisory Panel review 11/2013. Medical Director review 11/2013. No changes to Policy Statements.
Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence Specialty Matched Consultant Advisory Panel review 11/2013. Revised "When Covered" statement #1 as follows: "Periurethral bulking agents for the treatment of urinary incontinence are covered when one of the following conditions is present: For incontinence due to intrinsic sphincter deficiency where the patient has failed appropriate conservative therapy." Added L8605 to Billing/Coding section. Medical Director review 11/2013.
JAK2 and MPL Mutations in Myeloproliferative Neoplasms Specialty Matched Consultant Advisory Panel review 11/20/2013. Policy Guidelines revised. No change to policy intent.
Laparoscopic and Percutaneous Techniques for the Myolysis of Uterine Fibroids New policy developed. Laparoscopic and percutaneous techniques of myolysis as a treatment of uterine fibroids are considered investigational for all applications. Medical Director review. Notification given 10/1/13 for policy effective date 12/10/13.
Microwave Tumor Ablation Specialty Matched Consultant Advisory Panel review 11/20/2013. No change to policy.
Pelvic Floor Stimulation as a Treatment of Urinary Incontinence Specialty Matched Consultant Advisory Panel review 11/2013. Medical Director review 11/2013. References updated. No changes to Policy Statements.
Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers Reference added. "Applied to the limb" added to the first 2 covered policy statements and to the first non covered policy statement for clarification. In the statement on venous ulcers, "lymphedema pumps" changed to "pneumatic compression pumps". Senior Medical Director review.
Posterior Tibial Nerve Stimulation for Voiding Dysfunction Specialty Matched Consultant Advisory Panel review 11/2013. Medical Diretor review 11/2013. References updated. No changes to Policy Statements.
Power Operated Vehicle (Scooter) Under "When Covered" section: Reordered the statements #1 and #2, added "endurance" to statement #3, replaced the word "wheelchair" with "scooter" in statement #4. Medical director review 11/2013.
Pressure Reducing Support Surfaces Added Stage V and VI pressure ulcers to Description and "When Covered" sections. Reference added. Medical director review 10/2013.
Quantitative Assay for Measurement of HER2 Total Protein Expression and HER2 Dimers Policy Guidelines updated. Reference added.
Rehabilitative Therapies Under "When Covered" section statement A.4: added PT,OT,or speech therapist. Medical director review 11/2013.
Saturation Biopsy for Diagnosis and Staging of Prostate Cancer Specialty Matched Consultant Advisory Panel review 11/2013. Medical Director review 11/2013. References updated. No changes to Policy Statements.
Systems Pathology for Predicting Risk of Recurrence in Prostate Cancer Specialty Matched Consultant Advisory Panel review 11/2013. Medical Director review 11/2013. No changes to Policy Statements.
Treatment of Hereditary Angioedema Description section updated. References updated. Specialty Matched Consultant Advisory Panel review 11/2013. Medical Director review 11/2013. No changes to Policy Statements.
Tumor-Treatment Fields Therapy for Glioblastoma Specialty Matched Consultant Advisory Panel review 11/20/2013. No change to policy statement.
Urinary Tumor Markers for Bladder Cancer Description section updated to include new test "CxBladder." "CxBladder added to the "When not Covered" section. Unlisted CPT code 81599 added to "Billing/Coding" section. Specialty Matched Consultant Advisory Panel review 11/2013. Medical Director review 11/2013.
Vesicoureteral Reflux, Treatment with Periureteral Bulking Agents Specialty Matched Consultant Advisory Panel review 11/2013. References updated. Removed "duplicate ureters" as a non-covered clinical indication for use of bulking agents. Medical Director review 11/2013.
Xolair® (Omalizumab) Specialty Matched Consultant Advisory Panel review 11/2013. References updated. Description section updated. Medical Director review 11/2013.
Evidence Based Guidelines
Bevacizumab in Advanced Adenocarcinoma of the Pancreas Specialty Matched Consultant Advisory Panel review 11/20/13. No change to policy. Reference added.
Cryoablation of Prostate Cancer Medical Director review 11/2013. Specialty Matched Consultant Advisory Panel review 11/2013. No changes to Guideline Statements.