Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for May 13, 2014

Medical Guidelines Reason for Update
Allogeneic Hematopoietic Transplant for Genetic Diseases and Acquired Anemia Specialty Matched Consultant Advisory Panel review 4/29/2014. No change to policy.
Allogeneic Stem-Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms Specialty Matched Consultant Advisory Panel review 4/29/2014. No change to policy.
Ambulatory Event Monitors Specialty Matched Consultant Advisory Panel review 4/2014. Medical Director review 4/2014. No changes to Policy Statements.
Analysis of MGMT Promoter Methylation in Malignant Gliomas Specialty Matched Consultant Advisory Panel review 4/29/2014. No change to policy.
Baroreflex Stimulation Devices Specialty Matched Consultant Advisory Panel review 4/2014. Medical Director review 4/2014. No changes to Policy Statements.
Bone Morphogenetic Protein Specialty Matched Consultant Advisory Panel review 2/2014. Medical Director review 2/2014. Policy statement revised as follows: "BCBSNC will provide coverage for FDA-approved Bone Morphogenetic Proteins when it is determined to be medically necessary because the medical criteria and guidelines show below are met. BCBSNC will not provide coverage for non FDA-approved BMPs or for non-FDA-approved indications ("off label" use) of BMP's because they are considered investigational. BCBSNC does not cover investigational services." "When Covered" section revised as follows: "Use of recombinant human bone morphogenetic protein-2 (rhBMP-2, InFUSE) may be considered medically necessary in skeletally mature patients undergoing interbody spinal fusion when: the fusion is single-level, the approach is anterior, the fusion involves vertebral bodies L4 - S1, with or without spondylolisthesis of no more than grade 1 (25% displacement), and use of autograft is unfeasible. Use of recombinant human bone morphogenetic protein-2 (rhBMP-2, InFUSE) may be considered medically necessary in skeletally mature patients for the treatment of acute, open fracture of the tibial shaft, when use of autograft is unfeasible. Use of recombinant human bone morphogenetic protein-7 (rhBMP-7, OP-1) may be considered medically necessary in skeletally mature patients: For revision (i.e., repeat procedure after prior failure) posterolateral intertransverse lumbar spinal fusion, when use of autograft is unfeasible. For recalcitrant long-bone nonunions where use of autograft is unfeasible and alternative conservative treatments have failed." "When not Covered" section revised to delete "not medically necessary" and replace with "investigational" as follows: "Bone morphogenetic protein (rhBMP-2 or rhBMP-7) is considered investigational for all other indications, including but not limited to spinal fusion or treatment of acute, open fracture of the tibial shaft when use of autograft is feasible, or when used for non-FDA-approved indications (i.e., "off label"). Use of InFUSE for posterior (PLIF), posterolateral (TLIF) or lateral (XLIF) approaches to spinal fusion is not FDA-approved and is considered investigational. Use of InFUSE for multilevel (more than single level) fusion is not FDA-approved and is considered investigational. Use of OP-1 for interbody fusion is not FDA-approved and is considered investigational." Policy Guidelines updated. References updated. Policy noticed on 3/11/14 for effective date 5/13/14.
Bronchial Thermoplasty Specialty Matched Consultant advisory panel meeting 4/30/2014. No change to policy statement.
Bundling Guidelines Policy category changed from "Corporate Medical Policy" to "Corporate Reimbursement Policy". Removed this statement from the Description section, item A., Incidental Procedures: "Procedures that are considered incidental when billed with related primary procedures on the same date of service will be denied." Added the following statement related to New Visit Frequency: [claims will be recoded from New to Established evaluation and management codes if one is available] "Otherwise the claim will be denied." Removed the statement from the Policy Guidelines that read: "BCBSNC claims systems process only one modifier per CPT code."
Capsule Endoscopy, Wireless Specialty Matched Consultant Advisory Panel review 4/29/13. No change to Policy statement.
