Medical Policy Updates

Blue Cross and Blue Shield of North Carolina Medical Policy Update May 11, 2018

Medical Guidelines Reason for Update
Allergy Testing When Covered section of policy revised below section 4b; limiting diagnostic screening from 36 to 20 allergen specific antibodies. References updated. Policy noticed 3/9/18, effective 5/11/18. Specialty Matched Consultant Advisory Panel review 2/2018. Medical Director review.
Allogeneic Hematopoietic Transplant for Genetic Diseases and Acquired Anemia Specialty Matched Consultant Advisory Panel review 4/25/2018. Updated Policy Guidelines section. No change to policy statement. Reference added.
Ambulatory Event Monitors Minor revisions to Table 1. Specialty Matched Consultant Advisory Panel review 4/2018. Medical Director review 4/2018.
Analysis of MGMT Promoter Methylation in Malignant Gliomas Specialty Matched Consultant Advisory Panel review 4/25/2018. Reference added. No change to policy statement.
Assays of Genetic Expression to Determine Prognosis of Breast Cancer Specialty Matched Consultant Advisory Panel review 3/28/2018. Added "invasive" to clarify statement 1.c. Under "When Not Covered." Policy Guidelines section updated. Medical Director review.
Baroreflex Stimulation Devices Specialty Matched Consultant Advisory Panel review 4/2018. Medical Director review 4/2018.
BRAF Gene Mutation Testing to Select Melanoma or Glioma Patients for Targeted Therapy Specialty Matched Consultant Advisory Panel review 3/28/2018. Medical Director review. No change to policy statement.
Brentuximab Vedotin (Adcetris®) Added the following statement to "When Covered" section for classical Hodgkin lymphoma: "In combination with chemotherapy for previously untreated Stage III or IV disease" and updated "Policy Guidelines" section to include dosing for this indication. References added. Specialty Matched Consultant Advisory Panel review 4/25/2018.
Circulating Tumor DNA for Cancer Management (Liquid Biopsy) Specialty Matched Consultant Advisory Panel review 3/28/2018. Added MMA code 0011M to Billing/Coding section. Medical Director review 3/2018. No change to policy statement.
Denosumab (ProliaTM, XGEVATM) Updated "When Covered" section regarding when Xgeva is considered medically necessary to add the statement "in individuals with multiple myeloma or" to the prevention of skeletal-related events indication to reference newly approved indication. Removed multiple myeloma as investigational from "When Not Covered" section. Reference added.
Drug Testing in Pain Management and Substance Abuse Treatment In the When Covered section there are minor formatting changes and bullet point 4 deleted (urine drug testing is limited to 2 tests per month and 12 tests per year). The following changes were made in the When Not Covered section: added "Blanket orders or routine standing orders for all patients in the physician's practice are considered not medically necessary"; deleted "routine confirmation of presumptive tests with definitive testing is considered not medically necessary" and added "definitive testing is considered not medically necessary when criteria under C or D are not met"; and added "Definitive urine drug testing in pain management and substance abuse treatment, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers, qualitative or quantitative, is limited to 7 drug classes per day, including specimen validity testing and metabolite(s) if performed and one allowable procedure per date of service per member." Added statement to the Billing/Coding section: G0480 (1 – 7 drug classes) is the only covered panel code. Specialty Matched Consultant Advisory Panel review 1/2018. Senior Medical Director review 1/2018. Policy noticed 3/9/2018 for effective date 5/11/2018.
Eculizumab (Soliris®) Specialty Matched Consultant Advisory Panel review 4/2018. No change to policy intent.
Enhanced External Counterpulsation (EECP) Specialty Matched Consultant Advisory Panel review 4/2018. Medical Director review 4/2018.
Eribulin Mesylate (Halaven®) Added the following to "When Covered" section: "Eribulin Mesylate (Halaven) is considered medically necessary in the treatment of individuals with unresectable or metastatic liposarcoma following at least two prior systemic therapy regimens for advanced disease, including one with an anthracycline (unless contraindicated)." Updated "Description of Procedure or Service" section to include description of mechanism of action for clarity. References added. Specialty Matched Consultant Advisory Panel review 4/25/2018. Medical Director review 5/2018.
External Defibrillators Minor revisions to Policy Guidelines. Specialty Matched Consultant Advisory Panel review 4/2018. Medical Director review 4/2018.
Gene Expression Testing in the Evaluation of Patients With Stable Ischemic Heart Disease Specialty Matched Consultant Advisory Panel review 4/2018. Medical Director review 4/2018.
Genetic Cancer Susceptibility Panels Using Next Generation Sequencing Specialty Matched Consultant Advisory Panel review 4/25/2018. No change to policy statement.
Genetic Testing for Cardiac Ion Channelopathies Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 4/2018. Medical Director review 4/2018.
