Skip Navigation

Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for March 31, 2017

Medical Guidelines Reason for Update
Abatacept (Orencia®) Updated Description section. Added references. Specialty Matched Consultant Advisory Panel review 2/22/2017. No change to policy statement.
Ablation Procedures for Peripheral Neuromas and Peripheral Nerves References added. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 2/22/2017.
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. Updated Description and Policy Guidelines sections. Added HCPCS codes S0353, S0354 to Billing/Coding section. Reference added. Medical director review 10/2016. Notification given 12/30/16 for effective date 4/1/17.
Ambulance and Medical Transport Services Specialty Matched Consultant Advisory Panel review 2/22/2017. No change to policy statement.
Anesthesia Services The following statement was added to the section "When Anesthesia Services are Covered": Anesthesia may be considered medically necessary for the safe and effective administration of dental procedures for young children (below the age of 9 years), persons with serious mental or physical conditions or persons with significant behavioral problems. The first sentence in the "When Anesthesia Services are not Covered" was revised to read: The administration of local anesthesia or for anesthesia administered by the operating surgeon, surgical assistant or dentist is considered incidental to the surgical or dental procedure.
Antiemetic Injection Therapy Added ICD-10 codes Z51.11, Z51.12 and HCPCS codes S0353, S0354 to the Billing/Coding section. No change to policy statement. Notification given 12/30/16 for effective date 4/1/17.
Aqueous Shunts and Devices for Glaucoma Added HCPCS codes C1783 and L8612 to the Billing/Coding section. Updated Description and Policy Guidelines sections. Removed the word "currently" from covered statement #2 beginning with "Implantation of a single FDA approved microstent…" under "When Covered" section. Reference added.
Belimumab (Benlysta) Description section updated. Added specific laboratory findings to Item 2 in the When Covered section. Information regarding use during pregnancy and lactation added to Policy Guidelines section. Reference added. Specialty Matched Consultant Advisory Panel review meeting 2/22/2017.
Bevacizumab in Advanced Adenocarcinoma of the Pancreas Updated Description and Policy Guidelines section. Specialty Matched Consultant Advisory Panel review 11/30/2016. Medical Director review 11/2016. Added HCPCS codes S0353 and S0354 to Billing/Coding section. No change to policy statement. Notification given 12/30/16 for effective date 4/1/17.
Biofeedback Description section revised. For biofeedback for headache and chronic pain see policy titled: Biofeedback as a Treatment of Pain. Policy Guideline updated. Reference added. Specialty Matched Consultant Advisory Panel review meeting 2/22/2016.
Biofeedback as a Treatment of Pain New policy developed. This policy specifically deals with biofeedback for pain. Indications of headache and chronic pain were removed from original policy titled "Biofeedback". The original policy deals with all other indications for biofeedback. Biofeedback may be considered medically necessary as part of the overall treatment plan for migraine and tension-type headache. Biofeedback for the treatment of cluster headache, chronic pain, including but not limited to low back pain is considered investigational.
Bone Morphogenetic Protein Specialty Matched Consultant Advisory Panel review 2/22/17.
Brentuximab Vedotin (Adcetris) New policy developed. Brentuximab Vedotin (Adcetris) is considered medically necessary for the treatment of patients with classical Hodgkin lymphoma. Medical Director review 9/2016. Reference added. Added HCPCS codes S0353, S0354 to Billing/Coding section. Notification given 12/30/16 for effective date 4/1/17.
Cabazitaxel (Jevtana) New policy developed. Cabazitaxel (Jevtana) is considered medically necessary in combination with prednisone for the treatment of patients with hormone-refractory metastatic prostate cancer previously treated with a docetaxel-containing treatment regimen. Reference added. Medical Director review 8/2016. Added HCPCS codes S0353, S0354 to Billing/Coding section. Notification given 12/30/16 for effective date 4/1/17.