Code Bundling Rules Not Addressed in ClaimCheck® or Correct Coding Initiative Policy category changed from "Corporate Medical Policy" to "Corporate Reimbursement Policy". No changes to policy content.
Consistency Guidelines Policy category changed from "Corporate Medical Policy" to "Corporate Reimbursement Policy". No changes to policy content.
Co-Surgeon, Assistant Surgeon, Team Surgeon and Assistant-at-Surgery Guidelines Policy category changed from "Corporate Medical Policy" to "Corporate Reimbursement Policy". No changes to policy content.
ECG Reimbursement Policy category changed from "Corporate Medical Policy" to "Corporate Reimbursement Policy". No changes to policy content.
Electromagnetic Navigation Bronchoscopy Specialty Matched consultant advisory panel review meeting 4/30/14. No change to policy statement. Reference updated. Deleted CPT code 31626 from Billing/Coding section. Medical director review 4/2014.
Endobronchial Valves Specialty matched consultant advisory panel review meeting 4/30/2014. No change to policy statement. Reference updated.
Exhaled Nitric Oxide Measurement Specialty Matched Consultant advisory panel review meeting 4/30/2014. No change to policy statement.
Gastric Electrical Stimulation Specialty Matched Consultant Advisory Panel review 4/29/14. Related policy added. Summary statement updated. No change to policy statement.
Genetic Cancer Susceptibility Panels Using Next Generation Sequencing Specialty Matched Consultant Advisory Panel review 4/29/2014. No change to policy.
Genetic Testing for Breast and Ovarian Cancer Policy statement revised to reflect the most recent NCCN guidelines. Policy Guidelines section updated to reflect current U.S. Preventive Services Task Force (USPSTF) guidelines. No change to policy intent. Senior Medical Director review 4/18/2014. References added.
Group Visit (Shared Medical Appointment) Guidelines Policy category changed from "Corporate Medical Policy" to "Corporate Reimbursement Policy". No changes to policy content.
Guidelines for Global Maternity Reimbursement Policy category changed from "Corporate Medical Policy" to "Corporate Reimbursement Policy". No changes to policy content.
Hematopoietic Stem-Cell Transplantation for Breast Cancer Specialty Matched Consultant Advisory Panel review 4/29/2014. No change to policy.
Hematopoietic Stem-Cell Transplantation for Acute Lymphoblastic Leukemia Specialty Matched Consultant Advisory Panel review 4/29/2014. No change to policy.
Hematopoietic Stem-Cell Transplantation for Acute Myeloid Leukemia Specialty Matched Consultant Advisory Panel review 4/29/2014. No change to policy.
Immunization Guidelines Policy category changed from "Corporate Medical Policy" to "Corporate Reimbursement Policy". No changes to policy content.
In Vitro Chemoresistance and Chemosensitivity Assays Specialty Matched Consultant Advisory Panel review 4/29/2014. Added information regarding ex-vivoanalysis of programmed cell death (EVA/PCDTM) assay to the Description section. Reference added.
Intradialytic Parenteral Nutrition Specialty Matched Consultant Advisory Panel review 4/2014. Medical Director review 4/2014. No changes to Policy Statements.
Lipid Apheresis Specialty Matched Consultant Advisory Panel review 4/2014. Medical Director review 4/2014. No changes to Policy Statements.
Lung and Lobar Lung Transplantation Specialty matched consultant advisory panel review meeting 4/30/2014. No change to policy statement.
Maximum Units of Service Policy category changed from "Corporate Medical Policy" to "Corporate Reimbursement Policy". No changes to policy content.
Melanoma Vaccines Specialty Matched Consultant Advisory Panel review 4/29/2014. No change to policy.
Modifier Guidelines Policy category changed from "Corporate Medical Policy" to "Corporate Reimbursement Policy". No changes to policy content.
