Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for February 11, 2014

Medical Guidelines Reason for Update
Allergy Testing Specialty Matched Consultant Advisory Panel review 11/2013. References updated. Medical Director review 11/2013. Added the following statements to the "When Covered" section: "Repeat Allergy Skin Testing-a.) Repeat skin testing with multiple antigens is medically necessary for children who are Initially sensitive to food and indoor environmental exposures but later develop pollen and outdoor mold sensitivities. b.) Repeat skin testing may be considered medically necessary for adults who: i.)develop dramatic change of symptoms, ii)have received three to five years of venom immunotherapy, .iii.)are being evaluated for newly discovered purified or standardized allergens." Added the following statement to the "When not Covered" section: "Repeat skin testing with multiple antigens is considered not medically necessary when criteria in the covered section are not met." Policy noticed 12/10/13 for effective date 02/11/14.
Allogeneic Stem-Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms Description and Policy Guidelines sections updated. No change to policy intent. Reference added.
Anesthesia Services Specialty Matched Consultant Advisory Panel review 1/28/14. No change to policy statement.
Axial Lumbosacral Interbody Fusion "In 2013, TranS1 acquired Baxano and changed the company name to Baxano Surgical." added to the Description section. Reference added.
Balloon Ostial Dilation for Treatment of Chronic Sinusitis Title changed from "Balloon Sinuplasty" to "Balloon Ostial Dilation". Policy Guidelines updated. References added. No change to Policy statement.
Bioimpedance Devices for Detection of Lymphedema Reference added. No change to Policy Statement.
Capsaicin (Qutenza®) Specialty Matched Consultant Advisory Panel review 1/28/2014. No change to policy.
Cardiovascular Disease Risk Tests Description section updated. Added the following Policy Statements: "Cardiovascular disease risk panels are considered investigational. BCBSNC does not provide coverage for investigational services or procedures." Added the following tests as investigational: Brain Natriuretic Peptide and Leptin. Added the following statements to the "When not Covered" section: "Measurement of Brain Natriuretic Peptide (BNP) is considered investigational for predicting cardiovascular disease risk. Measurement of leptin is considered investigational for predicting cardiovascular disease risk. Cardiovascular disease risk panels, consisting of multiple individual biomarkers intended to assess cardiac risk, are considered investigational." Policy Guidelines updated. References updated. Added the following codes to the "Billing/Coding" section: Diagnosis codes 250, 250.0, 250.00, 250.01, 250.02, 250.03, 250.1, 250.10, 250.11, 250.12, 250.13,250.2, 250.20, 250.21, 250.22, 268.9, 402, 402.1, 402.10, 402.11, 402.9, 402.90, 402.91, V17.2, V17.4, V17.41, V17.49, V72.6, V72.60, V72.62, V72.69, V77, V77.1, V77.8, V77.9, V77.91, V77.99, V81, V81.0, V81.1, V81.2. Added CPT code 83880. Added the following statement: "There is no specific CPT code for Leptin. CPT code 83520 or 82397 may be used." Medical Director review 11/2013. Policy noticed 12/10/13 for effective date 2/11/14.
Dermatologic Applications of Photodynamic Therapy Description section updated. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 1/2014. Medical Director review 1/2014. References updated. No changes to Policy Statements.
Genetic Testing for Predisposition to Inherited Hypertrophic Cardiomyopathy References updated. No changes to Policy Statements.
Hematopoietic Stem-Cell Transplantation for CNS Embryonal Tumors and Ependymoma Minor updates to the Description and Policy Guidelines sections. No change to policy intent. Reference added.
Hematopoietic Stem-Cell Transplantation for Epithelial Ovarian Cancer Minor updates to the Description and Policy Guidelines sections. No change to policy intent. Reference added.
Hyperbaric Oxygen Pressurization Specialty Matched Consultant Advisory Panel review 1/28/2014. No change to policy.
Hyperhidrosis, Treatment of Specialty Matched Consultant Advisory Panel review 1/2014. Medical Director review 1/2014. No changes to Policy Statements.
Intensity Modulated Radiation Therapy (IMRT) of Abdomen and Pelvis Reference added. No change to policy statement.
Intravenous Anesthetics for the Treatment of Chronic Pain Specialty Matched Consultant Advisory Panel review 1/28/2014. No change to policy statement.
Laser Treatment of Onychomycosis Specialty Matched Consultant Advisory Panel review 1/1024. Medical Director review 1/2014. References updated. No changes to Policy Statement.
Light Therapy for Dermatologic Conditions Specialty Matched Consultant Advisory Panel review 1/2014. Medical Director review 1/2014. Re-formatted "When Covered" section to bulleted items and added Cutaneous T-cell lymphoma as a covered condition for treatment with targeted phototherapy. "When not Covered" section re-formatted to bulleted items and statement revised to state: "Targeted phototherapy is considered investigational for the following conditions, including but not limited to: First-line treatment of mild psoriasis, Generalized psoriasis or psoriatic arthritis, Vitiligo" Policy Guidelines updated.
