Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for December 31, 2013

Medical Guidelines Reason for Update
Ambulance and Medical Transport Services Added HCPCS codes S9960 and S9961 to Billing/Coding section for 2014 code update.
Aqueous Shunts and Devices for Glaucoma Added CPT code 66183 and deleted 0192T from the Billing/Coding section for 2014 code update.
Artificial Intervertebral Disc Specialty Matched Consultant Advisory Panel review 10/16/2013. Description section updated. No change to policy intent. Reference added.
Bioengineered Skin and Tissue C5271, C5272, C5273, C5274, C5275, C5276, C5277, C5278, Q4137, Q4138, Q4139, Q4140, Q4141, Q4142, Q4143, Q4145, Q4146, Q4147, Q4148, Q4149 added to Billing/Coding section. New products added to the "When not Covered" section.
Bone Morphogenetic Protein Policy extensively revised. Description section updated. "When Covered" section revised to state: "Use of recombinant human bone morphogenetic protein-2 (rhBMP-2, InFUSE) may be considered medically necessary in skeletally mature patients: • For anterior lumbar interbody fusion procedures when use of autograft is unfeasible. • For instrumented posterolateral intertransverse spinal fusion procedures when use of autograft is unfeasible. For the treatment of acute, open fracture of the tibial shaft, when use of autograft is unfeasible.Use of recombinant human bone morphogenetic protein-7 (rhBMP-7, OP-1) may be considered medically necessary in skeletally mature patients: • For revision posterolateral intertransverse lumbar spinal fusion, when use of autograft is unfeasible. • For recalcitrant long-bone nonunions where use of autograft is unfeasible and alternative conservative treatments have failed." "When not Covered" section revised to state: "Bone morphogenetic protein (rhBMP-2 or rhBMP-7) is considered not medically necessary for all other indications, including but not limited to spinal fusion when use of autograft is feasible." Policy Guidelines updated. References updated. Medical Director review 10/2013. Policy noticed on 10/15/13 for effective date 12/31/13.
Botulinum Toxin Injection Specialty Matched Consultant Advisory Panel review 10/16/2013. Description section updated. Changed the wording in #6 under the When Covered section from "and/or" to "with or without" for clarification. Added Facial wound healing and internal anal sphincter (IAS) achalasia to the When Not Covered section. Added new 2014 CPT codes, 64616, 64617, 64642, 64643, 64644, 64645, 64646, and 64647 to Billing/Coding section. Removed deleted codes, 64613 and 64614. Reference added.
Capsaicin (Qutenza®) Changed the following statement from "CPT code 64614 should not be used for the administration of capsaicin." to "CPT codes 64642, 64643, 64644, 64645, 64646 and 64647 should not be used for the administration of capsaicin." in the Billing/Coding section. CPT code 64614 deleted 12/31/2013.
Capsule Endoscopy, Wireless Reference added. Ulcerative colitis, acute GI bleeding and Lynch syndrome added to investigational policy statement. Medical Director review. Notification given 10/29/13 for policy effective date 12/31/13.
Chemoembolization of the Hepatic Artery, Transcatheter Approach Reference added. CPT code updated with new 2014 coding. CPT code 37204 deleted and CPT code 37243 added to Billing/Coding section. Policy statements unchanged.
Chiropractic Services Added "14. Kinesiology taping is considered investigational." to the When Not Covered section. Added the following statement to the Billing and Coding section to indicate; "Strapping codes (29200 - 29280, 29520 - 29580, and 29799) are only used for immobilization and should not be used for kinesiology taping." Senior Medical Director review 10/11/2013. Reference added. Notification given 10/29/2012. Policy effective 12/31/2013.
Chromosomal Microarray (CMA) Analysis for Genetic Evaluation of Developmental Delay/Autism Spectrum Disorder S3870 added to Billing/Coding section.
Code Bundling Rules Not Addressed in ClaimCheck® or Correct Coding Initiative New codes added for Interprofessional Telephone/Internet Consultations. 99446, 99447, 99448 and 99449 are considered incidental and not eligible for separate reimbursement.
Computerized 2-Lead Resting Electrocardiogram (Multifunction Cardiogram) References updated. No changes to Policy Statements.
Congenital Heart Defect, Repair Devices Removed all information regarding patent ductus arteriosus (PDA) and PDA closure devices. References updated. Deleted CPT code 37204. Added new CPT codes 37241, 37242, 37243, and 37244 to Billing/Coding section. Medical Director review 11/2013.
Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate, or Dermatologic Tumors Coding update. CPT code 0340T added to Coding/Billing section.
Dental Reconstructive Services Added Dental codes D6011, D6013, D6052 to Billing/Coding section for 2014 code update.
Gastroesophageal Reflux Disease, Transendoscopic Therapies Coding update. CPT code 43219 removed from Billing/Coding section.
