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Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for December 30, 2015

Medical Guidelines Reason for Update
Ablation Procedures for Peripheral Neuromas New policy issued. Ablation procedures of any type for treatment of all peripheral neuromas are considered investigational. Policy noticed 10/1/15 for policy effective date 12/30/15.
Accelerated Partial Breast Radiotherapy (Breast Brachytherapy) Added the following CPT codes: 77770, 77771, 77772 and deleted the following CPT codes: 77776, 77777, 77785, 77786, 77787 in Billing/Coding section for effective date 1/1/2016.
Ado-Trastuzumab Emtansine (Trastuzumab-DM1) for Treatment of HER-2 Positive Malignancies Evidence Based Guideline converted to Corporate Medical Policy. Senior Medical Director review. Reference added. Specialty Matched Consultant Advisory Panel review 8/26/2015. Under Description section: deleted the word "oral" from the third bullet "Pertuzumab (PerjetaTM) is a monoclonal antibody." No change to policy statement. Notification given 10/1/15 for effective date 12/30/15.
Alemtuzumab (LemtradaTM) Code J0202 added and code Q9979 removed from Billing/Coding section.
Allergy Testing When Covered section 9. b. revised to state, "Repeat skin testing may be considered medically necessary for adults who: i. have food allergy and require reevaluation to examine for resolution of their food allergy or; have received three to five years of venom immunotherapy and require reevaluation for resolution of their venom allergy or; develop increased atopic symptoms suggesting new sensitizations." References updated. Specialty Matched Consultant Advisory Panel review 11/2015. Medical Director review 11/2015.
Antiprothrombin Antibody Testing Specialty Matched Consultant Advisory Panel review 10/29/2015. Medical Director review 10/2015.
Artificial Intervertebral Disc Specialty Matched Consultant Advisory Panel review 10/28/2015. Reference added. Policy statement changed to "BCBSNC will provide coverage for cervical artificial intervertebral disc when it is determined to be medically necessary because the medical criteria and guidelines shown below are met".
Assays of Genetic Expression to Determine Prognosis of Breast Cancer Deleted HCPCS code S3854 from Billing/Coding section effective 1/1/2016.
Autologous Chondrocyte Implantation Reference added. Autologous chondrocyte implantation of the patella considered medically necessary; need for a prior surgical procedure removed from the policy statement.
Beta Amyloid Imaging With Positron Emission Tomography for Alzheimer's Disease Added HCPCS codes C9458 and C9459 to Billing/Coding section for effective date 1/1/2016.
Bevacizumab in Advanced Adenocarcinoma of the Pancreas Updated Policy Guidelines section. Reference added. Specialty Matched Consultant Advisory Panel review 11/18/2015. No change to policy statement.
Bioengineered Skin and Tissue Billing/Coding section updated to include codes: Q4161, Q4162, Q4163, Q4164, Q4165; effective 1/1/16. When Covered section updated to include additional products.
Bioimpedance Devices for Detection of Lymphedema Specialty Matched Consultant Advisory Panel review 11/18/2015.
Brachytherapy Treatment of Breast Cancer Added the following CPT codes: 0395T, 77770 and deleted the following CPT codes: 0182T, 77776, 77777, 77785, 77786, 77787 in Billing/Coding section for effective date 1/1/2016.
Bundling Guidelines CPT Code 72010 deleted, replaced with 72082. New codes for January, 2016 added: 0396T (intra-operative use of kinetic balance sensor for implant stability during knee replacement arthroplasty) and 0399T (myocardial strain imaging) are considered incidental to the primary procedure being performed and are not eligible for separate reimbursement. Section related to specimen handling and convenyance was deleted. 99000 and 99001 are not a covered service. Refer to policy titled "Code Bundling Rules Not Addressed in Claimcheck or Correct Coding Initiative."
Cardiac Hemodynamic Monitoring in the Outpatient Setting Description section updated. References updated. Specialty Matched Consultant Advisory Panel review 10/29/2015. Medical Director review 10/2015.
Cardiovascular Disease Risk Tests Billing/Coding section updated to reorder codes for clarity. Codes 82172, 83701, 83704 are always investigational. Policy Guidelines section updated. References updated. Policy noticed 10/30/15 for effective date 12/30/15. Billing/Coding section updated to add code 0423T; effective 1/1/16.
