Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for August 12, 2014

Medical Guidelines Reason for Update
Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions Added patella to the "When Covered" section. Deleted patella from the "When not Covered" section. Policy Guidelines updated. References updated. Specialty Matched Consultant Advisory Panel review 7/2014. Medical Director review 7/2014.
Autologous Chondrocyte Implantation Specialty Matched Consultant Advisory Panel review 7/2014. Medical Director review 7/2014. References updated. Description section and Policy Guidelines updated. No changes to Policy Statements.
Chelation Therapy Updated description section, Regulatory status, and policy guidelines. Reference added.
Computer Assisted Surgical Navigational Orthopedic Procedures Specialty Matched Consultant Advisory Panel review 7/29/14. No change to Policy statement.
Computer-Aided Evaluation of Malignancy with MRI of the Breast Description section updated to include FDA approved products. Specialty Matched Consultant Advisory Panel review 7/2014. References updated. Medical Director review 7/2014.
Continuous Passive Motion in the Home Setting Specialty Matched Consultant Advisory Panel review 7/2014. References updated. Medical Director review 7/2014 Policy Guidelines updated. No changes to Policy Statements.
Co-Surgeon, Assistant Surgeon, Team Surgeon and Assistant-at-Surgery Guidelines Policy category returned to "Corporate Medical Policy."
CT Perfusion Imaging of the Brain Specialty Matched Consultant Advisory Panel review 7/29/14. No change to policy statement.
Detection of Circulating Tumor Cells Updated Policy Guidelines. Reference added.
Digital Breast Tomosynthesis Specialty Matched Consultant Advisory Panel review 7/29/14. No change to Policy statement.
Dopamine Transporter Imaging with Single Photon Emission Computed Tomography Specialty Matched Consultant Advisory Panel review 7/29/14. Removed effective date 10/1/2014 from ICD-10 list. No change to Policy statement.
Electrical Bone Growth Stimulation Specialty Matched Consultant Advisory Panel review 7/2014. Medical Director review 7/2014. No changes to Policy Statements.
Electrothermal Arthroscopic Capsulorrhaphy Specialty Matched Consultant Advisory Panel review 7/2014. Medical Director review 7/2014. References updated. No changes to Policy Statements.
Extracorporeal Shock Wave Treatment for Musculoskeletal Conditions and Wound Healing Specialty Matched Consultant Advisory Panel review 7/2014. Medical Director review 7/2014. No changes to Policy Statements.
General Approach to Evaluating the Utility of Genetic Panels Added the following statement to the "When not Covered" section: "Genetic testing for mitochondrial disorders using expanded panel testing is considered investigational." Added panel names and laboratories to the Description section. References updated. Policy Guidelines updated. Medical Director review 8/2014.
Genetic Testing for FMR1 Mutations Including Fragile X Syndrome Policy Guidelines updated. References updated. No changes to Policy Statements.
Genetic Testing for Mental Health Conditions Specialty Matched Consultant Advisory Panel review 7/29/14. Reference added. Policy expanded to include other genetic testing panels. Title of policy changed from "Genecept Assay" to "Genetic Testing Panels for Mental Health Conditions." Rationale extensively revised. Policy statement changed to indicate that individual genetic tests and genetic testing panels for mental health disorders are investigational.
Genetic Testing for the Diagnosis of Inherited Peripheral Neuropathy Description section updated. Added the following codes to the Billing/Coding section: 81403, 81404, 81406, 81479. References updated. No changes to Policy Statements.
Insulin Therapy, Chronic Intermittent Intravenous (CIIIT) Specialty Matched Consultant Advisory Panel review 7/29/14. Reference added. No change to policy statement.
Intra Articular Hyaluronan Injections for Treatment of Osteoarthritis of the Knee Medical Director review 7/2014. Specialty Matched Consultant Advisory Panel review 7/2014. No changes to Policy Statements.
Laser Treatment of Port Wine Stains References updated. Policy Guidelines updated. No changes to Policy Statements.
Magnetic Resonance Spectroscopy Specialty Matched Consultant Advisory Panel review 7/29/14. No change to policy statement.
