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. |