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Blue Cross Blue Shield South Carolina Second Quarter 2017 Medical Policy Updates
Medical Policy Updates: Second Quarter 2017
| CAM | Policy Name | Review Date |
| 069 | Abatacept (Orencia®) | April 2017 |
| 108 | Abdominoplasty, Panniculectomy and Lipectomy | June 2017 |
| 20173 | Actigraphy | April 2017 |
| 70101 | Acupuncture and Dry Needling | May 2017 |
| 50109 | Advanced Therapies for Pharmacologic Treatment of Pulmonary Hypertension | June 2017 |
| 20429 | Analysis of Human DNA in Stool Samples as a Technique for Colorectal Cancer Screening | April 2017 |
| 012 | Anesthesia Services | May 2017 |
| 20193 | Antigen Leukocyte Antibody Test | April 2017 |
| 20436 | Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer | April 2017 |
| 20177 | Automated Point-of-Care Nerve Conduction Tests | June 2017 |
| 20485 | BCR-ABL1 Testing in Chronic Myelogenous Leukemia and Acute Lymphoblastic Leukemia | April 2017 |
| 365 | Behavioral Health Guidelines | May 2017 |
| 067 | Bevacizumab (Avastin) for Oncologic Use | April 2017 |
| 20130 | Biofeedback as a Treatment of Chronic Pain | April 2017 |
| 20182 | Bioimpedance Devices for Detection and Management of Lymphedema | April 2017 |
| 040 | Blepharoplasty (Upper and Lower) | June 2017 |
| 80114 | Brachytherapy for Clinically Localized Prostate Cancer Using Permanently Implanted Seeds | May 2017 |
| 20155 | Breast Duct Endoscopy | April 2017 |
| 60120 | Cardiac Applications of PET Scanning | June 2017 |
| 20224 | Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting | May 2017 |
| 20201 | Catheter Ablation for Cardiac Arrhythmias | June 2017 |
| 80153 | Cellular Immunotherapy for Prostate Cancer | June 2017 |
| 80116 | Chemical Peels | April 2017 |
| 065 | Chiropractic Services | June 2017 |
| 20184 | Chromoendoscopy as an Adjunct to Colonoscopy | June 2017 |
| 204122 | Chromosomal Microarray Analysis for the Evaluation of Pregnancy Loss | April 2017 |
| 70165 | Chronic Pulmonary Thromboendarterectomy | April 2017 |
| 20187 | Confocal Laser Endomicroscopy | June 2017 |
| 90316 | Conjunctival Incision with Posterior Juxtascleral Placement of Anecortave Acetate Depot Suspension | June 2017 |
| 10120 | Continuous or Intermittent Monitoring of Glucose in Interstitial Fluid | May 2017 |
| 10126 | Cooling Devices Used in the Outpatient Setting | May 2017 |
| 90328 | Corneal Collagen Cross-linking | April 2017 |
| 082 | Cosmetic/Reconstructive Services | June 2017 |
| 20438 | Cytochrome p450 Genotyping | June 2017 |
| 70193 | Decompression of the Intervertebral Disc Using Laser (Laser Discectomy) or Radiofrequency Coblation (Nucleoplasty™) | June 2017 |
| 70163 | Deep Brain Stimulation | June 2017 |
| 20101 | Diagnosis and Management of Idiopathic Environmental Intolerance (i.e., Clinical Ecology) | May 2017 |
| 20118 | Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome | May 2017 |
| 20474 | DNA-Based Testing for Adolescent Idiopathic Scoliosis | April 2017 |
| 201100 | Dry Needling and Trigger Point Injections for Myofascial Pain | April 2017 |
| 70185 | Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures | May 2017 |
| 80162 | Electronic Brachytherapy for Nonmelanoma Skin Cancer | June 2017 |
| 80311 | Endobronchial Brachytherapy | June 2017 |
| 70142 | Endoscopic Laser for Gastrointestinal Bleeding | June 2017 |
| 20180 | Endoscopic Radiofrequency Ablation or Cryoablation for Barrett’s Esophagus | June 2017 |
| 20125 | Erectile Dysfunction | April 2017 |
| 204115 | Expanded Molecular Panel Testing of Cancers to Identify Targeted Therapies | April 2017 |
| 116 | External Insulin Infusion Pump | June 2017 |
| 20140 | Extracorporeal Shock Wave Treatment for Plantar Faciitis and Other Musculoskeletal Conditions | May 2017 |
