Medical Policy Updates

Blue Cross and Blue Shield of North Carolina Medical Policy Update April 6, 2021

Medical Guidelines Reason for Update
Breast Surgeries Updated Section IV – Risk-Reducing Mastectomy Policy Guidelines for clarity. No change to policy statement.
Bundling Guidelines Effective 4/15/2021. 36600 added for clarity to “Topics of Frequent Interest” section Specimen Collection. No change to policy intent. Pathologist section removed from policy, see related Professional Pathology Billing Guidelines policy.
CAR-T Therapy Added newly approved lisocabtagene maraleucel (Breyanzi) to policy to be considered medically necessary for the treatment of patients with relapsed or refractory large B-cell lymphoma, after two or more lines of system therapy, when specified medical criteria and guidelines are met. Updated Description and Policy Guidelines sections to include information relevant to lisocabtagene maraleucel. Added HCPCS codes C9399, J3490, J3590, and J9999 to Billing/Coding section for Breyanzi. Reference added.
Convection-Enhanced Delivery of Therapeutic Agents to the Brain Specialty Matched Consultant Advisory Panel review 3/17/2021. Reference added. No change to policy statement.
Cord Blood as a Source of Stem Cells Specialty Matched Consultant Advisory Panel review 3/17/2021.Updated Policy Guidelines section. Removed diagnosis codes from Billing/Coding section. Reference added. No change to policy statement.
Detection of Circulating Tumor Cells and Cell Free DNA in Cancer Management (Liquid Biopsy) AHS-G2054 Specialty Matched Consultant Advisory Panel review 3/17/2021. No change to policy statement.
DNA Ploidy Cell Cycle Analysis AHS – M2136 Specialty Matched Consultant Advisory Panel review 3/17/2021. No change to policy statement.
Flow Cytometry AHS–F2019 Specialty Matched Consultant Advisory Panel review 3/17/2021. No change to policy statement.
Gene Expression Testing for Breast Cancer Prognosis AHS - M2020 Specialty Matched Consultant Advisory Panel review 3/17/2021. No change to policy statement.
Genetic Testing and Genetic Expression Profiling in Patients with Cutaneous Melanoma AHS-M2029 Specialty Matched Consultant Advisory Panel review 3/17/2021. No change to policy statement.
Genetic Testing for Germline Mutations of the RET Proto-Oncogene AHS - M2078 Specialty Matched Consultant Advisory Panel review 3/17/2021. No change to policy statement.
Immune Cell Function Assay for Organ Transplant Rejection AHS-G2098 Specialty Matched Consultant Advisory Panel review 3/17/2021. No change to policy statement.
In Vitro Chemoresistance and Chemosensitivity Assays AHS- G2100 Specialty Matched Consultant Advisory Panel review 3/17/2021. No change to policy statement.
Injectable Clostridial Collagenase for Fibroproliferative Disorders Clarification added around dosing and administration for Peyronie’s disease. Edits made throughout policy for clarity. Added the following to “When Covered” section: “initial authorization will be limited to two treatment cycles, each cycle consisting of two Xiaflex injections and a penile modeling procedure. Subsequent authorization(s) for third and fourth treatment cycles may be given if the penile curvature deformity remains at greater than 15 degrees after the second treatment cycle.” Added the following to “When Not Covered” section: “Retreatment of the same penile plaque after a completed course of injectable clostridial collagenase for the treatment of Peyronie’s disease is considered investigational.” References added. Medical Director review 2/2021. Policy notification given 2/9/2021 for effective date 4/6/2021
Microarray-Based Gene Expression Profile Testing for Multiple Myeloma Risk Stratification AHS-B0002 Specialty Matched Consultant Advisory Panel review 3/17/2021.No change to policy statement.
Molecular Analysis for Gliomas AHS - M2139 Specialty Matched Consultant Advisory Panel review 3/17/2021. No change to policy statement.
Monoclonal Antibody Imaging for Prostate Cancer Specialty Matched Consultant Advisory Panel review 3/17/2021. Reference added. No change to policy statement.
Multigene Expression Assay for Predicting Colon Cancer Recurrence AHS-M2111 Specialty Matched Consultant Advisory Panel review 3/17/2021. No change to policy statement.
Oncologic Applications of Photodynamic Therapy, Including Barrett’s Esophagus Specialty Matched Consultant Advisory Panel review 3/17/2021. Reference added. No change to policy statement.
Pancreatic Cancer Risk Testing Using Molecular Classifier in Pancreatic Cyst Fluid AHS-M2114 Specialty Matched Consultant Advisory Panel review 3/17/2021. No change to policy statement.
Proteogenomic Testing of Individuals with Cancer AHS-M2168 Specialty Matched Consultant Advisory Panel review 3/17/2021. No change to policy statement.
Testing for Targeted Therapy of Non-Small-Cell Lung Cancer AHS - M2030 Specialty Matched Consultant Advisory Panel review 3/17/21. Revised “When Covered” section: “Testing for EGFR, BRAF, MET Exon 14 Skipping mutations, ALK, ROS1, and RET rearrangements is considered medically necessary for targeted therapy for advanced non-small-cell lung cancer (NSCLC) before systemic therapy initiation.” Medical Director review 3/2021.
Use of Common Genetic Variants to Predict Risk of Non-Familial Breast Cancer AHS-M2126 Specialty Matched Consultant Advisory Panel review 3/17/2021. No change to policy statement.