Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for August 26, 2014

Medical Guidelines Reason for Update
Ambulatory Event Monitors Description section updated. Added following coverage criterion to "When Covered" section: "Patients with cryptogenic stroke who have a negative standard work-up for atrial fibrillation including a 24-hour Holter monitor." Policy Guidelines updated. References updated. Medical Director review 8/2014.
Breast Surgeries Deleted the following Related Policy from Description section: "Autologous Fat Grafting to the Breast." Removed the following statement from the section "When Breast Reconstruction is Not Covered": "Autologous fat grafting using liposuction technique for breast reconstruction is not covered. Please see policy titled, "Autologous Fat Grafting to the Breast."
Cardiac Hemodynamic Monitoring in the Outpatient Setting Description section extensively revised to include new hemodynamic monitoring devices. References updated. Policy Guidelines updated. Medical Director review 8/2014. No changes to Policy Statement. Added C9741 (effective October 1, 2014) to Billing/Coding section.
Carotid Intimal-Medial Thickness References updated. Policy Guidelines updated. No changes to Policy Statement.
Clinical Trial Services Updated Policy Guidelines and Benefits Application sections. Reference added. No change to policy statement. Senior Medical Director review 8/2014.
Continuous Monitoring of Glucose in the Interstitial Fluid Specialty Matched Consultant Advisory Panel review 7/29/2014. No change to Policy statement.
Cosmetic and Reconstructive Surgery References updated. No changes to Policy Statements.
DNA Based Testing for Adolescent Idiopathic Scoliosis Policy Guidelines and References updated. No changes to Policy Statements.
Esophageal pH Monitoring Reference added. No change to Policy statement.
Intracellular Micronutrient Analysis References updated. No changes to Policy Statement.
Intravitreal Implant "Under "When Covered" section; added indication for diabetic macular edema in patients who are pseudophakic or phakic and scheduled for cataract surgery. Updated the Description section. References added. Senior medical director review 8/2014.
Islet Cell Transplantation Related policy "Pancreas Transplant" added. The statement "islet transplantation is considered investigational in all other situations" added to the When Not Covered section. Reference added. Specialty Matched Consultant Advisory Panel Review 7/29/14.
Maximum Units of Service Statement added to section "Guidelines related to Maximum Units" that reads: When CPT code 88305 is submitted for greater than 10 units with prostate related diagnoses, the corresponding G-code will be substituted.
Ovarian and Internal Iliac Vein Embolization Reference added. No change to Policy statement.
Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention Description section updated. Policy Guidelines updated. References updated. No changes to Policy Statement.
Treatment of Hereditary Angioedema New FDA approved medication Ruconest® added to policy. Description section updated. Policy Guidelines updated. "When Covered" section updated as follows: "Ruconest® may be considered medically necessary for the treatment of acute attacks in adult and adolescent patients with hereditary angioedema (HAE) aged 13 years and older when the following criteria are met: 1.Patient must be experiencing at least one symptom of the moderate or severe attack (e.g., airway swelling, severe abdominal pain, facial swelling, nausea and vomiting, painful facial distortion) and 2.Diagnosis of HAE is documented based on evidenced of a normal C1 level and a C4 level below the lower limit of normal as defined by the laboratory performing the test with either of the following indicators: a.C1 inhibitor (C1INH) antigenic level below the lower limit of normal as defined by the laboratory performing the test b.C1INH functional level below the lower limit of normal as defined by the laboratory performing the test." The "When not Covered" section updated as follows: "Ruconest® is considered investigational as prophylaxis against angioedema attacks and all other indications except as described above." References updated. Added J3490 and J3590 to Billing/Coding section. Medical Director review 8/2014.
Vertebroplasty, Kyphoplasty, and Sacroplasty Percutaneous References added. Vertebral body stenting added to investigational statement.
Evidence Based Guidelines
Endovascular Stent Grafts for Thoracic Aortic Aneurysm Description section updated. References updated. No changes to Guideline Statements.
External Insulin Pumps Medical Director review. Reference added. Specialty Matched Consultant Advisory Panel review 7/29/14. No change to policy guidelines.
Fecal Analysis in the Diagnosis of Intestinal Dysbiosis Specialty Matched Consultant Advisory Panel review 4/29/14. No change to Guideline statement.
Maze Procedure for Atrial Fibrillation or Flutter Description section updated. References updated. No changes to Guideline statements.
Prostate Cancer Treatment with Brachytherapy Specialty matched consultant advisory panel review meeting 6/24/2014. Changed Gleason score from 5.6 to <6 under Guideline . References added. Sr. Medical Director review.