Golimumab (Simponi Aria) Updated "When Covered" section criterion #1c to include a comprehensive list of biologic agents for clarity. Updated the following statement in "When Not Covered" section from "when used in combination with Abatacept, Anakinra, and live vaccines" to "when used in combination with Abatacept, Adalimumab, Anakinra, Certolizumab, Etanercept, Infliximab, Rituximab, Sarilumab, Secukinumab, Tocilizumab, Tofacitinib, and live vaccines" to provide a comprehensive list of biologic agents. References added. Specialty Matched Consultant Advisory Panel review 2/28/18. Medical Director review 3/2018. No change to policy intent.
Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia Specialty Matched Consultant Advisory Panel review 4/25/2018. Reference added. No change to policy statement.
Hematopoietic Stem-Cell Transplantation for Acute Myeloid Leukemia Specialty Matched Consultant Advisory Panel review 4/25/2018. Reference added. No change to policy statement.
Immunoglobulin Therapy Updated "When Covered" section to include the following statement as medically necessary: "Patients with autoimmune encephalitis (AE), including but not limited to antibody-mediated, with an inadequate response to glucocorticoids, or in whom steroids are not tolerated or are contraindicated." References added. In medically necessary bullet point on neuromyelitis optica, "steroids or plasma exchange" changed to "first-line treatment". Specialty Matched Consultant Advisory Panel review 2/28/2018. Medical Director review 5/2018.
In Vitro Chemoresistance and Chemosensitivity Assays Specialty Matched Consultant Advisory Panel review 4/25/2018. No change to policy statement.
Infliximab, Infliximab-dyyb, Infliximab-abda Policy name changed from Infliximab, Infliximab-dyyb to Infliximab, Infliximab-dyyb, Infliximab-abd. No change to policy intent.
Infusion Therapy in the Home Description section reformatted and revised. The terms "licensed registered nurse" and "licensed practical nurse" changed to "qualified health care professional". Added related policy: Skilled Nursing Services.
Intradialytic Parenteral Nutrition Specialty Matched Consultant Advisory Panel review 4/2018. Medical Director review 4/2018.
Laboratory Tests for Heart Transplant Rejection References updated. Specialty Matched Consultant Advisory Panel review 4/2018. Medical Director review 4/2018.
Lipid Apheresis Specialty Matched Consultant Advisory Panel review 4/2018. Medical Director review 4/2018.
Monoclonal Antibodies for Non-Hodgkin Lymphoma and Acute Myeloid Leukemia In the Non-Hematopoietic Stem Cell Transplant Setting Specialty Matched Consultant Advisory Panel review 4/2018. Under "When Not Covered" section, removed the following statement from when ofatumumab (Arzerra) is considered investigational: "as maintenance therapy in patients with CLL" to coincide with indication listed in "When Covered" section. References added. Added CPT code C9467 to Billing/Coding section.
Monoclonal Antibody Imaging for Prostate Cancer Specialty Matched Consultant Advisory Panel review 4/25/2018. Updated Policy Guidelines section. Reference added. No change to policy statement.
Multigene Expression Assay for Predicting Recurrence in Colon Cancer Specialty Matched Consultant Advisory Panel review 4/25/2018. No change to policy statement.
Proteomic Testing for Targeted Therapy in Non-Small Cell Lung Cancer Specialty Matched Consultant Advisory Panel review 3/28/2018. Added PLA code 0022U to Billing/Coding section. Updated Description and Policy Guidelines sections. Reference added. No change to policy statement.
Radiofrequency Ablation of the Renal Nerves as a Treatment of Hypertension References updated. Specialty Matched Consultant Advisory Panel 4/2018. Medical Direcor review 4/2018.
Renal (Kidney) Transplantation Moved HIV criteria from the When covered section to the Policy Guidelines and reformatted the When Covered section. No change to policy intent. References updated. Specialty Matched Consultant Advisory Panel review 4/2018. Medical Director review 4/2018.
Serum Biomarker Human Epididymis Protein 4 (HE4) Updated Description section. Reference added. Specialty Matched Consultant Advisory Panel review 4/25/2018. No change to policy statement.
ST2 Assay for Chronic Heart Failure Specialty Matched Consultant Advisory Panel review 4/2018. Medical Director review 4/2018.
Surgical Management of Transcatheter Heart Valves Description section updated and Regulatory Status section added. FDA expanded indications added to Regulatory Status section to include severe aortic stenosis in individuals with intermediate surgical risk for aortic valve replacement. When Covered section revised under section - Transcatheter aortic valve implantation (TAVI), item 4 to include medically necessary indication for patients with intermediate risk for open surgery as follows: "Patient is not an operable candidate for open surgery, as judged by at least two cardiovascular specialists (cardiologist and/or cardiac surgeon) or patient is an operable candidate but is at high or intermediate risk for open surgery." Policy guidelines extensively revised for TAVI for aortic stenosis. References updated. Medical Director review 4/2018.
Synthetic Cartilage Implants for Joint Pain Specialty Matched Consultant Advisory Panel review.