Carfilzomib (Kyprolis®) New medical policy developed. "Carfilzomib® (Kyprolis) is considered medically necessary for the treatment of patients with relapsed or refractory multiple myeloma. References added. Medical Director review 8/2016. Added HCPCS codes S0353, S0354 to the Billing/Coding section. Notification given 12/30/16 for effective date 4/1/17.
Cellular Immunotherapy for Prostate Cancer Specialty Matched Consultant Advisory Panel review 8/31/2016. No change to policy statement. Medical Director review 8/2016. Added HCPCS codes S0353, S0354 to Billing/Coding section. Notification given 12/30/16 for effective date 4/1/17.
Chelation Therapy Updated Policy Guidelines section. Specialty Matched Consultant Advisory Panel review 2/22/2017. No change to policy statement.
Clinical Trial Services Specialty Matched Consultant Advisory Panel review 2/22/2017. No change to policy statement.
Code Bundling Rules Not Addressed in ClaimCheck® or Correct Coding Initiative The following section is deleted: A health risk assessment instrument (96160, 96161) is not reimbursed separately. It is considered incidental to the associated evaluation and management services.
Complementary and Alternative Medicine Updated Description section. Specialty Matched Consultant Advisory Panel review 2/22/2017. No change to policy statement.
Cranial Electrotherapy Stimulation (CES) and Auricular Electrostimulation Reference added.
Daratumumab (Darzalex) Medical Director review 8/2016. No change to policy statement. Deleted the following HCPCS codes C9476, C9399, J3490, J3590, J9999 and added HCPCS codes J9145, S0353, S0354 to Billing/Coding section. Notification given 12/30/16 for effective date 4/1/17.
Decompression of the Intervertebral Disc Using Laser Energy (Laser Discectomy) or Radiofrequency Coblation (Nucleoplasty) Reference added. Policy Guidelines updated.
Denosumab (ProliaTM, XGEVATM) Added HCPCS codes S0353,S0354 and ICD10 codes M81.0, M81.8, T50.905, Z79.811, Z87.311 to Billing/Coding section. Deleted HCPCS codes J3490, J3590. Notification given 12/30/16 for effective date 4/1/2017.
Diagnosis and Treatment of Chronic Cerebrospinal Venous Insufficiency in Multiple Sclerosis Reference added. Policy Guidelines updated. Medical Director review. Policy archived.
DNA Based Testing for Adolescent Idiopathic Scoliosis Reference added. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 2/22/2017.
Dynamic Posturography Specialty Matched Consultant Advisory Panel review 2/22/2017.
Electrical Stimulation for the Treatment of Arthritis Revised Description section. Updated Policy Guidelines. References added. Specialty Matched Consultant Advisory Panel review 2/22/2017. No change to policy statement.
Electrodiagnostic Studies Reference added. Specialty Matched Consultant Advisory Panel review 10/26/2016.
Elotuzumab (Empliciti) Medical Director review 9/2016. No change to policy statement. Deleted HCPCS codes C9477, C9399, J3490, J3590, J9999 and added HCPCS codes J9176, S0353, S0354 to Billing/Coding section. Notification given 12/30/16 for effective date 4/1/17.
Eribulin Mesylate (Halaven) New policy developed. Eribulin Mesylate (Halaven) is considered medically necessary in the treatment of individuals with locally recurrent or metastatic breast cancer and locally recurrent or metastatic HER2+ breast cancer. Reference added. Added HCPCS codes S0353, S0354 to Billing/Coding section. Notification given 12/30/16 for effective date 4/1/17. Medical Director review 9/2016.
Erythropoiesis-Stimulating Agents (ESAs) Updated Policy Guidelines section. Added covered indication language to "When Covered" section." Updated Regulatory status section with black box warning. ICD-10 diagnoses codes and S0353, S0354 added to "Billing/Coding" section. Senior Medical Director review 9/2016. Notification given 12/30/16 for effective date 4/1/17.
