Medical Policy Updates

Medical Policy Update for July 16, 2019

Medical Guidelines Reason for Update
Aqueous Shunts and Devices for Glaucoma Specialty Matched Consultant Advisory Panel review 6/17/2019. Updated description section. No change to policy statement. Medical director review 6/2019.
Artificial Pancreas Device Systems Description Section revised to include new devices. Coverage criteria revised to change age from 16 to 14 and definition of nocturnal hypoglycemia removed. Statement added to Non-Covered criteria: Use of an automated insulin delivery system (artificial pancreas device system) not approved by the FDA is investigational. Policy Guidelines updated and reference added. Specialty Matched Consultant Advisory Panel review 6/19/2019.
BRCA Reviewed by Avalon 1st Quarter 2019 CAB. Extensive revisions under When Covered section regarding personal and family history of cancer based on updated NCCN guidelines. Removed wording "Individual has a third-degree relative with breast cancer and/or ovarian carcinoma…" from the criteria on testing for individuals without cancer. Under When Not Covered section, added Notes 1-4. Reordered the notes for clarity, added Note 1 concerning ovarian cancer excluding germline tumors, and added a Note 4 concerning what tools are recommended by the USPSTF for clarity. Medical Director review 5/2019. Notification given 5/14/19 for effective date 7/16/19.
Burosumab-twza (Crysvita®) Specialty Matched Consultant Advisory Panel review 6/19/2019. No change to policy intent.
Cemiplimab-rwlc (Libtayo®) New policy developed. Libtayo is considered medically necessary for the treatment of adult patients (≥ years old) with cutaneous squamous cell carcinoma (CSCC). Added HCPCS codes C9044, J3490, J3590, J9999, S0353, and S0354 to Billing/Coding section. References added. Medical Director review 4/2019. Policy notification given 4/16/19 for effective date 7/16/19.
Computerized Corneal Topography Specialty Matched Consultant Advisory Panel review 6/19/19. Reference added. No change to policy statement. Medical Director review 6/2019.
Continuous Monitoring of Glucose in the Interstitial Fluid Description Section updated. Minor changes to Covered and Non-Covered Sections for clarity. No change to medical criteria. Policy Guidelines updated. References added. Specialty Matched Consultant Advisory Panel review 6/19/2019.
Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate, or Dermatologic Tumors Specialty Matched Consultant Advisory Panel review 6/28/2019.
Cryosurgical Ablation of Primary or Metastatic Liver Tumors Specialty Matched Consultant Advisory Panel review 6/28/2019.
Decompression of the Intervertebral Disc Using Laser Energy (Laser Discectomy) or Radiofrequency Coblation (Nucleoplasty) Reference added.
Diagnosis of Vaginitis including Multi-target PCR Testing Reviewed by Avalon 1st Quarter 2019 CAB. "Using molecular-based panel testing, including, but not limited to testing such as SmartJaneTM , to test for microorganisms involved in vaginal flora imbalance and/or infertility is considered investigational" was added to list of NonCovered indications. Policy Guidelines updated. Codes 87905 and 0068U added to Billing/Coding section. References added. Medical Director review 4/2019. Policy noticed 5/14/2019 for effective date 7/16/2019.
Endothelial Keratoplasty Specialty Matched Consultant Advisory Panel review 6/19/2019. Reference added. No change to policy statement.
Endovascular Therapies for Extracranial Vertebral Artery Disease Reference added.
Epiretinal Radiation Therapy for Age-Related Macular Degeneration Specialty Matched Consultant Advisory Panel review 6/19/2019. Reference added. No change to policy statement
Evaluation of Dry Eyes Reviewed by Avalon 1st Quarter 2019 CAB. Added additional investigational criteria: Testing for lactoferrin and/or IgE to aid in the diagnosis of patients suspected of having dry eye disease is considered investigational and all other testing used in the diagnosis of patients suspected of having dry eye disease is considered investigational. Added the following CPT codes to "Billing/Coding" section: 82785, 83520, 83861. Medical Director review 5/2019. Policy noticed 5/14/19 for effective date 7/16/19.Specialty Matched Consultant Advisory Panel review 6/19/19. No change to policy statement. Medical Director review 6/2019
Eyelid Thermal Pulsation for the Treatment of Dry Eye Syndrome Updated Description and Policy Guidelines sections. Specialty Matched Consultant Advisory Panel review 6/19/2019. Reference added. No change to policy statement.
Fundus Photography Specialty Matched Consultant Advisory Panel review 6/19/2019. No change to policy statement.
Gender Confirmation Surgery and Hormone Therapy Specialty Matched Consultant Advisory Panel review 6/28/2019.
Gene Expression Profiling for Uveal Melanoma Specialty Matched Consultant Advisory Panel review 6/19/2019. No change to policy statement.
General Genetic Testing, Germline Disorders Reviewed by Avalon 1st Quarter 2019 CAB. Related Policies added to Description section. Added item 3 and Note 1 to the When Covered sections as follows: "Germline multi-gene panel testing (See Note 1), defined as multiple gene tests for a medical condition or symptoms/non-specific presentation run on one testing platform, is considered medically necessary according to the guidelines in the preceding coverage criteria and the reimbursement limitations (see section regarding Reimbursement below). Note 1: For references regarding the clinical application of genomic sequencing and for appropriate medical coding, please refer to (ACMG, 2012; AMA, 2019)." Policy guidelines extensively revised. The following revisions were made to the Billing/Coding section: codes 81329, 81333, and 81336 were removed, code 81442 was added along with the reimbursement information. Medical Director review 5/2019. Policy noticed 5/14/19, for effective date 7/16/19.
Genetic Testing for Macular Degeneration Specialty Matched Consultant Advisory Panel review 6/19/2019. No change to policy statement.
