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Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for July 1, 2016

Medical Guidelines Reason for Update
Accelerated Partial Breast Radiotherapy (Breast Brachytherapy) Specialty Matched Advisory Panel review 5/25/2016. No change to policy statement.
Adaptive Behavioral Treatment for Autism Spectrum Disorders New policy developed. BCBSNC will provide coverage for Adaptive Behavior Treatment when it is determined to be medically necessary because the medical criteria and guidelines outlined in the policy are met. Notification given 4/29/16 for effective date 7/1/16.
Adoptive Immunotherapy Policy archived.
Advanced Illness/Advance Directives Corrected typo.
Alemtuzumab (LemtradaTM) Specialty Matched Consultant Advisory Panel review 5/25/2016.
Ambulatory Event Monitors Description section extensively revised with addition of the Ambulatory Cardiac Rhythm Monitoring Devices Table 1. Policy Statement updated to include "Patients who require long-term monitoring for atrial fibrillation or possible atrial fibrillation". Policy Guidelines extensively updated. References updated. Medical Director review 5/2016.
Atezolizumab (Tecentriq) for Intravenous Use New policy developed. Atezolizumab (Tecentriq) may be considered medically necessary for the following clinical conditions: 1.Locally advanced or metastatic urothelial carcinoma and Tecentriq is used as monotherapy; AND 2. Documented disease progression during or following platinum-containing chemotherapy; OR 3. Documented disease progression with 12 months of neoadjuvant or adjuvant treatment with platinum-containing chemotherapy. Medical director review 6/2016.
Automated Percutaneous and Endoscopic Discectomy Reference added. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 5/25/2016.
Bone Morphogenetic Protein Specialty Matched Consultant Advisory Panel review 2/24/2016.
Brachytherapy, Intracavitary Balloon Catheter for Brain Cancer Specialty Matched Consultant Advisory Panel review 5/25/2016. No change to policy statement.
Capsule Endoscopy, Wireless Specialty Matched Consultant Advisory Panel review 5/25/16 . Portal hypertensive enteropathy and unexplained chronic abdominal pain added to Non-covered section
Cardiac Hemodynamic Monitoring in the Outpatient Setting Minor updates to the Description section. Policy Guidelines updated. References updated. Medical Director review 5/2016.
Charged Particle Radiotherapy (Proton or Helium Ion) Specialty Matched Consultant Advisory Panel review 5/25/2016. Reference added. No change to policy statement.
Circulating Tumor DNA for Cancer Management (Liquid Biopsy) New policy issued. The use of circulating tumor DNA and circulating tumor cells for cancer management is considered investigational for all indications. References added. Sr. Medical Director review 5/2016
Computerized 2-Lead Resting Electrocardiogram (Multifunction Cardiogram) Regulatory status and policy guidelines updated. References updated. Medical Director review 5/2016.
Co-Surgeon, Assistant Surgeon, Team Surgeon and Assistant-at-Surgery Guidelines Statement regarding Assistant Surgeon Services in the Policy Guidelines Section revised to read: "When multiple procedures are performed and the secondary procedures are allowable according to the multiple procedure guidelines, as well as being eligible for assistant surgeon services, benefits for those services will be allowed and processed according to the multiple procedure guidelines." The following statement was deleted: "on occasion, a procedure for which assistant surgeon benefits are not allowed may be unusually complex for a particular patient and warrant assistant surgeon services. These cases will be reviewed on an individual consideration basis." Notification given 4/29/2016 for effective date of 7/1/2016.
Cranial Electrotherapy Stimulation (CES) and Auricular Electrostimulation Reference added. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 5/25/2016.
Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate, or Dermatologic Tumors Specialty Matched Consultant Advisory Panel review 5/25/16.
Cryosurgical Ablation of Primary or Metastatic Liver Tumors Specialty Matched Consultant Advisory Panel review 5/25/16.
Daratumumab (Darzalex) Specialty Matched Consultant Review panel meeting 4/27/16. No change to policy statement. Added HCPCS code C9476 to "Billing/Coding" section for effective date 7/1/16.
Denosumab (ProliaTM, XGEVATM) The wording in the "When denosumab is covered" section was revised. The statement regarding oral biphosphonate therapy was removed from the first paragraph and added to the first bulleted statement so that it now reads: "Treatment of postmenopausal women with osteoporosis at high risk for fracture (those who have had an osteoporotic fracture or have multiple risk factors for fracture) AND who have failed or are unable to tolerate at least one oral bisphosphonate OR for whom oral bisphosphonate therapy is contraindicated (including inability to swallow or to remain in an upright position after oral bisphosphonate administration)".
