Medical Policy Updates

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Medical Policy Update for October 15, 2019

Medical Guidelines Reason for Update
Children's Mobility and Positioning Equipment Specialty Matched Consultant Advisory Panel review 9/2019. Medical Director review 9/2019. 
Chiropractic Services Specialty Matched Consultant Advisory Panel 9/2019. Medical Director review 9/2019.
Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate, or Dermatologic Tumors Reference added. 
Dry Needling of Myofascial Trigger Points References updated. Specialty Matched Consultant Advisory Panel review 09/2019. Medical Director review 09/2019.
Durable Medical Equipment (DME) Specialty Matched Consultant Advisory Panel 9/2019. Medical Director review 9/2019.
Eculizumab (Soliris®)   Updated Description section, Policy Statement, and Policy Guidelines with indication of eculizumab (Soliris) for adults with neuromyelitis optica spectrum disorder (NMOSD) who are anti-aquaporin-4 (AQP4) antibody positive. References added. Medical Director review 10/2019.
Functional Capacity Assessment and Work Hardening Specialty Matched Consultant Advisory Panel 9/2019.  Medical Director review 9/2019.
Genetic Cancer Susceptibility Panels Using Next Generation Sequencing AHS - M2066 Reviewed by Avalon 2nd Quarter 2019 CAB. Deleted coding table from Billing/Coding section and deleted PLA code 0104U per October 1, 2019 code update. Medical Director review 8/2019.
Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence Reference added. 
Intensity-Modulated Radiation Therapy (IMRT) of the Prostate Under "When Covered" section added policy statement "IMRT to the prostate for definitive therapy of low-burden metastatic prostate cancer is considered medically necessary" with criteria. Medical Director review 10/2019. References added.
Investigational (Experimental) Services - B0005 Removed Avalon tag "AHS" from policy name to clarify this is a BCBSNC policy that applies to all medical coverage policies.
Laparoscopic and Percutaneous Techniques for the Myolysis of Uterine Fibroids Specialty Matched Consultant Advisory Panel review 9/18/2019. No change to policy statement. 
Patient Lifts    Specialty Matched Consultant Advisory Panel review 9/2019. Medical Director review 9/2019.
Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence Reference added. 
Pressure Reducing Support Surfaces The following code was removed from the Billing/Coding section effective 10/1/19, E0194. Specialty Matched Consultant Advisory Panel 9/2019.  Medical Director review 9/2019.
Rehabilitative Therapies Benefit Application section revised, adding the following statement based on a recent North Carolina law effective October 1, 2019: "Please refer to North Carolina Session Law 2019-43 House Bill 548 for definition of the scope of practice of physical therapists". No change to policy intent. References updated. Specialty Matched Consultant Advisory Panel review 9/2019 Medical Director review 9/2019.
Surgical Treatments for Lymphedema Reference added.
Synthetic Cartilage Implants for Joint Pain Reference added.  Policy Guidelines updated.
Three Dimensional Printed Orthopedic Implants Reference added. Policy Guidelines updated. 
Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders New policy developed. TMS considered medically necessary as a treatment of major depressive disorder when criteria are met. Medical Director review 10/2019
Varicose Veins of the Lower Extremities, Treatment for Medical Director review.  Microfoam sclerotherapy added to medically necessary treatments for symptomatic varicose tributaries.