Medical Policy Updates

Blue Cross and Blue Shield of North Carolina Medical Policy Update June 9, 2020

Medical Guidelines Reason for Update
Abatacept (Orencia®) Referenced "Place of Service for Medical Infusions" as a related policy. Site of Care criteria added to Policy Guidelines.
Automated Percutaneous and Endoscopic Discectomy Specialty Matched Consultant Advisory Panel review 5/20/2020.
Beta Amyloid Imaging With Positron Emission Tomography for Alzheimer's Disease References updated. Specialty Matched Consultant Advisory Panel review 5/20/2020. No change to policy statement.
BioZorb® Specialty Matched Consultant Advisory Panel review 5/20/2020.No change to policy statement.
Brachytherapy, Intracavitary Balloon Catheter for Brain Cancer Specialty Matched Consultant Advisory Panel review 5/20/2020. Updated Description section. Reference added. No change to policy statement.
Brentuximab Vedotin (Adcetris®) Specialty Matched Consultant Advisory Panel review 4/15/2020. No change to policy statements.
Cabazitaxel (Jevtana®) Specialty Matched Consultant Advisory Panel review 4/15/2020. No change to policy statements.
Capsule Endoscopy, Wireless Specialty Matched Consultant Advisory Panel, 5/2020. Medical Director review, 5/2020.
Carfilzomib (Kyprolis®) Specialty Matched Consultant Advisory Panel review 4/15/2020. No change to policy statements.
Charged Particle Radiotherapy Specialty Matched Consultant Advisory Panel review 5/20/2020. No change to policy statement.
Chemoembolization of the Hepatic Artery, Transcatheter Approach Policy guidelines updated. References added. Specialty Matched Consultant Advisory Panel review 5/20/2020.
Cranial Electrotherapy Stimulation (CES) and Auricular Electrostimulation Reference added. Cervella device added to Regulatory Status section. Specialty Matched Consultant Advisory Panel review 5/20/2020.
CT Perfusion Imaging of the Brain References updated. Specialty Matched Consultant Advisory Panel review 5/20/2020. No change to policy statement.
Daratumumab (Darzalex®) Specialty Matched Consultant Advisory Panel review 4/15/2020. No change to policy statements.
Dopamine Transporter Imaging with Single Photon Emission Computed Tomography References updated. Specialty Matched Consultant Advisory Panel review 5/20/2020. No change to policy statement.
Electrogastrography, Cutaneous Specialty Matched Consultant Advisory Panel 5/2020. Medical Director review 5/2020.
Electronic Brachytherapy for Nonmelanoma Skin Cancer Specialty Matched Consultant Advisory Panel review 5/20/2020. Reference added. No change to policy statement.
Elotuzumab (Empliciti®) Reference added. Specialty Matched Consultant Advisory Panel review 4/15/2020. No change to policy statements.
Emapalumab-lzsg (Gamifant™) Specialty Matched Consultant Advisory Panel review 4/15/2020. No change to policy intent.
Endovascular Procedures for Intracranial Arterial Disease Reference added. Regulatory Status updated. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 5/20/2020.
Endovascular Therapies for Extracranial Vertebral Artery Disease Specialty Matched Consultant Advisory Panel review 5/20/2020.
Enteral Nutrition Specialty Matched Consultant Advisory Panel 5/2020. Medical Director review 5/2020.
Eptinezumab-jjmr (Vyepti™) Under "When Covered," added the following clarification to initial and continuation sections: "CGRP antagonist indicated for migraine prophylaxis" to clarify intent to allow for concomitant use of one CGRP indicated for acute migraine treatment and one CGRP indicated for migraine prophylaxis. Medical Director review 6/2020.
Eribulin Mesylate (Halaven®) Specialty Matched Consultant Advisory Panel review 4/15/2020. No change to policy statements
Esophageal pH Monitoring References updated. Specialty Matched Consultant Advisory Panel 5/2020. Medical Director review 5/2020.
Fam-Trastuzumab Deruxtecan-nxki (Enhertu®) Specialty Matched Consultant Advisory Panel review 4/15/2020. No change to policy statements.
Fecal Analysis in the Diagnosis of Intestinal Dysbiosis AHS – G2060 Related Policies section added. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 5/2020. Medical Director review 5/2020.
Gastric Electrical Stimulation Specialty Matched Consultant Advisory Panel 5/2020. Medical Director review 5/2020.
Helicobacter Pylori Testing AHS – G2044 Specialty Matched Consultant Advisory Panel review 5/2020. Medical Director review 5/2020.
Image-Guided Minimally Invasive Decompression (IG-MLD) for Spinal Stenosis Reference added. Specialty Matched Consultant Advisory Panel review 5/20/2020.
Immunopharmacologic Monitoring of Therapeutic Serum Antibodies AHS - G2105 Clarified language in change log entry dated 5/26/20. 80187 removed from Coding section.
Intensity Modulated Radiation Therapy for Tumors of the Central Nervous System Specialty Matched Consultant Advisory Panel review 5/20/20. Updated Regulatory Status. Reference added. No change to policy statement.
Intensity Modulated Radiation Therapy (IMRT) for Sarcoma of the Extremities Specialty Matched Consultant Advisory Panel review 5/20/2020. Reference added. No change to policy statement
Intensity Modulated Radiation Therapy (IMRT) of Abdomen and Pelvis Specialty Matched Consultant Advisory Panel review 5/20/2020. Reference added. No change to policy statement.
Intensity Modulated Radiation Therapy (IMRT) of Head and Neck Specialty Matched Consultant Advisory Panel review 5/20/2020. Reference added. No change to policy statement.