Modifier Guidelines In the "Policy" section, deleted modifier 22 from the list of modifiers that may affect claims payment. In the "Modifier Guidelines" section, bulleted section on Modifier 59: added codes 22633 and 22634 so that the statement reads: "Modifier 59 will not allow additional payment when appended to CPT4 codes 63005, 63012, 63017, 63030, 63035, 63042, 63044, 63047 and 63048 when performed in conjunction with 22630, 22632, 22633 and/or 22634." Statement regarding anatomic-specific modifiers was reworded and modifiers LM and RI added to the list of coronary artery anatomic modifiers. In the "Policy Guidelines" section: deleted the statement "BCBSNC claims system processes only one modifier per CPT code." Notification given 12/10/13 for effective date 2/11/14.
Mohs' Micrographic Surgery Specialty Matched Consultant Advisory Panel review 1/2014. Medical Director review 1/2014. References updated. No changes to Policy Statements.
Navigated Transcranial Magnetic Stimulation (nTMS) New policy. "Navigated transcranial magnetic stimulation is considered investigational for all indications, including but not limited to the preoperative evaluation of patients under consideration for brain surgery, when localization of eloquent areas of the brain (eg, controlling verbal or motor function) is needed for surgical planning." Senior Medical Director review 1/29/14.
Neural Therapy Specialty Matched Consultant Advisory Panel review 1/28/2014. No change to policy. Reference added.
Non-Pharmacologic Treatment of Rosacea Routine annual policy review. The section titled "Hospital Acquired Conditions and Codes" that contained a table of ICD-9-CM codes was removed from this policy.
Nonpayment for Serious Adverse Events Specialty Matched Consultant Advisory Panel review 1/2014. References updated. Description section updated. Medical Director review 1/2014.No changes to Policy Statement.
Optical Diagnostic Devices for Evaluating Skin Lesions Suspected of Malignancy Specialty Matched Consultant Advisory Panel review 1/2014. Medical director review 1/2014. No changes to Policy Statements.
Proteomics-based Testing Related to Ovarian Cancer Specialty Matched Consultant Advisory Panel review 3/20/13. Related policy deleted. Related guideline added. Policy title changed from Proteomics-based Testing for the Evaluation of Ovarian (Adnexal) Masses to Proteomics-based Testing Related to Ovarian Cancer. Policy description extensively revised. Policy Guidelines updated. No change to Policy statement. Senior Medical Director review.
Sacroiliac Joint Fusion Revised statement in the When Covered section for clarification. Statement changed from; "when multisegment spinal constructs extend to the sacrum/ilium, for covered lumbar spine fusion procedures (See medical policy, 'Lumbar Spine Fusion Surgery')." to "when multisegment spinal constructs extend to the sacrum/ilium, as a component of medically necessary lumbar spine fusion procedures (See medical policy, 'Lumbar Spine Fusion Surgery')." Senior Medical Director review 1/30/2014.
Spinal Manipulation under Anesthesia Specialty Matched Consultant Advisory Panel review 1/28/2014. No changes to policy statement. Reference added.
Surgical Management of Transcatheter Heart Valves Description section updated. Policy Statements for Transcatheter Aortic Valve Implantation (TAVI) updated to include transapical approach as medically necessary with the same clinical indications as transfemoral approach. Policy Guidelines updated. References updated. Medical Director review 1/2014.
Transcranial Magnetic Stimulation CPT code 0310T removed from Billing/Coding section.
Ultraviolet Light Therapy in the Home Setting(UVB) Specialty Matched Consultant Advisory Panel review 1/2014. Medical Director review 1/2014. References updated. Added the following conditions under "When Covered" section: "hepatic or renal failure associated pruritus".
Ustekinumab (Stelara®) Specialty Matched Consultant Advisory Panel review 1/2014. Medical Director review 1/2014. No changes to Policy Statements.
Evidence Based Guidelines
Erythropoiesis-Stimulating Agents (ESAs) Added the following statement to the Description section; "In February 2013, Affymax, Takeda, and FDA announced a voluntary recall of all lots of peginesatide due to postmarketing reports of serious hypersensitivity reactions, including anaphylaxis. FDA currently lists peginesatide (Omontys) as discontinued." Removed "The use of peginesatide may be appropriate for: treatment of anemia associated with chronic kidney disease in adults on dialysis." from the Evidence Based Guideline section. Reference added.
KRAS and BRAF Mutation Analysis in Cancer Description section updated. Evidence Based Guideline section reworded, no change to intent. Reference added.
Monitored Anesthesia Care (MAC) Specialty Matched Consultant Advisory Panel review 1/28/2014. No change to guideline.
Total Body Photography References updated. Specialty Matched Consultant Advisory Panel review 1/2014. Medical Director review 1/2014.