| 701120 | Facet Arthroplasty | June 2017 |
| 168 | Familial Adenomatous Polyposis and MUYTH-Associated Polyposis Testing | May 2017 |
| 20426 | Fecal Analysis in the Diagnosis of Intestinal Dysbiosis | April 2017 |
| 40114 | First-Trimester Detection of Down Syndrome Using Fetal Ultrasound Markers Combined with Maternal Serum Assessment | April 2017 |
| 120 | Flow Cytometry | April 2017 |
| 80161 | Focal Treatments for Prostate Cancer | June 2017 |
| 80301 | Functional Neuromuscular Electrical Stimulation, Robotic-assisted Rehabilitation & Robotic-assisted Orthotics | April 2017 |
| 145 | Gender Reassignment Surgery | June 2017 |
| 20472 | Gene Expression Testing to Predict Coronary Artery Disease | April 2017 |
| 20454 | Gene Expression‒Based Assays for Cancers of Unknown Primary | April 2017 |
| 166 | General Genetic Testing, Germline Disorders | April 2017 |
| 167 | General Genetic Testing, Somatic Disorders | April 2017 |
| 20493 | Genetic Cancer Susceptibility Panels Using Next Generation Sequencing | June 2017 |
| 204104 | Genetic Testing for Alpha Thalassemia | April 2017 |
| 20479 | Genetic Testing for Alpha-1 Antitrypsin Deficiency | April 2017 |
| 20413 | Genetic Testing for Alzheimer’s Disease | April 2017 |
| 20443 | Genetic Testing for Cardiac Ion Channelopathies | April 2017 |
| 204106 | Genetic Testing for CHARGE Syndrome | April 2017 |
| 204114 | Genetic Testing for Dilated Cardiomyopathy | April 2017 |
| 204109 | Genetic Testing for Epilepsy | April 2017 |
| 204105 | Genetic Testing for Facioscapulohumeral Muscular Dystrophy | April 2017 |
| 204124 | Genetic Testing for FLT3 and NPM1 Mutations in Acute Myeloid Leukemia | April 2017 |
| 20402 | Genetic Testing for Hereditary Breast and/or Ovarian Cancer Syndrome (BRCA1/BRCA2) | April 2017 |
| 20480 | Genetic Testing for Hereditary Hemochromatosis | April 2017 |
| 20499 | Genetic Testing for Hereditary Pancreatitis | April 2017 |
| 056 | Genetic Testing for Inherited Disorders and Cancer Susceptibility | April 2017 |
| 20482 | Genetic Testing for Inherited Thrombophilia | April 2017 |
| 20494 | Genetic Testing for Lactase Insufficiency | April 2017 |
| 204101 | Genetic Testing for Li-Fraumeni Syndrome | April 2017 |
| 20470 | Genetic Testing for Lipoprotein(a) Variant(s) as a Decision Aid for Aspirin Treatment | May 2017 |
| 204103 | Genetic Testing for Macular Degeneration | April 2017 |
| 204110 | Genetic Testing for Mental Health Conditions | April 2017 |
| 204137 | Genetic Testing for Neurofibromatosis | April 2017 |
| 20487 | Genetic Testing for Nonsyndromic Hereditary Hearing Loss | June 2017 |
| 204126 | Genetic Testing for PALB2 Mutations | April 2017 |
| 20488 | Genetic Testing for PTEN Hamartoma Tumor Syndrome | April 2017 |
| 20496 | Genetic Testing for Statin-Induced Myopathy | April 2017 |
| 20489 | Genetic Testing for the Diagnosis of Inherited Peripheral Neuropathies | June 2017 |
| 204117 | Genetic Testing of Mitochondrial Disorders | April 2017 |
| 20471 | Genotyping for 9p21 Single Nucleotide Polymorphisms to Predict Risk of Cardiovascular Disease or Aneurysm | April 2017 |
| 80132 | Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia | June 2017 |
| 80142 | Hematopoietic Cell Transplantation for Primary Amyloidosis | April 2017 |
| 80135 | Hematopoietic Cell Transplantation in the Treatment of Germ Cell Tumors | April 2017 |
| 80134 | Hematopoietic Stem-Cell Transplantation for Solid Tumors of Childhood | May 2017 |
| 80133 | High-Dose Rate Temporary Prostate Brachytherapy | May 2017 |
| 20418 | HIV Genotyping and Phenotyping | April 2017 |
| 250 | Hospital Medical Services (Inpatient and Observation) and Consultation | May 2017 |
| 20495 | Human Leukocyte Antigen (HLA) Testing for Celiac Disease | June 2017 |
| 026 | Human Papillomavirus (HPV) Vaccines | May 2017 |