Detection of Circulating Tumor Cells Policy archived per May MPP and post MPP discussion.
Diagnosis and Treatment of Chronic Cerebrospinal Venous Insufficiency in Multiple Sclerosis Specialty Matched Consultant Advisory Panel review 5/25/2016.
Diagnosis and Treatment of Sacroiliac Joint Pain Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 5/25/2016.
Electrogastrography, Cutaneous References updated. Specialty Matched Consultant Advisory Panel review. 5/25/2016. Medical Director review 5/2016.
Elotuzumab (Empliciti) Specialty Matched Consultant Advisory Panel Review meeting 4/27/16. No change to policy statement. Added HCPCS code C9477 to "Billing/Coding" section for effective date 7/1/16
Endovascular Procedures for Intracranial Arterial Disease Reference added. Description section updated. Specialty Matched Consultant Advisory Panel review 5/25/2016.
Endovascular Therapies for Extracranial Vertebral Artery Disease Specialty Matched Consultant Advisory Panel review 5/25/2016. Reference added. Policy Guidelines updated.
Enteral Nutrition Specialty Matched Consultant Advisory Panel review 5/25/2016. Medical Director review 5/2016.
Esophageal pH Monitoring Description section slightly revised, adding "alarm symptoms such as Dysphagia or iron deficiency anemia or" per Consultant recommendation. Updated Policy Guidelines. Specialty Matched Consultant Advisory Panel review 5/25/2016.
External Defibrillators Regulatory Status section added with update. References updated. Medical Director review 5/2016.
Fecal Analysis in the Diagnosis of Intestinal Dysbiosis Updated Description section, related policy added. Specialty Matched Consultant Advisory Panel review 5/25/16. Medical Director review 5/2016.
Gastric Electrical Stimulation Specialty Matched Consultant Advisory Panel review 5/25/2016. Medical Director review 5/2016. No change to policy statement or guidelines.
Genetic Cancer Susceptibility Panels Using Next Generation Sequencing Policy Guidelines extensively revised. References added. No change to policy statement.
Genetic Testing for Cardiac Ion Channelopathies Specialty Matched Consultant Advisory Panel review 4/27/2016. Medical Director review 4/2016
Genetic Testing for Heterozygous Familial Hypercholesterolemia New policy developed. BCBSNC will provide coverage for genetic testing for heterozygous familial hypercholesterolemia when it is determined to be medically necessary because the medical criteria and guidelines noted below are met. Medical Director review 6/1/2016. Policy effective on 7/1/2016.
Image-Guided Minimally Invasive Lumbar Decompression (IG-MLD) for Spinal Stenosis Reference added. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 5/25/2016.
Infliximab (Remicade) Added code Q5102 to Billing/Coding section.
Intensity Modulated Radiation Therapy (IMRT) of Head and Neck Specialty Matched Consultant Advisory Panel review 5/25/2016. No change to policy statement.
Intensity Modulated Radiation Therapy (IMRT) of the Chest Specialty Matched Consultant Advisory Panel review 5/25/2016. No change to policy statement.
Intensity Modulated Radiation Therapy for Tumors of the Central Nervous System Added sarcoma as medically necessary diagnosis under "When Covered" section page 3, "Intensity-modulated radiation therapy (IMRT) may be considered medically necessary as a technique to deliver radiation therapy in patients with lung cancer, thoracic esophageal cancer or cancer of the gastroesophageal junction, thoracic lymphoma, or sarcoma when all (A, B, and C) of the following conditions have been met." Senior Medical Director approved March 2016.
Intensity-Modulated Radiation Therapy (IMRT) of the Prostate Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 5/25/2016. Reference added. No change to policy statement. CPT code 0438T added to the Billing/Coding section effective 7/1/16.
Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers) Reference added. Policy Guidelines updated. Regulatory Status updated. Specialty Matched Consultant Advisory Panel review 5/25/2016.
Interspinous Fixation (Fusion) Devices Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 5/25/2016.
Intradiscal Electrothermal (IDET) Annuloplasty and Percutaneous Intradiscal Radiofrequency Annuloplasty Specialty Matched Consultant Advisory Panel review 5/25/2016.
Intraoperative Neurophysiologic Monitoring (sensory-evoked potentials, motor-evoked potentials, EEG monitoring) Specialty Matched Consultant Advisory Panel review 5/25/2016.
