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Medical Policy Updates

Table Of Contents

Blue Cross and Blue Shield of North Carolina Medical Policy Update for April 28, 2017

Medical Guidelines Reason for Update
Allogeneic Hematopoietic Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms Title changed from "Allogeneic Stem-Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms" to "Allogeneic Hematopoietic Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms." Title change per NCCN terminology change. Updated Description section. Specialty Matched Consultant Advisory Panel review 3/29/2017. No change to policy statement.
Amniotic Membrane and Amniotic Fluid Injections Following statement added to the When Covered section: application of Epifix is limited to no more than 5 weekly applications per wound. (This statement was moved out of the Bioengineered Skin medical policy and into this policy).
Antiemetic Injection Therapy Added the following statement to "When Covered" section: "Use of Antiemetic Injection Therapy may be considered medically necessary for clinical indications not listed above when the drug is prescribed for the treatment of cancer either: In accordance with FDA label (when clinical benefit has been established, see Policy Guidelines); OR In accordance with specific strong endorsement or support by nationally recognized compendia, when such recommendation is based on strong/high levels of evidence, and/or uniform consensus of clinical appropriateness has been reached". Under "When Not Covered" section, added the statement "Antiemetic Injection Therapy is considered investigational when used for: 1)Non-cancer indications; OR 2) When criteria are not met regarding FDA labeling OR strong endorsement/ support by nationally recognized compendia, as stated under "When Antiemetic Injection Therapy is covered." Added the following statements under "Policy Guidelines" section: 1)Drugs prescribed for treatment of cancer in accordance with FDA label may be considered medically necessary when clinical benefit has been established, and should not be determined to be investigational as defined in Corporate Medical Policy, Investigational (Experimental) Services." 2) Please refer to CMP "Investigational (Experimental) Services" for a summary of evidence standards from nationally recognized compendia. Medical director review 3/2017. Specialty Matched Consultant Advisory Panel review 3/29/2017. Updated NCCN antiemesis table. Reference added. No change to policy statement.
Assays of Genetic Expression to Determine Prognosis of Breast Cancer Specialty Matched Consultant Advisory Panel review 3/29/2017. No change to policy statement.
Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions Reference added. Policy Guidelines and Description sections extensively revised. The following statements were added to the When Not Covered section: "Treatment of focal articular cartilage lesions with decellularized osteochondral allograft plugs (eg, Chondrofix) is considered investigational and treatment of focal articular cartilage lesions with reduced osteochondral allograft discs (eg, ProChondrix, Cartiform) is considered investigational. Notification given 2/24/17 for effective date 4/28/17.
Bioengineered Skin and Tissue Note regarding application limit for Epifix was removed from this policy and moved to policy titled "Amniotic Membrane and Amniotic Fluid Injections."
Bone Mineral Density Studies Minor wording changes to "When Covered" section. No change to policy statement or criteria. Reference added.
BRAF Gene Mutation Testing to Select Melanoma Patients for BRAF Inhibitor Therapy Updated Description section. Reference added. Specialty Matched Consultant Advisory Panel review 3/29/2017. No change to policy statement.
Bronchial Thermoplasty Revised Policy Guidelines section and placed Regulatory Status under Description section. No change to policy intent. Specialty Matched Consultant Advisory Panel review 3/29/2017.
Chromosomal Microarray Analysis for the Evaluation of Pregnancy Loss Specialty Matched Consultant Advisory Panel review 3/29/2017. No change to policy statement.
Circulating Tumor DNA for Cancer Management (Liquid Biopsy) Specialty Matched Consultant Advisory Panel review 3/29/2017. No change to policy statement.
Computer Assisted Surgical Navigational Orthopedic Procedures Reference added. Policy Guidelines updated. Code 0396T added to Billing/Coding section.
Convection-Enhanced Delivery of Therapeutic Agents to the Brain Specialty Matched Consultant Advisory Panel review 3/29/2017. Reference added. No change to policy statement.