Carrier Testing for Genetic Disease Description section updated. Billing/Coding section updated to include code 81412 effective 1/1/16. Policy Guidelines section updated. References updated.
Chromoendoscopy as an Adjunct to Colonoscopy References update. Specialty Matched Consultant Advisory Panel review 11/18/2015. Medical Director review 11/2015. Policy Statement remains unchanged.
Computed Tomography to Detect Coronary Artery Calcification References updated. Specialty Matched Consultant Advisory Panel review 10/29/2015. Medical Director review 10/2015.
Confocal Laser Endomicroscopy Billing/Coding section updated to add code 0397T effective 1/1/16. References updated. Specialty Matched Consultant Advisory Panel review 11/18/2015. Medical Director review 11/2015.
Corneal Collagen Cross-linking Added CPT code 0402T to Billing/Coding section for effective date 1/1/2016.
Corneal Topography Archived. Medical Director review 8/2015.
Cosmetic and Reconstructive Surgery When Covered section B. updated to include this statement, "Prolaryn Gel® and Prolaryn Plus® for for indications of vocal fold medialization and vocal fold insufficiency in accordance with FDA labeling". References updated. Policy Statement unchanged.
Co-Surgeon, Assistant Surgeon, Team Surgeon and Assistant-at-Surgery Guidelines Added benefit information to Policy section for clarity. Added policy information to Physician Assistant/Nurse Practitioner/Nurse Midwife and Team Surgeon subheadings under the "when services will be considered for payment' section for clarity. No change to policy intent.
Dental Criteria for use of Hospital Inpatient or Outpatient Facility Services or Ambulatory Surgery Center Facility Services Specialty Matched Consultant Advisory Panel review 10/29/2015. Medical Director Review 10/2015.
Documentation Requirements for Treatment of End Stage Renal Disease New payment policy regarding reimbursement guidelines for services for members with end stage renal disease. BCBSNC requires a CMS form 2728 for every member who undergoes a regular course of dialysis or receives a kidney transplant for the purpose of treating ESRD. BCBSNC requires providers of ESRD-related dialysis and transplant services to ensure that a CMS form 2728 is on file with BCBSNC for a member no later than sixty (60) days after an ESRD-related dialysis or transplant claim is submitted for reimbursement of dialysis or transplant services supplied to that member. Notification given 10/30/15 for effective date 12/30/15.
Drug Testing in Pain Management and Substance Abuse Treatment Billing/Coding section updated to delete codes: G0431, G0434, G6030, G6031, G6032, G6034, G6035, G6036, G6037, G6038, G6039, G6040, G6041, G6042, G6042, G6043, G6044, G6045, G6046, G6047, G6048, G6049, G6050, G6051, G6052, G6053, G6054, G6055, G6056, G6057, G6058 and add codes: G0477, G0478, G0479, G0480, G0481, G0482, G0483; effective 1/1/16.
Durable Medical Equipment (DME) Billing/Coding section updated to add code E1012 effective 1/1/16.
Electrocardiographic Body Surface Mapping Specialty Matched Consultant Advisory Panel review 10/29/2015. Medical Director review 10/2015
Electronic Brachytherapy for Nonmelanoma Skin Cancer Added the following CPT codes 0394T, 77767, 77768 and deleted 0182T in Billing/Coding section for effective date 1/1/2016.
Electrostimulation and Electromagnetic Therapy for Wounds Reference added. Specialty Matched Consultant Advisory Panel review 11/18/15.
Endovascular Procedures for Intracranial Arterial Disease Code 61645 added to Billing/Coding section.
Facet Joint Denervation Reference added.
Fecal Analysis in the Diagnosis of Intestinal Dysbiosis Billing/Coding section updated to delete code: 82492
Fecal Calprotectin Test Description section updated. Policy Guidelines section updated. References updated. Specialty Matched Consultant Advisory Panel review 11/18/2015. Medical Director review 11/2015.
Fecal Microbiota Transplantation References updated. Specialty Matched Consultant Advisory Panel review 11/2015. Senior Medical Director review 11/2015.
Gastroesophageal Reflux Disease, Transendoscopic Therapies Billing/Coding section updated to include code 43210 effective 1/1/16. References updated. Specialty Matched Consultant Advisory Panel review 11/18/2015. Medical Director review 11/2015.
