Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for April 15, 2014

Medical Guidelines Reason for Update
Assays of Genetic Expression to Determine Prognosis of Breast Cancer Specialty Matched Consultant Advisory Panel review 3/25/2014. No change to policy.
BRAF Gene Mutation Testing to Select Melanoma Patients for BRAF Inhibitor Therapy Specialty Matched Consultant Advisory Panel review 3/25/2014. No change to policy.
Cochlear Implant Specialty Matched Consultant Advisory Panel review 2/25/14. No change to policy statement.
Code Bundling Rules Not Addressed in ClaimCheck® or Correct Coding Initiative The section regarding Continuous intraoperative neurophysiology monitoring has been revised to read: "codes 95940, 95941 and G0453 are considered incidental to the surgeon's or anesthesiologist's primary service and not eligible for separate reimbursement when performed and billed by the surgeon or anesthesiologist. HCPCS Code G0453 will not be allowed when billed during the same operative session as 95940 or 95941. See also Corporate Medical Policy titled, "Intraoperative Neurophysiologic Monitoring (sensory-evoked potentials, motor-evoked potentials, EEG monitoring)."
Convection-Enhanced Delivery of Therapeutic Agents to the Brain Specialty Matched Consultant Advisory Panel review 3/25/2014. No change to policy.
Detection of Circulating Tumor Cells Specialty Matched Consultant Advisory Panel review 3/25/2014. No change to policy statement.
Epidermal Growth Factor Receptor (EGFR) Mutation Analysis for Patients with Non-Small Cell Lung Cancer (NSCLC) Description section updated. Updated the When Covered section from "Analysis of two types of somatic mutation within the EGFR gene small deletions in exon 19 and a point mutation in exon 21 (L858R) may be considered medically necessary to predict treatment response to erlotinib in patients with advanced NSCLC of nonsquamous cell type." to "Analysis of two types of somatic mutation within the EGFR gene small deletions in exon 19 and a point mutation in exon 21 (L858R) may be considered medically necessary to predict treatment response to erlotinib or afatinib in patients with advanced lung adenocarcinoma or in whom an adenocarcinoma component cannot be excluded (see Policy Guidelines section)." Policy Guidelines updated to include information regarding afatinib. Senior Medical Director review 3/22/2014. Reference added.
Hematopoietic Stem-Cell Transplantation for Breast Cancer Reference added.
Hematopoietic Stem-Cell Transplantation for Waldenstrom Macroglobulinemia Reference added.
Hematopoietic Stem-Cell Transplantation for Primary Amyloidosis Reference added.
Hematopoietic Stem-Cell Transplant for Non-Hodgkin Lymphomas Reference added.
Hyperthermic Intraperitoneal Chemotherapy Specialty Matched Consultant Advisory Panel review 3/25/2014. No change to policy.
Immune Cell Function Assay Specialty Matched Consultant Advisory Panel review 3/25/2014. No change to policy.
Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers) CPT code 22899 added to Billing/Coding section.
Intraoperative Neurophysiologic Monitoring (sensory-evoked potentials, motor-evoked potentials, EEG monitoring) Evidence based guideline converted to corporate medical policy. Added Related Policy: Electrodiagnostic Studies to the Description section. "Intraoperative monitoring, which includes somatosensory-evoked potentials, motor-evoked potentials using transcranial electrical stimulation, brainstem auditory-evoked potentials, EMG of cranial nerves, EEG, and electrocorticography (ECoG), may be considered medically necessary during spinal, intracranial, or vascular procedures." "Intraoperative monitoring of visual-evoked potentials is considered investigational." "Due to the lack of FDA approval, intraoperative monitoring of motor-evoked potentials using transcranial magnetic stimulation is considered investigational. Intraoperative EMG and nerve conduction velocity monitoring during surgery on the peripheral nerves is considered not medically necessary." "Intraoperative neurophysiology monitoring is considered not medically necessary when performed outside the 2009 American Clinical Neurophysiology Society recommended standards as stated in the Policy Guidelines." "Note: A physician can monitor NO more than three cases simultaneously." Policy Guidelines updated. Added the following codes to the Billing/Coding section; 51784, 51785, 95961, 95962, and 95829. Referenced Code Bundling Rules Not Addressed in ClaimCheck® or Correct Coding Initiative in the Billing/Coding section. References added. Senior Medical Director review 2/4/2014. Notification given 2/11/2014. Policy effective 4/15/2014.