Cord Blood as a Source of Stem Cells Specialty Matched Consultant Advisory Panel review 3/29/2017. No change to policy statement.
Corneal Collagen Cross-linking Updated Description section. Reference added. Medical Director review 3/2017. No change to policy statement.
Electronic Brachytherapy for Nonmelanoma Skin Cancer Specialty Matched Consultant Advisory Panel review 3/29/2017. No change to policy statement.
Endobronchial Valves Specialty Matched Consultant Advisory Panel review 3/29/2017. Reference added. No change to policy statement.
Epiretinal Radiation Therapy for Age-Related Macular Degeneration Updated Policy Guidelines section. Reference added. No change to policy statement.
Erythropoiesis-Stimulating Agents (ESAs) Added the following statement to "When Covered" section: "Use of Erythropoiesis Stimulating Agents (ESAs) may be considered medically necessary for clinical indications not listed above when the drug is prescribed for the treatment of cancer either: In accordance with FDA label (when clinical benefit has been established, see Policy Guidelines); OR In accordance with specific strong endorsement or support by nationally recognized compendia, when such recommendation is based on strong/high levels of evidence, and/or uniform consensus of clinical appropriateness has been reached". Under "When Not Covered" section, added the statement "Erythropoiesis Stimulating Agents (ESAs) are considered investigational when used for: 1)Non-cancer indications; OR 2) When criteria are not met regarding FDA labeling OR strong endorsement/ support by nationally recognized compendia, as stated under "When Erythropoiesis Stimulating Agents (ESAs) are covered." Added the following statements under "Policy Guidelines" section: 1)Drugs prescribed for treatment of cancer in accordance with FDA label may be considered medically necessary when clinical benefit has been established, and should not be determined to be investigational as defined in Corporate Medical Policy, Investigational (Experimental) Services." 2) Please refer to CMP "Investigational (Experimental) Services" for a summary of evidence standards from nationally recognized compendia. Medical Director review 3/2017. Specialty Matched Consultant Advisory Panel review 3/29/2017. No change to policy statement.
Exhaled Nitric Oxide Measurement Specialty Matched Consultant Advisory Panel review 3/29/2017. Reference added. No change to policy statement.
Eyelid Thermal Pulsation for the Treatment of Dry Eye Syndrome Updated Policy Guidelines section. Reference added. No change to policy statement.
General Approach to Evaluating the Utility of Genetic Panels Specialty Matched Consultant Advisory Panel review 3/2017. Medical Director review 3/2017.
General Approach to Genetic Testing Related Policies section updated. Specialty Matched Consultant Advisory Panel review 3/2017. Medical Director review 3/2017.
Genetic Testing for Alpha-1 Antitrypsin Deficiency Specialty Matched Consultant Advisory Panel review 3/2017. Medical Director review 3/2017.
Genetic Testing for CADASIL Syndrome Specialty Matched Consultant Advisory Panel review 3/2017. Medical Director review 3/2017.
Genetic Testing for Cutaneous Malignant Melanoma Minor revisions to Description section. Policy guidelines revised and entire policy updated with current genetic nomenclature. Specialty Matched Consultant Advisory Panel review 3/2017. Medical Director review 3/2017.
Genetic Testing for Duchenne and Becker Muscular Dystrophy When Covered section updated to include item number 3: "For at-risk male offspring: To confirm or exclude the need for medical and cardiac surveillance". No change to policy intent. Policy guidelines and references updated. Medical Director review 3/2017.
Genetic Testing for Evaluation of Developmental Delay/Autism Spectrum Disorder Specialty Matched Consultant Advisory Panel review 3/2017. Medical Director review 3/2017.
Genetic Testing for Fanconi Anemia Specialty Matched Consultant Advisory Panel review 3/2017. Medical Director review 3/2017.
Genetic Testing for FMR1 Mutations Including Fragile X Syndrome Specialty Matched Consultant Advisory Panel review 3/2017. Medical Director review 3/2017.
