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Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for September 30, 2016

Medical Guidelines Reason for Update
Ado-Trastuzumab Emtansine (Trastuzumab-DM1) for Treatment of HER-2 Positive Malignancies Specialty Matched Consultant Advisory Panel review 8/31/2016. No change to policy statement.
Cardiovascular Disease Risk Tests Under "Billing/Coding" section, deleted ICD-10 code E.78.0 and added the following ICD-10 codes for effective date 10/1/16: E78.00, E78.01.
Cellular Immunotherapy for Prostate Cancer Specialty Matched Consultant Advisory Panel review 8/31/2016. No change to policy statement. Medical Director review.
Chemotherapy for Malignant Disease Specialty Matched Consultant Advisory Panel review 8/31/2016. Added HCPC code G0498 to Billing/Coding section. No change to policy statement.
Common Genetic Variants to Predict Risk of Nonfamilial Breast Cancer Specialty Matched Consultant Advisory Panel review 8/31/2016. No change to policy statement.
Continuous Monitoring of Glucose in the Interstitial Fluid Specialty Matched Consultant Advisory Panel review 7/27/2016. Minor changes in the Description section. Added rationale for type 2 diabetes to the Policy Guidelines section. No change to policy statement or intent.
Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate, or Dermatologic Tumors Reference added. Policy Guidelines updated.
Enhanced External Counterpulsation (EECP) Description section updated. Medical Director review 8/2016.
Extracorporeal Photopheresis Updated Policy Guidelines section. Specialty Matched Consultant Advisory Panel review 8/31/2016. No change to policy statement.
Gene-Based Tests for Screening, Detection, and/or Management of Prostate Cancer Updated Policy Guidelines section. References added. Specialty Matched Consultant Advisory Panel review 8/31/2016. No change to policy statement.
Genetic Testing for Breast and Ovarian Cancer Updated Description and Policy Guidelines sections. Reference added. Specialty Matched Consultant Advisory Panel review 8/31/2016. No change to policy statement.
Genetic Testing for Colon Cancer Updated the Description and Policy Guidelines sections. Reference added. Specialty Matched Consultant Advisory Panel review 8/31/2016. No change to policy statement.
Genetic Testing for Evaluation of Developmental Delay/Autism Spectrum Disorder Description section updated, adding NGS description information. Policy Guidelines and references updated. Medical Director review 8/2016.
Glaucoma, Evaluation by Ophthalmologic Techniques Reference added. No change to policy statement.
Guidelines for Global Maternity Reimbursement In the Billing for Maternity Care section, Item B.4. revised to read: another provider in a different practice assumes care of the member prior to completion of global services. Added Item 5. Separate billing for pre/post-natal and delivery services is allowed when "during the member's pregnancy, there was a change in the member's benefit package or certificate number due to an employer change only." Codes O09.A0, O09.A1, O09.A2, O09.A3 added to Billing/Coding section.
Hyperthermia Therapy Reference added. Specialty Matched Consultant Advisory Panel review 8/31/2016. No change to policy statement.
Insulin Therapy, Chronic Intermittent Intravenous (CIIIT) Specialty Matched Consultant Advisory Panel review meeting 7/27/2016. No change to policy.
Intensity Modulated Radiation Therapy (IMRT) of Abdomen and Pelvis Updated Description and Policy Guidelines sections. No change to policy statement. Reference added.
Intensity Modulated Radiation Therapy (IMRT) of Head and Neck Description and Policy Guidelines sections updated. No change to policy statement. Reference added.
Intensity Modulated Radiation Therapy (IMRT) of the Chest Reference added. Description section updated. No change to policy statement.
Interleukin-5 Antagonists Moved dosing information for Nucala and Cinqair from the "When Covered" section to the Policy Guidelines. Under "Billing/Coding" section, deleted code C3999 and added code C9481 for effective date 10/1/16.
KRAS, NRAS, and BRAF Mutation Analysis in Metastatic Colorectal Cancer Specialty Matched Consultant Advisory Panel review 8/31/2016. No change to policy statement. Added Panitumumab and Cetuximab indications to "When Covered" section. Medical Director review 8/2016.
Laboratory and Genetic Testing for Use of 5-Fluorouracil in Patients with Cancer Specialty Matched Consultant Advisory Panel review 8/31/2016. No change to policy statement.
Microarray-based Gene Expression Testing for Cancers of Unknown Primary Specialty Matched Consultant Advisory Panel review 8/31/2016. No change to policy statement.
Molecular Markers in Fine Needle Aspirates of the Thyroid Specialty Matched Consultant Advisory Panel review 8/31/2016. No change to policy statement.
