Medical Policy Updates

Medical Policy Update February 23, 2021

Medical Guidelines Reason for Update
Abdominoplasty, Panniculectomy and Lipectomy Related policy "Breast Surgeries" statement added to description for clarification. Policy and When not covered section regarding Lipectomy/liposuction updated for clarification. No change to policy statement
Botulinum Toxin Injection Updated indication for Botox for neurogenic detrusor overactivity in pediatric patients 5 years of age and older to be consistent with FDA labeling. Added the following indication to "When Covered" section: neurogenic detrusor overactivity (NDO) in pediatric patients 5 years of age or older who have an inadequate response to or are intolerant of an anticholinergic medication." Reference added.
Detection of Circulating Tumor Cells and Cell Free DNA in Cancer Management (Liquid Biopsy) AHS-G2054 Off cycle review. Under "When Covered" section: Added coverage criteria for additional mutations for NSCLC as well as use for breast cancer. Medical Director review 2/2021.
Lumasiran (Oxlumo™) New policy developed. Oxlumo is considered medically necessary for the treatment of primary hyperoxaluria type 1 (PH1) in pediatric and adult patients when specific medical criteria and guidelines are met. Added HCPCS codes C9399, J3490, and J3590 to Billing/Coding section. References added. Medical Director review 2/2021.
Maximum Units of Service Policy statement revised to read: BCBSNC will not provide reimbursement for claims with units that exceed the assigned maximum for that service. The total number of units will be adjusted to the maximum and the excess units will be denied. Statements in the Guidelines section revised for consistency in allowing up to maximum units without requiring provider to resubmit except for lab claims. Drug code max units added to Guidelines. Routine policy review. Medical Director approved 12/2020. Notification given 12/17/2020 for effective date 2/23/2021. (eel)
Pegloticase (Krystexxa®) Updated “When Covered” section to include the following under definition of inadequate response: "and/or presence of frequent gout flares [≥2 flares/year] or persistent unresolved subcutaneous tophi despite maximum therapeutic doses." Added the following to continuation criteria in "When Covered" section for clarity with no change to criteria intent: "or would have met initial criteria for coverage at the time of therapy initiation." Blue Cross NC Pharmacy and Therapeutics Committee 1/5/2021. Reference added. Medical Director review 2/2021.
Testing of Homocysteine Metabolism Related Conditions AHS – M2141 Reviewed by Avalon 4th Quarter CAB. Description, Policy Guidelines, and References updated. Coverage Criteria updated for clarity. No change to policy statement. Removed code 83621, added 83921. (bb)