Eteplirsen for Duchenne Muscular Dystrophy New policy developed. The use of eteplirsen is considered investigational for all indications including treatment of Duchenne muscular dystrophy.
Gastric Electrical Stimulation Minor revision to Description section and Policy Guidelines. References updated. Medical Director review 2/2017.
Gene Expression Profiling for Uveal Melanoma Policy statement changed to medically necessary for patients with localized uveal melanoma under "When Covered" section: "Gene expression profiling for uveal melanoma with DecisionDx-UM is considered medically necessary for patients with primary, localized uveal melanoma." Updated Description and Policy Guidelines sections. Reference added. Sr. Medical Director review 2/2017.
Genetic and Protein Biomarkers for Diagnosis and Risk Assessment of Prostate Cancer Added CPT code 0005U to the Billing/Coding section for effective date 4/1/17.
Genetic Testing for Alpha Thalassemia Minor revisions with updated genetic terminology. Medical Director review 2/2017.
Genetic Testing for Dilated Cardiomyopathy Minor revisions with updated genetic terminology. Commercially Available Genetics Panel for DCM - table updated with current number of genes tested. References updated. Medical Director review 2/2017.
Genetic Testing for Epilepsy Reference added. Background section updated. Policy revised with updated genetics nomenclature.
Genetic Testing for Hereditary Pancreatitis Minor revisions with updated genetic terminology. References updated. Medical Director review 2/2017.
Genetic Testing for Marfan Syndrome, Thoracic Aortic Aneurysms and Dissections, and Related Disorders Description section updated to include clarifying information related to Marfan Syndrome and TAAD. Added updated genetic terminology throughout policy, policy statement remains unchanged. Policy guidelines and reference updates. Medical Director review 2/2017.
Genetic Testing for PTEN Hamartoma Tumor Syndrome Description section, policy statement and policy guidelines updated with current genetic terminology. References updated. Medical Director review 2/2017.
Genetic Testing for the Diagnosis of Inherited Peripheral Neuropathy Description section, Policy Guidelines and references updated. Medical Director review 1/2017.
Golimumab (Simponi Aria) Updated Description section. Added FDA labeling information and definitions to Policy Guidelines. Added References. Specialty Matched Consultant Advisory Panel review meeting 2/22/17. No change to policy statement.
Goserelin Acetate (Zoladex) New policy developed. Goserelin Acetate (Zoladex) may be considered medically necessary for the treatment of advanced breast cancer in menopausal or pre-and perimenopausal individuals with hormone receptor positive breast cancer and for clinically localized or advanced prostate cancer. Reference added. Added ICD-10 diagnoses codes and HCPCS codes S0353 and S0354 to the "Billing/Coding" section. Medical Director review 9/2016. Notification given 12/30/16 for effective date 4/1/17.
Growth Factors in Wound Healing Reference added. Wound Closure Outcomes added to Description section.
Handheld Radiofrequency Spectroscopy for Intraoperative Assessment of Surgical Margins during Breast-Conserving Surgery Reference added. Policy Guidelines updated.
Implantable Bone Conduction Hearing Aids Specialty Matched Consultant Advisory Panel review 2/22/2017.
Infliximab, Infliximab-dyyb Deleted several investigational indications from the Not Covered section. Specialty Matched Consultant Advisory Panel review 2/22/2017.
Infusion Therapy in the Home Specialty Matched Consultant Advisory Panel review 2/22/2017. No change to policy statement.
Injectable Clostridial Collagenase for Fibroproliferative Disorders Specialty Matched Consultant Advisory Panel (Orthopedics) review 2/22/2017.
Intravenous Antibiotic Therapy for Lyme Disease Reference added. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 2/22/2017. Codes S9494 and S9497 added to Billing/Coding section.
Ipilimumab (Yervoy) Medical Director review 8/2016. No change to policy statement. Added HCPCS codes S0353 and S0354 to Billing/Coding section. Notification given 12/30/16 for effective date 4/1/17.
