Medical Policy Updates

Blue Cross and Blue Shield of North Carolina Medical Policy Update November 24, 2020

Medical Guidelines Reason for Update
Ablation and Neural Therapy Procedures for Headache and Pain Management Medical Director review. Policy title changed from Ablation Procedures for Peripheral Neuromas and Peripheral Nerves to Ablation and Neural Therapy Procedures for Headache and Pain Management. Description section updated. Related policies added. Policy statements updated for clarity. When Not Covered section updated for clarity. Policy Guidelines updated. Codes 64620, 64630, 64455, 64999 and 20999 added to Billing/Coding section. ICD-10 diagnosis codes added. Notification given 9/22/2020 for policy effective date 11/24/2020.
Ado-Trastuzumab Emtansine (Trastuzumab-DM1) for Treatment of HER-2 Positive Malignancies Minor typographical errors made for clarity. Reference added. Specialty Matched Consultant Advisory Panel review 8/2020. No change to policy intent..
Bundling Guidelines Added related policy Professional Pathology Billing Guidelines.
CAR-T Therapy Specialty Matched Consultant Advisory Panel review 8/2020. No change to policy intent.
Cochlear Implant Specialty Matched Consultant Advisory Panel review 2/11/2020. Reference added. Policy Guidelines updated. Policy statements updated to reflect expanded indications in children aged 9-12 months with profound bilateral sensorineural hearing loss. Specialty Matched Consultant Advisory Panel review 10/2/2020.
Eptinezumab-jjmr (VyeptiTM) Under "When Covered" section, added the following: “The patient has tried and had an inadequate response to both erenumab (Aimovig) AND galcanezumab (Emgality); OR The patient has a clinical contraindication or intolerance to both erenumab (Aimovig) AND galcanezumab (Emgality) that is not expected to occur with eptinezumab; AND”. Medical Director review 7/2020. Notification given 9/22/2020 for effective date 11/24/2020.
Added HCPCS code J3032 to Billing/Coding section effective 10/1/2020 and deleted codes C9063, C9399, J3490, J3590 termed 9/30/2020. Policy remains on notice for effective date 11/24/2020
Specialty Matched Consultant Advisory Panel review 10/21/2020. No change to policy intent.
Facet Joint Denervation Updated policy guidelines #4, #5 and #6 easing requirement to a single medial branch block / facet injection. When not covered section updated with "More than two facet injections/medial branch blocks at the same level are considered investigational." Notification 9/22/20 for effective date 11/24/20.
Injection Therapy for Headache (Migraine and Other) and Non-Spine Management Medical Director review. Policy title changed from Sphenopalatine Ganglion Block for Headache to Injection Therapy for Headache (Migraine and Other) and Non-Spine Management. Description section updated. Related Policies added. Policy statements updated for clarity. When Not Covered section updated for clarity. Policy Guidelines updated. Codes 20605, 20606, 20999, 64400, 64405, 64408, 64415, 64417, 64418, 64420, 64421, 64450, 64454, 64455, 64505, 64999 added to Billing/Coding section. ICD-10 diagnosis codes added. Notification given 9/22/2020 for policy effective date 11/24/2020.
Modifier Guidelines Policy guidelines updated with "*01960 and 01967 are considered non-timed procedures and therefore do not require a modifier." No change to policy statement.
PD-1 Inhibitors Added additional FDA approved indications to "When Covered" section. References added. Specialty Matched Consultant Advisory Panel review 8/2020.
PD-L1 Inhibitors New indications added to "When Covered" section according to updated FDA label. References added. Specialty Matched Consultant Advisory Panel review 8/2020.
Topotecan Hydrochloride (Hycamtin) Specialty Matched Consultant Advisory Panel review 8/2020. No change to policy intent.