Gender Reassignment Surgery Specialty Matched Consultant Advisory Panel review 11/18/2015.
Gene-Based Tests for Screening, Detection, and/or Management of Prostate Cancer Extensive updates to Description and Policy Guidelines sections. Added investigational tests Prolaris® and Oncotype Dx® Prostate to the "When Not Covered" section. Reference added. Deleted HCPCS code S3721 from Billing/Coding section effective 1/1/2016.
General Approach to Evaluating the Utility of Genetic Panels Billing/Coding section updated to add codes: 81434, 81437, 81438, 81442 effective 1/1/16.
Genetic Cancer Susceptibility Panels Using Next Generation Sequencing Added CPT codes 81314, 81432, 81433 to Billing/Coding section effective 1/1/2016.
Genetic Testing for Alpha Thalassemia Evidence Based Guideline converted to a Corporate Medical Policy. Specialty Matched Consultant Advisory Panel review 8/26/2015. Medical Director review 8/2015. Policy notified 10/1/15 for effective date 12/30/15.
Genetic Testing for Alzheimer's Disease References added. Policy title changed to Genetic Testing for Alzheimer's Disease. Policy Guidelines updated
Genetic Testing for Breast and Ovarian Cancer Added CPT code 81162 to the Billing/Coding section effective 1/1/2016. Reference added.
Genetic Testing for CADASIL Syndrome Description section updated. Policy Guidelines section extensively revised. References updated. Policy Statement remains unchanged.
Genetic Testing for Colon Cancer Added CPT codes 81528, 81276 and deleted HCPCS codes G0464 and S3890 in Billing/Coding section for effective date 1/1/2016. Updated description section. References added
Genetic Testing for Dilated Cardiomyopathy References updated. Specialty Matched Consultant Advisory Panel review 10/29/2015. Medical Director review 10/2015.
Genetic Testing for Duchenne and Becker Muscular Dystrophy Evidence Based Guideline converted to Corporate Medical Policy. Description section updated. Specialty Matched Consultant Advisory Panel review 8/26/2015. Medical Director review 8/2015. Notification given 10/1/15 for effective date 12/30/15.
Genetic Testing for FLT3, NPM1 and CEBPA Mutations in Acute Myeloid Leukemia Specialty Matched Consultant Advisory Panel review 11/18/2015. No change to policy statement. Added CPT codes 81218, 81272, 81273 to Billing/Coding section for effective date 1/1/2016
Genetic Testing for Hereditary Hearing Loss "Evidence Based Guideline converted to Corporate Medical Policy. Description section updated. Policy Guidelines section added. Policy Statement unchanged. Specialty Matched Consultant Advisory Panel review 8/2015. Medical Director review 8/2015. Notification given 10/1/15 for effective date 12/30/15. Description section updated. Policy Guidelines section extensively revised. References updated."
Genetic Testing for Myeloproliferative Neoplasms Specialty Matched Consultant Advisory Panel review 11/18/2015. Policy title changed from "JAK2 and MPL Mutation Analysis in Myeloproliferative Neoplasms" to "Genetic Testing for Myeloproliferative Neoplasms." No change to policy statement or intent. Added CPT code 81219 to Billing/Coding section effective 1/1/2016.
Genetic Testing for Predisposition to Inherited Hypertrophic Cardiomyopathy References updated. Specialty Matched Consultant Advisory panel review 10/29/2015. Medical Director review 10/2015.
Genetic Testing for PTEN Hamartoma Tumor Syndrome Evidence Based Guideline converted to a Corporate Medical Policy. Description section revised. Policy Guidelines section added. Specialty Matched Consultant Advisory Panel review 8/26/2015. Medical Director review 8/2015. Policy noticed 10/1/15 for effective date 12/30/15
Growth Factors in Wound Healing Surgical wounds, total knee arthroplasty, and osteoarthritis added to list of investigational uses. Specialty Matched Consultant Advisory Panel review 11/18/2015.
Handheld Radiofrequency Spectroscopy for Intraoperative Assessment of Surgical Margins during Breast-Conserving Surgery Specialty Matched Consultant Advisory Panel review 11/18/2015.
