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Premera Blue Cross November 2017 Medical Policy Updates
Click here to view the Premera Blue Cross November 2017 Medical Policy Updates »
Medical Policies November 2017 Updates
| Policy Title | Comments | Policy Number | Effective | Updated |
| 1.01.11 Adjustable Cranial Orthoses for Positional Plagiocephaly and Craniosynostoses | Annual review approved September 21, 2017. Policy updated with literature review through June 22, 2017; references 25-26 added. Policy statements unchanged. | 1.01.11 | 10/01/2017 | 09/30/2017 |
| 1.01.29 Tumor-Treatment Fields Therapy for Glioblastoma | Annual Review, approved October 3, 2017. Policy updated with literature review through June 5, 2017; no references added. Removed HCPCS codes A9900 and E1399. Policy statements rewritten for clarity. | 1.01.29 | 11/01/2017 | 10/31/2017 |
| 10.01.514 Cosmetic and Reconstructive Services | Interim Review, approved October 3, 2017. Penis enhancement surgery added to the list of procedures considered cosmetic when medical necessity criteria are not met; code 54360 added to the cosmetic codes section in association with this update. | 10.01.514 | 11/01/2017 | 10/31/2017 |
| 11.01.523 Site of Service: Infusion Drugs and Biologic Agents | Interim Review, approved October 3, 2017. Clarified site of service exception criterion related to access. Removed related policy 5.01.566; it does not have site of service review application. | 11.01.523 | 11/01/2017 | 10/31/2017 |
| 12.04.520 General Approach to Evaluating the Utility of Genetic Panels | Policy re-instated, approved October 10, 2017. Removed sections on Cancer Panels and Reproductive Panels as these are covered in other policies. Removed Reference #9. | 12.04.520 | 11/01/2017 | 10/31/2017 |
| 12.04.86 Genetic Testing for Duchenne and Becker Muscular Dystrophy | Minor update, policy statements were slightly reformatted for clarity. | 12.04.86 | 11/01/2017 | 10/31/2017 |
| 12.04.91 General Approach to Genetic Testing | Annual Review, approved October 19, 2017. Removed appendix tables and other formatting edits were made. No changes to policy statement. | 12.04.91 | 11/01/2017 | 10/31/2017 |
| 2.01.526 Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders | Interim Review, approved Sept 21, 2017. Clarifications added regarding medical necessity being determined on a case-by-case basis (see policy for more details). Also added that an abbreviated repeat course of TMS is also known as a “mini-intensive.” | 2.01.526 | 10/01/2017 | 09/30/2017 |
| 2.01.57 Electrostimulation and Electromagnetic Therapy for Treating Wounds | Annual Review, approved October 19, 2017. Policy updated with literature review through July 21, 2017; reference 12 added; notes 14-15 updated. Policy statements unchanged. | 2.01.57 | 11/01/2017 | 10/31/2017 |
| 2.01.73 Actigraphy | Interim Review, approved October 19, 2017. Policy updated with literature review through July 21, 2017; no references added. Policy statement unchanged. | 2.01.73 | 11/01/2017 | 10/31/2017 |
| 2.01.77 Automated Point-of-Care Nerve Conduction Tests | Annual Review, approved September 21, 2017. Policy updated with literature review through July 6, 2017; references 11-13, 22, and 25-26 added. Policy statement unchanged. | 2.01.77 | 10/01/2017 | 09/30/2017 |
| 2.01.99 Polysomnography for Non‒Respiratory Sleep Disorders | Interim Review, approved October 19, 2017. Policy updated with literature review through July 21, 2017; no references added. Policy statements unchanged. | 2.01.99 | 11/01/2017 | 10/31/2017 |
| 2.02.18 Progenitor Cell Therapy for the Treatment of Damaged Myocardium Due to Ischemia | Annual Review, approved September 21, 2017. Policy updated with literature review through June 22, 2017; references 10, 19, and 21-22 added. Removed CPT code33999. Policy statements unchanged. | 2.02.18 | 10/01/2017 | 09/30/2017 |
| In Vitro Chemoresistance and Chemosensitivity Assays | Annual Review, approved October 19, 2017. Policy updated with literature search through June 20, 2017; reference 35 and 49 added. Policy statements unchanged. | 2.03.01 | 11/01/2017 | 10/31/2017 |
| 3.01.521 Psychiatric Evaluations in Inpatient and Residential Behavioral Health Treatment | New utilization management guideline, approved October 10, 2017. Adopting to support InterQual medical necessary requirements for psychiatric evaluations by clarifying the provider types who must conduct the evaluations. | 3.01.521 | 11/01/2017 | 10/31/2017 |
| 4.01.21 Noninvasive Prenatal Screening for Fetal Aneuploidies and Microdeletions Using Cell-Free Fetal DNA | Annual Review, approved September 21, 2017. Policy updated with literature review through June 22, 2017; references 10, 25-27, and 40-41 added; note 35 replaced. Removed CPT code 88271. Policy statements unchanged. | 4.01.21 | 10/01/2017 | 09/30/2017 |