Magnetoencephalography/Magnetic Source Imaging Specialty Matched Consultant Advisory Panel review 7/29/14. No change to Policy statement.
Meniscal Allografts and Other Meniscal Implants Specialty Matched Consultant Advisory Panel review 7/2014. Medical Director review 7/2014. No changes to Policy Statements.
Myocardial Sympathetic Innervation Imaging Reference added. Specialty Matched Consultant Advisory Panel review 7/29/14. No change to Policy statement.
Myoelectric Prosthetic Components for the Upper Limb Specialty Matched Consultant Advisory Panel review 7/2014. Description section updated. References updated. Medical Director review 7/2014.
Noninvasive Prenatal Testing for Trisomy 21 Using Cell-Free Fetal DNA Policy title changed from Sequencing Based Tests to Determine Trisomy 21 from Maternal Plasma DNA to Noninvasive Prenatal Testing for Trisomy 21 Using Cell-Free Fetal DNA. Reference added. Clarified that testing in women with twin or multiple pregnancies is considered investigational. Senior Medical Director review.
Progenitor Cell Therapy for the Treatment of Damaged Myocardium Due to Ischemia References updated. Policy Guidelines and Description section updated. No changes to Policy Statements.
Prolotherapy Specialty Matched Consultant Advisory Panel review 7/2014. References updated. Medical Director review 7/2014. No changes to Policy Statements.
Quantitative Electroencephalography as a Diagnostic Aid for Attention Deficit/Hyperactivity Disorder Specialty Matched Consultant Advisory Panel review 7/29/14. No change to Policy statement.
Rapid Opioid Detoxification Specialty Matched Consultant Advisory Panel review 7/29/14. No change to Policy statement.
Renal (Kidney) Transplantation "When Covered" item #4 revised from "Kidney re-transplant after a failed primary kidney transplant may be considered medically necessary." to "Kidney re-transplant after a failed primary kidney transplant may be considered medically necessary in patients who meet criteria for kidney transplant." Description section updated. References updated.
Sensory Integration Therapy Specialty Matched Consultant Advisory Panel review 7/29/14. No change to Policy statement.
Surgery for Femoroacetabular Impingement Specialty Matched Consultant Advisory Panel review 7/2014. Medical Director review 7/2014. References updated. No changes to Policy Statements.
Treatment for Severe Primary IGF-1 Deficiency Specialty Matched Consultant Advisory Panel review 7/29/14. References updated. Information regarding 2014 resupply added to Description section. No change to policy statement.
Vertebral Axial Decompression (VAD-X) Specialty Matched Consultant Advisory Panel review 7/2014. Medical Director review 7/2014. No changes to Policy Statements.
Evidence Based Guidelines
Automated Nerve Conduction Tests Specialty Matched Consultant Advisory Panel review 5/27/14. Reference added. No change to guideline.
Blood Glucose Monitors for Use in the Home References added. Specialty Matched Consultant Advisory Panel review 7/29/14. No change to Guideline.
Genetic Testing for Li-Fraumeni Syndrome New Evidence Based Guideline developed. Genetic testing for TP53 mutations may be recommended to confirm a diagnosis of Li-Fraumeni syndrome under the following conditions: In a patient who meets either the classic or the Chompret clinical diagnostic criteria for Li-Fraumeni syndrome or In women with early-onset breast cancer (age of diagnosis ≤35 years). Genetic testing for a TP53 mutation may be appropriate in an at-risk relative of a proband with a known TP53 mutation. Medical Director review 7/2014.
Psychoanalysis Specialty Matched Consultant Advisory Panel review 7/29/14. References removed. References added. Information from DSM IV removed from document. No changes to Guideline statement.
Screening for Vertebral Fracture with Dual X-ray Absorptiometry (DEXA) References added. Specialty Matched Consultant Advisory Panel review 7/29/14. Senior Medical Director review. No changes to guideline statement.
Thermography Reference added. Specialty Matched Consultant Advisory Panel review 7/29/14. No change to guideline statement.