Blue Cross Blue Shield Excellus January 2018 Medical Policy Updates

January 2018 Medical Policy updates:

• Coverage for Ambulatory Surgery Unit (ASU) and Anesthesia for Dental Surgery (PDF) Policy 7.03.01 (posted 1/9/2018)
• Applied Behavioral Analysis for the Treatment of Autism Spectrum Disorders (ABA), Pervasive Developmental Disorders (PDD) (PDF) Policy 3.01.11 (posted 1/18/18)
• Sex Specific Services, Gender Dysphoria, Gender Identity Disorder, GID, transgender, transsexualism (PDF) Policy 11.01.26 (posted 1/9/18)
• Transcranial Magnetic Stimulation: Deep TMS device, MagVita TMS, NeuroStar TMS device, rTMS, TMS (PDF) Policy 3.01.09 (posted 1/9/2018)
• Artificial Cervical Intervertebral Discs (e.g., Bryan, Mobi-C, PCM [Porous Coated Motion] Cervical Disc®, Prestige®, ProDisc®, Secure-C) (PDF) Policy 7.01.80 (posted 1/9/2018)
• Artificial Lumbar Intervertebral Disc (e.g.,ActivL®,Bryan, Charité, ProDisc, ) (PDF) Policy 7.01.63 (posted 1/9/2018)
• Intervertebral Disc Decompression: Laser (Laser Discectomy) and Radiofrequency Coblation (Disc Nucleoplasty™) Techniques (PDF) Policy 7.01.62 (posted 1/9/2018)
• Temporomandibular Joint (TMJ) Disease (PDF) Policy 11.01.17 (posted 1/9/2018)
• Auditory Processing Disorder (APD) Testing (PDF) Policy 2.01.39 (posted 1/9/2018)
• Cranial Orthotics/Helmet for Asymmetry (e.g., Dynamic Orthotic Cranioplasty, DOC) (PDF) Policy 1.01.32 (posted 1/8/18)
• Developmental Evaluation and Testing (PDF) Policy 2.01.54 (posted 1/17/18)
• Alopecia (e.g., Areata, Androgenic, Scarring), Baldness, Hair Loss (PDF) Policy 2.01.36 (posted 1/9/2018)
• Treatment of Hirsutism/Hypertrichosis (Hair Removal) (e.g., Electrolysis, Epilation) (PDF) Policy 2.01.38 (posted 1/9/2018)
• 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 1/16/18)
• CGMS, Continuous glucose monitor, DexCom STS, Freestyle Navigator, Interstitial glucose monitoring, MiniMed CGMS® System Gold™, MiniMed Guardian® Real-Time, MiniMed Paradigm Revel® Real-Time system, DexCom G5®,Wrist glucose monitor, Continuous subcutaneous insulin infusion, CSII, Insulin pump therapy (PDF) Policy 1.01.30 (posted 1/11/18)
• Magnetic Esophageal Ring for the Treatment of Gastroesophageal Reflux (GERD): Esophageal Sphincter Device, LINX™ System, Magnetic Sphincter Augmentation (PDF) Policy 7.01.89 (posted 1/9/2018)
• Augmentative and Alternative Communication Systems: AAC, Dynavox, Introtalker, VoiceMate, Walker Talker, Say-It-All, Speech Generating Devices (SGD) (PDF) Policy 1.01.03 (posted 1/8/18)
• Oximeters and Oximetry for Home Use (e.g., Oxygen Saturation, Pulse Oximetry) (PDF) Policy 1.01.45 (posted 1/9/2018)
• Implantable Bone Conduction Hearing Aids, Bone Anchored Hearing Aid (BAHA®), OBC bone anchored hearing aid system, Ponto Pro (PDF) Policy 7.01.77 (posted 1/15/18)
• Posturography (e.g., Balance Test, Equitest) (PDF) Policy 2.01.20 (posted 1/9/2018)
