Medical Policy Updates

Blue Cross and Blue Shield of North Carolina Medical Policy Update July 21, 2020

Medical Guidelines	Reason for Update
Aqueous Shunts and Devices for Glaucoma	Specialty Matched Consultant Advisory Panel review 6/17/2020. Updated Policy Guidelines section. Reference added. No change to policy statement.
Documentation Requirements for Treatment of End Stage Renal Disease	Corrected review dates in header.
Electrostimulation and Electromagnetic Therapy for Wounds	Reference added.
Esophageal Pathology Testing AHS – M2171	New policy developed. BCBSNC will provide coverage for esophageal pathology testing when it is determined to be medically necessary because the medical criteria and guidelines are met. Medical Director review 4/2020. Policy noticed 5/12/2020 for effective date 7/21/2020.
Glaucoma, Evaluation by Ophthalmologic Techniques	Specialty Matched Consultant Advisory Panel review 6/17/2020. Reference added. No change to policy statement.
Growth Factors in Wound Healing	References added. Policy Guidelines updated.
Implantable Cardioverter Defibrillator	Added last bullet when meeting medically necessary criteria as follows: “Diagnosis of cardiac sarcoid and considered to be at high risk for sudden cardiac death.” Policy guidelines updated. Added 0614T to the Billing/Coding section with effective date of 7/1/2020. References updated. Specialty Matched Consultant Advisory Panel review 6/2020. Medical Director review 6/2020.
MRI-guided Laser Interstitial Thermal Therapy for Neurological Indications	Medically necessary criteria added for brain tumors and radiation necrosis.
Non-Contact Ultrasound Treatment for Wounds	Reference added.
Onychomycosis Testing AHS – M2172	New policy developed. Reviewed by Avalon for 1st Quarter 2020 CAB. Medical Director review 4/2020. Policy noticed 5/12/2020 for effective date 7/21/2020.
Topical Negative Pressure Therapy for Wounds	Medically necessary criteria added for mechanical NPWT, with criteria. References added.