BCBS Excellus Medical Policy Updates – May 2018

May 2018 Medical Policy updates:

• Varicosities/Varicose Veins, Treatment Alternatives to Vein Stripping and Ligation (e.g., Ambulatory, Stab or Transilluminated Powered Phlebectomy, ClariVein®, Endoluminal Radiofrequency Ablation, Endovenous Laser Ablation, Mechanochemical Endovenous Ablation, MOCA, Sclerotherapy, Varithena™, Venaseal™,VNUS) (PDF) Policy 7.01.47 (posted 5/2/18)
• Plugs for Fistula Repair (PDF) Policy 7.01.86 (posted 5/2/18)
• Surgical Management of Obesity: Adjustable Gastric Band, Bariatric Surgery, Biliopancreatic Diversion, Duodenal Switch, Endobarrier, Gastric Bypass, Gastric Plication, Imbrication, Lap Band, Restorative Obesity Surgery, Ednoluminal [ROSE], Roux-en-Y, Sleeve Gastrectomy, Stomach Stapling, TOGA, Transoral or Vertical Banded Gastroplasty (PDF) Policy 7.01.29 (posted 5/2/18)
• Photodynamic Therapy (PDT) for Subfoveal Choroidal Neovascularization (CNV) (e.g., Verteporfin, Visudyne) (PDF) Policy 8.01.11 (posted 5/2/18)
• Prenatal Genetic Testing : Preconception genetic testing, Preimplantation genetic diagnosis (PGD), Prenatal carrier screening (PDF) Policy 4.01.03 (posted 5/2/18)
• Angioplasty of Intracranial Atherosclerotic Stenoses with or without Stenting (e.g., Percutaneous Transluminal Angioplasty, Neurolink® System, Wingspan™ Stent) (PDF) Policy 7.01.70 (posted 5/2/18)
• Home Automatic External Defibrilator (AEDs) and Wearable Defibrillator Vests (WCDs): HeartStart, LIFECOR (PDF) Policy 1.01.42 (posted 5/2/18)
• Microvolt T-Wave Alternans (PDF) Policy 2.01.45 (posted 5/2/18) First Trimester Screening for Down Syndrome (e.g., Cell-Free Fetal DNA, Harmony™, Free Beta PAPP-A, MaterniT21™, Non-invasive Prenatal Testing, Nuchal Translucency, Panorama™, Verify®) (PDF) Policy 2.02.25 (posted 5/2/18)
• Her-2 Testing in Invasive Breast Cancer Using Fluorescence in Situ Hybridization (FISH) or Immunohistochemistry (IHC) Assays: HercepTest, PathVysion, INFORM®, FISH pharmdX) (PDF) Policy 2.02.31 (posted 5/2/18)
• Neuropsychiatric Quantitative Encephalography in the Diagnosis of Attention Deficit/Hyperactivity Disorder (e.g., NEBA system) (PDF) Policy 2.01.53 (posted 5/2/18)
• Heart and Heart/Lung Transplants (PDF) Policy 7.02.06 (posted 5/2/18)
• Kidney (Renal) Transplantation (PDF) Policy 7.02.04 (posted 5/2/18)
• Lung and Lobar Lung Transplant (PDF) Policy 7.02.10 (posted 5/2/18)
• Small Bowel and Multivisceral Transplants in Adults and Children (PDF) Policy 7.02.05 (posted 5/2/18)
• Cervical Cancer Screening and Human Papilloma Virus (HPV) Testing (e.g., Cervista™, Cobas® HPV test, DNA with PAP, HPV, HPV DNA testing, Human Papillomavirus, HC 2, Hybrid Capture 2, Pap/ Papanicolaou smear: Direct visualization, Monolayer, Optical; FocalPoint™, MonoPrep Pap Test (MPPT), PapSure®, Speculite®, Speculoscopy, SurePath, ThinPrep®) (PDF) Policy 2.02.04 (posted 5/2/18)

Added 6/1/2018;

