Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for July 15, 2014

Medical Guidelines Reason for Update
Aqueous Shunts and Devices for Glaucoma Specialty matched consultant advisory panel meeting 6/24/2014. No changes to policy statement.
Assays of Genetic Expression to Determine Prognosis of Breast Cancer Description section revised to include updated list of available tests, including ProsignaTM. Statement in the "When not Covered" section revised as follows: "The use of other gene expression assays (e.g., MammaPrint® 70-gene signature, Mammostrat® Breast Cancer Test, the Breast Cancer Index SM, the BreastOncPxTM, NexCourse® Breast IHC4, or ProsignaTM PAM50 Breast Cancer Intrinsic Classifier) is considered investigational for any indication." Policy Guidelines updated. References updated. Added new code 0008M to Billing/Coding section. Medical Director review 7/2014.
Cardiac (Heart) Transplantation Specialty Matched Consultant Advisory Panel review 6/2014. Medical Director review 6/2014. No changes to Policy Statements.
Carotid Artery Angioplasty/Stenting (CAS) Description section updated. The statement regarding the ACT-1 clinical trial removed from the Policy Statements section, as that study is listed as terminated. Policy Guidelines updated. References updated. Added CPT code 37217 to Billing/Coding section. Specialty Matched Consultant Advisory Panel review 6/2014. Medical Director review 6/2014.
Catheter Ablation as a Treatment for Atrial Fibrillation Policy re-titled from "Catheter Ablation of the Pulmonary Veins as Treatment for Atrial Fibrillation" to "Catheter Ablation as a Treatment for Atrial Fibrillation". Description section updated. All references specific to ablation of "pulmonary veins" deleted from policy. "Transcatheter Radiofrequency Ablation" revised to "Transcatheter Ablation" in the "When Covered" section. The following statement removed from the "When not Covered" section: "Transcatheter cryoablation as a treatment for atrial fibrillation is considered investigational." Policy Guidelines revised. References updated. Medical Director review 6/2014. Specialty Matched Consultant Advisory Panel review 6/2014.
Computed Tomography to Detect Coronary Artery Calcification Description section updated. Policy Guidelines updated. References updated. No changes to Policy Statement.
Congenital Heart Defect, Repair Devices Specialty Matched Consultant Advisory Panel review 6/2014. Medical Director review. No changes to Policy Statements.
Corneal Collagen Cross-linking Specialty matched consultant advisory panel review meeting 6/24/2014. No change to policy statement.
Corneal Topography Specialty matched consultant advisory panel review meeting 6/24/2014. No change to policy statement.
Cytochrome p450 Genotyping References updated. No changes to Policy Statements.
Diagnosis and Treatment of Chronic Cerebrospinal Venous Insufficiency in Multiple Sclerosis Reference added. Specialty Matched Consultant Advisory Panel review 5/27/2014. No change to Policy statement.
Endothelial Keratoplasty Specialty matched consultant advisory panel review meeting 6/24/2014. No change to policy statement.
Epiretinal Radiation Therapy for Age-Related Macular Degeneration Specialty matched consultant advisory panel review 6/24/2014. No change to policy statement.
Esophageal pH Monitoring Removed "24-hour" from the policy statement on impedance monitoring as catheter-based impedance monitoring for any length of time is considered not medically necessary. No other changes to policy statements. Specialty Matched Consultant Advisory Panel review 4/29/14. Policy noticed 5/13/14 for effective date 7/15/14.
External Defibrillators Specialty Matched Consultant Advisory Panel review 4/2014. "When Covered" section revised to include the following indications: "Use of wearable cardioverter defibrillators for the prevention of sudden cardiac death is considered medically necessary as a bridge to ICD placement for patients within 40 days post myocardial infarction (MI) who: have sustained ventricular tachycardia/ventricular fibrillation (VT/VF) occurring > 48 hours after index MI; or have a measured left ventricular ejection <35%; or have presented with out of hospital cardiac arrest." "When not Covered" revised to state: "Use of wearable cardioverter defibrillators for the prevention of sudden cardiac death is considered investigational for all other indications. For patients who are post myocardial infarction (MI), use of the wearable cardioverter defibrillators is limited to forty days." Policy Guidelines updated. References updated. Medical Director review 6/2014.
Extracorporeal Photopheresis Under "When Covered" section Graft-Versus-Host Disease: added acute GVHD as medically necessary. Under "When Not Covered" section Autoimmune Diseases: added severe atopic dermatitis, and Crohn's disease. Reviewed by Sr. Medical Director. Reference added.
