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Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for January 26, 2016

Medical Guidelines Reason for Update
Artificial Pancreas Device Systems References added. Policy Guidelines updated.
Botulinum Toxin Injection Reference added. FDA approval given for Xeomin® to treat upper limb spasticity in adult patients.
Carotid Intimal-Medial Thickness Specialty Matched Consultant Advisory Panel review 10/29/2015. Medical Director review 10/2015.
Confocal Laser Endomicroscopy Policy Guidelines section revised. References updated.
Digital Breast Tomosynthesis Updated Policy Guidelines section. References added. No change to policy statement.
Dopamine Transporter Imaging with Single Photon Emission Computed Tomography Reference added. Added Alzheimer's disease to list of "including but not limited to" investigational indications under "When Not Covered" section. Sr. Medical Director review 11/2015.
Fecal Microbiota Transplantation Policy Guidelines section revised. References updated.
Gastroesophageal Reflux Disease, Transendoscopic Therapies Description section updated. Policy Guidelines extensively revised. Policy Statement remains unchanged. References updated.
Genetic Testing for Epilepsy Reference added. Policy Guidelines updated. Related policy added. Background section updated.
Ingestible pH and Pressure Capsule References updated.
Laser Treatment of Port Wine Stains References updated.
Multitarget Polymerase Chain Reaction Testing for Diagnosis of Bacterial Vaginosis Reference added.
Nerve Fiber Density Testing Reference added. Policy Guidelines updated.
Noninvasive Fetal RHD Genotyping Using Cell-Free Fetal DNA Reference added. Policy Guidelines updated. Policy title changed from "Fetal RhD Genotyping Using Maternal Plasma" to "Noninvasive Fetal RhD Genotyping Using Cell-Free Fetal DNA".
PD-1 Inhibitors Under "When Covered" section added additional criteria for Keytruda under bullet #2 and also for Opdivo under bullet #2: "and the patient with EGFR or ALK genomic tumor aberrations should have disease progression on FDA-approved therapy for these aberrations prior to receiving Keytruda or Opdivo." Notification given 11/24/15 for effective date 1/26/16. Added HCPCS codes J9271, J9299 and deleted HCPCS codes C9027, C9453, J3490,J3590, J9999 in Billing/Coding section for effective date 1/1/2016.
Peroral Endoscopic Myotomy for Treatment of Esophageal Achalasia Policy Guidelines section revised. References updated.
Proteomics-based Testing Related to Ovarian Cancer Reference added. Policy Guidelines updated.
Repository Corticotropin (H.P. Acthar Gel) Policy extensively revised. Repository corticotropin is medically necessary for infantile spasms (West syndrome) and acute exacerbations of multiple sclerosis when criteria are met. Senior Medical Director review 1/30/2014. Specialty Matched Consultant review 2/11/2014. Specialty Matched Consultant Advisory Panel review 5/27/2014. Specialty Matched Consultant Advisory Panel review 5/27/2015. References added. Notification given 11/24/2015. Policy effective date 1/26/2016.
TENS (Transcutaneous Electrical Nerve Stimulator) Reference added. Policy Guidelines updated.