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Medical Policy Updates

Table Of Contents

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

Medical Guidelines Reason for Update
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.
Amniotic Membrane and Amniotic Fluid Injections New policy developed. Injection of micronized amniotic membrane or amniotic fluid is considered investigational for all indications. See also policy titled "Bioengineered Skin and Tissue."
Aqueous Shunts and Devices for Glaucoma Specialty Matched Consultant Advisory Panel review 6/29/2016. Added CPT codes 0444T and 0445T to the Billing/Coding section for effective date 7/1/2016. No change to policy statement.
Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions Specialty Matched Consultant Advisory Panel review 6/29/2016. Medical Director review. "Large (>2.5 cm2)" removed from Policy Statement and Policy Guidelines related to osteochondral allografting.
Autologous Chondrocyte Implantation Specialty Matched Consultant Advisory Panel review 6/29/2016.
Beta Amyloid Imaging With Positron Emission Tomography for Alzheimer's Disease Codes Q9982, Q9983 added to Billing/Coding section. Specialty Matched Consultant Advisory Panel review 6/29/2016. No change to policy statement.
Bioengineered Skin and Tissue Description section extensively revised. Specific products removed from the Policy statement which is revised to read: BCBSNC will provide coverage for bioengineered skin and soft tissue substitutes when it is determined to be medically necessary because the medical criteria and guidelines shown below have been met. "When Covered" section reformatted and new products added. Policy Guidelines section extensively revised. Deleted the following products from the "investigational" list: AmnioBand, Biovance, Grafix CORE, Grafix PRIME and Neox 1K. Rationale added for individual indications.
Bone Morphogenetic Protein Reference added. Policy Guidelines updated. FDA approval for rhBMP-2 in oblique lateral interbody fusion added; rhBMP-7 removed from policy statements.
Brachytherapy Treatment of Breast Cancer Specialty Matched Consultant Advisory Panel review 5/25/2016. No change to policy statement.
Bronchial Thermoplasty Reference added. No change to policy statement.
Cardiac (Heart) Transplantation Specialty Matched Consultant Advisory Panel review 6/2016. Medical Director review 6/2016.
Carotid Artery Angioplasty/Stenting (CAS) Description section updated. Policy Guidelines and references updated. Specialty Matched Consultant Advisory Panel review 6/2016. Medical Director review 6/2016.
Catheter Ablation as a Treatment for Atrial Fibrillation Specialty Matched Consultant Advisory Panel review 6/2016. Medical Director review 6/2016.
Charged Particle Radiotherapy Specialty Matched Consultant Advisory Panel review 5/25/2016. Reference added. No change to policy statement. Updated Policy Guidelines section. Changed policy title from "Charged Particle Radiotherapy (Proton or Helium Ion)" to "Charged Particle Radiotherapy." Sr. Medical Director review 7/2016.
Chemoembolization of the Hepatic Artery, Transcatheter Approach CPT 75896 deleted, no longer a valid code. Specialty Matched Consultant Advisory Panel review 6/29/2016. No change to policy statement.
Computer Assisted Surgical Navigational Orthopedic Procedures Specialty Matched Consultant Advisory Panel review 6/29/2016. No change to policy statement.
Computer-Aided Evaluation of Malignancy with MRI of the Breast Specialty Matched Consultant Advisory Panel review 6/29/2016.
Congenital Heart Defect, Repair Devices Specialty Matched Consultant Advisory Panel review 6/2016. Medical Director review 6/2016.
Continuous Passive Motion in the Home Setting Specialty Matched Consultant Advisory Panel review 6/29/2016.
Corneal Collagen Cross-linking Specialty Matched Consultant Advisory Panel review 6/29/2016. No change to policy statement.
CT Perfusion Imaging of the Brain Specialty Matched Consultant Advisory Panel review 6/29/2016. No change to policy statement.
Digital Breast Tomosynthesis Specialty Matched Consultant Advisory Panel review 6/29/2016. No change to policy statement.
Dopamine Transporter Imaging with Single Photon Emission Computed Tomography Specialty Matched Consultant Advisory Panel review 6/29/2016. No change to policy statement.
Electrical Bone Growth Stimulation Specialty Matched Consultant Advisory Panel review 6/29/2016.
Electromagnetic Navigation Bronchoscopy Updated Policy Guidelines and Regulatory status sections. Reference added. No change to policy statement.
Endobronchial Valves Policy Guidelines updated. Reference added. No change to policy statement.
Endothelial Keratoplasty Specialty Matched Consultant Advisory Panel review 6/29/2016. No change to policy statement.
Epiretinal Radiation Therapy for Age-Related Macular Degeneration Specialty Matched Consultant Advisory Panel review 6/29/2016. No change to policy statement.
Exhaled Nitric Oxide Measurement Updated Policy Guidelines section, Reference added. No change to policy statement.
Extracorporeal Shock Wave Treatment for Musculoskeletal Conditions and Wound Healing Specialty Matched Consultant Advisory Panel review 6/29/2016. Reference added. Policy Guidelines updated.
Eyelid Thermal Pulsation for the Treatment of Dry Eye Syndrome Specialty Matched Consultant Advisory Panel review 6/29/2016. No change to policy statement.
Fundus Photography Specialty Matched Consultant Advisory Panel review 6/29/2016. No change to policy statement.
Gene Expression Profiling for Uveal Melanoma Specialty Matched Consultant Advisory Panel review 6/29/2016. Updated Description and Policy Guidelines sections. Reference added. No change to policy statement.
