Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for April 29, 2014

Medical Guidelines Reason for Update
Analysis of MGMT Promoter Methylation in Malignant Gliomas New policy. "MGMT promoter methylation testing for prognostic value or as a predictive biomarker for response to treatment with alkylating agents is considered investigational." Senior Medical Director review 2/8/2014. Notification given 2/25/2014. Policy effective 4/29/2014.
Breast Surgeries References updated. No changes to Policy Statements.
Electrical Bone Growth Stimulation Description section updated. Policy Guidelines and References updated. Use of electrical bone growth stimulation for stress fractures and arthrodesis added to "When not Covered" section. "When Covered" section updated to include the following criterion: "The patient can be adequately immobilized and is of an age likely to comply with non-weight bearing for fractures of the pelvis and lower extremities." Medical Director review 2/2014. Policy noticed on 2/25/14 for effective date 4/29/14.
Fetal Surgery for Malformations Reference added. Specialty Matched Consultant Advisory Panel review. No change to Policy statement.
Genetic Testing for Dilated Cardiomyopathy Policy retitled from "Chromosomal Microarray Analysis for Genetic Evaluation of Developmental Delay/Autism Spectrum Disorder" to "Genetic Testing for Evaluation of Developmental Delay/Autism Spectrum Disorder." Information regarding Next Generation Sequencing (NGS) testing added throughout policy. Description section updated. Policy statement revised to state: "BCBSNC will provide coverage for genetic testing for evaluation of developmental delay/autism spectrum disorder when it is determined to be medically necessary because the medical criteria and guidelines shown below are met." The following statement added to the "When not Covered" section: "Panel testing using next-generation sequencing is considered investigational in all cases of suspected genetic abnormality in children with developmental delay/intellectual disability or autism spectrum disorder." Added the following statement to the Billing/Coding section: "At this time, there are no specific CPT codes for next-generation sequencing panels. They would be reported with the unlisted molecular pathology code 81479." Policy Guidelines updated. References updated. Medical Director review 4/2014.
Genetic Testing for Evaluation of Developmental Delay/Autism Spectrum Disorder New policy implemented. Genetic testing for dilated cardiomyopathy is considered investigational in all situations. Medical Director review 2/25/14. Policy noticed 2/25/14 for effective date 4/29/14.
Hormone Pellet Implantation for Hormone Replacement Therapy in Women Specialty Matched Consultant Advisory Panel review 3/25/14. Senior Medical Director review. No change to Policy statement.
Implantable Cardioverter Defibrillator Revised "When Covered" section, under "Secondary Prevention" as follows: "Patients with a history of life-threatening clinical event associated with ventricular arrhythmic events such as sustained ventricular tachyarrhythmia, after reversible causes (e.g., acute ischemia) have been excluded. References updated.
Meniscal Allografts and Other Meniscal Implants References updated. No changes to Policy Statements.
Microprocessor-Controlled Prostheses for the Lower Limb References updated. No changes to Policy Statements.
Ovarian and Internal Iliac Vein Embolization Specialty Matched Consultant Advisory Panel review 3/25/14. Senior Medical Director review. Deleted CPT 37243 and added CPT 37241 to Billing/Coding section. Added ICD-9 code 625.5 to Billing/Coding section. No change to Policy statement.
Proteomics-based Testing Related to Ovarian Cancer Specialty Matched Consultant Advisory Panel review. No change to Policy statement.
Salivary Hormone Tests Reference added. Specialty Matched Consultant Advisory Panel review 3/25/14. Senior Medical Director review. No change to policy statement.
Surgical Interruption of Pelvic Nerve Pathways for Dysmenorrhea Specialty Matched Consultant Advisory Panel review 3/25/14. Senior Medical Director review. No change to Policy statement.
Systems Pathology for Predicting Risk of Recurrence in Prostate Cancer References updated. Description section updated. Policy Guidelines updated. No changes to Policy Statements.
Urinary Tumor Markers for Bladder Cancer References updated. No changes to Policy Statements.
Evidence Based Guidelines
Ado-Trastuzumab Emtansine (Trastuzumab-DM1) for Treatment of HER-2 Positive Malignancies Reference added.
Auditory Brainstem Implant Reference added. No change to Guideline Recommendations.
BCR-ABL1 Testing in Chronic Myelogenous Leukemia and Acute Lymphoblastic Leukemia Description and Evidence Based Guideline sections updated to include information related to acute lymphoblastic leukemia. Senior Medical Director review 4/11/2014. Added CPT codes 81401 and 81403 to Billing/Coding section. Reference added.
Bone Turnover Markers for the Diagnosis and Management of Osteoporosis and Diseases Associated with High Bone Turnover Specialty Matched Consultant Advisory Panel review 3/25/14. Senior Medical Director review. No change to Policy Statement.
Genetic Testing for Duchenne and Becker Muscular Dystrophy References updated. No changes to Guideline Statements.
Maternal and Fetal Diagnostics Reference added. Specialty Matched Consultant Advisory Panel review 9/18/13. No change to Guideline statement.
Photodynamic Therapy for Treatment of Specific Cancers Reference added.
Prothrombin Time Monitoring in the Home Description section updated. References updated. No changes to Guideline Statements.