Hematopoietic Stem-Cell Transplant for Non-Hodgkin Lymphomas Specialty Matched Consultant Advisory Panel review 11/18/2015. No change to policy statement.
Hematopoietic Stem-Cell Transplantation for Autoimmune Diseases Specialty Matched Consultant Advisory Panel review 11/18/2015. No change to policy statement.
Hematopoietic Stem-Cell Transplantation for Chronic Myelogenous Leukemia Specialty Matched Consultant Advisory Panel review 11/18/2015. No change to policy statement.
Hematopoietic Stem-Cell Transplantation for CLL and SLL Specialty Matched Consultant Advisory Panel review 11/18/2015. No change to policy statement.
Hematopoietic Stem-Cell Transplantation for CNS Embryonal Tumors and Ependymoma Specialty Matched Consultant Advisory Panel review 11/18/2015. No change to policy statement.
Hematopoietic Stem-Cell Transplantation for Epithelial Ovarian Cancer Specialty Matched Consultant Advisory Panel review 11/18/2015. Reference added. No change to policy statement
Hematopoietic Stem-Cell Transplantation for Hodgkin Lymphoma Specialty Matched Consultant Advisory Panel review 11/18/2015. No change to policy statement.
Hematopoietic Stem-Cell Transplantation for Miscellaneous Solid Tumors in Adults Specialty Matched Consultant Advisory Panel review 11/18/2015. Reference added. No change to policy statement
Hematopoietic Stem-Cell Transplantation for Plasma Cell Dyscrasias, Including Multiple Myeloma and POEMS Syndrome Updated Policy Guidelines section. Reference added. Specialty Matched Consultant Advisory Panel review 11/18/2015. No change to policy statement
Hematopoietic Stem-Cell Transplantation for Primary Amyloidosis Specialty Matched Consultant Advisory Panel review 11/18/2015. Reference added. No change to policy statement.
Hematopoietic Stem-Cell Transplantation for Solid Tumors of Childhood Specialty Matched Consultant Advisory Panel review 11/18/2015. No change to policy statement.
Hematopoietic Stem-Cell Transplantation for Waldenstrom Macroglobulinemia Specialty Matched Consultant Advisory Panel review 11/18/2015. Reference added. No change to policy statement.
Hematopoietic Stem-Cell Transplantation in the Treatment of Germ Cell Tumors Specialty Matched Consultant Advisory Panel review 11/18/2015. Reference added. No change to policy statement
Immune Globulin Therapy Senior Medical Director review. Site of care eligibility guidelines added to Policy Guidelines section. Notification given 10/30/2015 for policy effective date 12/30/2015. New code J1575 added to Billing/Coding section. Removed codes J3490 and J3590 from Billing/Coding section.
Implantable Cardioverter Defibrillator Description section updated. When Covered section updated to state "ICD medically necessary for patients with cardiac ion channelopathies with conditions; S-ICD medically necessary in limited situations". When Not Covered sections updated. Policy Guidelines section updated. References updated. Senior Medical Director review 11/2015.
Implantation of Intrastromal Corneal Ring Segments Added CPT code 65785 and deleted CPT code 0099T in Billing/Coding section for effective date 1/1/2016.
In Vitro Chemoresistance and Chemosensitivity Assays Added CPT codes 81535 and 81536 to Billing/Coding section for effective date 1/1/2016.
Ingestible pH and Pressure Capsule References updated. Specialty Matched Consultant Advisory Panel review 11/18/2015. Medical Director review 11/2015.
Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence Specialty Matched Consultant Advisory Panel review 11/18/2015.
Injectable Clostridial Collagenase for Fibroproliferative Disorders Reference added. Specialty Matched Consultant Advisory Panel (Urology) review 11/18/2015.
Intra Articular Hyaluronan Injections for Treatment of Osteoarthritis of the Knee Codes J7328 and Q9980 added to Billing/Coding section
Intravenous Antibiotic Therapy for Lyme Disease Reference added.
Intravitreal Implant Deleted HCPCS code C9450 from the Billing/Coding section for effective date 1/1/2016.
Invasive Prenatal (Fetal) Diagnostic Testing Reference added. Policy Guidelines updated.
