Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for May 27, 2014

Medical Guidelines Reason for Update
Autologous Fat Grafting to the Breast Medical Director review 5/2014. References updated. Policy archived.
Bone Mineral Density Studies Specialty Matched Consultant Advisory Panel review 9/18/13. References added. Policy Statement unchanged.
Cardiovascular Disease Risk Tests Specialty Matched Consultant Advisory Panel review 4/2014. References updated. Medical Director review 4/2014. No changes to Policy Statements.
Chromoendoscopy as an Adjunct to Colonoscopy Reference added. No change to Policy statement.
Use of Common Genetic Variants to Predict Risk of Nonfamilial Breast Cancer Policy combined with "Non-BRCA Breast Cancer Risk Assessment". Added the following to Policy Statement section; "Non-BRCA Breast Risk Assessment with OncoVue® and BREVAGenTM breast cancer risk tests are considered investigational for all applications. BCBSNC does not cover investigational services or procedures." Added the following statement to the "When not Covered" section: "The OncoVue® and BREVAGenTM breast cancer risk tests are considered investigational as a method of estimating individual patient risk for developing breast cancer. BCBSNC does not cover investigational services." Description section and Policy Guideline section revised to incorporate information regarding non-BRCA breast cancer risk tests. References updated. Medical Director review 5/2014.
Computerized 2-Lead Resting Electrocardiogram (Multifunction Cardiogram) Specialty Matched Consultant Advisory Panel review 4/2014. Medical Director review 4/2014. No changes to Policy Statements.
Corneal Collagen Cross-linking Reference updated. Updated regulatory status. No change to policy statement.
Corneal Topography Reference updated. Regulatory status updated. No change to policy statement.
Enhanced External Counterpulsation (EECP) Specialty Matched Consultant Advisory Panel review 4/2014. Medical Director review 4/2014. No changes to Policy Statements.
Gene-Based Tests for Screening, Detection, and/or Management of Prostate Cancer References updated. Description section updated. No changes to Policy Statements.
Gene Expression Testing to Predict Coronary Artery Disease Specialty Matched Consultant Advisory Panel review 4/2014. References updated. Medical Director review 4/2014. No changes to Policy Statement.
Genetic Testing for Alpha-1 Antitrypsin Deficiency Description section updated. References updated. No changes to Policy Statements.
Genetic Testing for Cardiac Ion Channelopathies Specialty Matched Consultant Advisory Panel review 4/2014. Medical Director review 4/2014. No changes to Policy Statements.
Genetic Testing for Hereditary Hemochromatosis References updated. Description section updated. No changes to Policy Statements.
Hematopoietic Stem-Cell Transplantation for Solid Tumors of Childhood References updated. Re-titled reference policy in Policy Statement section from "Clinical Trial Services for Life-Threatening Conditions" to "Clinical Trial Services." No other changes to Policy Statements.
Hematopoietic Stem-Cell Transplantation in the Treatment of Germ Cell Tumors Policy Guidelines updated. References updated. Updated reference policy title from "Clinical Trial Services for Life Threatening Conditions" to "Clinical Trial Services". No changes to Policy Statements.
In Vitro Chemoresistance and Chemosensitivity Assays References added. Description and Policy Guideline sections extensively revised. No changes to Policy Statements. Reference policy title changed from "Clinical Trial Services for Life Threatening Conditions" to "Clinical Trial Services".
Ingestible pH and Pressure Capsule Reference added. Senior Medical Director review. Policy guidelines updated. No change to Policy statement.
Intravascular Ultrasound Imaging (IVUS) and Intracoronary Doppler Ultrasonography Specialty Matched Consultant Advisory Panel review 4/2014. Medical Director review 4/2014. References updated. Policy archived.
Laboratory Tests for Heart Transplant Rejection Description section updated. Specialty Matched Consultant Advisory Panel review 4/2014. Medical Director review 4/2014.
Light Therapy for Dermatologic Conditions References updated. No changes to Policy Statements.
Molecular Markers in Fine Needle Aspirates of the Thyroid References updated. No changes to Policy Statements.
