| Medical Guidelines | Reason for Update |
|---|---|
| Anesthesia Services | References updated. Specialty Matched Consultant Advisory Panel review 10/2024. Medical Director Review 10/2024. No change to policy statement. |
| Continuous Monitoring of Glucose in the Interstitial Fluid | Updated the FDA approved device list. Added the following statement to Billing/Coding section: “Blue Cross NC considers Implantable CGM (Eversense) codes 0446-0448T to represent the procedure only, while A9276 represents the device. A9276 units are required to match implantable device life expectancy (e.g., 180 days = 180 units).” |
| Dental Criteria for use of Hospital Inpatient or Outpatient Facility Services or Ambulatory Surgery Center Facility Services | Specialty Matched Consultant Advisory Panel review 10/2024. Medical Director Review 10/2024. Changed “patient” to “individual” throughout the policy. No change to policy statement. |
| Dental Reconstructive Services | References updated. When covered section updated for clarity. Policy guidelines updated. Specialty Matched Consultant Advisory Panel review 10/2024. Medical Director Review 10/2024. No change to policy statement. |
| Gene Expression Profiling and Protein Biomarkers for Prostate Cancer AHS - M2166 | Added PLA code 0497U to Billing/Coding section for 10/1/24 code update. |
| Hyperbaric Oxygen Therapy | References updated. When covered section updated to include “avascular necrosis (aseptic osteonecrosis)” as an indication for coverage based on updated guidelines from Undersea and Hyperbaric Medical Society. Policy guidelines updated. Specialty Matched Consultant Advisory Panel review 10/2024. Medical Director review 10/2024. No change to policy statement. |
| Orthodontics for Pediatric Patients | References updated. Specialty Matched Consultant Advisory Panel review 10/2024. Medical Director Review 10/2024. No change to policy statement. |
| Orthognathic Surgery | References updated. Specialty Matched Consultant Advisory Panel review 10/2024. Medical Director Review 10/2024. No change to policy statement. |
| Spinal Manipulation Under Anesthesia | References updated. Specialty Matched Consultant Advisory Panel Review 10/2024. Medical Director Review 10/2024. No change to policy statement. |
| Temporomandibular Joint Dysfunction (TMJD) | Updated When Covered section #2b to include “muscle relaxant medications”. Updated When Not Covered #3 to include “Botulinum Toxin Injections”. References updated. Specialty Matched Consultant Advisory Panel review 10/2024. Medical Director Review 10/2024. Added S3900 to billing/coding section. Updated When Not Covered section #3 to include Botulinum Toxin Injections. |
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