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Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for October 25, 2016

Medical Guidelines Reason for Update
Amniotic Membrane and Amniotic Fluid Injections Specialty Matched Consultant Advisory Panel review 9/28/2016. Policy accepted as written.
Artificial Intervertebral Disc Reference added. Additional covered indications added. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 10/26/2016.
Bioengineered Skin and Tissue Specialty Matched Consultant Advisory Panel review 9/28/2016. Policy accepted as written.
Children's Mobility and Positioning Equipment Specialty Matched Consultant Advisory Panel review 9/30/2016. Medical Director review 9/2016.
Chiropractic Services Specialty Matched Consultant Advisory Panel 9/2016. Medical Director review 9/2016.
Composite Allotransplantation of the Hand and Face Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 9/28/2016. No change to policy statement.
Cosmetic and Reconstructive Surgery In the "When Covered" section, Item B.1. the word "otoplasty" changed to "auricular reconstruction." Specialty Matched Consultant Advisory Panel review 9/28/2016.
Durable Medical Equipment (DME) Updated Related Policies in Description Section. Specialty Matched Consultant Advisory Panel review 9/30/2016. Medical Director review 9/2016.
Functional Capacity Assessment and Work Hardening Specialty Matched Consultant Advisory Panel- 9/2016. Medical Director review 9/2016. (jd)
Intensity Modulated Radiation Therapy for Tumors of the Central Nervous System Updated Description and Policy Guidelines sections. No change to policy statement. Reference added.
Monoclonal Antibody Imaging for Prostate Cancer Reference added. Policy Guidelines updated. No change to policy statement.
Patient Lifts References updated. Specialty Matched Consultant Advisory Panel review 9/2016. Medical Director review 9/2016
Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention "When Covered" section revised to include CHADS2 and CHA2DS2-VASc scores and indicators, formal shared decision making with an independent non-interventional physician on oral anticoagulation in patients with NVAF prior to LAAC with requirement of documentation in the medical record, a suitability for short-term warfarin but deemed unable to take long-term oral anticoagulation following the conclusion of shared decision making, as LAAC is only covered as a second line therapy to oral anticoagulants. Code section and References updated. Specialty Matched Consultant Advisory Panel review 9/2016. Medical Director review 9/2016.
Pressure Reducing Support Surfaces Updated staging for what is now considered pressure injury by the national pressure advisory panel (NPUAP) and NCD 280.8 under the Description section. Minor revisions to "When Covered section for Group 2 and 3 pressure surfaces. References updated. Specialty Matched Consultant Advisory Panel 9/2016. Medical Director review 9/2016.
Radioembolization for Primary and Metastatic Tumors of the Liver Reference added. No change to policy statement.
Reconstructive Eyelid Surgery and Brow Lift Specialty Matched Consultant Advisory Panel review 9/28/2016. No change to policy statement.
Rehabilitative Therapies Updated coding section. Specialty Matched Consultant Advisory Panel review 9/30/2016. Medical Director review 9/2016.
Salivary Hormone Tests Statement added to the Not Covered section. Salivary hormone testing related to transgender hormonal therapy is considered investigational
Speech Generating Devices 16 References updated. Specialty Matched Consultant Advisory Panel review 9/2016. Medical Director review 9/2016.