| 701126 | Image-Guided Minimally Invasive Lumbar Decompression (IG-MLD) for Spinal Stenosis | April 2017 |
| 019 | Implantable Hormone Pellets for Females | April 2017 |
| 50115 | Infliximab | June 2017 |
| 457 | Inpatient Rehabilitation | June 2017 |
| 20172 | Insulin Potentiation Therapy | June 2017 |
| 80149 | Intensity-Modulated Radiation Therapy (IMRT): Abdomen and Pelvis | May 2017 |
| 701107 | Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers) | June 2017 |
| 701138 | Interspinous Fixation (Fusion) Devices | June 2017 |
| 20183 | Interventions for Progressive Scoliosis | June 2017 |
| 20473 | Intracellular Micronutrient Analysis | April 2017 |
| 60119 | Intracoronary Doppler Ultrasound | June 2017 |
| 50116 | Intravenous Anesthetics for the Management of Chronic Neuropathic Pain | April 2017 |
| 50108 | Intravenous Antibiotic Therapy for Lyme Disease | June 2017 |
| 90323 | Intravitreal Corticosteroid Implants | April 2017 |
| 091 | Ipilimumab (Yervoy) | June 2017 |
| 20460 | JAK2 and MPL Mutation Analysis in Myeloproliferative Neoplasms | April 2017 |
| 20467 | KIF6 Genotyping for Predicting Cardiovascular Risk and/or Effectiveness of Statin Therapy | April 2017 |
| 20453 | KRAS, NRAS, and BRAF Mutation Analysis in Metastatic Colorectal Cancer | April 2017 |
| 20468 | Laboratory and Genetic Testing for Use of 5-Fluorouracil in Patients With Cancer | April 2017 |
| 20449 | Laboratory Testing for HIV Tropism | April 2017 |
| 40119 | Laparoscopic, Percutaneous and Transcervical Techniques for the Myolysis of Uterine Fibroids | June 2017 |
| 20189 | Laser Treatment of Onychomycosis | June 2017 |
| 163 | Light Therapy for Dermatologic Conditions | April 2017 |
| 20186 | Light Therapy for Vitiligo and Alopecia Areata | June 2017 |
| 80204 | Lipid Apheresis | May 2017 |
| 20156 | Low-Level Laser Therapy | April 2017 |
| 70307 | Lung and Lobar Lung Transplant | May 2017 |
| 169 | Lynch Syndrome Testing | May 2017 |
| 60116 | Magnetic Resonance Angiography of Vessels of the Head, Neck, Abdomen, Pelvis and Lower Extremity | June 2017 |
| 60124 | Magnetic Resonance Spectroscopy | April 2017 |
| 701109 | Magnetic Resonance‒Guided Focused Ultrasound | June 2017 |
| 80140 | Manipulation Under Anesthesia | May 2017 |
| 204129 | Marfan Syndrome Testing | May 2017 |
| 20304 | Melanoma Vaccines | April 2017 |
| 70115 | Meniscal Allografts and Other Meniscal Implants | June 2017 |
| 30201 | Methadone Treatment for Opiate Addiction | May 2017 |
| 70162 | Minimally Invasive Coronary Artery Bypass Graft Surgery | June 2017 |
| 20445 | Molecular Analysis for Targeted Therapy of Non-Small-Cell Lung Cancer | April 2017 |
| 20478 | Molecular Markers in Fine Needle Aspirates of the Thyroid | April 2017 |
| 20461 | Multigene Expression Assay for Predicting Recurrence in Colon Cancer | April 2017 |
| 204132 | Mutation Testing for Limb-Girdle Muscular Dystrophies | April 2017 |
| 10116 | Negative Pressure Wound Therapy in the Outpatient Setting | June 2017 |
| 70181 | Nerve Graft with Radical Prostatectomy | June 2017 |
| 106 | Nivolumab (Opdivo) | May 2017 |
| 204108 | Noninvasive Fetal RHD Genotyping Using Cell-Free Fetal DNA | April 2017 |
| 40121 | Noninvasive Prenatal Screening for Fetal Aneuploidies Using Cell-Free Fetal DNA | April 2017 |
| 20441 | Noninvasive Techniques for the Evaluation and Monitoring of Patients With Chronic Liver Disease | April 2017 |
| 50128 | Nusinersen for Spinal Muscular Atrophy | May 2017 |
| 701125 | Occipital Nerve Stimulation | May 2017 |
| 80303 | Occupational Therapy | June 2017 |
| 170 | Ocrelizumab (Ocrevus™) | May 2017 |
| 058 | Omalizumab (Xolair®) | April 2017 |
| 30102 | Opioid Antagonists Under Heavy Sedation or General Anesthesia as a Technique of Opioid Detoxification | April 2017 |