• Acupuncture, Auricular Electrostimulation (e.g., E-Pulse, P-Stim™) (PDF) Policy 8.01.20 (posted 5/31/18)
• Autologous Chrondrocyte Implantation (e.g., Carticel®, Matrix-induced ACI, MACI, Minced cartilage, Neocartilage, Scaffold-induced ACI) (PDF) Policy 7.01.38 (posted 5/31/18)
• Manipulation Under Anesthesia (MUA), Manipulation under Joint Anesthesia (MUJA), Manipulation Under Sedation (MUS) (PDF) Policy 7.01.76 (posted 5/31/18)
• Orthotics (e.g., OttoBock E-Mag Active KAFO, OttoBock SensorWalk Electronic KAFO, MYOMO mPower 1000 arm brace) (PDF) Policy 1.01.25 (posted 5/31/18)
• Percutaneous Intradiscal Electrothermal Annuloplasty (IDET, IDTA, PIRFT, Biacuplasty) (PDF) Policy 7.01.17 (posted 5/31/18)
• Pneumatic Compression Devices/Lymphedema Pump/Sleeve (e.g., Flexitouch™) (PDF) Policy 1.01.17 (posted 5/31/18)
• Radium-223 (Xofigo) for Treatment of Castration-Resistant Prostate Cancer (PDF) Policy 6.01.44 (posted 5/31/18)
• Superficial Radiation Therapy for Treatment of Skin Cancers (orthovoltage x-ray, SR-100, Xstrahl-100) (PDF) Policy 6.01.43 (posted 5/31/18)
• Tumor-Treatment Field Therapy for Glioblastoma: Electrical Field Therapy, NovoTTF-100™ (PDF) Policy 6.01.45 (posted 5/31/18)
• Abdominoplasty and Panniculectomy (e.g., Belt Lipectomy, Lipectomy, Tummy Tuck) (PDF) Policy 7.01.53 (posted 5/31/18)
• Blepharoplasty/Eyelid Surgery with or without Levator Muscle Advancement (Pseudoptosis Surgery, Ptosis Surgery, Brow Lift) (PDF) Policy 7.01.55 (posted 5/31/18)
• Cryosurgical Tumor Ablation (PDF) Policy 7.01.03 (posted 5/31/18)
• Breast Pumps (PDF) Policy 1.01.39 (posted 5/31/18)
• Cervical Traction Devices (e.g., HomeTrac Deluxe, Saunders Cervical HomeTrac, Hydraulic, Over-The-Door, Pneumatic Cervical, Pronex) (PDF) Policy 1.01.47 (posted 5/31/18)
• Neuromuscular Electrical Stimulation (FNS, NMES, TES, VitalStim®) (PDF) Policy 1.01.48 (posted 5/31/18)
• Positive Airway Pressure Devices: CPAP, BiPAP, APAP, DPAP, C-FLex (PDF) Policy 1.01.06 (posted 5/31/18)
• Vitrectomy Chair/ Face-Down Positioning System (PDF) Policy 1.01.52 (posted 5/31/18)
• Aqueous Drainage Devices (Stents and Shunts): Ahmed, Aquaflow, Baerveldt, CyPass, Ex-PRESS, Glaucoma Filtration Device, IOP, iStent, Krupin, Molteno, XEN (PDF) Policy 9.01.18 (posted 5/31/18)
• Corneal Ultrasound Pachymetry (PDF) Policy 9.01.07 (posted 5/31/18)
• Optical Coherence Tomography for Ophthalmological Applications (OCT) (PDF) Policy 9.01.10 (posted 5/31/18)
• Keratoprosthesis: AlphaCor™, BIOKOP, Boston type I, Boston type II, Dolhman-Doane, KPro, OOKP (PDF) Policy #9.01.15 (posted 5/31/18)
• Genetic Testing for Familial Alzheimer’s Disease (PDF) Policy 2.02.16 (posted 5/31/18)
• End-Diastolic Pneumatic Compression (e.g., Circulator Boot) (PDF) Policy 1.01.31 (posted 5/31/18)
• Surgical Ventricular Reduction (e.g., Partial Ventriculectomy, Batista Procedure) (PDF) Policy 7.01.31 (posted 5/31/18)
