SC BlueCross, BlueChoice HealthPlan’s April 2018 Medical Policy Updates

We frequently revise the medical policies we use to make clinical determinations for a member’s coverage. Here are recent medical policies that have been reviewed, updated or newly added. A revision history for each policy covering the past two years is included. Please visit the Medical Policies and Clinical Guidelines pages of www.SouthCarolinaBlues.com and www.BlueChoiceSC.com regularly to stay informed of these changes and to read any policy in its entirety. 

 

CAM 188 — Cardiovascular Disease Risk Assessment 

February 2018: Updated coding with E72.11 and Z51.89.

January 2018: New Policy.

 

CAM 10304 — Powered Exoskeleton for Ambulation in Patients With Lower-Limb Disabilities

2018: No change to policy intent. Updated background, description, regulatory status, rationale and references.

2017: No change to policy intent. Updated background, description, rationale and references.

 

CAM 20171 — Non-Pharmacologic Treatment of Rosacea

2018: No change to policy intent. Updated rationale and references.

2017: No change to policy intent. Updated background, description, regulatory status, rationale and references. 

 

CAM 20222 — Ultrafiltration in Decompensated Heart Failure

2018: No change to policy intent. Updated rationale and references.

2017: No change to policy intent. Updated background, description, rationale and references. 

 

CAM 60112 — Thermography

2018: No change to policy intent. Updated regulatory status, rationale and references.

2017: No change to policy intent. Updated background, description, rationale and references. 

 

CAM 60146 — Dynamic Spinal Visualization

2018: No change to policy intent. Updated background, description, rationale and references.

2017: No change to policy intent.

 

CAM 70168 — Extracranial Carotid Angioplasty/Stenting

2018: No change to policy intent. Updated description, regulatory status, rationale and references.

2017: No change to policy intent. Updated background, description, rationale and references. 

 

CAM 70175 — Cryosurgical Ablation of Primary or Metastatic Liver Tumors

2018: No change to policy intent. Updated background, description, rationale and references.

2017: No change to policy intent. Updated background to correct typo.

 

CAM 70308 — Heart/Lung Transplant 

2018: No change to policy intent. Updated background, description, rationale and references.

2017: No change to policy intent.

 

CAM 80110 — Charged-Particle (Proton or Helium Ion) Radiotherapy for Neoplastic Conditions

2018: No change to policy intent. Updated title, description, rationale and references.

2017: Updated language related to medical necessity criteria. Corrected typographical errors. Updated policy statement to change diagnoses previously considered investigational to not medically necessary.

 

CAM 80305 — Outpatient Pulmonary Rehabilitation

2018: No change to policy intent. Updated background, description, rationale and references.

2017: No change to policy intent. Updated background, description, rationale and references.

 

CAM 90301 — Keratoprosthesis

2018: No change to policy intent. Updated background, regulatory status, rationale and references.

2017: Policy and guideline verbiage updated for clarity, but no change to intent. Also updated background, description, regulatory status, rationale and references. 

 

CAM 189 — PARSABIV™ (etelcalcetide)

2018: New Policy

 

CAM 60140 — Whole Body Dual X-ray Absorptiometry (DEXA) to Determine Body Composition

2018: No change to policy intent. Updated background, description, regulatory status, coding in guidelines, and references.

2017: No change to policy intent.

 

CAM 701127 — Bronchial Thermoplasty

2018: No change to policy intent. Updated rationale and references.

2017: No change to policy intent. Updated background, description, guidelines, rationale, references and coding. 

 

CAM 90314 — Implantation of Intrastromal Corneal Ring Segments

2018: No change to policy intent. Updated background, description, regulatory status, guidelines, rationale and references.

2017: No change to policy intent. Updated background, description, rationale and references. 

 

CAM 127 — Hepatitis C testing 

2018: Updated policy verbiage for clarity and to address testing frequency for HCV. Also expanded ICD 10 code range.

2017: Updated coding section. Updated category to Laboratory. 

 

CAM 20158 — Transanal Radiofrequency Treatment of Fecal Incontinence

2018: No change to policy intent. Updated background, description and rationale. 

2017: No change to policy intent. Updated background, description, rationale and references.

 

CAM 20448 — Genetic Testing for Warfarin Dose

2018: No change to policy intent. Updated background, description, guidelines, rationale and references.

2017: Updated category to Laboratory.

 

CAM 20475 — Genetic Testing of CADASIL Syndrome

2018: Added medical necessity criteria for asymptomatic members with first- or second-degree relatives diagnosed with CADASIL syndrome. Also updated background, description, guidelines, rationale and references.

2017: Updated category to Laboratory. 

 

CAM 20477 — BRAF Gene Mutation Testing To Select Melanoma Patients for BRAF Inhibitor Targeted Therapy

2018: Added policy statement: Testing for BRAF V600 variants in patients with glioma to select patients for targeted treatment is considered INVESTIGATIONAL. Also updated background, description, regulatory status, rationale and references.

2017: Updated category to Laboratory. Updated coding section.

 

CAM 40114 — Prenatal Screening for Fetal Aneuploidy

2018: Updated policy verbiage. Added medical necessity criteria related to Turner Syndrome. Also updated title, reformatted policy verbiage for clarity, and updated CPT and ICD coding.

2017: Revised policy verbiage to provide for more specific testing based on weeks of gestation. Updated background, description, rationale, category, references and review date. Updated coding section.

 

CAM 70125 — Spinal Cord and Dorsal Root Ganglion Stimulation

2018: Added policy verbiage to indicate dorsal root ganglion neurostimulation is investigational. Also updated title, background, description, regulatory status, rationale and references.