| 077 | Oral Screening, Lesion Identification Systems and Genetic Screening | April 2017 |
| 20198 | Orthopedic Applications of Platelet-Rich Plasma | June 2017 |
| 80152 | Orthopedic Applications of Stem Cell Therapy (Including Allografts and Bone Substitutes Used With Autologous Bone Marrow) | April 2017 |
| 90303 | Orthoptic Training for the Treatment of Vision or Learning Disabilities | May 2017 |
| 10115 | Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Conditions | June 2017 |
| 452 | Pain Management Services (Chronic Pain and Rehabilitation Therapies) | June 2017 |
| 70166 | Partial Left Ventriculectomy | April 2017 |
| 20452 | PathFinderTG® Molecular Testing | April 2017 |
| 701144 | Patient-Specific Cutting Guides and Custom Knee Implants | June 2017 |
| 10117 | Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence | April 2017 |
| 60138 | Percutaneous Balloon Kyphoplasty and Mechanical Vertebral Augmentation | May 2017 |
| 20175 | Percutaneous Treatment of Fracture Non-Unions or Bone Defects with Autologous Bone Marrow with or without Demineralized Bone Matrix (DBM) | May 2017 |
| 60125 | Percutaneous Vertebroplasty and Sacroplasty | April 2017 |
| 60151 | PET Scanning in Oncology to Detect Early Response during Treatment | June 2017 |
| 204131 | Pharmacogenetic Testing for Pain Management | April 2017 |
| 80302 | Physical Therapy | June 2017 |
| 20122 | Plasma HIV-1 RNA Quantification for HIV-1 Infection | April 2017 |
| 60148 | Positional Magnetic Resonance Imaging (MRI) | June 2017 |
| 110 | Pre-implantation Genetic Testing | June 2017 |
| 119 | Prenatal Screening | April 2017 |
| 086 | Preventive Services for Non-Grandfathered (PPACA) Plans: Behavioral Counseling for Prevention | April 2017 |
| 20126 | Prolotherapy | May 2017 |
| 70109 | Prophylactic Mastectomy | April 2017 |
| 204140 | Proteogenomic Testing for Patients With Cancer (GPS Cancer™ Test) | June 2017 |
| 20462 | Proteomics-Based Testing Related to Ovarian Cancer | April 2017 |
| 20139 | Quantitative Sensory Testing | June 2017 |
| 701154 | Radiofrequency Ablation of Peripheral Nerves to Treat Pain | May 2017 |
| 512 | Radiopharmaceutical Agents and Other In Vivo Diagnostic Aids | May 2017 |
| 455 | Registered Nurses Practicing in Extended Roles | May 2017 |
| 40204 | Reproductive Techniques | April 2017 |
| 060 | Rituximab | April 2017 |
| 70169 | Sacral Nerve Neuromodulation/Stimulation | June 2017 |
| 701121 | Saturation Biopsy for Diagnosis and Staging of Prostate Cancer | April 2017 |
| 60130 | Screening for Lung Cancer Using CT Scanning | April 2017 |
| 70184 | Semi-Implantable Middle Ear Hearing Aid for Moderate to Severe Sensorineural Hearing Loss | May 2017 |
| 80313 | Sensory Integration Therapy and Auditory Integration Therapy | April 2017 |
| 20430 | Serologic Diagnosis of Celiac Disease | April 2017 |
| 204118 | Serum Biomarker Tests for Multiple Sclerosis | June 2017 |
| 149 | SIMPONI ARIA (golimumab injection for intravenous use) | May 2017 |
| 10122 | Skin Contact Monochromatic Infrared Energy as a Technique to Treat Cutaneous Ulcers, Diabetic Neuropathy and Miscellaneous Musculoskeletal Conditions | April 2017 |
| 40115 | Speculoscopy | April 2017 |
| 80304 | Speech Therapy | June 2017 |
| 204130 | ST2 Assay for Chronic Heart Failure | April 2017 |
| 80155 | Stem-cell Therapy for Peripheral Arterial Disease | May 2017 |
| 70116 | Stereotactic Radiofrequency Pallidotomy for the Treatment of Parkinson’s Disease | May 2017 |
| 701142 | Surgery for Groin Pain in Athletes | June 2017 |
| 148 | Surgery for Lymphedema | April 2017 |
| 139 | Surgical and Minimally Invasive Treatments for Urinary Outlet Obstruction due to Benign Prostatic Hyperplasia (BPH) | May 2017 |
| 701118 | Surgical Treatment of Femoroacetabular Impingement | June 2017 |
