Medical Policy Updates

Blue Cross and Blue Shield of North Carolina Medical Policy Update April 27, 2018

Medical Guidelines Reason for Update
Ablation Procedures for Peripheral Neuromas and Peripheral Nerves Specialty Matched Consultant Advisory Panel review 2/28/2018.
Allogeneic Hematopoietic Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms Specialty Matched Consultant Advisory Panel review 3/28/2018. Reference added. No change to policy statement
CAR-T Therapy Removed the following criterion from "When Covered" section for both Kymriah and Yescarta coverage: "The prescriber will submit documentation of response within 3 months following therapy as a follow up to the prior approval request." Added the following to "Policy Guidelines" section: "Longitudinal follow up of individual member's treatment outcomes may be needed to verify effectiveness of therapy and the necessity for additional treatment. The various methods used to achieve this may include case management services, clinical registry data collection, evaluation of clinical trial eligibility, and/or requests for medical records." Other minor updates made to organization and wording of "Policy Guidelines" section for clarity. Removed codes C9399 and J3590 from Billing/Coding section, and added code descriptions for codes Q2040 and Q2041. References added. Medical Director review 4/2018.
Chromosomal Microarray Analysis for the Evaluation of Pregnancy Loss Deleted information regarding Natera products and code 88271 from the Billing/Coding section. Specialty Matched Consultant Advisory Panel review 3/28/2018. No change to policy statement
Electronic Brachytherapy for Nonmelanoma Skin Cancer Specialty Matched Consultant Advisory Panel review 3/28/2018. No change to policy statement.
Exhaled Nitric Oxide Measurement Specialty Matched Consultant Panel review 3/28/2018. No change to policy statement. Medical Director review.
Hormone Pellet Implantation for Treatment of Menopause Related Symptoms ICD-9 codes removed from Billing/Coding section. Diagnosis codes E28.310 and E28.29 added. Specialty Matched Consultant Advisory Panel review 3/28/18. No change to policy statement.
Injectable Clostridial Collagenase for Fibroproliferative Disorders Specialty Matched Consultant Advisory Panel (Orthopedics) review 2/28/2018.
Invasive Prenatal (Fetal) Diagnostic Testing Description and Policy Guidelines sections updated. References added. Specialty Matched Consultant Advisory Panel review 3/28/2018. No change to policy statement.
Ipilimumab (Yervoy) Added the following indications to "When Covered" section: "As subsequent therapy in combination with nivolumab (Opdivo) for patients with small cell lung cancer who have relapsed 6 months or less after primary therapy (NCCN 2A); OR As treatment of patients with intermediate or poor risk, previously untreated advanced renal cell carcinoma, in combination with nivolumab (Opdivo); AND". Updated "Policy Guidelines" section to include additional dosing recommendations. Minor typographical changes made to "Description of Procedure or Service" section. Added references. Specialty Matched Consultant Advisory Panel review 3/28/18.
Maternal and Fetal Diagnostics Specialty Matched Consultant Advisory Panel review 3/28/2018. No change to policy statement.
Maximum Units of Service Gradient compression stockings (A6530 – A6549) are limited to 6 pair per year. Notification given 2/23/2018 for effective date 4/27/2018.
Measurement of Serum Antibodies to Infliximab, Adalimumab and Vedolizumab Updated Description section to correctly define vedolizumab as an integrin receptor antagonist for clarity. Reference added. No change to policy intent.
Melphalan Hydrochloride (Evomela) for Intravenous Use Specialty Matched Consultant Advisory Panel review 3/2018. No change to policy intent.
Microarray-Based Gene Expression Profile Testing for Multiple Myeloma Risk Stratification Specialty Matched Consultant Advisory Panel review 3/28/2018. No change to policy statement.
Microprocessor-Controlled Prostheses for the Lower Limb Specialty Matched Consultant Advisory Panel review 2/28/2018.
Moderate Penetrance Variants Associated with Breast Cancer in Individuals at High Risk Specialty Matched Consultant Advisory Panel review 3/28/2018. No change to policy statement.
Modifier Guidelines Correction for codes related to Modifier AX. Correct codes are J0604 and J0606.
Orthotics Specialty Matched Consultant Advisory Panel review 2/28/2018.
Ovarian and Internal Iliac Vein Embolization Updated Description section. Deleted ICD-9 codes from Billing/Coding section. Reference added. Specialty Matched Consultant Advisory Panel review meeting 3/28/2018. No change to policy statement.
PathFinderTG® Molecular Testing Specialty Matched Consultant Advisory Panel review 3/28/2018. No change to policy statement.
PD-1 Inhibitors Under "When Covered" section for Pembrolizumab (Keytruda): Added additional covered indication: "4) The patient has metastatic nonsquamous non-small cell lung cancer (NSCLC) and is receiving pembrolizumab (Keytruda) as first-line treatment, in combination with pemetrexed and carboplatin; OR". Under "When Covered" section for Nivolumab (Opdivo): Added additional covered indications: "4) The patient has small cell lung cancer with relapse 6 months or less after primary therapy and is receiving nivolumab (Opdivo) as subsequent systemic therapy, alone or in combination with ipilimumab (NCCN 2A); OR" and "6) The patient has intermediate or poor risk, previously untreated advanced renal cell carcinoma and is receiving nivolumab (Opdivo) in combination with ipilimumab (Yervoy); OR". References added.
Progesterone Therapy in High Risk Pregnancies Specialty Matched Consultant Advisory Panel review 3/28/2018. No change to policy statement.
Proteogenomic Testing for Patients with Cancer (GPS CancerTM Test) Specialty Matched Consultant Advisory Panel review 3/28/2018. No change to policy statement. Medical Director review.
Proteomics-based Testing Related to Ovarian Cancer Revised Description section and Policy Guidelines. References added. Specialty Matched Consultant Advisory Panel review 3/28/2018. No change to policy statement.
Quantitative Assay for Measurement of HER2 Total Protein Expression and HER2 Dimers Specialty Matched Consultant Advisory Panel review 3/28/2018. No change to policy statement.
Salivary Hormone Tests Additional investigational tests added to the "When Not Covered" section for clarity. Added code S3652 to Billing/Coding section. Specialty Matched Consultant Advisory Panel review 3/28/2018. No change to policy intent.
Subtalar Arthroereisis Specialty Matched Consultant Advisory Panel review 2/28/2018.
Surgery for Groin Pain in Athletes Reference added.
Tocilizumab (Actemra) Updated the following statement in "When Not Covered" section from "when used for patients with" to "when used for patients who at initiation have" for clarity. Reference added. Specialty Matched Consultant Advisory Panel review 2/28/18. No change to policy intent.
Trastuzumab Specialty Matched Consultant Advisory Panel review 3/2018. No change to policy intent.
Ultrasound Accelerated Fracture Healing Device Specialty Matched Consultant Advisory Panel review 2/28/2018.