• Vision/Eye Therapy: Optometric Phototherapy, Occlusion Therapy, Orthoptics, Pleoptics (PDF) Policy 9.01.04 (posted 1/9/2018)
• Genetic Testing for Germline Mutations of the RET Proto Oncogene in Medullary Carcinoma of the Thyroid (PDF) Policy 2.02.07 (posted 1/9/2018)
• Genotyping Cytochrome P450 2C9 (CYP2C9) and Vitamin K Epoxide Reductase Subunit CI (VKORC) That Affect Response to Warfarin (Coumadin®) (PDF) Policy 2.02.33 (posted 1/9/2018)
• Genotyping Uridine Diphosphate Glycuronosyltransferase (UGT1A1) for Patients Treated with Irinotecan (PDF) Policy 2.02.34 (posted 1/9/2018)
• Blood Pressure Monitoring, Automated, Ambulatory (PDF) Policy 1.01.04 (posted 1/9/2018)
• Home Exercise/Physical Therapy Equipment (e.g., Home Gym, Jacuzzi) (PDF) Policy 1.01.12 (posted 1/9/2018)
• Telemedicine and Telehealth (PDF) Policy 1.01.49 (posted 1/11/18)
• Cardiovascular Disease Risk Assessment – Laboratory Evaluation of Lipids: Apolipoprotein A-1, B, and E, Lipoprotein (a) Enzyme Immunoassay (PDF) Policy 2.02.29 (posted 1/9/2018)
• Measurement of Serum Antibodies to Infliximab and Adalimumab: Anser™IFX, Anser™ADA (PDF) Policy 2.02.47 (posted 1/9/2018)
• Molecular Panel Testing of Cancers to Identify Targetes Therapies, Molecular Panel Testing, Targeted Therapy, Foundation One, Caris Life Sciences, OmniSeq, PyroSeq (PDF) Policy 2.02.51 (Posted 01/8/18)
• Viral Load Assay or Polymerase Chain Reaction Testing for HIV (e.g., HIV-1, HIV-2) (PDF) Policy 2.02.08 (posted 1/9/2018)
• Airway Clearance Devices: Oscillatory Devices – ABI Vest, Acapella, Flutter Valve, Lung Flute®, ThAIRapy Vest; Mechanical Percussors and Assisted Cough Devices – Cofflator, Cough-Alator, In-Exsufflator (PDF) Policy 1.01.15 (posted 1/9/2018)
• Clinical Trials (PDF) Policy 11.01.10 (posted 1/9/2018)
• Comfort, Convenience, Custodial or Cosmetic Services (PDF) Policy 11.01.11 (posted 1/9/2018)
• Medically Necessary Services (PDF) Policy 11.01.15 (posted 1/9/2018)
• Private Rooms (PDF) Policy 12.01.06 (posted 1/9/2018)
• Neuropsychiatric Quantitative Encephalography in the Diagnosis of Attention Deficit/Hyperactivity Disorder (e.g., NEBA system) (PDF) Policy 2.01.53 (posted 12/14/17)
• Positron Emission Tomography (PET), Oncologic Applications (FDG PET, FDG SPECT) (PDF) Policy 6.01.29 (posted 1/9/2018)
• Transcranial Doppler Ultrasound (PDF) Policy 6.01.18 (posted 1/9/2018)
• Transurethral Microwave Thermotherapy (e.g., Prostatron, Targis, Urowave System, CoreTherm, Prolieve, TMx-2000, TUMT) (PDF) Policy 7.01.28 (posted 1/9/2018)
• Immunizations/Vaccines (e.g., Hepatitis A, Hepatitis B, Human Papillomavirus [HPV, Cervarix, Gardasil], Meningococcal, Pneumococcal [Pneumovax 23, Prevnar], Rotavirus [Rotarix], Varicella [Varivax], Varicella Zoster [Zostavax]) (PDF) Policy 2.01.42 (posted 1/11/18)