Glaucoma, Evaluation by Ophthalmologic Techniques Specialty Matched Consultant Advisory Panel review 6/19/2019. Reference added. Removed the following paragraph in "When Covered" section: Factors defining individuals at high risk for developing glaucoma include any of the following:African Americans over 40 years old; Caucasians over 65 years old; Family history of glaucoma; Diabetes. Medical Director review 7/2019.
Implantation of Intrastromal Corneal Ring Segments Specialty Matched Consultant Advisory Panel review 6/19/2019. Reference added. No change to policy statement.
Insulin Therapy, Chronic Intermittent Intravenous (CIIIT) Policy Guidelines updated. References added. Specialty Matched Consultant Advisory Panel review meeting 6/19/2019.
Intravitreal Implant Specialty Matched Consultant Advisory Panel review 6/19/2019. No change to policy statements.
Islet Cell Transplantation Specialty Matched Consultant Advisory Panel 6/19/19.
Keratoprosthesis Specialty Matched Consultant Advisory Panel review 6/19/2019. Reference added. No change to policy statement.
Liver Transplant and Combined Liver-Kidney Transplant Specialty Matched Consultant Advisory Panel 6/28/2019.
Opioid Testing in Pain Management and Substance Abuse Policy archived. Refer to policy titled "Prescription Medication and Illicit Drug Testing in the Outpatient Setting."
Optical Coherence Tomography (OCT) Anterior Segment of the Eye Specialty Matched Consultant Advisory Panel review 6/19/2019. Reference added. No change to policy statement.
Parathyroid Hormone, Phosphorus, Calcium, and Magnesium Testing New policy developed. BCBSNC will provide coverage for Parathyroid Hormone, Phosphorus, Calcium, and Magnesium Testing when it is determined to be medically necessary because the medical criteria and guidelines are met. Medical Director review 4/1/2019. Policy noticed 5/14/2019 for effective date 7/16/2019.
Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers Reference added. Specialty Matched Consultant Advisory Panel review 6/28/2019.
Prescription Medication and Illicit Drug Testing in the Outpatient Setting New policy developed that replaces policy titled "Opioid Testing in Pain Management and substance Abuse". BCBSNC will provide coverage for prescription medication and illicit drug testing in the outpatient setting when it is determined to be medically necessary because the medical criteria and guidelines are met. Medical Director review 4/1/2019. Policy noticed 5/14/2019 for effective date 7/16/2019.
Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors Specialty Matched Consultant Advisory Panel review 6/28/2019.
Refractive Surgery Specialty Matched Consultant Advisory Panel review 6/19/2019. Reference added. No change to policy statement.
Retinal Prosthesis Updated Description section. Reference added. Specialty Matched Consultant Advisory Panel review 6/19/2019. No change to policy statement. Medical Director review 6/2019.
Sacral Nerve Neuromodulation/Stimulation for Pelvic Floor Dysfunction Reference added.
Salivary Hormone Testing Reviewed by Avalon 1st Quarter 2019 CAB. Minor changes to Description Section. Revised NonCovered statement to read: "Salivary hormone testing for the screening, diagnosis, and/or monitoring of menopause, infertility, endometriosis, polycystic ovary disease (PCOS), premenstrual syndrome, osteoporosis, sexual dysfunction, seasonal affective disorder, depression, multiple sclerosis, sleep disorders, or diseases related to aging is considered not medically necessary." Added Cortisol to list of NonCovered tests. Policy Guidelines section and References updated. Medical Director review 4/2019. Policy noticed 5/14/2019 for effective date 7/16/2019.
Somatostatin Analogs Added the following indication as medically necessary for Signifor LAR: The treatment of patients with Cushing's disease for whom pituitary surgery is not an option or has not been curative. Updated Description and Policy Guideline sections to reflect addition of new indication. References added. Specialty Matched Consultant Advisory Panel review 6/19/2019. Medical Director review 6/2019.
Thyroid Disease Testing Reviewed by Avalon 4th Quarter 2019 CAB. Added "Individuals with chronic or acute urticaria" to the list of Covered Indications. Added " Testing for thyroid dysfunction in asymptomatic nonpregnant individuals for thyroid disease is considered not medically necessary during general exam without abnormal findings" to list of NonCovered Indications. Updated Policy Guidelines section and References. Medical Director review 4/2019. Policy noticed 5/14/2019 for effective date July 16, 2019.
Topical Negative Pressure Therapy for Wounds Specialty Matched Consultant Advisory Panel review 6/28/2019.
Treatment for Severe Primary IGF-1 Deficiency Specialty Matched Consultant Advisory Panel review 6/19/2019. No change to policy statements.
Vestibular Function Testing Specialty Matched Consultant Advisory Panel review 2/20/2019. Reference added.
Viscocanalostomy and Canaloplasty Specialty Matched Consultant Advisory Panel review 6/19/2019. Reference added. Updated description section. No change to policy statement. Medical Director review 6/2019.
Voretigene Neparvovec-rzyl (LuxturnaTM) Added Luxturna dosing and administration information within Policy Guidelines. Reference added. Specialty Matched Consultant Advisory Panel review 6/19/2019.a No change to policy intent.
Wearable Cardioverter Defibrillators When Covered section revised under items I and II and added the following under "*" for clarification: "-Use of a WCD after a myocardial infarction (MI) without revascularization will be covered for 40 days from the initial diagnosis. -Use of a WCD for newly diagnosed non-ischemic dilated cardiomyopathy or for secondary cardiomyopathy that is potentially reversible will be covered for 90 days from the time of diagnosis during guideline-directed medical therapy. -Use of a WCD after revascularization, to include after an MI, will be covered for 90 days after the procedure." Medical Director review 7/2019.