| 5.01.535 Erythropoiesis-Stimulating Agents | Annual review, approved October 19, 2017. Updated guidelines from KDIGO. Removed HCPCS code J0890. | 5.01.535 | 11/01/2017 | 10/31/2017 |
| 5.01.536 Nulojix® (belatacept) for Adults | Annual Review, approved October 3, 2017. Clarified site of service exception criterion related to access. Added 7-year results of a long term follow up study. | 5.01.536 | 11/01/2017 | 10/31/2017 |
| 5.01.540 Miscellaneous Oral Oncology Drugs | Interim Review, approved October 19, 2017. Added coverage criteria for Verzenio™. | 5.01.540 | 11/01/2017 | 10/31/2017 |
| 5.01.544 Prostate Cancer Targeted Therapies | Interim Review, approved October 19, 2017. Updated criteria for Zytiga® and Xtandi®. | 5.01.544 | 11/01/2017 | 10/31/2017 |
| 5.01.550 Pharmacotherapy of Arthropathies | Interim Review, approved Oct 3, 2017.Clarified site of service exception criterion related to access. | 5.01.550 | 11/01/2017 | 10/31/2017 |
| 5.01.560 Excessively High Cost Drug Products with Lower Cost Alternatives | Interim Review, approved September 21, 2017. Changed criteria for Differin, clarified criteria for auvi-q, added criteria for omePPi. | 5.01.560 | 10/01/2017 | 09/30/2017 |
| 5.01.562 Imlygic® (talimogene laherparepvec) | Annual Review, approved September 5, 2017. A literature search was conducted from 04/13/16 to 8/18/17. No new studies were found that would require changes to this policy. | 5.01.562 | 10/01/2017 | 09/30/2017 |
| 5.01.563 Pharmacotherapy of Inflammatory Bowel Disorder | Interim Review, approved October 3, 2017. Clarified site of service exception criterion related to access. | 5.01.563 | 11/01/2017 | 10/31/2017 |
| 5.01.564 Pharmacotherapy of Miscellaneous Autoimmune Diseases | Interim Review, approved October 3, 2017. Clarified site of service exception criterion related to access. Removed HCPCS codes J3490 and J3590. | 5.01.564 | 11/01/2017 | 10/31/2017 |
| 5.01.566 Pharmacotherapy of Thrombocytopenia | Annual Review, approved September 21, 2017. Updated dosage and quantity limits with specific age range of eltrombopag. | 5.01.566 | 10/01/2017 | 09/30/2017 |
| 5.01.569 Pharmacotherapy of Type I and Type II Diabetes Mellitus | Interim Review, approved October 19, 2017. Updated criteria if metformin is contraindicated. | 5.01.569 | 11/01/2017 | 10/31/2017 |
| 5.01.571 Soliris® (eculizumab) | Interim Review, approved October 3, 2017. Clarified site of service exception criterion related to access. | 5.01.571 | 11/01/2017 | 10/31/2017 |
| 5.01.574 Pharmacotherapy of Spinal Muscular Atrophy (SMA) | Interim Review, approved October 10, 2017. Clarified Spinraza® (nusinersen) criteria to include Type 1, 2, and 3 information. | 5.01.574 | 11/01/2017 | 10/31/2017 |
| 5.01.605 Medical Necessity Criteria for Pharmacy Edits | Interim Review, approved October 3, 2017. Updated oral acne antibiotics criteria and updated brand testosterone products criteria. | 5.01.605 | 11/01/2017 | 10/31/2017 |
| 5.01.606 Hepatitis C Antiviral Therapy | Interim Review, approved September 22, 2017, effective September 25, 2017. Modified step therapy criteria. Harvoni re-incorporated into policy as a preferred treatment agent; length of therapy information included. | 5.01.606 | 09/25/2017 | 09/14/2017 |
| 6.01.38 Percutaneous Balloon Kyphoplasty and Mechanical Vertebral Augmentation | Annual Review, approved September 21, 2017. Policy updated with literature review through June 22, 2017; references 20 and 22 added. Radiofrequency kyphoplasty added to title and investigational statement. | 6.01.38 | 10/01/2017 | 09/30/2017 |
| 6.01.56 Myocardial Sympathetic Innervation Imaging in Patients with Heart Failure | Annual Review, approved October 19, 2017. Policy updated with literature review through July 20, 2017; references 4-5 added. Policy statement unchanged. | 6.01.56 | 11/01/2017 | 10/31/2017 |
| 7.01.104 Subtalar Arthroereisis | Annual Review, approved September 21, 2017. Policy updated with literature review through June 22, 2017; no references added. Removed CPT code 28899. Policy statement unchanged. | 7.01.104 | 10/01/2017 | 09/30/2017 |
| 7.01.113 Bioengineered Skin and Soft Tissue Substitutes | Interim Review, approved Oct 10, 2017.CellerateRX® (CRXa™) and Integra® Omnigraft™ Dermal Regeneration Matrix removed from the investigational policy statement, may be considered medically necessary if criteria are met. | 7.01.113 | 11/01/2017 | 10/31/2017 |
| 7.01.133 Microwave Tumor Ablation | Annual Review, approved October 19, 2017. Policy updated with literature review through July 20, 2017; no references added, references 44 and 47 updated. Policy statement unchanged. Removed CPT code 47379. Added CPT codes 32999 and 49999. | 7.01.133 | 11/01/2017 | 10/31/2017 |