• Surgical Management of Sleep Disorders/Sleep Apnea: Airvance®, Atrial overdrive pacing, Aura6000 System, CAPSO, Encore™, HGNS®, Hypoglossal Nerve Stimulation, Inspire II Upper Airway Stimulation System, LAUP, Pillar™, Repose™, Snoreplasty, Somnoplasty, UPPP (PDF) Policy 7.01.41 (posted 5/31/18)
• Ambulance: Air (PDF) Policy 11.01.06 (posted 5/31/18)
• Ambulance: Land/Ground (PDF) Policy 10.01.07 (posted 5/31/18)
• Emergency Care Services (PDF) Policy 10.01.12 (posted 5/31/18)
• Gender Reassignment Surgery: Gender Dysphoria, Gender Identity Disorder (GID), Genital Correction Surgery, Genital Reassignment Surgery, Genital Reconstruction, Gender Realignment Surgery, Gender Confirmation Surgery, Intersex, Transsexualism, Transsexual Surgery (PDF) Policy 7.01.84 (posted 5/31/18)
• Interfacility (Hospital-to-Hospital, Inpatient, Interhospital) Transfer of a Registered Inpatient (PDF) Policy 11.01.18 (posted 5/31/18)
• Out of Area/Out of Network Services (PDF) Policy 11.01.13 (posted 5/31/18)
• Second Medical and Second Surgical Opinions, Confirmatory Consultation (PDF) Policy 10.01.10 (posted 5/31/18)
• Skilled Nursing Facility (SNF) Care for Medicare Advantage Members (PDF) Policy 11.01.21 (posted 5/31/18)
• Deep Brain Stimulation (PDF) Policy 7.01.23 (posted 5/31/18)
• Percutaneous Posterior Tibial Nerve Stimulation (PPTNS) (PDF) Policy 8.01.22 (posted 5/31/18)
• Proton Beam Radiation (Charged Particle, Conformal) (PDF) Policy 6.01.11 (posted 5/31/18)
• Bioengineered Tissue Products (Affinity™, AlloDerm®, AlloMax™, AlloSkin™, AlloWrap™, AmnioBand™, Amnioexcel®, AmnioMatrix®, Apligraf®, Artacent™ Wound, ArthroFlex™, Artificial skin, Avaulta Plus™, Biobrane®, Biobrane l®, Bioengineered skin, Biologic tissue, Biovance®, Clarix® Flo, Collamend, Conexa™, Cygnus Solo™, Cygnus Matrix™, Cygnus Max™,Cymetra®, Cytal™ Burn Matrix, Cytal™ Wound Matrix, DermACELL AWM™, DermaMatrix, DermaPure™, DermaSpan™, Dermavest™, Endoform Dermal Template™, ENDURAgen™, Epicel®, EpiCord™, EpiFix, Excellagen®, E-Z Derm™, FlexHD®, GammaGraft, Grafix® CORE, Grafix® PRIME, GraftJacket®, GraftJacket® Xpress, Graftskin, Guardian, hMatrix®, Hyalomatrix®, Integra™, Integra™ Bilayer Wound® Matrix, Integra™ Dermal Regeneration Matrix®, Integra™ FlowMiroderm®, Flowable Wound® Matrix, InteguPly™, Interfyl™, Laserskin, MariGen, Mediskin®, Neoform, Neox®, Neox 1K, Neox® Flo, NuShield™, OASIS® Wound Matrix, OASIS® Burn Matrix, OASIS® Ultra, Omnigraft™, Orcel™, Orthoadapt, PalinGen® – Membrane, Hydromembrane, Flow, and SportFlow, Pelvicol, Pelvisoft, Permacol™, Primatrix, PuraPly, Restore, Revitalon™, Skin substitute, StrataGraft, Strattice™, SurgiMend®, TenSIX™, TheraSkin®, Tissuemend, TranZgraft, TruSkin™, Veritas® Collagen Matrix, XCM Biological Tissue Matrix) (PDF) Policy 7.01.35 (posted 5/31/18)
• Bone Growth Stimulators for the Appendicular Skeleton (PDF) Policy 1.01.53 (posted 6/1/18)
• Sialendoscopy (PDF) Policy 7.01.94 (posted 6/1/18)