Genetic Testing for Hereditary Hemochromatosis Description section and regulatory status updated. Specialty Matched Consultant Advisory Panel review 3/2017. Medical Director review 3/2017.
Genetic Testing for Macular Degeneration Updated Description and Policy Guidelines sections. ARUP test reference removed. Reference added. No change to policy statement.
Genetic Testing for Marfan Syndrome, Thoracic Aortic Aneurysms and Dissections, and Related Disorders Specialty Matched Physician Advisory Panel review 3/2017. Medical Director review 03/2017.
Genetic Testing for Rett Syndrome When Covered section, removed the sentence "a definitive diagnosis cannot be made with genetic testing". Minor updates to Description section; Regulatory status updated. Policy guidelines extensively updated. No change to policy intent. Specialty Matched Consultant Advisory Panel review 3/2017. Medical Director review 3/2017.
Glaucoma, Evaluation by Ophthalmologic Techniques Updated Description and Policy Guidelines sections. Doppler ultrasonography removed from Description section and "When Not Covered" section. No change to intent nor policy statement. Added CPT code 0469T to Billing/Coding section for effective date 7/1/17. Reference added.
Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia Policy title changed from "Hematopoietic Stem Cell Transplantation for Chronic Myelogenous Leukemia" to Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia." Description and Policy Guidelines sections revised. Reference added. No change to policy intent. Medical Director review 1/2017.
Hematopoietic Cell Transplantation for CLL and SLL Policy title changed from "Hematopoietic Stem Cell Transplantation for CLL and SLL" to Hematopoietic Cell Transplantation for CLL and SLL." Description and Policy Guidelines sections revised. Reference added. No change to policy intent. Medical Director review 1/2017.
Hematopoietic Cell Transplantation for Hodgkin Lymphoma Policy title changed from "Hematopoietic Stem-Cell Transplantation for Hodgkin Lymphoma" to "Hematopoietic Cell Transplantation for Hodgkin Lymphoma" Description and Policy Guidelines sections revised. Reference added. No change to policy intent. Medical Director review 1/2017.
Hematopoietic Cell Transplantation for Plasma Cell Dyscrasias, Including Multiple Myeloma and POEMS Syndrome Titled changed from "Hematopoietic Stem-Cell Transplantation for Plasma Cell Dyscrasias, Including Multiple Myeloma and POEMS Syndrome" to " Hematopoietic Cell Transplantation for Plasma Cell Dyscrasias, Including Multiple Myeloma and POEMS Syndrome." Revised Description and Policy Guidelines sections. Reference added. No change to policy intent. Medical Director review 1/2017.
Hormone Pellet Implantation for Treatment of Menopause Related Symptoms Specialty Matched Consultant Advisory Panel review 3/29/17. Policy statement unchanged.
Hyperthermic Intraperitoneal Chemotherapy Updated Description and Policy Guidelines sections. Reference added. Specialty Matched Consultant Advisory Panel review 3/29/2017. No change to policy statement.
Identification of Microorganisms Using Nucleic Acid Probes Minor revisions only. New code added to Billing/Coding section. Specialty Matched Consultant Advisory Panel review 3/2017. Medical Director review 3/2017.
Immune Cell Function Assay Specialty Matched Consultant Advisory Panel review 3/29/2017. No change to policy statement.
Implantation of Intrastromal Corneal Ring Segments Updated Policy Guidelines section. Reference added. No change to policy statement.
Intracellular Micronutrient Analysis Minor revisions to Description section. Regulatory status updated and Policy Guidelines extensively revised. Referenced updated. Specialty Matched Consultant Advisory Panel review 3/2017. Medical Director review 3/2017.