| 7.01.136 Radiofrequency Ablation of the Renal Sympathetic Nerves as a Treatment for Resistant Hypertension | Annual Review, approved October 19, 2017. Policy updated with literature review through July 20, 2017; no references added. Policy statement unchanged. | 7.01.136 | 11/01/2017 | 10/31/2017 |
| 7.01.144 Patient-Specific Cutting Guides and Custom Knee Implants | Annual Review, approved September 21, 2017. Policy updated with literature review through June 22, 2017; references 3-6 added; some references removed. Policy statement unchanged. | 7.01.144 | 10/01/2017 | 09/30/2017 |
| 7.01.153 Adipose-Derived Stem Cells in Autologous Fat Grafting to the Breast | Annual Review, approved October 19, 2017. Policy updated with literature review through July 20, 2017; no references added. Policy statement unchanged. Added CPT codes 11950, 11951, 11952, and 11954. | 7.01.153 | 11/01/2017 | 10/31/2017 |
| 7.01.154 Radiofrequency Ablation of Peripheral Nerves to Treat Pain | Annual Review, approved October 19, 2017. Policy updated with literature review through July 20, 2017; no references added. Policy statement clarified; added “including but not limited to”. | 7.01.154 | 11/01/2017 | 10/31/2017 |
| 7.01.533 Reconstructive Breast Surgery/Management of Breast Implants | Interim Review, approved October 19, 2017. Added indications to medical necessity criteria: reduce risk of breast cancer occurrence, and treat disease (severe fibrocystic disease unresponsive to medical therapy). | 7.01.533 | 11/01/2017 | 10/31/2017 |
| 7.01.558 Rhinoplasty | Interim Review, approved October 10, 2017. Added trauma and other congenital craniofacial deformity to medical necessity statement. Clarified list of conservative care of obstructive symptoms. No new references added. | 7.01.558 | 11/01/2017 | 10/31/2017 |
| 7.01.562 Intraoperative Neurophysiologic Monitoring | New policy, approved Oct 10, 2017, effective Feb 2, 2018. Policy was previously archived, now reinstated. Literature review through Oct 11, 2016. Considered medically necessary for high risk thyroid and anterior cervical spine surgeries when criteria met. | 7.01.562 | 02/02/2018 | 10/31/2017 |
| 7.01.78 Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions | New policy, approved Oct 10, 2017, effective Feb 2, 2018. This policy was previously archived (7.01.506), now being reinstated. Service may be considered medically necessary when criteria are met, investigational when not met and for add’l indications. | 7.01.78 | 02/02/2018 | 10/31/2017 |
| 7.01.95 Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors | Annual Review, approved October 19, 2017. Policy updated with literature review through July 20, 2017; reference 59 added. Policy statements unchanged. | 7.01.95 | 11/01/2017 | 10/31/2017 |
| 7.03.11 Total Artificial Hearts and Implantable Ventricular Assist Devices | Annual review approved Oct 10, 2017. Literature review through July 22, 2017; references added. Policy statements revised to add information regarding total artificial hearts and implantable ventricular assist devices, Coding updated. | 7.03.11 | 11/01/2017 | 10/31/2017 |
| 8.01.503 Immune Globulin Therapy | Interim Review, approved October 10, 2017. Policy updated to address different therapy approach for ITP; pediatrics versus adults. Additional detail for alternative treatments added. Clarified site of service exception criterion related to access. | 8.01.503 | 11/01/2017 | 10/31/2017 |
| 8.01.505 Transcatheter Arterial Chemoembolization as a Treatment for Primary or Metastatic Liver Malignancies | Annual Review, approved Sept 5, 2017. References updated and added. Minor addition to policy statement, no changes to intent. | 8.01.505 | 10/01/2017 | 09/30/2017 |
| 8.01.61 Focal Treatments for Prostate Cancer | Annual Review, approved October 19, 2017. Policy updated with literature review through July 20, 2017; reference 16 added. Policy statement unchanged. | 8.01.61 | 11/01/2017 | 10/31/2017 |
| 8.03.01 Functional Neuromuscular Electrical Stimulation | Annual Review, approved September 21, 2017. Policy moved into new format. Policy updated with literature review through June 22, 2017; reference 1 added. Policy statement unchanged. *This policy varies slightly from the BCBSA Reference Policy. | 8.03.01 | 10/01/2017 | 09/30/2017 |
| 8.03.05 Outpatient Pulmonary Rehabilitation | Annual Review, approved October 19, 2017. Policy updated with literature review through January 25, 2017; references 3, 12, 14, 18, 26, and 30 added. Policy statements unchanged. | 8.03.05 | 11/01/2017 | 10/31/2017 |
Click here to view the Premera Blue Cross November 2017 Medical Policy Updates »
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