Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for April 1, 2014

Medical Guidelines Reason for Update
Abatacept (Orencia®) Specialty Matched Consultant Advisory Panel review meeting 2/25/2014. No changes to policy statement.
Artificial Intervertebral Disc Description and Policy Guidelines sections updated. No change to policy intent. Senior Medical Director review 2/27/2014. References added.
Belimumab (Benlysta) Specialty Matched Consultant Advisory Panel review meeting 2/25/2014. Updated Policy Guidelines section. Reference updated.
Bioengineered Skin and Tissue Description section updated. Added the following statement to the "When Covered" section: "D. Breast reconstructive surgery using allogeneic acellular dermal matrix products (ie, AlloDerm®, AlloMaxTM, DermaMatrixTM, FlexHD®, GraftJacket®) may be considered medically necessary." "When Covered" section re-formatted. Updated "When not Covered" section to include new products and to remove products that are now considered medically necessary for use in breast reconstruction surgery. Deleted code C9367 from Billing/Coding section. Policy Guidelines updated. References updated. Medical Director review 3/2014.
Cardiovascular Disease Risk Tests Policy Guidelines updated. References updated. No changes to Policy Statements.
Composite Allotransplantation of the Hand and Face Policy Guidelines updated to include clinical trial information. References updated. No changes to Policy Statement.
Computer-Aided Evaluation of Malignancy with MRI of the Breast References added. No change to Policy statement.
Confocal Laser Endomicroscopy Reference added. No change to Policy statement.
Cryosurgical Ablation of Primary or Metastatic Liver Tumors Reference added. No change to Policy statement.
Dental Reconstructive Services Under Description section, changed related policy from Cosmetic and Reconstructive Services to Orthognathic Surgery.
Dynamic Posturography Reference added. Specialty Matched Consultant Advisory Panel review 2/25/2014. Senior Medical Director review. No change to Policy statement.
Extracorporeal Shock Wave Treatment for Musculoskeletal Conditions and Wound Healing References updated. Policy Guidelines updated. No changes to Policy Statements.
Gait Analysis Reference updated. Medical director review 2/18/14. Archive policy.
Genetic Testing for Cardiac Ion Channelopathies Policy re-titled from "Genetic Testing for Long QT Syndrome" to "Genetic Testing for Cardiac Ion Channelopathies". Description section and Policy Guidelines section extensively revised. Added the following criteria to the "When Covered" section: "Genetic testing for CPVT may be considered medically necessary for patients who do not meet the clinical criteria for CPVT but who have: a close relative (i.e. first-, second-, or third-degree relative) with a known CPVT mutation; or a close relative diagnosed with CPVT by clinical means whose genetic status is unavailable; or signs and/or symptoms indicating a moderate-to-high pretest probability of CPVT. Added the following statements to the "When not Covered" section: "Genetic testing for Brugada syndrome is considered investigational. Genetic testing for short QT syndrome is considered investigational." References updated. Medical Director review 1/2014. Policy noticed on 1/28/2014 for effective date 4/1/2014.
Genetic Testing for Epilepsy New policy. Genetic testing for epilepsy is considered investigational. Senior Medical Director review 1/13/2014. Notification given 1/28/2014. Policy effective 4/1/2014.
Hematopoietic Stem-Cell Transplantation for CLL and SLL Reference added.
Intra Articular Hyaluronan Injections for Treatment of Osteoarthritis of the Knee References updated to include the U.S. Food and Drug Administration (FDA) PMA approval for MonoviscTM (Anika Therapeutics, Inc.). J3490 added to Billing/Coding section.
Intravenous Antibiotic Therapy for Lyme Disease Reference added. Specialty Matched Consultant Advisory Panel review 2/25/14. Medical Director review. No change to Policy statement.
Keratoprosthesis Reference updated. No change to policy statement.
Light Therapy for Dermatologic Conditions References updated. No changes to Policy Statements.
Liver Transplant References added. Policy Guidelines updated. Policy statement on polycystic liver disease moved to a separate policy statement. Pediatric non-metastatic hepatoblastoma added as may be medically necessary. Policy statement added that liver transplantation is considered investigational in all other situations not described. Senior Medical Director review.
Magnetic Resonance Spectroscopy Reference added. No change to Policy statement.
Multianalyte Assays for Predicting Risk of Type 2 Diabetes References updated. Policy Guidelines updated. No changes to Policy Statement.
Noninvasive Respiratory Assist Devices References added. Specialty Matched Consultant Advisory Panel review 2/25/14. No change to Policy statement.
Optical Coherence Tomography for Imaging of Coronary Arteries Description section updated. References updated. No changes to Policy Statements.
Optical Coherence Tomography (OCT) Anterior Segment of the Eye Reference updated. No change to policy statement.
Progesterone Therapy in High Risk Pregnancies Removed Home Uterine Activity Monitoring from the list of Related Policies.
Respiratory Syncytial Virus Prophylaxis Specialty Matched Consultant Advisory Panel review 2/25/14. No change to policy statement.
Retinal Prosthesis Reference updated. Regulatory status updated. No change to policy statement.
Rituximab for the Treatment of Rheumatoid Arthritis Specialty Matched Consultant Advisory Panel review meeting 2/25/2014. Under Description section, changed DC20 to CD20 in description of the drug; changed "bad" cells to "targeted" cells to describe B cells. Medical director review. No change to policy statement.
Sequencing Based Tests to Determine Trisomy 21 from Maternal Plasma DNA Description of Procedure or Service section updated. Reference added. No change to Policy statement. Senior Medical Director review.
Evidence Based Guidelines
Genetic Testing for PTEN Hamartoma Tumor Syndrome "When not Recommended" section updated. Statement revised from "Genetic testing for a PTEN mutation is not recommended for all other indications, including, but not limited to, prenatal testing" to "Genetic testing for a PTEN mutation is not recommended for all other indications." References updated.
Glaucoma, Evaluation by Ophthalmologic Techniques References updated. No change to guideline statement.
Laboratory Testing for HIV Tropism Reference added. Specialty Matched Consultant Advisory Panel review 2/25/14. No change to Guideline statement.
Transpupillary Thermotherapy for Treatment of Choroidal Neovascular Conditions Reference updated. Medical director review 2/18/14. Archive policy.