Medical Policy Updates

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

Medical Guidelines Reason for Update
Abdominoplasty, Panniculectomy and Lipectomy When Covered section updated from dermatitis to persistent dermatitis. Reworded weight loss statement for clarity in When Covered section with no change to policy statement intent.
Artificial Pancreas Device Systems References added. Added A4226 and E0787 to Coding section. Policy Guideline and Description updated. Specialty Matched Consultant Advisory Panel review 6/17/2020. When covered criteria statement added for coverage of hybrid closed-loop system.
Balloon Ostial Dilation (Balloon Sinuplasty) New policy developed. Balloon ostial dilation is considered medically necessary with criteria. Policy noticed 5/12/2020 for policy effective date 7/14/2020.
Bundling Guidelines Added to Description section, item D: global surgery guidelines also apply to facility claims. Added Outpatient Code Editor (OCE) Edits to Related Policies section. Notification given 5/12/2020 for effective date 7/14/2020.
Burosumab-twza (Crysvita®) Updated "Description" and "When Covered" sections with indication expanded to XLH in pediatric patients 6 months of age and older. Reference added. Specialty Matched Consultant Advisory Panel review 6/17/2020.
Continuous Monitoring of Glucose in the Interstitial Fluid References updated. Specialty Matched Consultant Advisory Panel review 6/17/2020. No change to policy statement.
Dopamine Transporter Imaging with Single Photon Emission Computed Tomography Medical Director review, policy archived.
Hormonal Testing in Females AHS - G2161 References updated. Specialty Matched Consultant Advisory Panel review 06/17/2020. No changes to policy statement.
Hormonal Testing in Males AHS - G2013 References updated. Specialty Matched Consultant Advisory Panel review 6/17/2020. No changes to policy.
Insulin Therapy, Chronic Intermittent Intravenous (CIIIT) References added. Description and Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 6/17/2020.
Intravitreal Implant Added clinical trial evidence summary in Policy Guidelines for Yutiq. Minor typographical edits made. Reference added. Specialty Matched Consultant Advisory Panel review 6/17/2020.
Islet Cell Transplantation Specialty Matched Consultant Advisory Panel review 6/17/20. References added. Policy Guidelines updated. No change to policy statement.
Laparoscopic and Percutaneous Techniques for the Myolysis of Uterine Fibroids Corrected grammatical and spelling errors. Added Sonata statement for clarity in When not covered section. Description section updated. Added 0404T to coding section.
Magnetic Resonance Imaging (MRI) Targeted Biopsy of the Prostate References updated. Specialty Matched Consultant Advisory Panel review 5/20/2020. Medical Director review, policy archived.
Outpatient Code Editor (OCE) Edits Updated description section to include global surgical package description. Added reference to Bundling Guidelines policy. Statement added to Policy Guidelines section: Evaluation and Management services during the global surgical period that are related to the surgical procedure are not eligible for separate reimbursement. Global surgery edits apply to professional and facility claims. Notification given 5/12/2020 for effective date 7/14/2020.
Parathyroid Hormone, Phosphorus, Calcium, and Magnesium Testing AHS – G2164 References updated. Specialty Matched Consultant Advisory Panel review 6/17/2020. No change to policy statement.
Percutaneous Intradiscal and Intraosseous Radiofrequency Procedures of the Spine References added. Regulatory Status updated. Intraosseous radiofrequency ablation of the basivertebral nerve (e.g., Intracept® system) for the treatment of vertebrogenic back pain added to When Not Covered section. Policy Guidelines updated. Code 22899 added to Billing/Coding section. Title changed from Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, and Biacuplasty to "Percutaneous Intradiscal and Intraosseous Radiofrequency Procedures of the Spine". Medical Director review.
Somatostatin Analogs Specialty Matched Consultant Advisory Panel review 6/17/2020. No change to policy statements.
Surgical Treatment of Sinus Disease Medical Director review. Criteria for balloon ostial dilation (BOD) moved to a separate medical policy. Silent sinus syndrome and antrochoanal polyps added to list of covered indication.
Thyroid Disease Testing AHS – G2045 References updated. Specialty Matched Consultant Advisory Panel review 06/17/2020. No change to policy statement.
Treatment for Severe Primary IGF-1 Deficiency Specialty Matched Consultant Advisory Panel review 6/17/2020. No change to policy statements.
Voretigene Neparvovec-rzyl (Luxturna®) Minor typographical changes made throughout policy for clarity. Reference added. Specialty Matched Consultant Advisory Panel review 6/17/2020.