Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for July 1, 2014

Medical Guidelines Reason for Update
Accelerated Partial Breast Radiotherapy (Breast Brachytherapy) Updated the Description section and Regulatory status. Under "When Covered" section added to statement a.: The patient is 45 years old or older for invasive cancer and age 50 years or older for DCIS." References updated. Medical director review 3/2014. Policy noticed on 4/15/14 for effective date 7/1/14.
Brachytherapy Treatment of Breast Cancer Updated Description, Regulatory status, and Policy Guidelines sections. Under "When Not Covered" section added Accuboost as investigational: "Noninvasive brachytherapy using Accuboost® for patients undergoing initial treatment for stage I or II breast cancer when used as local boost irradiation in patients who are also treated with BCS and whole breast external beam radiotherapy". References added. Medical director review 3/2014. Policy noticed 4/15/14 for effective date 7/1/14.
Capsaicin (Qutenza®) Removed ICD-10 effective date from Billing/Coding section.
Continuous Monitoring of Glucose in the Interstitial Fluid Codes S1034, S1035, S1036, S1037 added to Billing/Coding Section.
Diagnosis and Treatment of Chronic Cerebrospinal Venous Insufficiency in Multiple Sclerosis Removed ICD-10 effective date from Billing/Coding section.
Endovascular Procedures for Intracranial Arterial Disease Description and Policy Guidelines sections updated. Added the following statements to the When Not Covered section; "Intracranial percutaneous transluminal angioplasty with or without stenting is considered investigational in the treatment of cerebral vasospasm after aneurysmal subarachnoid hemorrhage." "Use of intracranial aneurysm flow diverter systems (i.e., Pipeline® Embolization Device) for the endovascular treatment of adults (22 years of age or older) with large or giant wide-necked intracranial aneurysms is considered investigational." "Endovascular interventions (mechanical embolectomy, angioplasty, stenting) are considered investigational in the treatment of acute stroke." This information was previously located in the medical policy titled, Mechanical Embolectomy for Treatment of Acute Stroke which is being archived. Senior Medical Director review 4/27/2014. Reference added. Specialty Matched Consultant Advisory Panel review 5/27/14. Notification given 4/15/2014. Policy effective 7/1/2014.
Gender Reassignment Surgery Removed ICD-10 effective date from Billing/Coding section.
Investigational (Experimental) Services Policy category changed from Medical Policy to Reimbursement policy. No change to current policy statement.
Laboratory and Genetic Testing for Use of 5-Fluorouracil in Patients with Cancer Policy title changed from "Laboratory Testing to Allow Area Under the Curve (AUC) Targeted 5-Fluorouracil (5-FU) Dosing for Patients Administered 5-FU for Cancer" to "Laboratory and Genetic Testing for Use of 5-Fluorouracil in Patients with Cancer". Description section updated to change the name of OnDose® to My5-FU® and to add information regarding TheraGuide®. Additional non-coverage statement added to policy indicating; "TheraGuide® testing for genetic mutations in dipyrimidine dehydrogenase (DPYD) or thymidylate synthase (TYMS) to guide 5-FU dosing and/or treatment choice in patients with cancer is considered investigational." Added the following statement to the When Not Covered section to indicate; "There is no specific CPT coding for the TheraGuide testing. The following codes may be used: 81400 and 81401. Policy Guidelines updated. Reference added. Senior Medical Director review 4/9/2014. Notification given 4/29/2014. Policy effective 7/1/2014.
Laser Treatment of Port Wine Stains Removed ICD-10 effective date from Billing/Coding section.
Mechanical Embolectomy for Treatment of Acute Stroke Policy information combined into Endovascular Procedures for Intracranial Arterial Disease. Policy archived.
Medical Necessity Policy category changed from Medical Policy to Reimbursement policy. No change to current policy statement.
Molecular Markers in Fine Needle Aspirates of the Thyroid Removed ICD-10 effective date from Billing/Coding section.
Orthopedic Applications of Stem Cell Therapy Specialty Matched Consultant Advisory Panel review 2/2014. Medical Director review 2/2014. Additional products added to the Description section. The following statement added to the "When not Covered" section: "Allograft bone products that are intended to be mixed with autologous bone marrow aspirate are considered investigational." CPT codes 38232 and 38220 in combination with 22520, 22521, 22522, 22523, 22524, 22525, 22533, 22534, 22548, 22551, 22552, 22554, 22558, 22585, 22586, 22590, 22595, 22600, 22612, 22614, 22630, 22632, 22633, 22634, 22800, 22802, 22804, 22808, 22810, 22812, 22856, 22857, 22861, 22864, 22865, 27280, 27299, 27702, 27703 added to "Billing/Coding" section. References updated. Policy noticed 4/15/14 for effective date 7/1/14.
Rituximab for the Treatment of Rheumatoid Arthritis Removed ICD-10 effective date from Billing/Coding section.
Systems Pathology for Predicting Risk of Recurrence in Prostate Cancer Removed ICD-10 effective date from Billing/Coding section.
Varicose Veins, Treatment for Reference added. Removed ICD-10 effective date. No change to Policy statement.
Vedolizumab (Entyvio) New medical policy issued. Entyvio (vedolizumab) may be medically necessary when the following criteria are met: 1.One of the following conditions is present: a) Adult patients ( ≥ 18 years of age) with moderately to severely active ulcerative colitis who have had an inadequate response with, were intolerant to, or demonstrated dependence on corticosteroids; Or b)Adult patients ( ≥ 18 years of age) with moderately to severely active Crohn's Disease who have had an inadequate response with, were intolerant to, or demonstrated dependence on corticosteroids; AND 2.The patient has failed to respond adequately or is intolerant to Remicade® (infliximab).Medical director review 6/2014.
Evidence Based Guidelines
Endoscopic Radiofrequency Ablation or Cryoablation for Barrett's Esophagus Reference added. No change to the Evidence Based Guideline.
Fecal Calprotectin Test Reference added. No change to Guideline statement.
Monitored Anesthesia Care (MAC) New code added to Billing/Coding section: S0144.