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Premera Blue Cross August 2017 Medical Policy Updates
Click here to view the Premera Blue Cross July 2017 Medical Policy Updates »
Medical Policies Recent Updates
August 2017
| Policy Title | Comments | Policy Number | Effective | Updated |
|---|---|---|---|---|
| 1.01.15 Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Disorders | Annual review, approved July 18, 2017. Literature review through April 25, 2017; reference 9 added. Other applications areconsidered not medically necessary when criteria are not met. | 1.01.15 | 08/01/2017 | 07/31/2017 |
| 10.01.518 Clinical Trials | Interim update, approved July 11, 2017. Policy clarification made; requirement for member consent form replaced with records demonstrating member agrees to participate in a clinical trial. No other changes. | 10.01.518 | 08/01/2017 | 07/31/2017 |
| 12.04.108 Fetal RHD Genotyping Using Maternal Plasma | Annual Review, approved July 11, 2017. Policy moved into new format. Policy updated with literature review through March 23, 2017; reference 9 added. Policy statement unchanged. | 12.04.108 | 08/01/2017 | 07/31/2017 |
| 12.04.117 Genetic Testing for Mitochondrial Disorders | Annual Review, approved July 18, 2017, new format. Literature review through April 25, 2017; references added. Policy statements revised regarding genetic testing restrictions. | 12.04.117 | 08/01/2017 | 07/31/2017 |
| 12.04.131 Pharmacogenetic Testing for Pain Management | Annual Review, approved July 11, 2017. Policy moved into new format. Policy updated with literature review through March 23, 2017; references 3 and 52- 53 added. Policy statement unchanged. | 12.04.131 | 08/01/2017 | 07/31/2017 |
| 12.04.140 Proteogenomic Testing in Patients with Cancer (GPS Cancer™ Test) | Annual Review, approved July 25, 2017. Policy updated with literature review through April 25, 2017; references 27-28 and 33 added. Policy statement unchanged. | 12.04.140 | 08/01/2017 | 07/31/2017 |
| Molecular Testing in the Management of Pulmonary Nodules | New Policy, approved July 18, 2017. Literature review through March 30, 2017. Plasma-based proteomic screening (Xpresys® Lung) & Gene expression profiling on bronchial brushings (Percepta® Bronchial Genomic Classifier) considered investigational. | 12.04.142 | 08/01/2017 | 07/31/2017 |
| 12.04.48 Genetic Testing for Initial Warfin Dosing | Annual Review, approved July 25, 2017. Policy moved into new format. Policy updated with literature review through April 25, 2017; no references were added. Policy revised with updated genetics nomenclature; statement otherwise unchanged. | 12.04.48 | 08/01/2017 | 07/31/2017 |
| 12.04.51 Genetic Testing for Tamoxifen Treatment | Annual Review, approved July 25, 2017. Policy moved to new format. Policy updated with literature review through April 25, 2017; reference 64 added. Policy revised with updated genetics nomenclature; policy statement otherwise unchanged. | 12.04.51 | 08/01/2017 | 07/31/2017 |
| 12.04.515 Genetic Testing for Mental Health Conditions | Annual Review. Policy approved on July 25, 2017. No changes to policy statement. | 12.04.515 | 08/01/2017 | 07/31/2017 |
| 12.04.517 CYP450 Genotyping to Determine Drug Metabolizer Status | Annual review. Policy approved on July 25, 2017. Selection or Dosing of Tetrabenazine and Eliglustat were added to the Evidence Review section. No changes to policy statement. | 12.04.517 | 08/01/2017 | 07/31/2017 |
| 12.04.81 Genetic Testing for Rett Syndrome | Annual review. Literature review through March 23, 2017. Policy statements updated to define “genetic testing for Rett syndrome- associated genes. Removed “female” requirement of child for testing; Added 2 new medical necessity statements. | 12.04.81 | 08/01/2017 | 07/31/2017 |
| 2.02.30 Transcatheter Mitral Valve Repair | Annual Review, approved July 11, 2017. Policy moved into new format. Policy updated with literature review through March 23, 2017; references 27-28 and 36 added. “Cleared” changed to “approved” in the medically necessary policy statement. | 2.02.30 | 08/01/2017 | 07/31/2017 |