Intensity Modulated Radiation Therapy (IMRT) of the Chest Specialty Matched Consultant Advisory Panel review 5/20/2020. Reference added.No change to policy statement.
Intensity-Modulated Radiation Therapy (IMRT) of the Prostate Specialty Matched Consultant Advisory Panel review 5/20/2020. References added.No change to policy statement.
Interspinous Fixation (Fusion) Devices Reference added. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 5/20/2020.
Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers) Reference added. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 5/20/2020.
Laboratory Procedures Reimbursement Policy AHS - R2162 Revised final statement in the Guidelines section to read: If a procedure code that is assigned a maximum unit value is reported with a greater unit count, the claim line will be denied, and the provider will be responsible for resubmitting the claim only for the number of units up to but not exceeding the allowed maximum.
Lumbar Spine Fusion Surgery Specialty Matched Consultant Advisory Panel review 5/20/2020.
Magnetic Resonance Spectroscopy Reference added. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 5/20/2020. No change to policy statement.
Magnetoencephalography/Magnetic Source Imaging References added. Specialty Matched Consultant Advisory Panel review 5/20/2020. No change to policy statement.
Maximum Units of Service Policy statement revised to read: BCBSNC will not provide reimbursement for claims with units that exceed the assigned maximum for that procedure. If a procedure code that is assigned a maximum unit value is reported with a greater unit count, the claim line will be denied, and the provider will be responsible for resubmitting the claim only for the number of units up to but not exceeding the allowed maximum. Statements in the Guidelines section revised for consistency.
Melphalan Hydrochloride (Evomela) for Intravenous Use Specialty Matched Consultant Advisory Panel review 3/18/2020.
Monoclonal Antibodies for Non-Hodgkin Lymphoma and Acute Myeloid Leukemia In the Non-Hematopoietic Stem Cell Transplant Setting Specialty Matched Consultant Advisory Panel review 4/15/2020. No change to policy statements.
MRI-Guided Focused Ultrasound (MRgFUS) Specialty Matched Consultant Advisory Panel review 5/20/2020. No change to policy statement.
Myocardial Sympathetic Innervation Imaging Reference added. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 5/20/2020. No change to policy statement.
Occipital Nerve Stimulation Reference added. Specialty Matched Consultant Advisory Panel review 5/20/2020.
Paclitaxel (Abraxane®) Specialty Matched Consultant Advisory Panel review 4/15/2020. No change to policy statement.
Pancreas Transplant Refences updated. Specialty Matched Consultant Advisory Panel 5/2020. Medical Director review 5/2020.
Pancreatic Enzyme Testing for Acute Pancreatitis AHS – G2153 Specialty Matched Consultant Advisory Panel review 5/2020. Medical Director review 5/2020.
Pemetrexed (Alimta®) Specialty Matched Consultant Advisory Panel review 4/15/2020. No change to policy statement.
Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, and Biacuplasty Reference added. Policy guidelines updated. Specialty Matched Consultant Advisory Panel review 5/20/2020.
Peroral Endoscopic Myotomy for Treatment of Esophageal Achalasia Specialty Matched Consultant Advisory Panel 5/2020. Medical Director review¬ 5/2020.
Pertuzumab for Treatment of Malignancies Reference added. Specialty Matched Consultant Advisory Panel review 4/15/2020. No change to policy statements
Polatuzumab vedotin-piiq (Polivy™) Specialty Matched Consultant Advisory Panel review 4/15/2020. No change to policy statements.
Positional Magnetic Resonance Imaging (MRI) Reference added. Specialty Matched Consultant Advisory Panel review 5/20/2020. No change in policy statement.
Radioembolization for Primary and Metastatic Tumors of the Liver Specialty Matched Consultant Advisory Panel review 5/20/2020. Reference added. No change to policy statement.
Radiosurgery, Stereotactic Approach Specialty Matched Consultant Advisory Panel review 5/20/2020. Reference added. No change to policy statement.
Ravulizumab-cwvz (Ultomiris™) Added dosing and clinical trial information for aHUS indication in Policy Guidelines section. Specialty Matched Consultant Advisory Panel review 4/15/2020.
Sacroiliac Joint Fusion/Stabilization Reference added. Clinical Trials information updated. Specialty Matched Consultant Advisory Panel review 5/20/2020.
Screening for Vertebral Fracture with Dual X-ray Absorptiometry (DXA) Reference added. Specialty Matched Consultant Advisory Panel review 5/20/2020. No change to policy statement.
Serum Testing for Hepatic Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease AHS – G2110 Specialty Matched Consultant Advisory Panel review 5/2020. Medical Director review 5/2020.
Siltuximab (Sylvant®) Specialty Matched Consultant Advisory Panel review 4/15/2020. No change to policy statement.
Small Bowel, Small Bowel with Liver, or Multivisceral Transplant Specialty Matched Consultant Advisory Panel 5/2020. Medical Director review 5/2020.
Surgical Deactivation of Headache Trigger Sites Reference added. Biofeedback removed from list of Related Policies. Specialty Matched Consultant Advisory Panel review 5/20/2020.
Tagraxofusp-erzs (Elzonris™) Specialty Matched Consultant Advisory Panel review 4/15/2020. No change to policy intent.
TENS (Transcutaneous Electrical Nerve Stimulator) Reference added. Specialty Matched Consultant Advisory Panel review 4/15/2020. No change to policy statement.
Vagus Nerve Stimulation Reference added. Description section updated. Policy Guidelines updated. Policy statement unchanged. Specialty Matched Consultant Advisory Panel review 5/20/2020.