Medical Policy Updates

Blue Cross and Blue Shield of North Carolina Medical Policy Update April 28, 2020

Medical Guidelines Reason for Update
Bronchial Thermoplasty Description, Policy Guidelines and References updated. Specialty Matched Consultant Advisory Panel review 3/31/2020. No change to policy statement.
Cardiac Biomarkers for Myocardial Infarction AHS – G2150 Specialty Matched Consultant Advisory Panel review 4/2020. Medical Director review 4/2020.
Denosumab (ProliaTM, XGEVATM) Updated structure of policy statements in "When Covered" section for clarity and consistency with FDA label. No change to policy intent. Reference added. Medical Director review 4/2020.
Diagnosis and Treatment of Sacroiliac Joint Pain References added. Policy guidelines updated. No change to policy statement. Specialty Matched Consultant Advisory Panel review 4/15/2020.
Electromagnetic Navigation Bronchoscopy Specialty Matched Consultant Advisory Panel review 3/31/2020. Policy guidelines updated. No change to policy statement.
Endobronchial Valves Description, Policy Guidelines and References updated. Specialty Matched Consultant Advisory Panel review 3/31/2020. No change to policy statement.
Epidural Steroid Injections for Back Pain References added. Societal guidelines added to Policy guidelines section. Clarification of fluoroscopic guidance as "live" and "(video type x-ray pictures of the epidural space)" added to When covered section. Clarification of fluorography as "still image" and "(snapshot x-ray pictures of the epidural space)" added to When not covered section. Added clarification for substantial relief to When not covered section "(i.e. at least 50% reduction of pain with overall improvement of activities of daily living and/or walking)." Clarification added to When covered section injection limits "regardless of spine level treated or procedural approach.: When covered statement for persistent pain clarified with "(i.e. documented limits in day to day activities and/or walking)." Specialty Matched Consultant Advisory Panel review 4/15/2020. No change to policy statement.
Facet Joint Denervation References added. Specialty Matched Consultant Advisory Panel review 4/15/2020. No change to policy statement.
Genetic Testing for Inherited Cardiomyopathies and Channelopathies AHS – M2025 Specialty Matched Consultant Advisory Panel review 4/2020. Medical Director review 4/2020.
Genetic Testing for Lipoprotein A Variant(s) as a Decision Aid for Aspirin Treatment and/or CVD Risk Assessment AHS – M2082 Specialty Matched Consultant Advisory Panel review 4/2020. Medical Director review 4/2020.
Hemodialysis Treatment for ESRD Specialty Matched Consultant Advisory Panel review 4/2020. Medical Director review 4/2020.
Intradialytic Parenteral Nutrition Specialty Matched Consultant Advisory Panel review 4/2020. Medical Director review 4/2020.
Intravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric Disorders References added. Policy guidelines updated. Specialty Matched Consultant Advisory Panel review 4/15/2020. Policy statement updated to include psychiatric disorders to reflect existing when not covered statement. Policy title changed from "Intravenous Anesthetics for the Treatment of Chronic Pain" to "Intravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric Disorders."
Lipid Apheresis Specialty Matched Consultant Advisory Panel review 4/2020. Medical Director review 4/2020.
Lung and Lobar Lung Transplantation References added. Specialty Matched Consultant Advisory Panel review 3/31/2020. No change to policy statement.
Lung Volume Reduction Surgery Policy Guidelines, Coding and References updated. Specialty Matched Consultant Advisory Panel review 3/31/2020. No change to policy statement.
Lysis of Epidural Adhesions References added. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 4/15/2020. No change to policy statement.
Molecular Testing of Bronchial Brushings AHS - M2160 Specialty Matched Consultant Advisory Panel 3/31/2020. No change to policy statement.
Neural Therapy References added. Specialty Matched Consultant Advisory Panel review 4/15/2020. No change to policy statement.
Oscillatory Devices for the Treatment of Respiratory Conditions Description and References updated. Criteria moved from Policy Guidelines to When Covered section for clarity. No change to intent or coverage. Specialty Matched Consultant Advisory Panel review 3/31/2020.
Phrenic Nerve Stimulation for Central Sleep Apnea References updated. Specialty Matched Consultant Advisory Panel 3/31/2020. No changes to policy statement.
Prolotherapy References added. No change to policy statement. Specialty Matched Consultant Advisory Panel review 4/15/2020.
Radiofrequency Ablation of the Renal Nerves as a Treatment of Hypertension Specialty Matched Consultant Advisory Panel review 4/2020. Medical Director review 4/2020.
Renal (Kidney) Transplantation Specialty Matched Consultant Advisory Panel review 4/2020. Medical Director review 4/2020.
ST2 Assay for Chronic Heart Failure AHS – G2130 Specialty Matched Consultant Advisory Panel review 4/2020. Medical Director review 4/2020.
Teprotumumab-trbw (TepezzaTM) Under "When Covered" section, the following typographical clarification made to criterion #9: "compensation" updated to "decompensation".
Transplant Rejection Testing AHS – M2091 Specialty Matched Consultant Advisory Panel review 4/2020. Medical Director review 4/2020.