General Approach to Evaluating the Utility of Genetic Panels References updated. Medical Director review 6/2016.
Genetic Testing for Macular Degeneration Specialty Matched Consultant Advisory Panel review 6/29/2016. No change to policy statement.
Glaucoma, Evaluation by Ophthalmologic Techniques Specialty Matched Consultant Advisory Panel review 6/29/2016. No change to policy statement.
Guidelines for Global Maternity Reimbursement In the section "Billing for Maternity Care" Item C.1.a. "Baby A: File the appropriate "vaginal delivery" code" was revised to read "Baby A: File the appropriate "global vaginal delivery" code".
Heart-Lung Transplantation Specialty Matched Consultant Advisory Panel review 6/2016. Medical Director review 6/2016.
Implantable Cardioverter Defibrillator Description section updated and minor update to Policy Guidelines. References updated. Specialty Matched Consultant Advisory Panel review 6/29/16. Medical Director review.
Implantation of Intrastromal Corneal Ring Segments Specialty Matched Consultant Advisory Panel review 6/29/2016. No change to policy statement.
Interferential Stimulation Reference added. Policy Guidelines updated.
Intra Articular Hyaluronan Injections for Treatment of Osteoarthritis of the Knee Reference added. Specialty Matched Consultant Advisory Panel review 6/29/2016.
Intravitreal Implant Specialty Matched Consultant Advisory Panel review 6/29/2016. No change to policy statement.
Keratoprosthesis Specialty Matched Consultant Advisory Panel review 6/29/2016. No change to policy statement.
Lung Volume Reduction Surgery Updated Policy Guidelines section. Reference added. No change to policy statement.
Magnetic Resonance Imaging (MRI) Targeted Biopsy of the Prostate Updated Billing/Coding section: Add-on code 0443T was developed for the Precision Biopsy ClariCore Optical Biopsy System® which is not yet approved for use by the FDA. It would be used with code 55700 and is reported only once per session. Specialty Matched Consultant Advisory Panel review 6/29/2016. No change to policy statement.
Magnetic Resonance Spectroscopy Specialty Matched Consultant Advisory Panel review 6/29/2016. No change to policy statement.
Magnetoencephalography/Magnetic Source Imaging Specialty Matched Consultant Advisory Panel review 6/29/2016. No change to policy statement.
Melanoma Vaccines Policy archived.
MRI-Guided Focused Ultrasound (MRgFUS) Specialty Matched Consultant Advisory Panel review 6/29/2016. No change to policy statement.
Myocardial Sympathetic Innervation Imaging Specialty Matched Consultant Advisory Panel review 6/29/2016. No change to policy statement.
Myoelectric Prosthetic Components for the Upper Limb Specialty Matched Consultant Advisory Panel review 6/29/2016.
Navigated Transcranial Magnetic Stimulation (nTMS) Reference added. Policy Guidelines updated.
Neurostimulation, Electrical Reference added. Policy Guidelines updated.
Optical Coherence Tomography (OCT) Anterior Segment of the Eye Specialty Matched Consultant Advisory Panel review 6/29/2016. No change to policy statement.
Oscillatory Devices for the Treatment of Respiratory Conditions Policy Guidelines section updated. Reference added. No change to policy statement.
Patient-Specific Cutting Guides and Custom Knee Implants Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 6/29/2016.
Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention Minor updates to Description section. Policy statement revised for FDA approved percutaneous LAA closure device, changing from investigational to medically necessary. Policy Guidelines and references updated. Specialty Matched Consultant Advisory Panel review 6/2016 Medical Director review 6/2016.
Positional Magnetic Resonance Imaging (MRI) Specialty Matched Consultant Advisory Panel review 6/29/2016. No change to policy statement.
Prolotherapy Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 6/29/2016.
Proteogenomic Testing for Patients with Cancer (GPS CancerTM Test) New policy developed. Proteogenomic testing of patients with cancer (including but not limited to GPS CancerTM Test) is considered investigational. Medical Director review 6/2016.
Pulmonary Hypertension, Drug Management Specialty Matched Consultant Advisory Panel review 3/30/16. No change to policy statement. Reference added.
Refractive Surgery Specialty Matched Consultant Advisory Panel review 6/29/2016. No change to policy statement.
Retinal Prosthesis Specialty Matched Consultant Advisory Panel review 6/29/2016. No change to policy statement.
Screening for Vertebral Fracture with Dual X-ray Absorptiometry (DXA) References updated. Specialty Matched Consultant Advisory Panel review 6/29/2016. No change to policy statement.
Surgery for Athletic Pubalgia Specialty Matched Consultant Advisory Panel review 6/29/2016.
Surgery for Femoroacetabular Impingement Specialty Matched Consultant Advisory Panel review 6/29/2016.
Surgical Management of Transcatheter Heart Valves Policy Guidelines and references updated. Specialty Matched Consultant Advisory Panel review 6/2016. Medical Director review 6/2016.
Surgical Ventricular Restoration Specialty Matched Consultant Advisory Panel review 6/2016. Medical Director review 6/2016.
Transcatheter Closure of Ventricular Septal Defects References updated. Specialty Matched Consultant Advisory Panel review 6/2016. Medical Director review 6/2016.
Vertebral Axial Decompression (VAD-X) Specialty Matched Consultant Advisory Panel review 6/29/2016. Reference added.
Viscocanalostomy and Canaloplasty Specialty Matched Consultant Advisory Panel review 6/29/2016. No change to policy statement.