KRAS, NRAS, BRAF Mutation Analysis and Related Treatment in Metastatic Colorectal Cancer Notification given 12/30/16 for effective date 4/1/17. Title changed from "KRAS, NRAS, and BRAF Mutation Analysis in Metastatic Colorectal Cancer" to "KRAS, NRAS, BRAF Mutation Analysis and Related Treatment in Metastatic Colorectal Cancer"
Measurement of Serum Antibodies to Infliximab and Adalimumab Updated Policy Guidelines section. Specialty Matched Consultant Advisory Panel review meeting 2/22/2017. No change to policy statement.
Microprocessor-Controlled Prostheses for the Lower Limb Specialty Matched Consultant Advisory Panel review 2/22/2017.
Monoclonal Antibodies for Non-Hodgkin Lymphoma and Acute Myeloid Leukemia In the Non-Hematopoietic Stem Cell Transplant Setting Added HCPCS codes J9302, S0353, S0354 and deleted J9010, J9300 in "Billing/Coding" section. Also added ICD-10 diagnoses codes to the "Billing/Coding" section. Medical Director review 9/2016. Revisions under "When Covered" (WC) section: Bullet c. added "CD positive", Bullet g. added "Castleman’s disease.", Bullet f. added Burkitt lymphoma. Also in WC section #2 Ofatumumab (Arzerra): removed statements: "the treatment of CLL that is refractory to fludarabine and alemtuzumab * and previously untreated CLL in patients not suitable for treatment with fludarabine. *" and added the following statements: "As a single agent or in combination with fludarabine and cyclophosphamide for the treatment of relapsed/refractory CLL in combination with chlorambucil previously untreated CLL in patients not suitable for treatment with fludarabine and for extended treatment of patients who are in complete or partial response after at least two lines of therapy for recurrent or progressive CLL."Gemtuzumab and alemtuzumab removed from policy due to withdrawal from market. Added covered indication for Burkitt lymphoma under Rituximab. Added covered indication for follicular lymphoma under Obinutuzumab. Updated Regulatory status, Description section and Policy Guidelines sections. Reference added. Medical Director review 12/2016. Notification given 12/30/16 for effective date 4/1/17.
Necitumumab (Portrazza) Deleted the following HCPCS codes C9475, C9399, J9999, J3490, J3590 and added HCPCS codes J9295, S0353, S0354 to Billing/Coding section. Notification given 12/30/16 for effective date 4/1/17.
Non-Contact Ultrasound Treatment for Wounds Reference added. Wound Closure Endpoints information added to Description section.
Noninvasive Fractional Flow Reserve Using Computed Tomography Angiography New policy developed. Use of noninvasive FFR-CT is considered investigational preceding invasive coronary angiography in patients with suspected stable ischemic heart disease. Medical Director review 12/2016. Policy noticed 1/27/17 for effective date 4/1/17.
Noninvasive Respiratory Assist Devices References added. Specialty Matched Consultant Advisory Panel review 2/22/2017.
Nusinersen (SpinrazaTM) New policy developed. Nusinersen may be considered medically necessary for the treatment of spinal muscle atrophy when criteria are met.
Nutrient/Nutritional Panel Testing Specialty Matched Consultant Advisory Panel review 2/22/2017. No change to policy.
Observation Room Services Specialty Matched Consultant Advisory Panel review 2/22/2017. No change to policy.
Orthopedic Applications of Stem Cell Therapy Specialty Matched Consultant Advisory Panel review 2/22/2017.
Orthotics Specialty Matched Consultant Advisory Panel review 2/22/2017.
Paclitaxel (Abraxane)® New policy issued. Paclitaxel (Abraxane®) is considered medically necessary for the treatment of patients with: Metastatic breast cancer, locally advanced or metastatic non-small cell lung cancer (NSCLC), metastatic adenocarcinoma of the pancreas. Removed statement "prior therapy should have included an anthracycline unless clinically contraindicated" in the "When Covered" section. Medical Director review 9/2016. Added HCPCS codes S0353, S0354 to Billing/Coding section. Notification given 12/30/16 for effective date 4/1/17.
