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Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for February 29, 2016

Medical Guidelines Reason for Update
Accelerated Partial Breast Radiotherapy (Breast Brachytherapy) Added the following ICD-10 diagnoses codes to the Billing/Coding section: Diagnoses that are subject to medical necessity review: C50.0 - C50.929, C79.81, D05.0 – D05.92, D48.60 - D48.62, D49.3 (Effective 3/11/2016). No change to policy statement.
Ado-Trastuzumab Emtansine (Trastuzumab-DM1) for Treatment of HER-2 Positive Malignancies Updated Policy Guidelines section. Reference added. No change to policy statement.
Advanced Illness/Advance Directives New policy developed. Blue Cross Blue Shield North Carolina (BCBSNC) will reimburse advanced illness care planning when the criteria outlined in this policy are met. Senior Medical Director review1/2016. Specialty Matched Consultant Advisory Panel review 8/2015. Policy effective date 3/15/2016.
Analysis of MGMT Promoter Methylation in Malignant Gliomas Updated Policy Guidelines section. Reference added. No change to policy intent.
Anesthesia Services When Covered section updated. References updated. Specialty Matched Consultant Advisory Panel review 1/27/2016. Medical Director Review 1/2016.
Brachytherapy Treatment of Breast Cancer Added the following ICD-10 Diagnoses codes to the Billing/Coding section: Diagnoses that are subject to medical necessity review: C50.0 - C50.929, C79.81, D05.0 – D05.92, D48.60 - D48.62, D49.3 (Effective 3/11/2016). No change to policy statement.
Capsaicin (Qutenza®) References updated. Specialty Matched Consultant Advisory Panel review 1/27/2016. Medical Director review 1/2016.
Chromosomal Microarray Analysis for the Evaluation of Pregnancy Loss Reference added. Policy Guidelines updated. Gestational age requirement removed from medically necessary statement. Title changed to "Chromosomal Microarray Analysis for the Evaluation of Pregnancy Loss".
Code Bundling Rules Not Addressed in ClaimCheck® or Correct Coding Initiative Statement regarding real-time intra-fraction target tracking (codes 77387, G6017) deleted.
Diagnosis and Treatment of Sacroiliac Joint Pain Reference added. Related policy added. Policy Guidelines updated.
Enzyme Replacement Therapy for Lysosomal Storage Disorders Policy name changed from "Enzyme Replacement Therapy for Lysosomal Storage Disorders" to "Enzyme Replacement Therapy for Lysosomal Storage Disorders". Policy revised to include criteria and information regarding Kanuma. References updated. Senior Medical Director review 2/2016
Gastric Electrical Stimulation Description section revised. Policy Guidelines section updated. References updated.
Genetic Testing for Cutaneous Malignant Melanoma Policy Guidelines revised. References updated.
Genetic Testing for Macular Degeneration Updated Description and Policy Guidelines sections. Reference added. No change to policy statement.
Genetic Testing for Predisposition to Inherited Hypertrophic Cardiomyopathy Description section revised. When Not Covered statement clarified to indicate that familial testing should be in a family member with established HCM; policy intent otherwise unchanged. Policy Guidelines section revised. References updated.
Hyperbaric Oxygen Therapy Policy name changed from Hyperbaric Oxygen Pressurization" to "Hyperbaric Oxygen Therapy". Description section updated. References updated. Matched Consultant Advisory Panel review 1/27/2016. Medical Director review 1/2016.
Hyperhidrosis, Treatment of Specialty Matched Consultant Advisory Panel review 1/2016. Medical Director review 1/2016.
Intravenous Anesthetics for the Treatment of Chronic Pain Description section updated. Policy Guidelines section extensively revised. References added. Policy statement remains unchanged. Specialty Matched Consultant Advisory Panel 1/27/2016. Medical Director review 1/2016.
Laparoscopic and Percutaneous Techniques for the Myolysis of Uterine Fibroids Deleted code 0404T from Billing/Coding section.
Laser Treatment of Onychomycosis References updated. Specialty Matched Consultant Advisory Panel review 1/27/2016. Medical Director review 1/2016.
Magnetic Resonance Spectroscopy Updated Policy Guidelines section. Reference added. No change to policy statement.