2017: Removed investigational status from high frequency spinal cord stimulation.

 

CAM 70158 — Intraoperative Neurophysiologic Monitoring

2018: Added policy verbiage regarding the medical necessity of laryngeal nerve monitoring. Also updated title, background, description, guidelines, rationale and references.

2017: No change to policy intent.

 

CAM 70196 — Computer-Assisted Navigation for Orthopedic Procedure

2018: Updated guidelines and coding to include CPT 0396T. 

2017: Updated policy to remove investigational status of this procedure and replace policy language with: The use of computer assistance for orthopedic procedures of the pelvis and appendicular skeleton is a technique that is integral to the primary surgery being performed and, therefore, not eligible for separate reimbursement. When billed, there will be no separate or additional payment for charges associated with computer-assistance technology. Reimbursement will be based on the payment for the standard surgical procedure(s). 

 

CAM 80160 — Extracorporeal Membrane Oxygenation for Adult Conditions

2018: No change to policy intent. Coding from prior to 2015 removed from guidelines. Also updated background, description, rationale and references.

2017: No change to policy intent. Updated background, description, regulatory status, rationale and references. 

 

CAM 190 — Enteral Feeding In-Line Cartridge (EFIC™)/Immobilized Lipase Cartridge/Relizorb™

2018: New Policy

 

CAM 078 — Discarded Drugs/Biologicals - Pharmaceutical Waste

2018: No change to policy intent. Updated background, description and rationale.

2017: No change to policy intent.

 

CAM 10109 — Transcutaneous Electrical Nerve Stimulation (TENS) 

2018: No change to policy intent. Updated background, description, rationale and references.

2017: No change to policy intent.

 

CAM 10130 — Artificial Pancreas Device Systems 

2018: Expanded investigational statement to include: “Use of hybrid closed loop insulin delivery system (including the Food and Drug Administration approved device for age 14 and older) as an artificial pancreas device system is considered INVESTIGATIONAL.” Also updated background, description, regulatory status, rationale and references.

2017: No change to policy intent. Updated background, description, regulatory status, rationale and references.

 

CAM 10305 — Patient-Controlled End of Range Motion Stretching Devices

2018: No change to policy intent. Updated background, description, rationale and references.

2017: No change to policy intent. Updated title, background, description, regulatory status, guidelines, rationale and references.

 

CAM 20131 — Intra-Articular Hyaluronan Injections for Osteoarthritis

2018: No change to policy intent. Updated background, description and guidelines. 

2017: Added code J7320 to coding section. Corrected formatting. Updated background, description, guidelines, coding, regulatory status, rationale and references. 

 

CAM 20154 — Endovascular Procedures for Intracranial Arterial Disease (Atherosclerosis and Aneurysms) 

2018: No change to policy intent. Updated background, description, regulatory status, rationale and references.

2017: No change to policy intent. Updated background, description, rationale and references. 

 

CAM 20181 — Ingestible pH and Pressure Capsule

2018: No change to policy status. Adding regulatory status and updating rationale. 

2017: No change to policy intent. Updated background, description, rationale and references.

 

CAM 20196 — Autonomic Nervous System Testing

2018: No change to policy intent. Updated background, description, regulatory status, rationale and references.

2017: No change to policy intent.

 

CAM 20210 — Biventricular Pacemakers (Cardiac Resynchronization Therapy) for the Treatment of Heart Failure

2018: No change to policy intent. Updated background, description, rationale and references.

2017: No change to policy intent. Updated background, description, regulatory status, rationale and references. 

 

CAM 20402 — Genetic Testing for Hereditary Breast and/or Ovarian Cancer Syndrome (BRCA1/BRCA2)

2018: Added clarifying language to medical necessity criteria No. 4. Removed criteria No. 6, as it is addressed in a separate policy. 

2017: Updated coding. Corrected formatting error in coverage criteria 3 last bullet points. Corrected a typo in the rationale section. Included extensive revision of policy verbiage for clarity and updated coverage.

 

CAM 20480 — Genetic Testing for Hereditary Hemochromatosis

2018: Updated policy verbiage for clarity. No change to policy intent. Updated background, description, guidelines, rationale and references.

2017: Updated category and coding section. No change to policy intent.

 

CAM 20481 — Genetic Testing for Rett Syndrome

2018: Updated policy to indicate specific mutations for Rett syndrome testing. Also updated background, description, rationale, references and coding.

2017: Updated category to Laboratory. Removed the requirement for the testing to be done on a female. 

 

CAM 204128 — Genetic Testing for Fanconi Anemia

2018: Updated policy to include genetic counseling. Also updated background, description, rationale and references.

2017: Updated category to Laboratory. Updated codes in coding section.

 

CAM 50128 — Nusinersen for Spinal Muscular Atrophy

2018: No change to policy intent. Updated background, description, regulatory status, rationale and references.

2017: Updated with 2018 coding. Updated coding section.

 

CAM 60121 — Magnetoencephalography/Magnetic Source Imaging

2018: No change to policy intent. Updated guidelines and coding to include CPT 0396T.

2017: No change to policy intent.

 

CAM 60144 — Vertebral Fracture Assessment with Densitometry

2018: No change to policy intent. Updated background, description, regulatory status, rationale and references. Also removed coding from prior to 2015 from guidelines.

2017: No change to policy intent. Updated background, description, rationale and references.

 

CAM 60152 — Positron Emission Mammography (PEM)

2018: No change to policy intent. Updating rationale and references.

2017: No change to policy intent. Updated background, description, rationale and references.