KRAS, NRAS, and BRAF Mutation Analysis in Metastatic Colorectal Cancer New policy issued. KRAS mutation analysis may be considered medically necessary for patients with metastatic colorectal cancer to predict nonresponse prior to planned therapy with anti-EGFR monoclonal antibodies cetuximab or panitumumab. NRAS mutation analysis is considered investigational to predict nonresponse to anti-EGFR monoclonal antibodies cetuximab and panitumumab in the treatment of metastatic colorectal cancer. BRAF mutation analysis is considered investigational to predict nonresponse to anti-EGFR monoclonal antibodies cetuximab and panitumumab in the treatment of metastatic colorectal cancer. Information on KRAS previously included in Corporate Medical Policy "Molecular Analysis for Targeted Therapy of Non-Small-Cell Lung Cancer." Added CPT codes 81276 and 81311 to Billing/Coding section effective 1/1/2016. Reference added.
Laboratory Tests for Heart Transplant Rejection Billing/Coding section updated to include code 81595; effective 1/1/16.
Laparoscopic and Percutaneous Techniques for the Myolysis of Uterine Fibroids Code 0404T added to Billing/Coding section.
Magnetic Esophageal Ring to Treat Gastroesophageal Reflux Disease (GERD) Specialty Matched Consultant Advisory Panel review 11/18/2015
Microarray-based Gene Expression Testing for Cancers of Unknown Primary Updated the Description and Policy Guidelines sections. Reference added. Added CPT code 81540 to Billing/Coding section for effective date 1/1/2016.
Microwave Tumor Ablation Policy Guidelines and Description sections updated. Reference added. Specialty Matched Consultant Advisory Panel review 11/18/2015. No change to policy statement.
Molecular Analysis for Targeted Therapy for Non-Small Cell Lung Cancer (NSCLC) Policy retitled from "Epidermal Growth Factor Receptor (EGFR) Mutation Analysis for Patients with Non-Small Cell Lung Cancer (NSCLC) to "Molecular Analysis for Targeted Therapy for Non-Small Cell Lung Cancer." Extensive revisions and updates to entire policy. Added KRAS information from previous evidence based guideline. Under "When Not Covered" section added investigational indications: Analysis of somatic mutations of the KRAS gene is considered investigational as a technique to predict treatment non-response to anti-EGFR therapy with tyrosine-kinase inhibitors and for the use of the anti-EGFR monoclonal antibody cetuximab in NSCLC; Testing for genetic alterations in the genes ROS, RET, MET, BRAF and HER2, for targeted therapy in patients with NSCLC is considered investigational and Analysis of somatic rearrangement mutations of the ALK gene is considered investigational in all other clinical situations. Under " When Covered" section added medically necessary indication: Analysis of somatic rearrangement mutations of the ALK gene may be considered medically necessary to predict treatment response to crizotinib in patients with advanced lung adenocarcinoma or in whom an adenocarcinoma component cannot be excluded (see Policy Guidelines). Reference added. Specialty Matched Consultant Advisory Panel review 8/26/2015. Notification given 10/1/15 for effective date 12/30/15.KRAS information can now be found in Corporate Medical Policy "KRAS, NRAS, and BRAF Mutation Analysis in Metastatic Colorectal Cancer." Removed references to KRAS in this medical policy. No change to policy statement or intent.
Molecular Markers in Fine Needle Aspirates of the Thyroid Added CPT code 81545 to Billing/Coding section for effective date 1/1/2016.
Molecular Panel Testing of Cancers to Identify Targeted Therapies Added CPT code 81311 to Billing/Coding section for effective date 1/1/2016.
Monoclonal Antibodies for Non-Hodgkin Lymphoma and Acute Myeloid Leukemia In the Non-Hematopoietic Stem Cell Transplant Setting Added HCPCS code J0202 to Billing/Coding section effective 1/1/2016.
MRI-Guided Focused Ultrasound (MRgFUS) Added CPT code 0398T to Billing/Coding section for effective date 1/1/2016.
Multianalyte Assays for the Evaluation and Monitoring of Patients with Liver Disease References updated. Specialty Matched Consultant Advisory Panel 11/18/2015. Senior Medical Director review 11/2015.
Multigene Expression Assay for Predicting Recurrence in Colon Cancer Added CPT code 81525 to Billing/Coding section for effective date 1/1/2016.
