Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for January 28, 2014

Medical Guidelines Reason for Update
Alefacept Injection (Amevive) Medical Director review. Product remains unavailable in the United States. Policy archived.
BRAF Gene Mutation Testing to Select Melanoma Patients for BRAF Inhibitor Therapy Description and Policy Guidelines sections updated. No change to policy intent. Medical Director review 1/10/2014. Reference added.
Carrier Testing for Genetic Disease New policy developed. Carrier testing for genetic diseases is considered medically necessary when one of the following criteria is met: The individuals have a previously affected child with the genetic disease OR One or both individuals have a first- or second-degree relative who is affected OR One or both individuals have a first-degree relative with an affected offspring OR One individual is known to be a carrier OR One or both individuals are members of a population known to have a carrier rate that exceeds a threshold considered appropriate for testing for a particular condition; AND all of the following criteria are met: The natural history of the disease is well understood and there is a reasonable likelihood that the disease is one with high morbidity in the homozygous or compound heterozygous state. Alternative biochemical or other clinical tests to definitively diagnose carrier status are not available, or, if available, provide an indeterminate result or are individually less efficacious than genetic testing. The genetic test has adequate sensitivity and specificity to guide clinical decision making and residual risk is understood. An association of the marker with the disorder has been established. Expanded carrier screening panels are considered to be not medically necessary. Medical Director review 12/2013.
Developmental Delay Screening and Testing Guidelines Medical Director review. References updated. Added information regarding coverage of preventive screenings to the "Benefits Application" section.
Fetal RHD Genotyping Using Maternal Plasma New policy developed. Fetal RHD genotyping using maternal plasma is considered investigational. Medical Director review 1/2014.
Gastroesophageal Reflux Disease, Transendoscopic Therapies References added. CPT codes 43212, 43236, and 43266 added to Billing/Coding section. Specialty Matched Consultant Advisory Panel review 10/16/13. No change to policy statement.
Gene-Based Tests for Screening, Detection, and/or Management of Prostate Cancer Added information regarding microarray-based gene expression analysis to the Description and Policy Guidelines sections. The statement; "Gene expression analysis to guide management of prostate cancer is considered investigational in all situations." was added to the When Not Covered section. Added CPT code 81479, 81599 and 84999 to Billing/Coding section. Senior Medical Director review 1/13/2014. Reference added.
Genecept Assay New policy developed. The GeneceptTM panel assay is considered investigational for all indications. Medical Director review 1/2014.
Genetic Testing for Breast and Ovarian Cancer Minor revisions to Description and Policy Guidelines section. Senior Medical Director review 1/13/14. Reference added.
Genetic Testing for Colon Cancer "Genetic testing for BRAF V600E or MLH1 promoter methylation may be considered medically necessary to exclude a diagnosis of Lynch syndrome when MLH1 protein is not expressed in a colorectal cancer on immunohistochemical (IHC) analysis." added to the When Covered section. "Genetic testing for all other gene mutations for Lynch syndrome or colorectal cancer is considered investigational." added to the When Not Covered section. CPT code 81210 added to the Billing/Coding section. References added. Senior Medical Director review 1/13/2014.
Genetic Testing for Lactase Insufficiency New policy developed. The use of targeted mutation analysis (genetic testing) of -13910 C>T for the prediction of lactase insufficiency is considered investigational. Medical Director review 1/2014.
Immune Cell Function Assay Policy Guidelines section updated. Reference added.
Multiple Surgical Procedure Guidelines for Professional Providers Determination of the primary procedure, as stated in the section "Guidelines for Reimbursement of Multiple Surgical Procedures" was changed from the procedure with the highest charge to procedure with the higher RVU. Statement now reads: "Typically the primary procedure is the one with the higher RVU (relative value units)."
Occipital Nerve Stimulation Reference added.
Pharmacogenetic Testing for Warfarin Dose Description section updated. References updated. No changes to Policy Statements.
Quantitative Electroencephalography as a Diagnostic Aid for Attention Deficit/Hyperactivity Disorder New policy developed. Quantitative electroencephalographic (EEG)-based assessment is considered investigational as a diagnostic aid for neuropsychiatric disorders. Medical Director review 1/2014.
Sacral Nerve Neuromodulation/Stimulation for Pelvic Floor Dysfunction Diagnosis code 788.22 deleted from Billing/Coding section.
Sensory Integration Therapy Reference added. No change to Policy statement.
Small Bowel, Small Bowel with Liver, or Multivisceral Transplant Reference added. No change to Policy Statement.
Suprachoroidal Delivery of Pharmacologic Agents Reference added. No change to policy statement.
Surgery for Obstructive Sleep Apnea and Upper Airway Resistance Syndrome Specialty Matched Consultant Advisory Panel review 8/21/13. No change to policy statement or coverage criteria.
Evidence Based Guidelines
Bevacizumab in Advanced Adenocarcinoma of the Pancreas Description section updated.
Diagnosis and Treatment of Sacroiliac Joint Pain Added HCPCS codes G0259 and G0260 to Billing/Coding section.
Endovascular Stent Grafts for Abdominal Aortic Aneurysm References updated. No changes to Guideline Statements.
Endovascular Stent Grafts for Thoracic Aortic Aneurysm References updated. No changes to Guideline Statements.