PD-1 Inhibitors Specialty Matched Consultant Advisory Panel review 8/31/2016. Added covered indications for NSCLC under "When Covered" section Keytruda statements #2 and #3: "The patient has metastatic non-small cell lung cancer (NSCLC) with high PD-L1 tumor expression (Tumor Proportion Score or TPS > 50%) as determined by an FDA-approved test, with no EGFR or ALK genomic tumor aberrations, and no prior systemic chemotherapy treatment for metastatic NSCLC" and "The patient has metastatic non-small cell lung cancer (NSCLC) with tumor expression of PD-L1 (TPS > 1%) as determined by an FDA-approved test." Added a covered indication for head and neck squamous cell cancer under "When Covered" section Pembrolizumab (Keytruda) statement #4: "The patient has recurrent or metastatic head and neck squamous cell cancer (HNSCC) with disease progression on or after platinum-containing chemotherapy." Removed the "L" from PD-1 in statement #5 under Keytruda. Added covered indication for head and neck squamous cell cancer under "When Covered" section Nivolumab (Opdivo) statement #5: "The patient has recurrent or metastatic squamous cell carcinoma of the head and neck with disease progression on or after a platinum-based therapy." Added HCPCS codes S0353, S0354 to Billing/Coding section. Reference added. Medical Director review 12/2016. Notification given 12/30/16 for effective date 4/1/17.
Pemetrexed (Alimta) New policy developed. Pemetrexed (Alimta®) is considered medically necessary for the treatment of patients with nonsquamous non-small cell lung cancer, mesothelioma, urothelial carcinoma, epithelial ovarian cancer and thymic carcinoma. References added. Added HCPCS codes S0353, S0354 to Billing/Coding section. Notification given 12/30/16 for effective date 4/1/17. Medical Director review 8/2016.
Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, and Biacuplasty Reference added. Description section and Policy Guidelines Section revised. Title changed from Intradiscal Electrothermal (IDET) Annuloplasty and Percutaneous Intradiscal Radiofrequency Annuloplasty to Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, and Biacuplasty. Policy statement terminology revised to reflect the changes in the title but policy intent is unchanged.
Pertuzumab for Treatment of Malignancies Updated Description section extensively and removed Table 1. Updated Policy Guidelines section. Medical Director review 10/2016. No change to policy statement. Reference added. Added HCPCS codes S03653, S0354 to Billing/Coding section. Notification given 12/30/16 for effective date 4/1/17.
Powered Exoskeleton for Ambulation in Patients with Lower Limb Disabilities Specialty Matched Consultant Advisory Panel review 2/22/2017.
Private Duty Nursing Services Specialty Matched Consultant Advisory Panel review 2/22/2017. No change to policy.
Prostatic Urethral Lift Reference added. Specialty Matched Consultant Advisory Panel review 11/30/2016.
Respiratory Syncytial Virus Prophylaxis Specialty Matched Consultant Advisory Panel review– 2/22/2017.
Sacral Nerve Neuromodulation/Stimulation for Pelvic Floor Dysfunction Reference added. Policy Guidelines updated. ICD-9 codes removed from Billing/Coding section.
Semi-Implantable and Fully Implantable Middle Ear Hearing Aid Specialty Matched Consultant Advisory Panel review 2/22/17.
Serum Biomarker Panel Testing for Systemic Lupus Erythematosus Updated Policy Guidelines section. Reference added. Specialty Matched Consultant Advisory Panel review 2/22/2017. No change to policy statement.
Siltuximab (Sylvant) Medical Director review 8/2016. Added HCPCS codes S0353, S0354 to Billing/Coding section. Notification given 12/30/16 for effective date 4/1/17.
Skilled Nursing Facility Care Specialty Matched Consultant Advisory Panel review 2/22/2017. No change to policy statement.