Fecal Microbiota Transplantation New policy developed. Fecal Microbiota Transplantation may be considered medically necessary for patients who meet criteria (i.e. at least 3 episodes of recurrent C. difficile infection and episodes are refractory to appropriate antibiotic regimens, including at least one regimen of pulsed Vancomycin. Fecal Microbiota Transplantation is considered investigational for all other situations. Senior Medical Director review.
Functional Endoscopic Sinus Surgery (FESS) Description section updated to include general information on drug-eluting sinus implants and specific information on the PropelTM sinus implant. Medical necessity criteria for use of a mometasone furoate sinus implant added to When Covered section. Not medically necessary criteria for use of a mometasone furoate sinus implant added to When Not Covered section. Policy Guidelines updated.
Fundus Photography Specialty matched consultant advisory panel review meeting 6/24/2014. No change to policy statement.
Gene Expression Profiling for Uveal Melanoma New medical policy issued. Gene expression profiling for uveal melanoma is considered investigational. Reviewed with Sr. Medical Director 7/2014.
Genetic Testing for Macular Degeneration Specialty matched consultant advisory panel review meeting 6/24/2014. No change to policy statement.
Heart-Lung Transplantation Specialty Matched Consultant Advisory Panel review 6/2014. Medical Director review 6/2014. No changes to Policy Statements.
Hematopoietic Stem-Cell Transplantation for Acute Lymphoblastic Leukemia References updated. No changes to Policy Statements.
Hyperhidrosis, Treatment of References updated. No changes to Policy Statements.
Idiopathic Environmental Intolerance (i.e. Multiple Chemical Sensitivities) References updated. Policy Guidelines updated. No changes to Policy Statements.
Immune Globulin Therapy Specialty Matched Consultant Advisory Panel review 2/25/14. Added hypogammaglobulinemia and prevention of infection in preterm infants and/or low-birth weight neonates to the list of covered indications. Reference added.
Implantable Cardioverter Defibrillator Specialty Matched Consultant Advisory Panel 6/2014. Medical Director review 6/2014. No changes to Policy Statements.
Implantation of Intrastromal Corneal Ring Segments Specialty matched consultant advisory panel review meeting 6/24/2014. No change to policy statement.
Infliximab (Remicade) Under "When Covered" section: changed and to or under 1.f. Under "When Not Covered" section: #23 Sarcoidosis-added "except neurosarcoidosis". Reviewed by Sr.Medical Director. No change to policy statement.
Intradialytic Parenteral Nutrition References updated. No changes to Policy Statements.
Intravitreal Implant Specialty matched consultant advisory panel review meeting 6/24/2014. No change to policy statement.
Investigational (Experimental) Services Policy category name returned to "Corporate Medical Policy."
Keratoprosthesis Specialty matched consultant advisory panel review meeting 6/24/2014. No change to policy statement.
Laser Treatment of Onychomycosis References updated. No changes to Policy Statement.
Medical Necessity Policy category returned to Corporate Medical Policy.
Melanoma Vaccines References updated. No changes to Policy Statement.
Optical Coherence Tomography (OCT) Anterior Segment of the Eye Specialty matched consultant advisory panel review meeting 6/24/2014. No change to policy statement.
Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention Specialty Matched Consultant Advisory Panel review 6/2014. Medical Director review 6/2014. References updated. Description section and Policy Guidelines updated. No changes to Policy Statements.
Refractive Surgery Specialty matched consultant advisory panel review meeting 6/24/2014. No change to policy statement.
Retinal Prosthesis Specialty matched consultant advisory panel review meeting 6/24/2014. No change to policy statement.
Stem-cell Therapy for Peripheral Arterial Disease References updated. No changes to Policy Statements.
Suprachoroidal Delivery of Pharmacologic Agents Specialty matched consultant advisory panel review meeting 6/24/2014. No change to policy statement.
Surgery for Morbid Obesity References added. Specialty Matched Consultant Advisory Panel review 5/14/2014. Coverage criteria for long limb Roux-en-Y and biliopancreatic bypass with duodenal switch added to When Covered section. Under Revision Bariatric Surgery in When Covered section, additional criteria added at C. Under When Not Covered section, removed biliopancreatic bypass and Roux-en-Y for failed Nissen Fundoplasty from list. Added "Laparoscopic gastric plication (laparoscopic greater curvature plication [LGCP]) with or without gastric banding" to When Not Covered section. Clarification added to nutritional evaluation guidelines. Requirement that patient be an active participant in non-surgical weight reduction program for at least 6 months prior to surgery removed.
