Medical Policy Updates

Medical Policy Update for February 25, 2020

Medical Guidelines Reason for Update
Bone Mineral Density Studies Removed "dual x-ray absorptiometry of peripheral sites" from When not covered section.
Bundling Guidelines Code 0399T for myocardial strain imaging deleted and replaced with code 93356.
Diagnosis of Idiopathic Environmental Intolerance AHS – G2056 Specialty Matched Consultant Advisory Panel review 11/2019. Medical Director review 11/2019.
Documentation Requirements for Treatment of End Stage Renal Disease Corrected review dates in header.
Enfortumab vedotin-ejfv (PadcevTM) New policy developed. Padcev is considered medically necessary for the treatment of adult patients with locally advanced or metastatic urothelial cancer when specified medical criteria and guidelines are met. Added HCPCS codes C9399, J3490, J3590, J9999, S0353, and S0354 to Billing/Coding section. References added. Medical Director review 2/2020.
Fam-Trastuzumab Deruxtecan-nxki (Enhertu®) New policy developed. Enhertu is considered medically necessary for the treatment of adult patients with unresectable or metastatic HER2-positive breast cancer when specified medical criteria and guidelines are met. Added HCPCS codes C9399, J3490, J3590, J9999, S0353, and S0354 to Billing/Coding section. References added. Medical Director review 2/2020.
Fecal Microbiota Transplantation Minor revisions to description, related policies, and policy guidelines. References updated. Specialty Matched Consultant Advisory Panel review 11/2019. Medical Director review 11/2019.
General Approach to Evaluating the Utility of Genetic Panels Specialty Matched Consultant Advisory Panel review 7/2019. Medical Director review 7/2019
Laparoscopic and Percutaneous Techniques for the Myolysis of Uterine Fibroids Added "Laparoscopic ultra-sound guided radiofrequency ablation using AcessaTM is considered investigational for myomata with intracavitary or subserosal locations (FIGO Types 0,1, or 7). [See Policy Guidelines.]" to When not covered section. All coverage criteria newly added to When covered section. Policy guidelines and references updated.
Leadless Cardiac Pacemakers Billing/Coding section updated: removed CPT codes 0387T-0391T and added 33274 and 33275.
Molecular Markers in Fine Needle Aspirates of the Thyroid AHS - M2108 Corrected typo on date entered for CAP review in previous entry to 8/21/19. No change to policy statement.
MRI-guided Laser Interstitial Thermal Therapy for Neurological Indications Policy titled changed from MRI-Guided Laser-induced Thermotherapy for Neurological Indications to MRI-Guided Laser Interstitial Thermal Therapy for Neurological Indications. Medically necessary criteria added for refractory epilepsy. References added. Specialty Matched Consultant Advisory Panel review 10/16/2019.
Nonpayment for Serious Adverse Events Corrected review dates in header.
Orthotics Specialty Matched Consultant Advisory Panel review 2/20/2019.
Pancreatic Enzyme Testing for Acute Pancreatitis AHS – G2153 Policy statement revised to read: BCBSNC will provide coverage for pancreatic enzyme testing for acute pancreatitis when it is determined the medical criteria or reimbursement guidelines below are met. Wording revised in When Covered section. "Medically Necessary" changed to "Reimbursement is allowed..." Wording revised in the Not Covered section. "Not Medically Necessary" changed to read "Reimbursement is not allowed..." Deleted coding grid. Notification given 10/1/2019 for effective date 12/2/2019.
Prenatal Screening for Fetal Aneuploidy AHS – G2055 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
Radiosurgery, Stereotactic Approach Corrected typo under When Not Covered section regarding numerical reference for oligometastses. Statement should read "Stereotactic body radiation therapy (SBRT) for oligometastases is considered not medically necessary when criteria listed above in section B #8 are not met". No changes to policy intent.
Speech Generating Devices Specialty Matched Consultant Advisory Panel review 9/2019. Medical Director review 9/2019.
Stem-cell Therapy for Peripheral Arterial Disease Minor revisions and updates to the Description section, regulatory status, policy guidelines, and reference section. No change to policy intent.