| 2.02.510 Mobile Cardiac Outpatient Telemetry | Annual review, approved July 11, 2017. No changes to policy statement. | 2.02.510 | 08/01/2017 | 07/31/2017 |
| 3.01.510 Applied Behavior Analysis (ABA) | Interim review, approved July 25, 2017. Clarifications made to policy statement. | 3.01.510 | 08/01/2017 | 07/31/2017 |
| 5.01.560 Excessively High Cost Drug Products with Lower Cost Alternatives | Interim review, approved July 25, 2017. Addition of excessively high cost kits. | 5.01.560 | 08/01/2017 | 07/31/2017 |
| 5.01.605 Medical Necessity Criteria for Pharmacy Edits | Interim review, approved July 25, 2017. Update ADHD drugs (add Mydayis); update reauthorization criteria for Xyrem. | 5.01.605 | 08/01/2017 | 07/31/2017 |
| 6.01.25 Percutaneous Vertebroplasty and Sacroplasty | Annual Review, approved July 18, 2017, in new format. Literature review through March 2017; references 9, 16, 26-27, and 30-31 added; vertebroplasty may be medically necessary when criteria met. | 6.01.25 | 08/01/2017 | 07/31/2017 |
| 7.01.127 Bronchial Thermoplasty | Annual Review, approved July 25, 2017. Policy moved into new format. Policy updated with literature review through April 25, 2017; references 14-17 and 22 added. Removed CPT code 31899. Policy statement unchanged. | 7.01.127 | 08/01/2017 | 07/31/2017 |
| 7.01.128 Endobronchial Valves | Annual Review, approved July 25, 2017. Policy moved to new format. Policy updated with literature review through April 25, 2017; reference 4 added. “Endobronchial” changed to “Bronchial” in policy and title. Policy statement otherwise unchanged. | 7.01.128 | 08/01/2017 | 07/31/2017 |
| 7.01.149 Amniotic Membrane and Amniotic Fluid Injections | Interim Review, approved July 18, 2017, in new format. Literature review through April 27, 2017; refs added. Sutured amniotic membrane grafts considered medically necessary when criteria met. Added HCPCS codes Q4131-Q4133, Q4145, and Q4154. | 7.01.149 | 08/01/2017 | 07/31/2017 |
| Sphenopalatine Ganglion Block for Headache | New Policy, approved July 18, 2017, add to Surgery section. Literature review through March 23, 2017. Sphenopalatine ganglion blocks are considered investigational for all indications. | 7.01.159 | 08/01/2017 | 07/31/2017 |
| 8.01.511 Hematopoietic Stem-Cell Transplantation for Solid Tumors of Childhood | Annual Review. Retinoblastoma was divided (metastatic [MN] vs without metastases [Inv]). HCT for late stage Wilms Tumor previously covered as med nec, now inv. Tandem auto HCT (high risk / relapsed neuroblastoma) now covered as medically necessary. | 8.01.511 | 08/01/2017 | 07/31/2017 |
| 8.01.60 Extracorporeal Membrane Oxygenation for Adult Conditions | Annual Review, approved July 11, 2017. Policy moved into new format. Policy updated with literature review through March 23, 2017; references 36, 51, 58, and 61 added. Policy statements unchanged. | 8.01.60 | 08/01/2017 | 07/31/2017 |
| 8.01.61 Focal Treatments for Prostate Cancer | Annual Review, approved July 11, 2017. Policy moved into new format. No changes to policy statement. | 8.01.61 | 08/01/2017 | 07/31/2017 |
| 8.02.04 Lipid Apheresis | Annual Review, approved July 11, 2017. Policy updated with literature review through March 23, 2017; references added. The investigational statement on LDL apheresis for all other uses expanded. Revised Definition of Terms. | 8.02.04 | 08/01/2017 | 07/31/2017 |
| 8.03.08 Cardiac Rehabilitation in the Outpatient Setting | Annual Review, approved July 18, 2017.Literature review through May 31, 2017; references added. Added statement that intensive cardiac rehabilitation with the Pritikin Program or the Ornish Program is considered investigational. | 8.03.08 | 08/01/2017 | 07/31/2017 |
Click here to view the Premera Blue Cross July 2017 Medical Policy Updates »
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