Non-Contact Ultrasound Treatment for Wounds Specialty Matched Consultant Advisory Panel review 11/18/2015.
Noninvasive Respiratory Assist Devices Code E0466 added to Billing/Coding section.
Nutrient/Nutritional Panel Testing New policy issued. Nutrient/Nutritional panel testing is considered investigational for all indications including but not limited to testing for nutritional deficiencies in patients with mood disorders, fibromyalgia, unexplained fatigue and healthy individuals. Medical director review 8/2015. Notification given 10/1/15 for effective date 12/30/15.
Optical Diagnostic Devices for Evaluating Skin Lesions Suspected of Malignancy Billing/Coding section updated to include codes: 96931, 96932, 96933, 96934, 96935, 96936 effective 1/1/16.
Orthodontics for Pediatric Patients Specialty Matched Consultant Advisory Panel review 10/29/2015. Medical Director Review 10/2015.
Orthognathic Surgery Description section updated to change pedodontist to pediatric dentist. When Covered section C) 1) b) iii) revised to state maxillary excess or mandibular deficiency. References updated. Specialty Matched Consultant Advisory Panel review 10/29/2015. Medical Director Review 10/2015.
Outpatient Code Editor (OCE) Edits New policy developed regarding Outpatient Code Editor (OCE) Edits. BCBSNC will not provide reimbursement for services identified through the OCE editing system as billing/coding errors. Notification date 10/30/15 for effective date of 12/30/2015.
Pasireotide (Signifor® LAR) Code J2502 added and codes C9454, J3490, and J3590 removed from Billing/Coding section.
Patient Lifts Billing/Coding section updated to add codes: E1035, E1036, and E0172 and codes reformatted for clarity. References updated. Specialty Matched Consultant Advisory Panel review 9/30/2015. Medical Director review 9/2015. Policy noticed October 30, 2015 for effective date December 30, 2015.
Patient-Specific Cutting Guides and Custom Knee Implants Code 0396T added to Billing/Coding section.
Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence Specialty Matched Consultant Advisory Panel review 11/18/2015.
Peripheral Arterial Tonometry (PAT) References updated. Specialty Matched Consultant Advisory Panel review 10/29/2015. Medical Director review 10/2015.
Plugs for Fistula Repair Reference added. Specialty Matched Consultant Advisory Panel review 11/18/2015. The word "rectal" removed from the policy statement.
Polysomnography for Non-Respiratory Sleep Disorders New policy issued. Polysomnography for Non-Respiratory Sleep Disorders may be considered medically necessary when criteria are met. Notification given 10/30/15 for policy effective date 12/30/15.
Postsurgical Outpatient Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis Specialty Matched Consultant Advisory Panel review 11/18/2015
Progenitor Cell Therapy for the Treatment of Damaged Myocardium Due to Ischemia References updated. Specialty Matched Consultant Advisory Panel review 10/29/2015. Medical Director review 10/2015.
Quantitative Electroencephalography as a Diagnostic Aid for Attention Deficit/Hyperactivity Disorder Reference added. Codes 95816 and 95819 added to Billing/Coding section. Policy Guidelines updated.
Removal of Impacted Cerumen CPT 69209 added to the Billing/Coding section.
Respiratory Syncytial Virus Prophylaxis Reference added.
Sacral Nerve Neuromodulation/Stimulation for Pelvic Floor Dysfunction Specialty Matched Consultant Advisory Panel review 11/18/2015.
Sacroiliac Joint Fusion Specialty Matched Consultant Advisory Panel review 5/27/2015. Reference added.
Septoplasty Evidence based guideline converted to corporate medical policy. Medical Director review. Specialty Matched Consultant Advisory Panel Review 8/26/15. Notification given 10/1/2015 for policy effective date 12/30/2015.
Signal-Averaged ECG Policy Guidelines section updated. References updated. Specialty Matched Consultant Advisory Panel review 10/29/2015. Senior Medical Director review 10/2015.
Siltuximab (Sylvant) Deleted HCPCS codes C9455, J3490, J3590 from Billing/Coding section for effective date 1/1/16.
Skilled Nursing Services Added HCPCS codes G0299, G0300 and deleted HCPCS code G0154 in Billing/Coding section for effective date 1/1/2016.