Magnetoencephalography/Magnetic Source Imaging Updated Description and Policy Guidelines sections. Reference added. No change to policy statement.
Mepolizumab (Nucala®) Original policy issued titled, "Mepolizumab (Nucala®)" with the following policy statement, "BCBSNC will provide coverage for Mepolizumab (Nucala®) when it is determined to be medically necessary because the medical criteria and guidelines shown below are met." Specialty Matched Consultant Advisory Panel review 2/2016. Senior Medical Director review 2/2016.
Molecular Analysis for Targeted Therapy for Non-Small Cell Lung Cancer (NSCLC) Reference added. No change to policy statement.
Neural Therapy Policy Guidelines section revised References updated. Specialty Matched Consultant Advisory Panel review 1/27/2016. Medical Director review 1/2016.
Non-Pharmacologic Treatment of Rosacea Billing/Coding section revised to remove ICD-9 codes. Policy Guidelines section revised. References updated. Specialty Matched Consultant Advisory Panel review 1/27/2016. Medical Director review 1/2016.
Optical Diagnostic Devices for Evaluating Skin Lesions Suspected of Malignancy Policy notified 12/30/15 for effective date 2/29/16.Specialty Matched Consultant Advisory Panel review 1/27/2016. Medical director review 1/2016.
PD-1 Inhibitors Under "When Covered" section: expanded coverage for Keytruda regardless of BRAF mutation status; added renal cell carcinoma coverage indication for Opdivo as well as expanded coverage for use of Opvido in combination with Yervoy(ipilimumab) regardless of BRAF status. Updated Description and Policy Guidelines sections. Medical Director review. References added.
Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention Description section updated. Policy Guidelines section updated. Policy intent remains unchanged. References updated. Senior Medical Director review 2/2016.
Power Operated Vehicle (Scooter) Policy combined with policy titled, "Wheelchairs and Power Operated Vehicles (Scooters)". Power Operated Vehicle (Scooter) policy archived.
Sacroiliac Joint Fusion Specialty Matched Consultant Advisory Panel review 5/27/2015. Reference added.
Serum Biomarker Human Epididymis Protein 4 (HE4) Updated Policy Guidelines section. Reference added. No change to policy statement.
Spinal Manipulation under Anesthesia References updated. Specialty Matched Consultant Advisory Panel review 1/27/2016. Medical Director review 1/2016.
Surgery for Morbid Obesity References added. Vagal nerve blocking therapy added to When Not Covered section. Notification given 12/30/2015 for policy effective date 2/29/2016
Testosterone Pellet Implantation for Androgen Deficiency in Men Reference added. Policy Guidelines updated.
Transanal Radiofrequency Treatment of Fecal Incontinence Description section updated. Policy Guidelines revised. References updated.
Ultraviolet Light Therapy in the Home Setting(UVB) References updated. Specialty Matched Consultant Advisory Panel review 1/27/2016. Medical Director review 1/2016.
Urinary Tumor Markers for Bladder Cancer Reference added.
Varicose Veins, Treatment for Reference added. Specialty Matched Consultant Advisory Panel review 11/18/2015. The requirement of failure of compression therapy was removed from the policy statements on ulceration secondary to venous stasis and recurrent superficial thrombophlebitis; terminology was changed from greater and lesser to great and small saphenous veins. CEAP classification system added to policy, Cyanoacrylate adhesive of any vein added to investigational statement.
Wheelchairs and Power Operated Vehicles (Scooter) Policy retitled, "Wheelchairs and Power Operated Vehicles (Scooters)". Combined and archived policy titled, "Power Operated Vehicles (Scooters)". Changes to reflect title change made throughout policy. Description section updated. When Covered section updated to include Power Operated Vehicle statements. When Not Covered section updated to include power operated vehicle statements. Billing/Coding section updated to add codes: E1012(effective 1/1/16), E1230, K0800, K0801, K0802, K0806, K0807, K0808, K0812. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 9/30/2015. Medical Director review 9/2015
Xolair® (Omalizumab) When Covered section revised to list coverage after 12 months by indication. Specialty Matched Consultant Advisory Panel review 11/18/2015. Medical Director review 11/2015. References added. Policy noticed 12/30/15 for effective date 2/29/16.