Skilled Nursing Services Specialty Matched Consultant Advisory Panel review 2/22/2017. No change to policy statement.
Spinal Cord Stimulation Reference added. Specialty Matched Consultant Advisory Panel review 10/26/2016. Policy Guidelines updated.
Subtalar Arthroereisis Specialty Matched Consultant Advisory Panel review 2/22/2017.
Surgery for Groin Pain in Athletes Reference added. Policy title changed from Surgery for Athletic Pubalgia to Surgery for Groin Pain in Athletes. Policy Guidelines updated.
Surgical Management of Transcatheter Heart Valves Description section updated with expanded indications for SAPIEN XT. Policy guidelines and references updated. No change to policy intent. Medical Director review 2/2017.
Surgical Ventricular Restoration Minor edits, deleted "or post infarction left ventricular aneurysm" from policy statement. No change to policy intent. References updated. Medical Director review, 2/2017.
Testing Serum Vitamin D Levels Added USPSTF recommendation to Policy Guidelines section. Specialty Matched Consultant Advisory Panel review 2/22/2017. No change to policy statement.
Tinnitus Treatment Reference added. Policy Guidelines updated. Psychological coping therapy may be considered medically necessary for persistent and bothersome tinnitus added to the covered policy statement. Combined psychological and sound therapy added to the investigational policy statement.
Tocilizumab (Actemra) Updated Description section. Added definitions to Policy Guidelines. Added References. Specialty Matched Consultant Advisory Panel review meeting 2/22/17. No change to policy statement.
Topical Negative Pressure Therapy for Wounds Reference added. Policy Guidelines updated
Topotecan Hydrochloride (Hycamtin) New policy developed. Topotecan Hydrochloride (Hycamtin) is considered medically necessary for the treatment of patients with: acute myeloid leukemia, bone cancer, cervical cancer, lymphoma of CNS, Merkel cell skin cancer, small cell lung cancer, soft tissue sarcoma, uterine cancer, endometrial cancer. Reference added. Medical director review 9/2016. Added HCPCS codes S0353, S0354 to Billing/Coding section. Notification given 12/30/16 for effective date 4/1/17.
Total Facet Arthroplasty Reference added. Policy Guidelines updated.
Trastuzumab Added definition of HER2 in the "When Covered" section. Added covered indication for esophageal adenocarcinoma: "Trastuzumab may be considered medically necessary for treatment of patients with esophageal adenocarcinoma (not squamous or upper esophageal cancer) with clearly positive HER2 overexpression, Category 1 when used with Cisplatin and 5FU or Capecitabine, and Category 2B with other combinations." Added HCPCS codes S0353 and S0354 to Billing/Coding section. Updated Policy Guidelines section. Medical Director review 10/2016. Reference added. Notification given 12/30/16 for effective date 4/1/17.
Ultrasound Accelerated Fracture Healing Device Specialty Matched Consultant Advisory Panel review 2/22/2017. Policy Guidelines updated.
Ustekinumab (Stelara®) Added code C9487 to Billing/Coding section.
Vectra® DA Blood Test for Rheumatoid Arthritis Updated Policy Guidelines section. Specialty Matched Consultant Advisory Panel review 2/22/2017. No change to policy statement.
Vertebroplasty, Kyphoplasty, and Sacroplasty Percutaneous Reference added. Information on vertebral body stenting removed from policy, Policy Guidelines updated. Clarifying statements on kyphoplasty and vertebroplasty added to When Not Covered section.
White Blood Cell Growth Factors New policy developed. Pegfilgrastim (Neulasta), Filgrastim (Neupogen), Sargramostim (Leukine), Tbo-filgrastim (Granix) and Filgrastim-sndz (Zarxio) are considered medically necessary to enhance recovery of blood related functions in neutropenia. References added. Added HCPCS codes S0353, S0354 and ICD-10 diagnoses codes to "Billing/Coding" section. Medical Director review 12/2016. Notification 12/30/16 for effective date 4/1/17.