Genetic Testing for Colon Cancer Deleted HCPCS codes S3833 and S3834 from Billing/Coding section.
Golimumab (Simponi Aria) "Extensive revisions made to the "When Covered" and "When Not Covered" sections. Deleted the following statements from the "When Covered" section: 1.a) treatment of ankylosing spondylitis; 1.b) treatment of psoriatic arthritis; b.3) Rheumatoid or psoriatic arthritis is rapidly progressing and advancing; c.1 and 2) deleted the entire statement: moderate to server ulcerative colitis when the member requires continuous steroid or inadequate response or intolerance to prior steroid treatment; 3. Deleted entire statement: the member has been screened for the presence of latent TB infection." Deleted statement: "The member previously used either etanercept (Enbrel) or adalimumab (Humira), and such drug was ineffective or not tolerated." Revised description section and added Aria to any Simponi indication throughout the policy. Effective date remains 1/1/14. Added HCPCS code J1602 to "Billing/Coding" section for 1/1/2014 code update."
Handheld Radiofrequency Spectroscopy for Intraoperative Assessment of Surgical Margins during Breast-Conserving Surgery New policy developed. Handheld radiofrequency spectroscopy for intraoperative assessment of surgical margins during breast-conserving surgery is considered investigational. Medical Director review 9/2013. Notification given 10/29/13 for policy effective date 12/31/13.
Identification of Microorganisms Using Nucleic Acid Probes Added CPT code 87661 to Billing/Coding section.
Immune Globulin Therapy "Reference added. Medical Director review. Severe anemia due to parvovirus B19 added as medically necessary. Opsoclonus-myoclonus, birdshot retinopathy, epidermolysis bullosa acquisita, necrotizing fasciitis and polyradiculoneuropathy (other than CIDP) added as investigational. Notification given 10/29/13 for policy effective date of 12/31/13. Coding update. C9130 deleted and J1556 added effective 01/01/14."
Intra Articular Hyaluronan Injections for Treatment of Osteoarthritis of the Knee Evidence Based Guideline converted to Corporate Medical Policy. Description section revised. Information regarding preferred medications Euflexxa® and Synvisc/Synvisc One®, added to Policy Statement. "When Covered" section revised as follows: Euflexxa® and Synvisc/Synvisc One® injections may be considered medically necessary for the treatment of pain in osteoarthritis of the knee when conservative treatment has failed. Non-preferred intra-articular hyaluronan injections may be covered if the patient has previously used at least one of the preferred drugs as indicated above, and such drug has been detrimental to the patient's health or has been ineffective in treating the patient's condition. "When not Covered" section revised to state: "The use of intra-articular hyaluronan injections in the knee is not covered when the above criteria are not met. Intra-articular injections in joints other than the knee are considered investigational." Medical Director review. References updated. Notification given 10/15/13 for effective date 12/31/13. Added the following statement to the ""When Covered"" section: "Non-preferred intra-articular hyaluronan injections may be covered if the patient is currently receiving treatment with a non-preferred drug." Effective date remains 12/31/13.
Magnetic Esophageal Ring to Treat Gastroesophageal Reflux Disease (GERD) Reference added. Specialty Matched Consultant Advisory Panel review 11/20/2013. Medical Director review. HCPCS code C9737 added to Billing/Coding section effective 01/01/2014. CPT 43289 removed from Billing/Coding section. No change to Policy statement.
Microarray-based Gene Expression Testing for Cancers of Unknown Primary Description section updated. Added CPT code 81504 to the Billing/Coding section. Reference added.
Microprocessor-Controlled Prostheses for the Lower Limb L5969 added to Billing/Coding section.
Nerve Fiber Density Testing Specialty Matched Consultant Advisory Panel review 10/16/13. No change to policy intent. Added new 2014 CPT code, 88343 to Billing/Coding section. Reference added.
Neurostimulation, Electrical Archived Neuromuscular Electrical Stimulation (NMES) and Threshold Electrical Stimulation sections of policy.
Non-Contact Ultrasound Treatment for Wounds Specialty Matched Consultant Advisory Panel review 11/20/2013. No change to Policy statement. Coding update. Code 0183T deleted and code 97610 added effective 01/01/14.
Occipital Nerve Stimulation Added the following codes to the Billing/Coding section: L8679, L8680, L8681, .L8682, L8683, L8684, L8685, L8686, L8687, L8688, and L8689.
Orthotics L0455, L0457, L0467, L0469, L0641, L0642, L0643, L0648, L0649, L0650, L0651, L1812, L1833, L1848, L3678, L3809, L3916, L3918, L3924, L3930, L4361, L4387, L4397 added to Billing/Coding section.
Oscillatory Devices for the Treatment of Respiratory Conditions Added CPT code 94669 to Billing/Coding section for 2014 code update.
Ovarian and Internal Iliac Vein Embolization Coding update. CPT 37204 deleted. CPT 37243 added.
