Medical Policy Update for May 2, 2023
| Medical Guidelines | Reason for Update |
|---|---|
| Specialty Matched Consultant Advisory Panel review 11/16/2022. | |
| References, Description, Related Policies and Policy Guidelines updated. No change to policy statement. Specialty Matched Consultant Advisory Panel review 4/2023. Medical Director review 4/2023. | |
| Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 8/24/2022. | |
| Policy review. Specialty Matched Consultant Advisory Panel review 10/19/2022. | |
| References added. Related policies and policy guidelines updated. No change to policy statement. Specialty Matched Consultant Advisory Panel review 4/2023. Medical Director review 4/2023. | |
| Electrodiagnostic Studies (PDF) | Policy review. Specialty Matched Consultant Advisory Panel review 10/19/2022. |
Electrostimulation and Electromagnetic Therapy for Wounds (PDF) | Specialty Matched Consultant Advisory Panel review 11/16/2022. |
| Description and policy guidelines updated. References added. Specialty Matched Consultant Advisory Panel review 4/2023. Medical Director review 4/2023. No change to policy statement. | |
| Description updated for clarity. References added. Updated When Covered section as follows: “If there has been a prior successful radiofrequency (RF) denervation (previously authorized by BCBSNC), then a minimum time of six (6) months has elapsed since prior RF denervation treatment (per side, per anatomical level of the spine). Prior success is defined as 50% or more pain relief documented in medical record. A repeat block is not necessary after 6 months or more have elapsed since prior RF denervation treatment, if symptoms and treatment are at the same location(s) or spinal level(s), and presentation is similar to that of initial or prior treatment.” Specialty Matched Consultant Advisory Panel review 4/2023. Medical Director Review 4/2023. | |
General Approach to Evaluating the Utility of Genetic Panels (PDF) | References updated. Specialty Matched Consultant Advisory Panel review 4/2023. Medical Director review 4/2023. |
| Policy review. References added. Specialty Matched Consultant Advisory Panel review 11/16/2022. | |
Injection Therapy for Headache (Migraine and Other) and Non-Spine Management (PDF) | Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 10/19/2022. |
| Interferential Stimulation (PDF) | Policy update. Reference added. Specialty Matched Consultant Advisory Panel review 10/19/2022. |
Intravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric Disorders (PDF) | Policy guidelines updated. References added. Added the following statement to billing coding section “Use CPT code J3490 for Ketamine”. Specialty Matched Consultant Advisory Panel review 4/2023. Medical Director review 4/2023. No Change to policy statement. |
Magnetic Esophageal Sphincter Augmentation to Treat Gastroesophageal Reflux Disease (GERD) (PDF) | Policy review. Regulatory Status updated. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 11/16/2022. |
MRI-guided Laser Interstitial Thermal Therapy for Neurological Indications (PDF) | Policy update. Specialty Matched Consultant Advisory Panel review 10/19/2022. |
| Policy update. Specialty Matched Consultant Advisory Panel review 10/19/2022. | |
| Related policies updated. References added. Specialty Matched Consultant Advisory Panel review 4/2023. Medical Director review 4/2023. No change to policy statement. | |
| References added. Specialty Matched Consultant Advisory Panel review 4/2023. Medical Director review 4/2023. No change to policy statement. | |
| Specialty Matched Consultant Advisory Panel review 11/16/2022. | |
| Policy review. Specialty Matched Consultant Advisory Panel review 11/16/2022. | |
Postsurgical Home Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis (PDF) | Policy review. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 11/16/2022. |
| Description updated. References added. Specialty Matched Consultant Advisory Panel review 4/2023. Medical Director review 4/2023. No change to policy statement. | |
| Policy update. Specialty Matched Consultant Advisory Panel review 10/19/2022. | |
| Policy review. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 10/19/2022. | |
| Policy review. Specialty Matched Consultant Advisory Panel review 11/16/2022. | |
| Policy guidelines updated. References added. Specialty Matched Consultant Advisory Panel review 4/2023. Medical Director review 4/2023. No change to policy statement. | |
| Policy review. Specialty Matched Consultant Advisory Panel review 10/19/2022. | |
Varicose Veins of the Lower Extremities, Treatment for (PDF) | Policy review. Specialty Matched Consultant Advisory Panel review 11/16/2022. |
| Policy review. Reference added. NCCN guideline updated. Specialty Matched Consultant Advisory Panel review 11/16/2022. Description section updated. When Covered statement updated to include criteria for whole gland cryoablation for initial treatment. When Covered statement for whole gland high intensity focused ultrasound unchanged. Policy Guidelines updated. Medical Director review. |
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