Intravitreal Implant Extensive revisions to Description and Policy Guidelines section as well as Regulatory status. Added the following statement and investigational indications to the "When Not Covered" section: A fluocinolone acetonide intravitreal implant 0.59 mg (Retisert®) or 0.19 mg (Iluvien®) or dexamethasone intravitreal implant 0.7 mg (OzurdexTM) is considered investigational for the treatment of Birdshot retinochoroidopathy, Cystoid macular edema related to retinitis pigmentosa, Idiopathic macular telangiectasia type 1, Postoperative macular edema, Circumscribed choroidal hemangiomas, Proliferative vitreoretinopathy, Radiation retinopathy. Reference added. Medical Director review 3/2017.
Invasive Prenatal (Fetal) Diagnostic Testing Specialty Matched Consultant Advisory Panel review 3/29/2017. No change to policy statement.
Ipilimumab (Yervoy) Added the following statement to "When Covered" section: "Use of Ipilimumab (Yervoy) may be considered medically necessary for clinical indications not listed above when the drug is prescribed for the treatment of cancer either: In accordance with FDA label (when clinical benefit has been established, see Policy Guidelines); OR In accordance with specific strong endorsement or support by nationally recognized compendia, when such recommendation is based on strong/high levels of evidence, and/or uniform consensus of clinical appropriateness has been reached". Under "When Not Covered" section, added the statement "Ipilimumab (Yervoy) is considered investigational when used for: 1)Non-cancer indications; OR 2) When criteria are not met regarding FDA labeling OR strong endorsement/ support by nationally recognized compendia, as stated under "When Ipilimumab (Yervoy) is covered." Added the following statements under "Policy Guidelines" section: 1)Drugs prescribed for treatment of cancer in accordance with FDA label may be considered medically necessary when clinical benefit has been established, and should not be determined to be investigational as defined in Corporate Medical Policy, Investigational (Experimental) Services." 2) Please refer to CMP "Investigational (Experimental) Services" for a summary of evidence standards from nationally recognized compendia. Medical director review 3/2017. Specialty Matched Consultant Advisory Panel review 3/29/17. No change to policy statement.
Keratoprosthesis Updated Description and Policy Guidelines sections as well as Regulatory Status. Reference added. No change in policy statement.
Laboratory and Genetic Testing for Use of 5-Fluorouracil in Patients with Cancer Updated Description and Policy Guidelines sections. Under "When Covered" changed "mutations" to "variants." Reference added. No change to policy statement.
Lung and Lobar Lung Transplantation Specialty Matched Consultant Advisory Panel review 3/29/2017. No change to policy statement.
Lung Volume Reduction Surgery Specialty Matched Consultant Advisory Panel review 3/29/2017. No change to policy statement.
Maternal and Fetal Diagnostics Added information regarding 3-D and 4-D fetal ultrasound to Description section. Added fetal and maternal risk factors to the list in the Fetal Echocardiography section. Added an indication for amniocentesis to the section on Amniocentesis and Chorionic Villus Sampling. Reference added. Specialty Matched Consultant Advisory Panel review 3/29/2017.
Melphalan Hydrochloride (Evomela) for Intravenous Use Specialty Matched Consultant Advisory Panel review 3/29/2017. No change to policy statement.
Microarray-Based Gene Expression Profile Testing for Multiple Myeloma Risk Stratification Specialty Matched Consultant Advisory Panel review 3/29/2017. No change to policy statement.
Microarray-based Gene Expression Testing for Cancers of Unknown Primary Updated Description and Policy Guidelines sections. Reference added. No change to policy statement.
Moderate Penetrance Variants Associated with Breast Cancer in Individuals at High Risk Specialty Matched Consultant Advisory Panel review 3/29/2017. No change to policy statement.
Optical Coherence Tomography (OCT) Anterior Segment of the Eye Updated Description and Policy Guidelines sections. Added CPT codes 0470T, 0471T to the Billing/Coding section for effective date 7/1/17. Reference added. Medical Director review 3/2017. No change to policy statement.
Oscillatory Devices for the Treatment of Respiratory Conditions Specialty Matched Consultant Advisory Panel review 3/29/2017. No change to policy statement.
Ovarian and Internal Iliac Vein Embolization Updated Policy Guidelines. Added reference. Specialty Matched Consultant Advisory Panel review meeting 3/29/2017. No change to policy statement.
