Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for June 10, 2014

Medical Guidelines Reason for Update
Automated Percutaneous and Endoscopic Discectomy Specialty Matched Consultant Advisory Panel review 5/27/2014. Reference added. No change to policy.
Cardiovascular Disease Risk Tests Added the following statement to Policy Guidelines: "The LPA-Aspirin Check® test has not been cleared or approved by the U.S. Food and Drug Administration (FDA)." References updated. Removed effective date for ICD-10 codes from Billing/Coding section.
Continuous Monitoring of Glucose in the Interstitial Fluid References added. Senior Medical Director review. No change to Policy statement.
Cranial Electrotherapy Stimulation (CES) and Auricular Electrostimulation Specialty Matched Consultant Advisory Panel review 5/27/2014. No change to policy.
Cryosurgical Ablation of Primary or Metastatic Liver Tumors Specialty Matched Consultant Advisory Panel review 5/27/14. No change to policy.
Epiretinal Radiation Therapy for Age-Related Macular Degeneration Added investigational indication to "When Not Covered" section regarding stereotactic radiation therapy: Sterotactic radiation therapy for the treatment of choroidal neovascularization is considered investigational. Updated Policy Guidelines section. Reference added. Medical director review 3/2014. Notification 4/1/14 for effective date 6/10/14.
Image-Guided Minimally Invasive Lumbar Decompression (IG-MLD) for Spinal Stenosis Specialty Matched Consultant Advisory Panel review 5/27/2014. Reference added. No changes to policy intent.
Infliximab (Remicade) Specialty Matched Consultant Advisory Panel review meeting 2/25/2014. Renumbered quantity limitations under Policy Guidelines section. Under "When Covered" section 1.g.: added neurosarcoid to diagnosis reference; under 2.contraindications list:added "any active infections" for c. and "demyelinating disease" for d. Under "When Not Covered" section added (JIA) juvenile idiopathic arthritis to (JRA) juvenile rheumatoid arthritis reference as these terms are synonomous. Medical director review. Policy noticed on 4/1/14 for effective date 6/10/14.
Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers) Specialty Matched Consultant Advisory Panel review 5/27/2014. No change to policy.
Interspinous Fixation (Fusion) Devices Specialty Matched Consultant Advisory Panel review 5/27/2014. No change to policy.
Intradiscal Electrothermal (IDET) Annuloplasty and Percutaneous Intradiscal Radiofrequency Annuloplasty Specialty Matched Consultant Advisory Panel review 5/27/2014. No change to policy.
Liver Transplant Specialty Matched Consultant Advisory Panel 5/27/14.
Lumbar Spine Fusion Surgery Specialty Matched Consultant Advisory Panel review 5/27/2014. No change to policy.
Natalizumab (Tysabri) Specialty Matched Consultant Advisory Panel review 5/27/14. No change to policy statement.
Non-Pharmacologic Treatment of Rosacea Removed the ICD-10 effective date from the Billing/Coding section.
Occipital Nerve Stimulation Specialty Matched Consultant Advisory Panel review 5/27/2014. No change to policy.
Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers Specialty Matched Consultant Advisory Panel review 5/27/14. No change to policy intent.
Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors Specialty Matched Consultant Advisory Panel review 5/27/14. No change to policy statement.
Sacroiliac Joint Fusion Specialty Matched Consultant Advisory Panel review 5/27/2014. No change to policy intent.
Surgical Deactivation of Headache Trigger Sites Specialty Matched Consultant Advisory Panel review 5/27/2014. No change to policy.
Topical Negative Pressure Therapy for Wounds Specialty Matched Consultant Advisory Panel review 5/27/14. No change to policy statements.
Vagus Nerve Stimulation Specialty Matched Consultant Advisory Panel review 5/27/2014. Description section updated to include information regarding the VNS (t-VNS®) system developed by Cerbomed. The following investigational indications were added to the When Not Covered section; "headaches, tinnitus, and traumatic brain injury" and "Non-implantable vagus nerve stimulation devices are considered investigational for all indications." No change to policy intent. Policy Guidelines updated. Reference added.
Vertebroplasty, Kyphoplasty, and Sacroplasty Percutaneous Specialty Matched Consultant Advisory Panel review 5/27/2014. Updated Description section to include information regarding Parallax® Contour® Vertebral Augmentation and Vessel-X®, (MAXXSPINE) and vertebral body stenting. Updated Policy Guidelines section. No change to policy intent. Reference added.
Evidence Based Guidelines
Deep Brain Stimulation Specialty Matched Consultant Advisory Panel review 5/27/2014. No changes to guideline.
Laboratory Testing for HIV Tropism References added. Senior Medical Director review. Rationale section reorganized. Guideline changed to remove statement that HIV V3 genotyping by deep sequencing is not recommended; statement added to Rationale section that V3 genotyping may be conducted by either standard sequencing methods or deep sequencing.
Radiofrequency Ablation of Primary or Metastatic Liver Tumors Specialty Matched Consultant Advisory Panel meeting 5/27/14. No change to guideline statement.