Surgical Management of Transcatheter Heart Valves Specialty Matched Consultant Advisory Panel review 6/2014. Medical Director review 6/2014. Deleted 0342T from Billing/Coding section. References updated. Policy Guidelines updated. Deleted the following statement from the "When not Covered" section: "Transcatheter aortic valve replacement is considered investigational for all other indications, including but not limited to... procedures performed via the transaxillary, transiliac, transaortic, or other approaches." Added the Medtronic Core Valve System as new FDA approved aortic valve device. Description section updated.
Surgical Ventricular Restoration Specialty Matched Consultant Advisory Panel review 6/2014. Medical Director review 6/2014. No changes to Policy Statements.
Tinnitus Treatment Reference added. No change to Policy statement.
Transcatheter Closure of Ventricular Septal Defects Description section updated. Added the following statement to the "When not Covered" section : "Use of non-FDA approved devices is considered investigational." References updated. Specialty Matched Consultant Advisory Panel review 6/2014. Medical Director review 6/2014.
Viscocanalostomy and Canaloplasty Specialty matched consultant advisory panel review meeting 6/24/2014. No change to policy statement.
Evidence Based Guidelines
Biventricular Pacemakers/Cardiac Resynchronization Therapy for Heart Failure Specialty Matched Consultant Advisory Panel review 6/2014. Medical Director review 6/2014. No changes to Guideline Statements.
Cryoablation of Prostate Cancer Description section updated. References updated. No changes to Guideline Statements.
Diabetic Retinopathy Telescreening Specialty matched consultant advisory panel review meeting 6/24/2014. No change to guideline statement.
Donor Lymphocyte Infusion References updated. No changes to Guideline Statements.
Endovascular Stent Grafts for Abdominal Aortic Aneurysm Specialty Matched Consultant Advisory Panel review 6/2014. Medical Director review 6/2014. No changes to Guideline Statements.
Endovascular Stent Grafts for Thoracic Aortic Aneurysm Specialty Matched Consultant Advisory Panel review 6/2014. Medical Director review 6/2014. No changes to Guideline Statements.
Glaucoma, Evaluation by Ophthalmologic Techniques Specialty matched consultant advisory panel review meeting 6/24/2014. Under "Evidenced Based Guideline for OphthalmologicTechniques to Evaluate Glaucoma" section: Patients who are defined as a glaucoma suspect should have at least one of the following documented: 4th bullet: changed the value to 0.5 from 5 for cup disc ratio. No change to guideline statement.
Implantable Infusion Pumps Specialty Matched Consultant Advisory Panel review 5/27/2014. No change to guideline statement.
Intravitreal Angiogenesis Inhibitors for Choroidal and Retinal Vascular Conditions Specialty matched consultant advisory panel review meeting 6/24/2014. No change to guideline statement.
Maze Procedure for Atrial Fibrillation or Flutter Added the following statement to the "Not Recommended" section: "Hybrid ablation (defined as a combined percutaneous and thoracoscopic approach) is not recommended for the treatment of atrial fibrillation or flutter." Description section updated to include information regarding Hybrid Ablation technique. References updated. Specialty Matched Consultant Advisory Panel review 6/2014. Medical Director review 6/2014.
Photodynamic Therapy, Ocular Updated Description section. Specialty matched consultant advisory panel review meeting 6/24/2014. No change to guideline statement.
Radioimmunotherapy in the Treatment of Non-Hodgkin Lymphoma Updated Description, EBG Guideline and Not Recommended sections to reflect removal of references to tositumomab (Bexxar®) due to discontinuation. Also added updated statements for ibritumomab tiuxetan (Zevalin®) due to current FDA labeling. Reference added. Sr.Medical Director review.
Therapeutic Apheresis References updated. No changes to Guideline Statements.
Transmyocardial Revascularization References updated. Specialty Matched Consultant Advisory Panel review 6/2014. Medical Director review 6/2014. No changes to Guideline Statements.
Ultrafiltration in Decompensated Heart Failure Specialty Matched Consultant Advisory Panel review 6/2014. Medical Director review 6/2014. References updated. No changes to Guideline Statements.
Ventricular Assist Devices and Total Artificial Hearts Description section updated. References updated. Specialty Matched Consultant Advisory Panel review 6/2014. Medical Director review 6/2014. No changes to Guideline Statements.