Non-BRCA Breast Cancer Risk Assessment Non-BRCA Breast Cancer Risk Assessment
Optical Coherence Tomography for Imaging of Coronary Arteries Specialty Matched Consultant Advisory Panel review 4/2014. Medical Director review 4/2014. No changes to Policy Statements.
Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence Policy re-titled from "Pelvic Floor Stimulation as a Treatment of Urinary Incontinence" to "Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence." Description section updated. Added the following statement to the "When not Covered" section: "Electrical or magnetic stimulation of the pelvic floor muscles (pelvic floor stimulation) as a treatment for fecal incontinence is considered investigational." Policy Guidelines updated. References updated. Medical Director review 5/2014.
Retainer Practices Policy archived. See Provider Blue Book (April 2014) for information regarding Retainer Practices.
Sacral Nerve Neuromodulation/Stimulation for Pelvic Floor Dysfunction Description section updated. Added new clinical condition to the "When Covered" section: "Overactive Bladder". References updated.
Semi-Implantable and Fully Implantable Middle Ear Hearing Aid Reference added. Medical Director review. No change to policy statement.
Serum Biomarker Tests for Multiple Sclerosis New policy developed. Serum biomarker tests for multiple sclerosis are considered investigational for all applications. Medical Director review 5/2014.
Tocilizumab (Actemra) Under "When Covered" section, revised statement #2 to read: Tocilizumab (Actemra®) may be medically necessary for the treatment of patients 2 years of age and older with active systemic juvenile idiopathic arthritis (sJIA). Removed/deleted statement #4 which read: Tocilizumab (Actemra®) may be medically necessary for the treatment of patients 6 years of age and older with active systemic juvenile idiopathic arthritis (sJIA) who have failed to respond adequately or are intolerant to Remicade ® (infliximab).
Ustekinumab (Stelara®) "When Covered" section revised as follows: "Ustekinumab (StelaraTM) may be considered medically necessary for the treatment of moderate to severe plaque psoriasis in patients who are 18 years of age or older; and have already been treated with phototherapy (i.e., PUVA or broadband or narrowband UVB) unless the patient is not a candidate for phototherapy or phototherapy is not available to the patient; or have already been treated with or are not a candidate for any other systemic treatments such as methotrexate (oral or IM), cyclosporin, and acitretin (Soriatane®)." Medical Director review 5/2014.
Vectra® DA Blood Test for Rheumatoid Arthritis New policy developed. The Vectra DA blood test to predict rheumatoid arthritis is considered investigational. Medical director review 5/2014.
Evidence Based Guidelines
Biventricular Pacemakers/Cardiac Resynchronization Therapy for Heart Failure Description section updated. References updated. No changes to Guideline Statements.
Cardiac Rehabilitation Specialty Matched Consultant Advisory Panel review 4/2014. Medical Director review 4/2014. No changes to Guideline Statements.
Endovascular Stent Grafts for Abdominal Aortic Aneurysm Description section updated. References updated. No changes to Guideline Statements.
Homocysteine Testing in Cardiac Disease Risk Assessment Specialty Matched Consultant Advisory Panel review. Medical Director review 4/2014. References updated. No changes to Guideline Statements.
Monoclonal Antibodies for Non-Hodgkin Lymphoma, including Chronic Lymphocytic, & Acute Myeloid Leukemia In the Non-Hematopoietic Stem Cell Transplant Setting Specialty Matched Consultant Advisory Panel review 4/29/2014. Added "rituximab may be appropriate for 1st line and subsequent line treatment for all CD20 B cell malignancies including mantle cell lymphoma, marginal zone lymphoma and Burkitt lymphoma." "Obinatuzumab (Gazyva) may be appropriate in combination with chlorambucil as 1st line treatment of chonic lymphocytic leukemia (CLL)." Reference added.
Therapeutic Apheresis Specialty Matched Consultant Advisory Panel review 4/2014. Medical Director review 4/2014. Added the following indication to the Evidence Based Guidelines section: "Hemolytic uremic syndrome (HUS); typical (diarrheal-related). Treatment may be appropriate when the delay of diagnosis would place the patient at risk for severe end-organ damage, central nervous system or cardiac injury)"