Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for July 29, 2014

Medical Guidelines Reason for Update
Accelerated Partial Breast Radiotherapy (Breast Brachytherapy) Specialty matched consultant advisory panel review meeting 6/24/14. No change to policy statement.
Acoustic Cardiography References updated. Medical Director review 7/2014. Policy archived.
Allergy Immunotherapy (Desensitization) Policy Guidelines updated. References updated. Added the following statement to the "When not Covered" section: "Subcutaneous immunotherapy performed in the home setting is considered investigational." Added the following statement to the Billing/Coding section: "Per unit reimbursement for allergy immunotherapy is based on the number of dosages prepared and intended for administration. Allergy immunotherapy is limited to 180 units for the first year of therapy during escalation, and 120 units for yearly maintenance therapy thereafter." Medical Director review 5/2014. Policy noticed on May 27, 2014 for effective date July 29, 2014. Added information regarding FDA approved sublingual immunotherapy products: Oralair®, Grastek®, and Ragwitek® and reference to BCBSNC Pharmacy website.
Biofeedback Reference added. No change to policy statement.
Brachytherapy, Intracavitary Balloon Catheter for Brain Cancer Specialty matched consultant advisory panel review meeting 6/24/2014. No change to policy statement. Reference added.
Brachytherapy Treatment of Breast Cancer Specialty matched consultant advisory panel review meeting 6/24/14. No change to policy statement.
Charged Particle Radiotherapy (Proton or Helium Ion) Specialty matched consultant advisory panel review meeting 6/24/2014. No change to policy statement. Reference added.
Gene Expression Testing to Predict Coronary Artery Disease "When not Covered" statement revised to state: "Gene expression testing to predict coronary artery disease is considered investigational for all indications, including but not limited to prediction of the likelihood of CAD in stable, nondiabetic patients." References updated. Policy Guidelines updated.
General Approach to Evaluating the Utility of Genetic Panels References updated. Policy Guidelines updated. No changes to Policy Statements.
General Approach to Genetic Testing Related Policies list updated. References updated. No changes to Policy Statements.
Genetic Cancer Susceptibility Panels Using Next Generation Sequencing Description section extensively revised to include additional gene panels and panel components. Policy Guidelines updated. References updated. No changes to Policy Statements. Medical Director review 7/2014.
Genetic Testing for Lactase Insufficiency Description section updated. References updated. No changes to Policy Statements.
Genetic Testing for Statin-induced Myopathy Description section updated. References updated. Policy Guidelines updated. No changes to Policy Statements.
Group Visit (Shared Medical Appointment) Guidelines Updated link to reference for American Academy of Family Physicians (AAFP). Coding for Group Visits.
Growth Factors in Wound Healing Reference added. Information on Augment Bone Graft added to Description section. No change to Policy statement.
Intensity Modulated Radiation Therapy for Tumors of the Central Nervous System Specialty matched consultant advisory panel review meeting 6/24/2014. No changes to policy statement. Reference added.
Intensity Modulated Radiation Therapy (IMRT) of Abdomen and Pelvis Specialty matched consultant advisory panel review meeting 6/24/2014. No change to policy statement.
Intensity Modulated Radiation Therapy (IMRT) of Breast and Lung Specialty matched consultant advisory panel review meeting 6/24/2014. No change to policy statement. Reference added.
Intensity Modulated Radiation Therapy (IMRT) of Head and Neck Specialty matched consultant advisory panel review meeting 6/24/2014. No change to policy statement. Reference added.
Intensity-Modulated Radiation Therapy (IMRT) of the Prostate Specialty matched consultant advisory panel review meeting 6/24/2014. No change to policy statement. Reference added.
Intraoperative Neurophysiologic Monitoring (sensory-evoked potentials, motor-evoked potentials, EEG monitoring) Reference added. No change to policy statement.
Lung Volume Reduction Surgery Reference updated. Specialty matched consultant advisory panel review meeting 4/30/14. No change to policy statement.
Maximum Units of Service Per unit reimbursement for allergy immunotherapy is based on the number of dosages prepared and intended for administration. Allergy immunotherapy is limited to 180 units for the first year of therapy during escalation, and 120 units for yearly maintenance therapy thereafter. Policy noticed on May 27, 2014 for effective date July 29, 2014.
PathFinderTG® Molecular Testing Description section extensively revised to include individual PathFinder tests. "When not Covered" policy statement revised as follows: "Molecular testing using the PathFinderTG® system is considered investigational for all indications including the evaluation of pancreatic cyst fluid, suspected or known gliomas, and Barrett esophagus." Policy Guidelines updated. Unlisted code 84999 added to Billing/Coding section. References updated. Medical Director review 7/2014.
Radioembolization for Primary and Metastatic Tumors of the Liver Removed ICD-10 effective date 10/1/2014 from Billing/Coding section. Specialty matched consultant advisory panel review meeting 6/24/2014. No change to policy statement. Reference added.
Radiosurgery, Stereotactic Approach Specialty matched consultant advisory panel review meeting 6/24/2014. No change to policy statement.
Small Bowel, Small Bowel with Liver, or Multivisceral Transplant References added. Added "pediatric patients" to the statement "A small bowel transplant is considered investigational for adult and pediatric patients with intestinal failure who are able to tolerate TPN."
Evidence Based Guidelines
Cardiac Rehabilitation References updated. No changes to Guideline Recommendations.
Endobronchial Brachytherapy Specialty matched consultant advisory panel review meeting 6/24/2014. No change to guideline statement. Reference added.
Human Leukocyte Antigen (HLA) Testing for Celiac Disease Reference added. No change to Guideline statement.
Interventions for Progressive Scoliosis References updated. No changes to Guideline Statements.
Intraoperative Radiation Therapy Specialty matched consultant advisory panel review meeting 6/24/2014. No change to guideline statement.
Pertuzumab for Treatment of Malignancies Guideline titled changed from "Pertuzumab for Treatment of HER2-Positive Malignancies" to "Pertuzumab for Treatment of Malignancies." Extensive revision of guideline content to include new FDA approval for Pertuzumab as follows: "In patients who have HER2-positive breast cancer, the use of pertuzumab in combination with trastuzumab and a taxane (eg, docetaxel, paclitaxel) is recommended: for neoadjuvant treatment of locally advanced, inflammatory, or early stage (either greater than 2 cm in diameter or node positive) breast cancer; or for treatment of locally recurrent or metastatic breast cancer if pertuzumab was not previously administered." "Not Recommended" section updated to include the following statement: "Pertuzumab dose reductions are not recommended. If trastuzumab is discontinued, pertuzumab should be discontinued." References updated. Medical Director review 7/2014.
Pharmacogenomic and Metabolite Markers for Treatment with Thiopurines Reference added. Clarified the Not Recommended statement by adding the following: "Genotypic and/or phenotypic analysis of the enzyme TPMT is not recommended in all other situations." Removed HCPCS G0452 from Billing/Coding section.
Vertical Expandable Prosthetic Titanium Rib References updated. No changes to Guideline Statement.