Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for January 14, 2014

Medical Guidelines Reason for Update
Balloon Sinuplasty for Treatment of Chronic Sinusitis Specialty Matched Consultant Advisory Panel review 8/21/13. No change to policy statement.
Bioimpedance Devices for Detection of Lymphedema Specialty Matched Consultant Advisory Panel review 11/20/13. No change in policy statement.
Breast Surgeries References updated. No changes to Policy Statements.
Cardiac (Heart) Transplantation Description section updated. Policy Guidelines updated. No changes to Policy Statements. References updated.
Clinical Trial Services for Life-Threatening Conditions Updated coverage criteria, description and benefits section for consistency with Patient Protection and Affordable Care Act of 2010. Medical director review 1/2014.
Electrostimulation and Electromagnetic Therapy for Wounds Reference added. Specialty Matched Consultant Advisory Panel review 11/20/13. When Not Covered section reworded for clarity. No change to Policy statement.
Genetic Testing for Macular Degeneration New medical policy issued. Genetic testing for macular degeneration is considered investigational. Medical director review 12/2013.
Golimumab (Simponi Aria) Under "When Covered" section: Statement #1 added Moderate to Severe and to #A: added the word alone to the statement (there has been a therapeutic failure/inadequate response with methotrexate alone, or). Medical director review 1/2014.
Growth Factors in Wound Healing Specialty Matched Consultant Advisory Panel review 11/20/13. No change to Policy statement.
Heart-Lung Transplantation Added the following statement to the "When Covered" section: "Heart/lung re-transplantation after a failed primary heart/lung transplant may be considered medically necessary in patients who meet criteria for heart/lung transplantation." Description section updated. Policy Guidelines updated. References updated.
Ingestible pH and Pressure Capsule Specialty Matched Consultant Advisory Panel review 10/16/13. No change to Policy statement.
Multianalyte Assays for the Evaluation and Monitoring of Patients with Liver Disease Reference added. The statement "Combined serum markers of hepatic fibrosis, evaluated with algorithms to produce a predictive score, are considered investigational in the diagnosis and monitoring of patients with chronic liver disease" was removed from the When Not Covered section. Medical Director review. Specialty Matched Consultant Advisory Panel review 10/16/13. No change to Policy statement.
Outpatient Use of Limb Pneumatic Compression Devices for Venous Thromboembolism Prophylaxis Specialty Matched Consultant Advisory Panel review 11/20/13. No change to Policy statement.
Plugs for Fistula Repair Reference added. Specialty Matched Consultant Advisory Panel review 11/20/2013. No change to Policy statement.
Rhinoplasty Specialty Matched Consultant Advisory Panel review 8/21/13. Removed the statement "For correction of vestibular stenosis and/or nasal valve collapse causing airway compromise but without nasal bony deformity requiring correction" from the When Not Covered section.