Peripheral Arterial Tonometry (PAT) New policy developed. Peripheral arterial tonometry is considered investigational for all applications. BCBSNC does not provide coverage for investigational services or procedures. Medical Director review 11/2013.
Radioembolization for Primary and Metastatic Tumors of the Liver Added CPT code 37210 to the Billing/Coding section for 2014 code update and deleted CPT 37204.
Radiofrequency Ablation of the Renal Nerves as a Treatment of Hypertension Deleted unlisted code 64999 and added CPT codes 0338T and 0339T to Billing/Coding section.
Rehabilitative Therapies Added CPT codes 92521, 92522, 92523, 92524 to Billing/Coding section for 2014 coding update. Deleted CPT code 92506.
Removal of Impacted Cerumen New information added to Billing/Coding section: Effective 1/1/2014 CPT 69210 describes a unilateral procedure. To report a bilateral procedure, append modifier -50 with "2" in the units field.
Rituximab for the Treatment of Rheumatoid Arthritis Added ICD-10 diagnosis code M08.029 to Billing/Coding section and changed M05.11 to M05.111 for 2014 code update.
Sacral Nerve Neuromodulation/Stimulation for Pelvic Floor Dysfunction Specialty Matched Consultant Advisory Panel review 11/2013. Added the following codes to the Billing/Coding section: CPT code L8679. Diagnosis codes 787.60, 787.61, 787.62, 787.63, 788.20, 788.21, 788.22, 788.29, 788.30, 788.31, 788.32, 788.33, 788.34, 788.35, 788.36, 788.37, 788.38, 788.39. ICD-10 Diagnosis codes R15.9, R15.0, R15.1, R15.2, R33.9, R33.9, R39.14, R33.0, R33.8, R32, N39.41, N39.3, N39.46, N39.42, N39.43, N39.44, N39.45, N39.490, N39.498. Medical Director review 12/2013.
Sequencing Based Tests to Determine Trisomy 21 from Maternal Plasma DNA Coding update. CPT code 0005M deleted. CPT code 81507 added.
Sleep Apnea: Diagnosis and Medical Management New code A7047 added to Billing/Coding section.
Spinal Cord Stimulation Added new 2014 HCPCS code, L8679, to Billing/Coding section.
Subtalar Arthroereisis CPT code 0335T added to Billing/Coding section.
Surgical Management of Transcatheter Heart Valves Policy title changed from "Transcatheter Heart Valve Implantation" to "Surgical Management of Transcatheter Heart Valves." Coding updated. Removed CPT code 0318T. Added 0342T, 0343T, 0344T, 0345T and 33666 to Billing/Coding section. Added the following statement to "When not Covered" section: "Transcatheter mitral valve implantation is considered investigational." Description section updated. Policy Guidelines updated. References updated. Medical Director review 11/2013.
Tumor-Treatment Fields Therapy for Glioblastoma Added new HCPCS codes, A4555 and E0766, to the Billing/Coding section. Removed the following statement from the Billing/Coding section; "Providers will most likely use E1399 and A9900 for claim submission."
Vagus Nerve Stimulation Added new 2014 HCPCS code, L8679 to Billing/Coding section.
Varicose Veins, Treatment for Specialty Matched Consultant Advisory Panel review 11/20/2013. No change to Policy statement. Coding update. CPT codes 37241 and 37244 added to policy.
Evidence Based Guidelines
Ado-Trastuzumab Emtansine (Trastuzumab-DM1) for Treatment of HER-2 Positive Malignancies Added 2014 HCPCS code, J9354 to Billing/Coding section. Deleted HCPCS code C9131.
Deep Brain Stimulation Added new 2014 HCPCS code, L8679, to Billing/Coding section.
Endovascular Stent Grafts for Abdominal Aortic Aneurysm Coding updated. Deleted CPT codes 0078T, 0079T, 0080T and 0081T. Added 34841, 34842, 34843, 34844, 34845, 34846, 34847, and 34848 to Billing/Coding section.
Interventions for Progressive Scoliosis L0455, L0457, L0467, L0469, L0641, L0642, L0643, L0648, L0649, L0650, L0651 added to Billing/Coding section.
KRAS and BRAF Mutation Analysis in Cancer Specialty Matched Consultant Advisory Panel review 8/21/13. No change to guideline.
Ocriplasmin for Symptomatic Vitreomacular Adhesion Added HCPCS code J7316 to "Billing/Coding" section for 1/1/14 code update. Deleted HCPCS code C9298.
Pertuzumab for Treatment of HER2-Positive Malignancies Added 2014 HCPCS code, J9306, to Billing/Coding section. Deleted HCPCS code C9292.
Uterine Artery Occlusion in the Treatment of Uterine Fibroids Coding update. CPT 37210 removed. CPT 37243 added.