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

S.C. BlueCross, BlueChoice HealthPlan’s May 2018 Medical Policy Updates

5/1/2018

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 139 — Surgical and Minimally Invasive Treatments for Urinary Outlet Obstruction due to Benign Prostatic Hyperplasia (BPH)

2018: Updated procedures to indicate ILCP, CLAP, TULIP, VLAP, TUIP and ultrasonic aspiration may be considered medically necessary if criteria are met. Categorizing water-induced thermotherapy as investigational. Limited update to description/background. Also updated references.

2017: Updated coding section.

CAM 158 — SPECT/CT Fusion Imaging

2018: No change to policy intent. Updated references and removed unlisted code from coding section. 

2017: New policy.

CAM 60101 — Bone Mineral Density Studies

2018: Updated policy to include: "peripheral BMD testing could be considered medically necessary when convention central (hip/spine) DXA screening is not feasible or in the management of hyperparathyroidism, where peripheral DXA measurement at the distal forearm (i.e. radius) is essential for evaluation." Also updated background, description, regulatory status, guidelines, rationale and references.

2017: No change to policy intent.

CAM 60106 — Miscellaneous (Noncardiac, Nononcologic) Applications of Fluorine 18 Fluorodeoxyglucose Positron Emission Tomography

2018: No change to policy intent. Updated title to maintain consistency with industry terminology. Also updated regulatory status, rationale and references.

2017: No change to policy intent. Added Fluorodeoxygucose F18 to the title and FDG to the investigational status. Also updated background, description, regulatory status, rationale and references. 

CAM 60123 — Diagnosis and Treatment of Non-Surgical Sacroiliac Joint Pain

2018: Updated related policies, background, description, rationale and references.

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

CAM 60126 — Oncologic Applications of PET Scanning

2018: Policy revised to indicate the following: "Additional details added to policy statements.” Updated guidelines, rationale and references.

2017: No change to policy intent.

CAM 60147 — Functional Magnetic Resonance Imaging of the Brain

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

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

CAM 80130 — Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia

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

2017: Updated policy with 2018 coding. Removed the word "stem" and changed "myelogenous" to "myeloid" in the title and policy statements. Updated background, description, guidelines, rationale and references.

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 119 — Prenatal Screening 

2018: Rewritten for clarity. Expanded verbiage related to blood typing and Rh antibody testing. Updated CPT codes with 86480 and 86481.

2017: Updated with 2018 coding. Removed criteria related to SMA screening requiring a family history. SMA screening is now considered medically necessary for all pregnant women and those seeking pre-conception care. Included language regarding thyroid testing and Zika testing, which is also addressed in other policies. Corrected formatting. Updated category to Laboratory. 

CAM 10120 — Continuous or Intermittent Monitoring of Glucose in Interstitial Fluid 

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

2017: Updated policy verbiage significantly to include reformatted medical necessity criteria and criteria to allow for coverage for Type II diabetes. Increased the glucose level for hypoglycemia from 50 to 70 in policy statement. Also updated background, description, rationale and references.  

CAM 083 — Eculizumab (Soliris®) IV  

2018: Added medical necessity criteria for the treatment of adult patients with generalized Myasthenia Gravis (gMG) who are anti-acetylcholine receptor (AchR) antibody positive.

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

CAM 086 — Preventive Services for Non-Grandfathered (PPACA) Plans: Behavioral Counseling for Prevention

2018: Removed tobacco use and cessation, as this is addressed in CAM 089 with CPT coding specific to that counseling. 

2017: No changes to the USPSTF guidelines. 

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

April 3, 2018: Updated coding section with Q9994.

March 2018: New Policy

CAM 472 — Laboratory/Pathology Services

2018: Removed codes for which CMS no longer supports a 26 modifier: 80500, 80502, 85097, 85396, 86077, 8607886079, 86485, 86486, 86490, 86510, 86580, 88141, 88187, 88188, 88291, 88299, 88321, 88325, 88329, 89049, 89220, 89230, 89240, G0124 and G0141.

2017: Updated category to Laboratory. Removed 88184 and 88185 from the list of codes appropriate for a 26 modifier, as they are technical component only by verbiage.

CAM 10105 — Ultrasound Accelerated Fracture Healing Device

2018: Updated to state the following indications are considered not medically necessary: fresh fractures (surgically and non-surgically managed) and nonunion/delayed union fractures. These issues were previously considered medically necessary. Also updated background, description, guidelines rationale, and references.  

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

CAM 20104 — Hyperbaric Oxygen Therapy

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

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

CAM 20215 — Wearable Cardioverter-Defibrillators

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

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

CAM 204129 — Marfan Syndrome Testing

2018: Updated background section to add z score values. 

2017: New Policy

CAM 70311 — Total Artificial Hearts and Implantable Ventricular Assist Devices

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

2017: Updated with 2018 coding. Added HeartMate 3 LVAS to the list of approved devices. Updated background, description, regulatory status, rationale and references. 

CAM 701116 — Paravertebral Facet Joint Denervation (Radiofrequency Neurolysis)

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

2017: Major revision to policy for clarity and to maintain industry standards for this procedure. Updated title, policy and references. 

CAM 701148 — Endovascular Therapies for Extracranial Vertebral Artery Disease

2018: No change to policy intent. Updated regulatory status.

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

CAM 701149 — Amniotic Membrane and Amniotic Fluid Injections

2018: Included specific investigational items. Also updated background, description, guidelines, rationale, references and coding.

2017: Moved coverage criteria for patch formulations of amniotic membrane from policy 701113 to this policy. Updated background, description, policy, guidelines, regulatory status, rationale and references. 

CAM 90306 — Ophthalmologic Techniques That Evaluate the Posterior Segment for Glaucoma  

2018: Removed “Doppler ultrasonography” in the second policy statement. This is for clarity and does not change the policy intent. Also updated title, background, rationale and references.

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

CAM 90318 — Optical Coherence Tomography of the Anterior Eye Segment

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 90320 — Intraocular Radiation Therapy for Age-Related Macular Degeneration 

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

2017: No change to policy intent. Updated ICD 10 coding.