Medical Policy Updates

Table Of Contents

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

Medical Guidelines Reason for Update
Ambulance and Medical Transport Services Specialty Matched Consultant Advisory Panel review meeting 2/25/2014. No change to policy statement.
Biofeedback Specialty Matched Consultant Advisory panel review meeting 2/25/2014. No change to policy statement. Reference added.
Chelation Therapy Specialty Matched Consultant Advisory Panel review meeting 2/25/2014. No change to policy statement.
Clinical Trial Services Policy renamed from "Clinical Trial Services for Life Threatening Conditions" to "Clinical Trial Services." No change to policy statement. Specialty Matched Consultant Advisory Panel review meeting 2/25/2014. Medical Director review 2/2014.
Complementary and Alternative Medicine Specialty Matched Consultant Advisory Panel review meeting 2/25/2014. No change to policy statement.
DNA Based Testing for Adolescent Idiopathic Scoliosis Description section and Policy Guidelines updated. CPT code 81479 added to "Billing/Coding" section. Specialty Matched Consultant Advisory Panel review 2/2014. Medical Director review 2/2014. No changes to Policy Statement.
Durable Medical Equipment (DME) Added an asterisk (*) to last statement in the Not Covered section to link the meaning of the asterisk when used in some of the statements in the Not Covered section. No change to policy statement.
Electrical Stimulation for the Treatment of Arthritis Description section updated. Specialty Matched Consultant Advisory Panel review meeting 2/25/2014. References updated. No change to policy statement.
E-visits (Online Medical Evaluations) Specialty Matched Consultant Advisory Panel review meeting 2/25/2014. No change to policy statement.
Golimumab (Simponi Aria) Specialty Matched Consultant review meeting 2/25/2014. No change to policy statement.
Home Uterine Activity Monitoring Reference added. Medical Director review. Archive policy.
Infusion Therapy in the Home Specialty Matched Consultant Advisory Panel review meeting 2/25/2014. No change to policy statement.
Injectable Clostridial Collagenase for Fibroproliferative Disorders References updated. Description section updated. Specialty Matched Consultant Advisory Panel review 2/2014. Medical Director review 2/2014. No changes to Policy Statements.
Lipid Apheresis "New policy developed. LDL apheresis is covered for patients with homozygous familial hypercholesterolemia as an alternative to plasmapheresis. LDL apheresis is covered for patients with heterozygous familial hypercholesterolemia who have failed a 6-month trial of diet therapy and maximum tolerated combination drug therapy AND who meet the following FDA approved indications: (All LDL levels represent the best achievable LDL level after a program of diet and drug therapy.) 1. Functional hypercholesterolemic heterozygotes with LDL > 300 mg/dL 2. Functional hypercholesterolemic heterozygotes with LDL > 200 mg/dL AND documented coronary artery disease. LDL apheresis is not covered for all other clinical indications, with the exception of those listed above. HDL delipidation is not covered for any clinical indication. Medical Director review 11/2013. Notification given 12/31/2013 for effective date 3/11/2014."
Measurement of Serum Antibodies to Infliximab and Adalimumab Specialty matched consultant advisory panel review meeting 2/25/2014. No change to policy statement.
Microprocessor-Controlled Prostheses for the Lower Limb Specialty Matched Consultant Advisory Panel review 2/2014. Medical Director review 2/2014. No changes to the Policy Statements.
Monochromatic Infrared Energy Treatment (MIRE) Specialty Matched Consultant Advisory Panel review meeting 2/25/2014. No change to policy statement. Reference added.
Observation Room Services Specialty Matched Consultant Advisory Panel review meeting 2/25/2014. No change to policy statement. Reference updated.
Private Duty Nursing Services Specialty Matched Consultant Advisory panel review meeting 2/25/2014. No change to policy statement.
Rapid Opioid Detoxification Reference added. No change to Policy statement.
Residential Treatment for Chemical Dependence Specialty Matched Consultant Advisory Panel review 7/17/13. No changes to policy statement. References added.
Skilled Nursing Facility Care Specialty Matched Consultant Advisory review panel meeting 2/25/2014. No change to policy statement.
Skilled Nursing Services Specialty Matched Consultant Advisory panel review meeting 2/25/2014. No change to policy statement.
Sleep Apnea: Diagnosis and Medical Management Clarification added for a single night for a home sleep study. PAP-NAP studies are considered investigational. Reference added. Specialty Matched Consultant Advisory Panel review 8/21/13. Senior Medical Director review. Notification given 12/31/13 for policy effective date 3/11/14.
Small Bowel, Small Bowel with Liver, or Multivisceral Transplant Reference added. Statement added that small bowel retransplant may be considered medically necessary after a failed primary small bowel transplant.
Subtalar Arthroereisis Specialty Matched Consultant Advisory Panel review 2/2014. Medical Director review 2/2014. CPT code 27899 added to Billing/Coding section.
Telemedicine Specialty Matched Consultant Advisory Panel review meeting 2/25/2014. No change to policy statement.
Tocilizumab (Actemra) Reference updated. Specialty Matched consultant advisory panel meeting 2/25/2014. No change to policy statement.
Ultrasound Accelerated Fracture Healing Device Description section revised. "When not Covered" statement revised to include "failed arthrodesis" and "fresh surgically-treated closed fractures" as non-covered indications. References updated. Specialty Matched Consultant Advisory Panel review 2/2014. Medical Director review 2/2014.
Evidence Based Guidelines
Arthroscopic Debridement and Lavage as Treatment of Knee Osteoarthritis Specialty Matched Consultant Advisory Panel review 2/2014. Medical Director review 2/2014. References updated. "When not Recommended" section updated.
Hip Resurfacing Specialty Matched Consultant Advisory Panel review 2/2014.Medical Director review 2/2014. No changes to Guideline Statements.
Interventions for Progressive Scoliosis References updated. Medical Director review 2/2014. Specialty Matched Consultant Advisory Panel review 2/2014. No changes to Guideline Statements.
Vertical Expandable Prosthetic Titanium Rib Specialty Matched Consultant Advisory Panel 2/2014. Medical Director review 2/2014. No changes to Guideline Statements.
Low Density Lipid Apheresis Evidence Based Guideline archived. Please see policy titled "Lipid Apheresis". Medical Director review 11/2013.