Molecular Panel Testing of Cancers to Identify Targeted Therapies New policy. "The use of expanded cancer mutation panels for selecting targeting cancer treatment is considered investigational." Senior Medical Director review 4/18/2014.
Monoclonal Antibody Imaging for Prostate Cancer Specialty Matched Consultant Advisory Panel review 4/29/2014. No change to policy.
Multigene Expression Assay for Predicting Recurrence in Colon Cancer Specialty Matched Consultant Advisory Panel review 4/29/2014. No change to policy.
Multiple Surgical Procedure Guidelines for Professional Providers Policy category changed from "Corporate Medical Policy" to "Corporate Reimbursement Policy". No changes to policy content.
Neurostimulation, Electrical Policy Guidelines updated. Reference added.
Nonpayment for Serious Adverse Events Policy category changed from "Corporate Medical Policy" to "Corporate Reimbursement Policy". No changes to policy content.
Oscillatory Devices for the Treatment of Respiratory Conditions Description and Policy Guidelines sections updated. Under "When Covered" section, Flutter and/or Acapella changed to oscillatory positive expiratory pressure device. Under Policy Guidelines section, standard chest physiotherapy treatment changed to standard treatment. Reference updated. Specialty matched consultant advisory panel review meeting 4/30/2014.
Peroral Endoscopic Myotomy for Treatment of Esophageal Achalasia Specialty Matched Consultant Advisory Panel review 4/29/14. No change to Policy statement.
Pricing and Adjudication Principles for Professional Providers Policy category changed from "Corporate Medical Policy" to "Corporate Reimbursement Policy". No changes to policy content.
Pulmonary Hypertension, Drug Management Removed references to the oral drugs from "When Covered" section since pharmacy has the "Oral Pulmonary Hypertension" policy which includes these drugs. Revised and updated Description Policy Guidelines sections. Reference updated. Specialty matched consultant advisory panel review meeting 4/30/2014. No change to policy statement.
Radiofrequency Ablation of the Renal Nerves as a Treatment of Hypertension Description section updated. References updated. Specialty Matched Consultant Advisory Panel review 4/2014. Medical Director review 4/2014. No changes to Policy Statements.
Removal of Impacted Cerumen Policy category changed from "Corporate Medical Policy" to "Corporate Reimbursement Policy". No changes to policy content.
Renal (Kidney) Transplantation Medical Director review 4/2014. Specialty Matched Consultant Advisory Panel review 4/2014. No changes to Policy Statements.
Small Bowel, Small Bowel with Liver, or Multivisceral Transplant Specialty Matched Consultant Advisory Panel review 4/29/14. No change to Policy Statement.
Treatment of Hereditary Angioedema Age limitation for Ecallantide/Kalbitor revised from 16 years of age or older to 12 years of age or older.
Evidence Based Guidelines
Ambulatory Blood Pressure Monitoring Specialty Matched Consultant Advisory Panel review 4/2014. Medical Director review 4/2014. References updated. No changes to Guideline Statements.
Human Leukocyte Antigen (HLA) Testing for Celiac Disease Specialty Matched Consultant Advisory Panel review 4/29/14. No change to guideline statement.
Inhaled Nitric Oxide Specialty matched consultant advisory review panel meeting 4/30/2014. No change to guideline statement.
Pertuzumab for Treatment of HER2-Positive Malignancies Specialty Matched Consultant Panel review 4/26/2014. Added "neoadjuvant breast cancer" to the Evidence Based Guideline section.
Pharmacogenomic and Metabolite Markers for Treatment with Thiopurines Specialty Matched Consultant Advisory Panel review 4/29/14. No change to Guideline statement.
Pulmonary Rehabilitation Specialty Matched Consultant Advisory Panel review 3/25/14. Senior Medical Director review. No change to Policy Statement.
Serum Biomarker Human Epididymis Protein 4 (HE4) Specialty Matched Consultant Advisory Panel review 4/29/2014. No change to guideline. Reference added.
Trastuzumab Reference added.