Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for February 25, 2014

Medical Guidelines Reason for Update
Adoptive Immunotherapy Reference added.
Chromosomal Microarray (CMA) Analysis for Genetic Evaluation of Developmental Delay/Autism Spectrum Disorder Specialty Matched Consultant Advisory Panel review 1/2014. Medical Director review 1/2014. References updated. No changes to Policy Statements.
End Diastolic Pneumatic Compression Boot References updated. No changes to Policy Statements.
Enhanced External Counterpulsation (EECP) Policy Guidelines updated. References updated. No changes to Policy Statements.
Exhaled Nitric Oxide Measurement Description and Policy Guidelines sections updated. References updated. No change to policy statement.
External Defibrillators Policy Guidelines updated. References updated. No changes to Policy Statements.
Functional Endoscopic Sinus Surgery (FESS) Reference added. The word "spacer removed from its association with the word "stent" throughout the policy. No change to Policy intent.
General Approach to Evaluating the Utility of Genetic Panels Specialty Matched Consultant Advisory Panel review 1/2014. Medical Director review 1/2014.
General Approach to Genetic Testing Specialty Matched Consultant Advisory Panel review 1/2014. Description section updated with additional "Related Policies".
Genetic Testing for Alpha-1 Antitrypsin Deficiency Specialty Matched Consultant Advisory Panel review 1/2014. Medical Director review 1/2014. No changes to Policy Statements.
Genetic Testing for CADASIL Syndrome Specialty Matched Consultant Advisory Panel review 1/2014. No changes to Policy Statements.
Genetic Testing for Cutaneous Malignant Melanoma Specialty Matched Consultant Advisory Panel review 1/2014. No changes to Policy Statements.
Genetic Testing for FMR1 Mutations Including Fragile X Syndrome Specialty Matched Consultant Advisory Panel review 1/2014. Medical Director review 1/2014. Added the following clinical conditions to the "When Covered" section: "Women who have ovarian failure before the age of 40; Individuals with symptoms consistent with Fragile X associated tremor and ataxia."
Genetic Testing for Hereditary Hemochromatosis Specialty Matched Consultant Advisory Panel review 1/2014. No changes to Policy Statements.
Genetic Testing for Rett Syndrome Specialty Matched Consultant Advisory Panel review 1/2014. No changes to Policy Statements.
Hematopoietic Stem-Cell Transplantation for Chronic Myelogenous Leukemia Reference added.
Hematopoietic Stem-Cell Transplantation for Hodgkin Lymphoma Reference added.
Identification of Microorganisms Using Nucleic Acid Probes Specialty Matched Consultant Advisory Panel review 1/2014. No changes to Policy Statements.
Interferential Stimulation Reference added.
Intracellular Micronutrient Analysis Specialty Matched Consultant Advisory Panel review 1/2014. No changes to Policy Statements.
Lung and Lobar Lung Transplantation Under "When Covered" section: added the statement "Lung or lobar lung retransplantation after a failed lung or lobar lung transplant may be considered medically necessary in patients who meet criteria for lung transplantation." Under "When Not Covered" section: added the statement "Lung or lobar lung transplantation is considered investigational in all other situations." References updated.
Lysis of Epidural Adhesions Description and Policy Guidelines sections updated. Reference added.
Monoclonal Antibody Imaging for Prostate Cancer Reference added.
Multianalyte Assays for Predicting Risk of Type 2 Diabetes Specialty Matched Consultant Advisory Panel review 1/2014. No changes to Policy Statements.
Non-Contact Ultrasound Treatment for Wounds References added. No change to Policy statement.
Postsurgical Outpatient Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis Reference added. "Pneumatic" removed from policy statements and policy title. Major nonorthopedic surgery changed to "major nonorthopedic surgery or nonmajor orthopedic surgery" in 2nd covered policy statement and 2nd non covered policy statement. "Postsurgical" added to policy title. Senior Medical Director review. No change to coverage guidelines.
Saturation Biopsy for Diagnosis and Staging of Prostate Cancer Policy Guidelines updated. References updated. No changes to Policy Statement.
Spinal Cord Stimulation "treatment of cancer-related pain" added to the When Not Covered statement. Policy Guidelines updated. No change to policy intent.
Whole Exome Sequencing Specialty Matched Consultant Advisory Panel review 1/2014. No changes to Policy Statements.
Evidence Based Guidelines
Ambulatory Blood Pressure Monitoring References updated. No changes to guideline statements.
Genetic Testing for Alpha Thalassemia Specialty Matched Consultant Advisory Panel review 1/2014. No changes to Guideline statements.
Implantable Infusion Pumps Reference added.
Pulmonary Rehabilitation Under the "Not Recommended" section: added the statement "Pulmonary rehabilitation programs are not recommended in all other situations." Reference updated.