Medical Policy Updates

Blue Cross and Blue Shield of North Carolina Medical Policy Update April 14, 2020

Medical Guidelines Reason for Update
Allogeneic Hematopoietic Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms Updated Policy Guidelines and When Covered sections. References added. Specialty Matched Consultant Advisory Panel review 3/18/2020. Medical Director review 3.2020. No change to policy statement.
Alpha 1-Antitrypsin Inhibitor Therapy Minor typographical edits made throughout policy for clarity. Specialty Matched Consultant Advisory Panel review 3/18/2020. No change to policy statements
Detection of Circulating Tumor Cells and Cell Free DNA in Cancer Management (Liquid Biopsy) AHS-G2054 Specialty Matched Consultant Advisory Panel review 3/18/2020. No change to policy statement.
DNA Ploidy Cell Cycle Analysis AHS – M2136 Specialty Matched Consultant Advisory Panel review 3/18/2020. No change to policy statement. Reference added.
Epithelial Cell Cytology in Breast Cancer Risk Assessment AHS - G2059 Specialty Matched Consultant Advisory Panel review 3/18/2020. No change to policy statement.
Erythropoiesis-Stimulating Agents (ESAs) Updated REMS information and evidence summary in Policy Guidelines. Minor typographical edits made throughout policy for clarity. Reference added. Specialty Matched Consultant Advisory Panel review 3/18/2020.
Genetic Testing for Familial Cutaneous Malignant Melanoma AHS – M2037 Specialty Matched Consultant Advisory Panel review 3/2020. Medical Director review 3/2020.
Genetic Testing for Li_Fraumeni Syndrome AHS – M2081 Added the following to the When Not Covered section: "when the above criteria have not been met." Specialty Matched Consultant Advisory Panel review 3/2020. Medical Director review 3/2020.
Genetic Testing of Mitochondrial Disorders AHS – M2085 Specialty Matched Consultant Advisory Panel review 3/2020. Medical Director review 3/2020.
Infertility Diagnosis and Treatment – B0006 Description section updated. When covered section updated to allow "Saline infusion sonohysterography (SIS or SHG)", "Anti-Mullerian hormone (AMH)", and endocrine evaluation to include "luteinizing hormone (LH), testosterone, and prolactin." Added "Please check the member's benefit booklet for information regarding pharmacy benefit coverage for infertility treatment, which may be separate from medical infertility coverage." to When covered section. "Non-steroidal aromatase inhibitor for medical conditions associated with infertility i.e. polycystic ovarian disease." Added to basic treatments under When covered section. Reference values for semen analysis removed from When covered section. When covered section clarified Artificial Means of Conception with "Artificial insemination (AI), Intrauterine Insemination (IUI), and/or In Vitro fertilization (IVF)." Added "thawing of cryopreserved embryos" and "Assisted hatching" to Artificial Menas of Conception in When covered section. Mechanically assisted fertilization (MAF) clarified to Intracytoplasmic Sperm Injection (ICSI) in When covered section. “Current American Society for Reproductive Medicine (ASRM) and Society for Assisted Reproductive Technology (SART) guidelines regarding limits to the number of embryos transferred should be followed. (see Policy Guidelines)” added to When covered section. Removed "Administration of letrozole" from When not covered section. When not covered section relating to In Vitro Fertilization (IVF) and services associated with IVF rewritten to include "Charges related to cryopreservation of reproductive tissue, including sperm and oocytes, are not covered under standard medical benefits or under infertility benefits unless otherwise stated in the member's benefit booklet." Policy Guidelines section updated. References added. Coding section updated. Medical Director review 2/2020. Notification given 2/11/2020 for effective date 4/14/2020.
Letermovir (Prevymis™) Dosing information added to Policy Guidelines for consistency with FDA label. Minor typographical edits made throughout policy for clarity. Specialty Matched Consultant Advisory Panel review 3/18/2020.
Mogamulizumab-kpkc (Poteligeo®) Specialty Matched Consultant Advisory Panel review 3/18/2020. No change to policy statement.
Oncologic Applications of Photodynamic Therapy, Including Barrett's Esophagus Specialty Matched Consultant Advisory Panel review 3/18/2020. No change to policy statements.
Teprotumumab-trbw (Tepezza™) New policy developed. Teprotumumab-trbw (Tepezza) may be considered medically necessary for the treatment of thyroid eye disease (TED) in adult patients (≥ 18 years of age) when specified medical criteria and guidelines are met. Added HCPCS codes C9399, J3490, and J3590 to Billing/Coding section. References added. Medical Director review 4/2020.