Medical Policy Updates

Blue Cross and Blue Shield of North Carolina Medical Policy Update March 31, 2020

Medical Guidelines	Reason for Update
Abdominoplasty, Panniculectomy and Lipectomy	Replaced "reconstructive" with "medically necessary" in When covered statement. Removed coverage requirement related to significant weight loss. Clarified coverage requirement related to documented functional impairment. Broadened when covered statement from bacterial cellulitis to cellulitis, dermatitis or skin ulcerations.
Cervical Cancer Screening AHS - G2002	Specialty Matched Consultant Advisory Panel 3/18/2020. No change to policy statement.
Chromosomal Microarray AHS - M2033	Specialty Matched Consultant Advisory Panel 3/18/20. No change to policy statement.
Colorectal Cancer Screening AHS-B0001	Specialty Matched Consultant Advisory Panel review 8/21/19. Consultant agreed with the policy. No change to policy intent. Reference added. Medical Director review 8/2019 with CAP.
Convection-Enhanced Delivery of Therapeutic Agents to the Brain	Specialty Matched Consultant Advisory Panel review 3/18/2020. Reference added. No change to policy statement.
Cord Blood as a Source of Stem Cells	Specialty Matched Consultant Advisory Panel review 3/18/2020. Reference added. No change to policy statement.
Crizanlizumab-tmca (Adakveo®)	Added HCPCS code C9053 to Billing/Coding section effective 4/1/2020. Specialty Matched Consultant Advisory Panel review 3/18/2020. No change to policy statements.
Cryosurgical Ablation of Primary or Metastatic Liver Tumors	Microwave Tumor Ablation removed from list of Related Policies.
Gene Expression Testing for Breast Cancer Prognosis AHS - M2020	Specialty Matched Consultant Advisory Panel review 3/18/2020. No change to policy statement.
General Genetic Testing, Somatic Disorders AHS-M2146	Specialty Matched Consultant Advisory Panel review 3/2020. Medical Director review 3/2020.
Genetic Testing and Genetic Expression Profiling in Patients with Cutaneous Melanoma AHS-M2029	Specialty Matched Consultant Advisory Panel review 3/18/2020. No change to policy statement.
Genetic Testing for Fanconi Anemia AHS – M2077	Specialty Matched Consultant Advisory Panel review 3/2020. Medical Director 3/2020.
Genetic Testing for FMR1 Mutations AHS – M2028	Specialty Matched Consultant Advisory Panel review 3/2020. Medical Director review 3/2020.
Genetic Testing for Germline Mutations of the RET Proto-Oncogene AHS - M2078	Specialty Matched Consultant Advisory Panel review 3/18/2020.No change to policy statement.
Genetic Testing for Hereditary Hemochromatosis AHS – M2012	Specialty Matched Consultant Advisory Panel review 3/2020. Medical Director review 3/2020.
Genetic Testing for Rett Syndrome AHS – M2088	Specialty Matched Consultant Advisory Panel review 3/2020. Medical Director review 3/2020.
Genetic Testing of CADASIL Syndrome AHS – M2069	Specialty Matched Consultant Advisory Panel review 3/2020. Medical Director review 3/2020.
Givosiran (Givlaari™)	Added HCPCS code C9056 to Billing/Coding section effective 4/1/2020.
Hormone Pellet Implantation for Treatment of Menopause Related Symptoms	Specialty Matched Consultant Advisory Panel review 3/18/2020. No change to policy statement.
Immune Cell Function Assay for Organ Transplant Rejection AHS-G2098	Specialty Matched Consultant Advisory Panel review 3/18/2020. No change to policy statement.
Intracellular Micronutrient Analysis AHS – G2099	Specialty Matched Consultant Advisory Panel review 3/2020. Medical Director review 3/2020.
Maternal and Fetal Diagnostics	Reference and Description sections updated. Specialty Matched Consultant Advisory Panel review 3/18/2020. No change to policy statement.
Metabolite Markers of Thiopurines AHS – G2115	Specialty Matched Consultant Advisory Panel review 3/2020. Medical Director review 3/2020.
Microarray-Based Gene Expression Profile Testing for Multiple Myeloma Risk Stratification AHS-B0002	Specialty Matched Consultant Advisory Panel review 3/18/2020. No change to policy statement.
Pancreatic Cancer Risk Testing Using Molecular Classifier in Pancreatic Cyst Fluid AHS-M2114	Specialty Matched Consultant Advisory Panel review 3/18/2020. No change to policy statement.
Pathogen Panel Testing AHS – G2149	Specialty Matched Consultant Advisory Panel review 3/2020. Medical Director review 3/2020.
Prenatal Screening for Fetal Aneuploidy AHS – G2055	Specialty Matched Consultant Advisory Panel review 3/18/20. No change to policy statement.
Progesterone Therapy in High Risk Pregnancies	Description, Policy Guidelines, Coding and Reference sections updated. Specialty Matched Consultant Advisory Panel review 3/18/2020. No change to policy statement.
Proteogenomic Testing of Individuals with Cancer AHS-M2168	Specialty Matched Consultant Advisory Panel review 3/18/2020. No change to policy statement.
Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors	Microwave Tumor Ablation removed from list of Related Policies.
Salivary Hormone Testing AHS – G2120	Specialty Matched Consultant Advisory Panel 3/18/20. No change in policy statement.
Sleep Apnea: Diagnosis and Medical Management	Medical Director review 3/2020. The following changes were made to the policy. Under When Covered, item I E, the words "moderate or" added to the policy statement ("who are at moderate or high risk for obstructive sleep apnea"). Under When Not Covered, item I B, removed the words "to moderate" from the statement ("Unattended (unsupervised) sleep studies are considered investigational in patients who are considered at low to moderate risk for OSA"). Under Policy Guidelines, changed "all 4" to "at least one", and replaced the word "high" with the word "moderate".
Testing for Alpha-1 Antitrypsin Deficiency AHS-M2068	Specialty Matched Consultant Advisory Panel review 3/2020. Medical Director review 3/2020.
Trastuzumab (Herceptin®) and Trastuzumab Biosimilars	Under "When Covered," added Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) for the treatment of HER2 overexpressing breast cancer indications. Reformatted "When Not Covered" section for clarity, with no change to intent. Updated Description section to reflect addition of Herceptin Hylecta to policy. Added reference to related policy for Nerlynx. Added HCPCS code J9356 to Billing/Coding section. References added. Medical Director review 12/2019. Notification given 12/31/2019 for effective date 4/1/2020. Policy title changed from Trastuzumab to Trastuzumab (Herceptin®) and Trastuzumab Biosimilars. Specialty Matched Consultant Advisory Panel review 3/18/2020. No change to policy statements.
Use of Common Genetic Variants to Predict Risk of Non-Familial Breast Cancer AHS-M2126	Specialty Matched Consultant Advisory Panel review 3/18/2020. No change to policy statement.
Venous Thrombosis Risk Testing AHS – M2041	Specialty Matched Consultant Advisory Panel review 3/2020. Medical Director review 3/2020.
White Blood Cell Growth Factors	Added HCPCS code C9058 to Billing/Coding section effective 4/1/2020.
Whole Genome and Whole Exome Sequencing AHS – M2032	Specialty Matched Consultant Advisory Panel review 3/2020. Medical Director review 3/2020.