Medical Policy Updates

Blue Cross and Blue Shield of North Carolina Medical Policy Update August 25, 2020

Medical Guidelines Reason for Update
Artificial Intervertebral Disc References added. Change in terminology from 'artificial intervertebral disc arthroplasty of the cervical spine' to 'cervical disc arthroplasty' throughout policy.
Balloon Ostial Dilation (Balloon Sinuplasty) Medical Director review. Added mucocele to when not covered section. Updated Wegener's granulomatosis to more current name of Granulomatosis with polyangiitis (GPA).
Bariatric Surgery Medical Director review. Updated Policy Guideline #4 for consistency with established 2019 Clinical Practice Guidelines for the Perioperative Nutrition, Metabolic, and Nonsurgical Support of Patients Undergoing Bariatric Procedures.
Bioimpedance Devices for Detection of Lymphedema Reference added. Description section updated. Related policy added. Policy Guidelines updated.
Decompression of the Intervertebral Disc Using Laser Energy (Laser Discectomy) or Radiofrequency Coblation (Nucleoplasty) Reference added.
Dynamic Posturography Reference added.
Gender Confirmation Surgery and Hormone Therapy Medical Director review. Provider Documentation Criteria updated to include "licensed" behavioral health professional, and "with established competence and clinical expertise in the assessment and treatment of gender dysphoria".
Handheld Radiofrequency Spectroscopy for Intraoperative Assessment of Surgical Margins during Breast-Conserving Surgery Reference added.
Microprocessor-Controlled Prostheses for the Lower Limb Reference added.
Pharmacogenetics Testing AHS – M2021 Specialty Matched Consultant Advisory Panel review 7/2020. Medical Director review 7/2020.
Sacral Nerve Neuromodulation/Stimulation for Pelvic Floor Dysfunction Reference added. Expired code 95973 removed from Billing/Coding section.
Semi-Implantable and Fully Implantable Middle Ear Hearing Aid Reference added.
Spinal Cord and Dorsal Root Ganglion Stimulation Reference added.
Subtalar Arthroereisis Reference added.
Topical Negative Pressure Therapy for Wounds Medical Director review. Added "One week of negative pressure wound therapy (NPWT) is considered medically necessary as part of the post-operative care for patients who receive split thickness skin grafting (STSG)" to the When Covered section.
Total Facet Arthroplasty Reference added.