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Medical Policy Update for May 2, 2023 May 02, 2023
Medical GuidelinesReason for Update

Bioimpedance Devices for Detection of Lymphedema

Specialty Matched Consultant Advisory Panel review 11/16/2022.

Carrier Screening for Genetic Disease

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.

Cochlear Implant

Policy Guidelines updated.  Specialty Matched Consultant Advisory Panel review 8/24/2022. 

Decompression of the Intervertebral Disc Using Laser Energy (Laser Discectomy) or Radiofrequency Coblation (Nucleoplasty)

Policy review.  Specialty Matched Consultant Advisory Panel review 10/19/2022.

Diagnosis and Treatment of Sacroiliac Joint Pain

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 StudiesPolicy review.  Specialty Matched Consultant Advisory Panel review 10/19/2022.

Electrostimulation and Electromagnetic Therapy for Wounds

Specialty Matched Consultant Advisory Panel review 11/16/2022. 

Epidural Steroid Injections for Back Pain

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.

Facet Joint Denervation

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

References updated. Specialty Matched Consultant Advisory Panel review 4/2023. Medical   Director review 4/2023.

Handheld Radiofrequency Spectroscopy for Intraoperative Assessment of Surgical Margins during Breast-Conserving Surgery

Policy review.  References added.  Specialty Matched Consultant Advisory Panel review 11/16/2022.

Injection Therapy for Headache (Migraine and Other) and Non-Spine Management

Policy Guidelines updated.  Specialty Matched Consultant Advisory Panel review 10/19/2022. 
Interferential StimulationPolicy update.  Reference added.  Specialty Matched Consultant Advisory Panel review 10/19/2022.

Intravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric Disorders

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)

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

Policy update.  Specialty Matched Consultant Advisory Panel review 10/19/2022.

Navigated Transcranial Magnetic Stimulation (nTMS)

Policy update.  Specialty Matched Consultant Advisory Panel review 10/19/2022.

Neural Therapy

Related policies updated. References added. Specialty Matched Consultant Advisory Panel review 4/2023. Medical Director review 4/2023. No change to policy statement.

Neurostimulation, Electrical

References added.  Specialty Matched Consultant Advisory Panel review 4/2023. Medical Director review 4/2023. No change to policy statement.

Non-Contact Ultrasound Treatment for Wounds

Specialty Matched Consultant Advisory Panel review 11/16/2022.

Plugs for Fistula Repair

Policy review.  Specialty Matched Consultant Advisory Panel review 11/16/2022.

Postsurgical Home Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis

Policy review.  Policy Guidelines updated.  Specialty Matched Consultant Advisory Panel review 11/16/2022.

Prolotherapy

Description updated. References added. Specialty Matched Consultant Advisory Panel review 4/2023. Medical Director review 4/2023. No change to policy statement.

Quantitative Sensory Testing

Policy update.  Specialty Matched Consultant Advisory Panel review 10/19/2022.

Spinal Cord and Dorsal Root Ganglion Stimulation

Policy review.  Policy Guidelines updated.  Specialty Matched Consultant Advisory Panel review 10/19/2022.

Surgical Treatments for Lymphedema

Policy review.  Specialty Matched Consultant Advisory Panel review 11/16/2022.

TENS (Transcutaneous Electrical Nerve Stimulator)

Policy guidelines updated. References added. Specialty Matched Consultant Advisory Panel review 4/2023. Medical Director review 4/2023. No change to policy statement.

Total Facet Arthroplasty

Policy review.  Specialty Matched Consultant Advisory Panel review 10/19/2022.

Varicose Veins of the Lower Extremities, Treatment for

Policy review.  Specialty Matched Consultant Advisory Panel review 11/16/2022.

Whole Gland Ablative Treatments of Prostate Cancer

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.