Necitumumab (Portrazza) 16 Specialty Matched Consultant Advisory Panel review 8/31/2016. Medical Director review 8/2016. No change to policy statement.
Optical Coherence Tomography (OCT) Anterior Segment of the Eye Reference added. Regulatory status updated. No change to policy statement.
Optical Diagnostic Devices for Evaluating Skin Lesions Suspected of Malignancy Statement in the non-covered section regarding multispectral digital skin lesion analysis was clarified to read: Multispectral digital skin lesion analysis is considered investigational in all situations including but not limited to: Evaluating pigmented skin lesions; Serially monitoring pigmented skin lesions; Defining peripheral margins of skin lesions suspected of malignancy prior to surgical excision. In the Billing/Coding section, the following statement added for code 96904: Whole body photography represents 1 component of dermatoscopy. CPT code 96904 may also be submitted to describe whole body photography without dermatoscopy. Policy intent unchanged.
Orthotics Reference added. Patient-actuated serial stretch devices changed to patient-controlled serial stretch devices throughout document.
Pasireotide (Signifor® LAR) Policy archived. Information for pasireotide is found in new policy titled, "Somatostatin Analogs."
PD-1 Inhibitors Specialty Matched Consultant Advisory Panel review 8/31/2016. Added the following covered indication for head and neck squamous cell cancer under "When Covered" section Pembrolizumab (Keytruda) #3: "The patient has recurrent or metastatic head and neck squamous cell cancer (HNSCC) with disease progression on or after platinum-containing chemotherapy." Reference added. Medical Director review 8/2016.
Respiratory Syncytial Virus Prophylaxis Reference added.
Rhinoplasty Reference added. Specialty Matched Consultant Advisory Panel review 8/31/2016.
Sacral Nerve Neuromodulation/Stimulation for Pelvic Floor Dysfunction Codes N39.491 and N39.492 added to Billing/Coding section.
Septoplasty References added. Specialty Matched Consultant Advisory Panel review 8/31/2016.
Sleep Apnea: Diagnosis and Medical Management Specialty Matched Consultant Advisory Panel review 8/31/2016.
Somatostatin Analogs Policy titled "Pasireotide" combined with new medical policy titled "Somatostatin Analogs." This new policy addresses pasireotide (Signifor® LAR), octeotide acetate (Sandostatin® LAR Depot), and lanreotide (Somatuline® Depot). BCBSNC will provide coverage for somatostatin analogs when they are determined to be medically necessary because the medical criteria and guidelines outlined in the policy are met. Notification given 7/26/2016 for effective date 9/30/2016.
Surgery for Morbid Obesity Added codes 47379 and 49329 to Billing/Coding section. Policy noticed 7/26/2016 for effective date 9/30/2016.
Surgery for Obstructive Sleep Apnea and Upper Airway Resistance Syndrome Specialty Matched Consultant Advisory Panel review 8/31/2016.
Surgical Management of Transcatheter Heart Valves When Covered section for TAVI, updated to include coverage of the following: "Transcatheter aortic valve replacement with a transcatheter heart valve system approved for use for repair of a degenerated bioprosthetic valve may be considered medically necessary when all of the following conditions are present"; When Not Covered section revised to remove the following from investigational as it is now considered medically necessary: "patients with a bio prosthetic valve ("Valve in Valve" implantation). Description section and Policy Guidelines extensively revised for TAVI to support policy statement. References updated. Medical Director review 9/2016.
Surgical Treatment of Sinus Disease Specialty Matched Consultant Advisory Panel review 8/31/2016. Reference added and updated.
Talimogene Laherparepvec (ImlygicTM) Specialty Matched Consultant Advisory Panel review 8/31/2016. No change to policy statement.
Temporomandibular Joint Dysfunction (TMJD) Item 3 in the non-covered section updated to include an additional investigational treatment. Statement now reads: The following non-surgical treatments are considered investigational in the treatment of TMJ dysfunction: Alpha-Stim. Added CPT code 21089.
Testing Serum Vitamin D Levels Statement in the non-covered section referring to routine screening was deleted. The screening diagnosis codes were removed from the Billing/Coding section.
Tinnitus Treatment Specialty Matched Consultant Advisory Panel review 8/31/2016.
Transtympanic Micropressure Applications as a Treatment of Meniere's Disease Specialty Matched Consultant Advisory Panel review 8/31/16.
Vagus Nerve Stimulation Code F32.89 added to Billing/Coding section.
Xolair® (Omalizumab) When Covered section updated to included expanded coverage for asthma treatment to individuals 6 years of age and older. References updated.