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. |