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Blue Cross Blue Shield South Carolina Second Quarter 2017 Medical Policy Updates

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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

Click here to view the Blue Cross Blue Shield South Carolina Second Quarter 2017 Medical Policy Updates »


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.

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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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