| 701103 | Surgical Ventricular Restoration | June 2017 |
| 20464 | Systems Pathology in Prostate Cancer | May 2017 |
| 150 | TECENTRIQ™ (atezolizumab) | June 2017 |
| 50123 | Testosterone Replacement Therapies | April 2017 |
| 10119 | Threshold Electrical Stimulation as a Treatment of Motor Disorders | April 2017 |
| 135 | Thyroid Disease Testing | June 2017 |
| 061 | Tocilizumab (Actemra®) | April 2017 |
| 10201 | Total Parenteral Nutrition and Enteral Nutrition in the Home | June 2017 |
| 140 | Toxicology | April 2017 |
| 60107 | Transcranial Doppler Ultrasound | May 2017 |
| 70153 | Transjugular Intrahepatic Portosystemic Shunt (TIPS) | May 2017 |
| 70154 | Transmyocardial Revascularization | May 2017 |
| 10123 | Transtympanic Micropressure Applications as a Treatment of Meniere’s Disease | April 2017 |
| 50112 | Trastuzumab | April 2017 |
| 80119 | Treatment of Hyperhidrosis | June 2017 |
| 80139 | Treatment of Tinnitus | June 2017 |
| 164 | Ultraviolet Light Therapy in the Home Setting (UVB) | April 2017 |
| 036 | Unicompartmental and Bicompartmental Knee Arthroplasties | June 2017 |
| 70188 | Unicondylar Interpositional Spacer as a Treatment of Unicompartmental Arthritis of the Knee | April 2017 |
| 20407 | Urinary Tumor Markers for Bladder Cancer | April 2017 |
| 60150 | Use of Magnetic Resonance Imaging to Monitor Integrity of Silicone Gel-Filled Breast Implants | June 2017 |
| 70199 | Vasectomy Using a Polymeric Clip | April 2017 |
| 204119 | Vectra DA Blood Test for Rheumatoid Arthritis | April 2017 |
| 104 | Vedolizumab (Entyvio™) | April 2017 |
| 80309 | Vertebral Axial Decompression | May 2017 |
| 701110 | Vertical Expandable Prosthetic Titanium Rib | June 2017 |
| 60132 | Virtual Colonoscopy/CT Colonography | June 2017 |
| 90326 | Viscocanalostomy and Canaloplasty | May 2017 |
| 034 | Visual and Auditory Evoked Potentials | June 2017 |
| 130 | Vitamin B12 and Methylmalonic Acid Testing | April 2017 |
| 126 | Vitamin D Testing | June 2017 |
| 60141 | Whole Body Computed Tomography Scan as a Screening Test | June 2017 |
| 204102 | Whole Exome and Whole Genome Sequencing for Diagnosis of Patients With Suspected Genetic Disorders | April 2017 |
| 70179 | Whole Gland Cryoablation of Prostate Cancer | May 2017 |
| 094 | Women’s Preventive Services | June 2017 |
| 153 | Zika Virus Risk Assessment | April 2017 |
Policy Alerts monitors Commercial and Medicare medical policies for changes. While Payers typically update medical policies annually, there are many reasons why a Payer might review or update a policy. When reviews occur out of cycle, they may go unnoticed. Policy Alerts keeps you informed of upcoming and unexpected coverage changes affecting your product. Quickly understanding the changes Payers make can help you adjust reimbursement strategies impacting your business.
Policy Alerts continuously monitors Commercial and Medicare Payer coverage information to keep you up-to-date on Payer decisions in real-time. Whenever changes occur, email notifications containing a summary of those changes are delivered to your inbox. Clients can access detailed coverage reports and medical policies on the interactive Dashboard portal. Save time and keep focused on the important Payer medical policy reviews and coverage decisions affecting your product!
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Health economic and reimbursement information provided by Policy Alerts is gathered from third-party sources and is subject to change without notice as a result of complex and frequently changing laws, regulations, rules and policies. This information is presented for illustrative purposes only and does not constitute reimbursement or legal advice.
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