Sleep Apnea: Diagnosis and Medical Management HCPCS code S8262 deleted from Billing/Coding section. Under IIB, changed "The device is prescribed by a treating physician, and/or dentist" to "The device is prescribed by a treating physician". Under Policy Guidelines, clarified that the medical professional "should have performed a face to face evaluation of the patient". Specialty Matched Consultant Advisory Panel review 8/26/15. Policy noticed 10/1/15 for effective 12/30/15.
Small Bowel, Small Bowel with Liver, or Multivisceral Transplant Billing/Coding section updated to delete code 47136.
Spinal Cord Stimulation Code C1822 added to Billing/Coding section.
Stem-cell Therapy for Peripheral Arterial Disease References updated. Specialty Matched Consultant Advisory Panel review 10/29/2015. Medical Director review 10/2015.
Surgery for Obstructive Sleep Apnea and Upper Airway Resistance Syndrome Codes 0424T-0436T added to Billing/Coding section.
Surgical Management of Transcatheter Heart Valves Description section updated. When Covered section updated to state transcatheter mitral valve repair considered medically necessary for degenerative mitral regurgitation in patients at prohibitive surgical risk. When Not Covered section updated. Billing/Coding section updated to delete code 0262T and add code 33477 effective 1/1/16. Policy Guidelines section updated. References updated.
Surgical Treatment of Sinus Disease Codes 0406T and 0407T added to Billing/Coding section.
Systems Pathology in Prostate Cancer Specialty Matched Consultant Advisory Panel review 11/18/2015. Code 88347 removed from Billing/Coding section. Code 88350 added to Billing/Coding section.
Testing Serum Vitamin D Levels New medical policy issued. Testing vitamin D levels in patients with signs and/or symptoms of vitamin D deficiency or toxicity (see Policy Guidelines section) may be considered medically necessary. Testing vitamin D levels in asymptomatic patients may be considered medically necessary in the following patient populations: Individuals who have risk factors for vitamin D deficiency and Institutionalized patients. Sr. Medical director review 9/2015. Notification given 10/30/15 for effective date 12/30/15.
Testosterone Pellet Implantation for Androgen Deficiency in Men New policy developed. Testosterone replacement therapy is medically necessary for men with androgen deficiency and symptoms of hypogonadism; for HIV patients with low testosterone levels and weight loss; and for patients on chronic steroid treatment with low testosterone levels. Testosterone replacement therapy is investigational in all other situations. Notification given 10/30/15 for effective date 12/30/15.
Transanal Endoscopic Microsurgery (TEMS) Policy Guidelines section updated. References updated. Specialty Matched Consultant Advisory Panel review 11/18/2015. Senior Medical Director review 11/2015
Transanal Radiofrequency Treatment of Fecal Incontinence References updated. Specialty Matched Consultant Advisory Panel review 11/18/2015. Senior Medical Director review 11/2015.
Treatment of Hereditary Angioedema Billing/Coding section updated to delete code C9445 and add code J0956 effective 1/1/16. References updated. Specialty Matched Consultant Advisory Panel review 11/18/2015. Medical Director review 11/2015.
Tumor-Treatment Fields Therapy for Glioblastoma Updated Policy Guidelines. Specialty Matched Consultant Advisory Panel review 11/18/2015. Reference added. No change to policy statement.
Urinary Tumor Markers for Bladder Cancer Specialty Matched Consultant Advisory Panel review 11/18/2015.
Vectra® DA Blood Test for Rheumatoid Arthritis Added CPT code 81490 to Billing/Coding section for effective date 1/1/2016.
Vedolizumab (Entyvio) Billing/Coding section updated to delete code C9026 and add code J3380 effective as of 1/1/16.
Vertebroplasty, Kyphoplasty, and Sacroplasty Percutaneous Codes S2360 and S2361 removed from Billing/Coding section.
Vesicoureteral Reflux, Treatment with Periureteral Bulking Agents Reference added. Specialty Matched Consultant Advisory Panel review 11/18/2015. HCPCS L8603 and L8606 removed from policy. Policy Guidelines updated. "When medical therapy has failed" added to When Covered statement.
Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders Description section updated. Policy Guidelines section updated. Billing/Coding section updated. References updated.