KRAS, NRAS, and BRAF Mutation Analysis in Metastatic Colorectal Cancer Added covered indication for NRAS under "When Covered" section: "NRAS 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." Revised Policy Guidelines section. Deleted HCPCS code S3713 from Billing/Coding section. Reference added. Sr. Medical Director review 5/2016.
Laboratory Tests for Heart Transplant Rejection Description section extensively updated. Non-Covered section updated from "grade 3" to "grade 2R/grade 3" due to updated rejection grades and brand name of test removed. Policy Guidelines and references updated. Medical Director review 4/2016.
Liver Transplant Specialty Matched Consultant Advisory Panel 5/25/16.
Lumbar Spine Fusion Surgery Specialty Matched Consultant Advisory Panel review 5/25/2016. Reference added
Melphalan Hydrochloride (Evomela) for Intravenous Use New policy developed. Evomela may be considered medically necessary for the following clinical conditions: 1. For the diagnosis of multiple myeloma; 2. As a high-dose conditioning treatment prior to hematopoietic progenitor (stem) cell transplantation; 3. For the palliative treatment of patients with an intolerance to oral melphalan therapy. Medical Director review 6/2016.
Multianalyte Assays for the Evaluation and Monitoring of Patients with Liver Disease Policy archived.
Natalizumab (Tysabri) Specialty Matched Consultant Advisory Panel review 5/25/16.
Occipital Nerve Stimulation Reference added. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 5/26/2016.
Orthopedic Applications of Stem Cell Therapy Specialty Matched Consultant Advisory Panel review 2/24/2016. Reference added. Policy Guidelines updated.
Pancreas Transplant Specialty Matched Consultant Advisory Panel review 5/25/2016. Medical Director review 5/2016. No Changes to policy.
Paraspinal Surface Electromyography (SEMG) Specialty Matched Consultant Advisory Panel review 5/25/2016.
PD-1 Inhibitors Added the following covered indication for Classical Hodgkin lymphoma under "When Covered" #5. a-d. "The patient has been diagnosed with Classical Hodgkin lymphoma: and a.the patient has disease progression after autologous hematopoietic stem cell transplantation (HSCT): and b. the patient has disease progression after post-transplant treatment with brentuximab vedotin: and c. Opdivo is used as monotherapy; d.the patient has not received treatment with another PD-1 inhibitor. Medical director review 6/2016. References added.
Peroral Endoscopic Myotomy for Treatment of Esophageal Achalasia Specialty Matched Consultant Advisory Panel review 5/25/2016. Medical Director review 5/2016. No change to Policy Statement.
Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers Matched Consultant Advisory Panel review 5/25/16.
Polysomnography for Non‒Respiratory Sleep Disorders Specialty Matched Consultant Advisory Panel review 5/25/2016.
Radioembolization for Primary and Metastatic Tumors of the Liver Specialty Matched Consultant Advisory Panel review 5/25/2016. No change to policy statement.
Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors Specialty Matched Consultant Advisory Panel review 5/25/16.
Radiosurgery, Stereotactic Approach Specialty Matched Consultant Advisory Panel review 5/25/2016. No change to policy statement.
Repository Corticotropin (H.P. Acthar Gel) References added. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 5/25/2016. No change to policy statement.
Sacroiliac Joint Fusion Specialty Matched Consultant Advisory Panel review 5/25/2016.
Small Bowel, Small Bowel with Liver, or Multivisceral Transplant Specialty Matched Consultant Advisory Panel review 5/25/2016. Medical Director review 5/2016. No changes to policy.
ST2 Assay for Chronic Heart Failure Policy Guidelines updated, references updated. Medical Director review 5/2016.
Surgery for Morbid Obesity Specialty Matched Consultant Advisory Panel review 5/25/2016. Reference added. Information regarding the AspireAssist® device added to Description section. Surgically-placed gastric tubes intended to drain a portion of the stomach contents added to When Not Covered section.
Surgical Deactivation of Headache Trigger Sites Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 5/25/2016.
Topical Negative Pressure Therapy for Wounds Reference added. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 5/25/16.
Vagus Nerve Stimulation Specialty Matched Consultant Advisory Panel review 5/25/2016.
Vedolizumab (Entyvio) Specialty Matched Consultant Advisory Panel review 5/25/2016. Medical Director review 5/2016. No changes to policy.
Vertebroplasty, Kyphoplasty, and Sacroplasty Percutaneous Specialty Matched Consultant Advisory Panel review 5/25/2016.
Wireless Pressure Sensors in Endovascular Aneurysm Repair Policy archived.