PathFinderTG® Molecular Testing Specialty Matched Consultant Advisory Panel review 3/29/2017. No change to policy statement.
Progesterone Therapy in High Risk Pregnancies Specialty Matched Consultant Advisory Panel review 3/29/2017. No change to policy statement.
Proteogenomic Testing for Patients with Cancer (GPS CancerTM Test) Specialty Matched Consultant Advisory Panel review 3/29/2017. No change to policy statement.
Proteomic Testing for Targeted Therapy in Non-Small Cell Lung Cancer Updated Description and Policy Guidelines sections. Reference added. Specialty Matched Consultant Advisory Panel review 3/29/2017. No change to policy statement.
Proteomics-based Testing Related to Ovarian Cancer Updated Description section and Policy Guidelines. Reference added. Specialty Matched Consultant Advisory Panel review 3/29/2017. No change to policy statement.
Pulmonary Hypertension, Drug Management Updated Description and Policy Guidelines sections. Reference added. Specialty Matched Advisory Panel review 3/29/2017. Under Description section, Chronic Thromboembolic PH on page 4, designated that CTEPH is in WHO Group 4. Under Policy Guidelines section, page 6, clarified that Riociguat for CTEPH is addressed under the Pharmacy policy titled "Oral Pulmonary Hypertension." No change to policy statement.
Quantitative Assay for Measurement of HER2 Total Protein Expression and HER2 Dimers Specialty Matched Consultant Advisory Panel review 3/29/2017. No change to policy statement.
Retinal Prosthesis Updated Policy Guidelines section. Added CPT codes 0472T, 0473T to the Billing/Coding section for effective date 7/1/17. Reference added. No change to policy statement.
Rituximab for the Treatment of Rheumatoid Arthritis Description section and Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 2/22/2017. No change to policy statement.
Salivary Hormone Tests Specialty Matched Consultant Advisory Panel review 3/29/2017. No change to policy statement.
Surgical Deactivation of Headache Trigger Sites Reference added. Policy Guidelines updated. Codes 64722, 64771, and 64772 added to Billing/Coding section.
Transtympanic Micropressure Applications as a Treatment of Meniere’s Disease Reference added. Policy Guidelines updated.
Trastuzumab Added the following statement to "When Covered" section: "Use of Trastuzumab may be considered medically necessary for clinical indications not listed above when the drug is prescribed for the treatment of cancer either: In accordance with FDA label (when clinical benefit has been established, see Policy Guidelines); OR In accordance with specific strong endorsement or support by nationally recognized compendia, when such recommendation is based on strong/high levels of evidence, and/or uniform consensus of clinical appropriateness has been reached". Under "When Not Covered" section, added the statement "Trastuzumab is considered investigational when used for: 1)Non-cancer indications; OR 2) When criteria are not met regarding FDA labeling OR strong endorsement/ support by nationally recognized compendia, as stated under "When Trastuzumab is covered." Added the following statements under "Policy Guidelines" section: 1)Drugs prescribed for treatment of cancer in accordance with FDA label may be considered medically necessary when clinical benefit has been established, and should not be determined to be investigational as defined in Corporate Medical Policy, Investigational (Experimental) Services." 2) Please refer to CMP "Investigational (Experimental) Services" for a summary of evidence standards from nationally recognized compendia. Medical director review 3/2017. Specialty Matched Consultant Advisory Panel review 3/29/17. No change to policy statement.
Viscocanalostomy and Canaloplasty Viscocanalostomy changed to not medically necessary from investigational under "When Not Covered" section. Policy statement for Viscocanalostomy changed to not medically necessary. Reference added. Medical Director review 3/2017.
Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders Description section updated. Added laboratory, Illumina to the table titled: "Examples of laboratories offering exome sequencing as a clinical service". Policy guidelines updated. Specialty Matched Consultant Advisory Panel review 3/2107. Medical Director review 3/2017.