Intravitreal Implant Reference updated. No change to policy statement.
Ipilimumab (Yervoy) Specialty Matched Consultant Advisory Panel review 3/25/2014. No Change to policy.
JAK2 and MPL Mutations in Myeloproliferative Neoplasms Reference added.
Microarray-Based Gene Expression Profile Testing for Multiple Myeloma Risk Stratification Specialty Matched Consultant Advisory Panel review 3/25/2014. No change to policy.
Molecular Markers in Fine Needle Aspirates of the Thyroid Added CPT codes, 81210, 81275, and 81403 to the Billing/Coding section. Notification given 2/11/14. Policy effective 4/15/14.
MRI-Guided Focused Ultrasound (MRgFUS) Reference added. No change to policy statement.
Neurostimulation, Electrical Description and Policy Guidelines updated in the Functional Neuromuscular Electrical Stimulation section. No change to policy intent. Reference added.
Non-BRCA Breast Cancer Risk Assessment Specialty Matched Consultant Advisory Panel review 3/25/2014. No change to policy.
Nonpayment for Serious Adverse Events Link to CMS code information added to Billing/Coding section.
Orthotics References updated. Specialty Matched Consultant Advisory Panel review 2/2014. Medical Director review 3/2014.
Pancreas Transplant References added. Statement on retransplantation modified to state that it applies to patients who meet criteria for pancreas transplant. Senior Medical Director review.
PathFinderTG® Molecular Testing Specialty Matched Consultant Advisory Panel review 3/25/2014. No change to policy statement.
Quantitative Assay for Measurement of HER2 Total Protein Expression and HER2 Dimers Specialty Matched Consultant Advisory Panel review 3/25/2014. No change to policy statement.
Rehabilitative Therapies Under "When Covered" section D.Speech Therapy: deleted statement f. "stammering or stuttering, which may be excluded as a non-covered benefit per the terms of the member's benefit booklet." Medical director review 4/2014.
Semi-Implantable and Fully Implantable Middle Ear Hearing Aid Specialty Matched Consultant Advisory Panel review 2/25/14. No change to policy statement.
Topical Negative Pressure Therapy for Wounds References added. Senior Medical Director review. No change to Policy statements.
Xolair® (Omalizumab) Medical Director review. Description section updated. References updated. The following statement added to the "When Covered" section: "Xolair is indicated for treatment of chronic idiopathic urticaria (CIU) in adults and adolescents (12 years of age and above) who remain symptomatic despite H1 antihistamine treatment."
Evidence Based Guidelines
Donor Lymphocyte Infusion Specialty Matched Consultant Advisory Panel review 3/25/2014. No change to guideline.
Erythropoiesis-Stimulating Agents (ESAs) Specialty Matched Consultant Advisory Panel review 3/25/2014. No change to guideline.
Fecal Analysis in the Diagnosis of Intestinal Dysbiosis Reference added. No change to Guideline statement.
Intravitreal Angiogenesis Inhibitors for Choroidal and Retinal Vascular Conditions Reference updated. No change to guideline statement.
KRAS and BRAF Mutation Analysis in Cancer Description section updated. Evidence Based Guideline section on KRAS mutation analysis in non-small-cell lung cancer reworded, no change to intent. Senior Medical Director review 3/22/2014. Reference added.
Monitored Anesthesia Care (MAC) Reference added.
Radioimmunotherapy in the Treatment of Non-Hodgkin Lymphoma Specialty Matched Consultant Advisory Panel review 3/25/2014. No change to policy.
Trastuzumab Specialty Matched Consultant Advisory Panel review 3/25/2014. No changes made to guideline.