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Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for February 24, 2017

Medical Guidelines Reason for Update
Allogeneic Stem-Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms Revised Policy Guidelines section. Reference added. No change to policy statement.
Amniotic Membrane and Amniotic Fluid Injections Description section extensively revised. Policy statement revised: "BCBSNC will provide coverage for human amniotic membrane when it is determined to be medically necessary because the medical criteria and guidelines shown below have been met." Treatment of nonhealing diabetic lower-extremity ulcers using the following human amniotic membrane products may be considered medically necessary: AmnioBand® Membrane, Biovance®, Epifix®, GrafixTM. All other human amniotic membrane products (micronized or particulated human amniotic membrane or human amniotic fluid) for any other indications are considered investigational. Policy Guidelines section updated. Coding/Billing section updated to include codes and coding instructions.
Bioengineered Skin and Tissue Minor change to Description section. AlloMend added to list of products covered for breast reconstructive surgery. AlloPatch added to list of products covered for chronic, noninfected, full-thickness diabetic lower-extremity ulcers. List of investigation/ noncovered products was extensively revised. All amniotic membrane and amniotic fluid injection deleted from this list—refer to policy titled: Amniotic Membrane and Amniotic Fluid Injections. Policy Guidelines section updated. Billing/Coding section updated.
Bundling Guidelines Deleted information regarding Vision Services. Statement revised to read: Determination of refractive state (92015) performed incidental to a medical eye exam is permissible and may be covered when performed outside of any global allowance and subject to member benefits.
Cord Blood as a Source of Stem Cells Reference added. No change to policy intent.
Gene Expression Testing in the Evaluation of Patients With Stable Ischemic Heart Disease Title changed to "Gene Expression Testing in the Evaluation of Patients With Stable Ischemic Heart Disease". Policy statement unchanged but wording updated to reflect current terminology and guidelines; Policy Guidelines and references updated.
Genetic Testing for Alpha-1 Antitrypsin Deficiency Regulatory status section and Policy Guidelines updated. References updated. Medical Director review.
Genetic Testing for Cardiac Ion Channelopathies Policy Guidelines and references updated.
Genetic Testing for CHEK2 Mutations for Breast Cancer Archived policy. See CMP "Moderate Penetrance Variants Associated with Breast Cancer in Individuals at High Risk." Medical Director review 12/2016.
Genetic Testing for FLT3, NPM1 and CEBPA Mutations in Acute Myeloid Leukemia Revised Policy Guidelines section. Reference added. No change to policy intent.
Genetic Testing for FMR1 Mutations Including Fragile X Syndrome Minor word additions for clarity to "When Covered" section of the Policy Statement but no change to policy intent. Policy Guidelines and references updated. Medical Director review 1/2017.
Genetic Testing for Neurofibromatosis Updated Description section and added Legius syndrome information. Added Testing Strategy for evaluation of neurofibromatosis type 1 (NF1) to the Policy Guidelines. References updated.
Hematopoietic Stem-Cell Transplantation for Acute Lymphoblastic Leukemia Policy Guidelines revised. Reference added. No change to policy intent.
Hematopoietic Stem-Cell Transplantation for CNS Embryonal Tumors and Ependymoma Revised Policy Guidelines section. Reference added. No change to policy intent.
Hematopoietic Stem-Cell Transplantation for Epithelial Ovarian Cancer Revised Description and Policy Guidelines sections. Reference added. No change to policy intent.
Hematopoietic Stem-Cell Transplantation for Miscellaneous Solid Tumors in Adults Revised Policy Guidelines and Description sections. Reference added. No change to policy intent.
Hematopoietic Stem-Cell Transplantation in the Treatment of Germ Cell Tumors Revised Description and Policy Guidelines sections. Reference added. No change to policy intent.
Intravenous Anesthetics for the Treatment of Chronic Pain Last paragraph of Description section regarding IV Ketamine revised for clarity to read: IV ketamine for the treatment of chronic pain or psychiatric disorders is an off-label use.
Lumbar Spine Fusion Surgery Codes 22853, 22854, and 22859 added to Billing/Coding section.
Maximum Units of Service Statement added to section "Guidelines related to Maximum Units" that reads: Mastectomy bras are limited to two per year.
Moderate Penetrance Variants Associated with Breast Cancer in Individuals at High Risk Policy title revised. Extensive revisions to Description and Policy Guidelines sections. Under When Covered section: added medically necessary indication for PALB2 testing: Testing for PALB2 variants for breast cancer risk assessment in adults who meet the following criteria may be considered medically necessary: 1. The individual meets criteria for genetic risk evaluation (see Policy Guidelines section) AND 2. The individual has undergone testing for sequence variants in BRCA1 and BRCA2 (see Policy Guidelines section) with negative results. Under When Not Covered section, added the following statements: Testing for PALB2 sequence variants in individuals who do not meet the criteria outlined above is considered investigational and testing for CHEK2 and ATM variants in the assessment of breast cancer risk is considered investigational. Medical director review 12/2016. References added.