Medical Policy Updates

Blue Cross and Blue Shield of North Carolina Medical Policy Update June 1, 2021

Medical Guidelines Reason for Update
Automated Percutaneous and Endoscopic Discectomy Reference added. Specialty Matched Consultant Advisory Panel review 5/19/2020.
Beta Amyloid Imaging With Positron Emission Tomography for Alzheimer’s Disease References updated. Specialty Matched Consultant Advisory Panel review 5/2021. Medical Director review 5/2021. No change to policy statement.
Bundling Guidelines The following sections were removed from policy and moved to new commercial reimbursement policy “Evaluation and Management Services”: New Visit Frequency, After Hours Care, Immunization Administration, Medical Records Copying Fee, Durable Medical Equipment Determination, Prolonged Evaluation and Management Service, and Resource Intensive Service.
Chemoembolization of the Hepatic Artery, Transcatheter Approach Description section updated. Policy guidelines section: National Comprehensive Cancer Network Guidelines updated. References added. Specialty Matched Consultant Advisory Panel review 5/2021. Medical Director review 5/2021.
Cranial Electrotherapy Stimulation (CES) and Auricular Electrostimulation Reference added. Related policy added. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 5/19/2021.
Electrogastrography, Cutaneous Specialty Matched Consultant Advisory Panel 5/2021. Medical Director review 5/2021
Endovascular Procedures for Intracranial Arterial Disease Reference added. Specialty Matched Consultant Advisory Panel review 5/19/2021.
Endovascular Therapies for Extracranial Vertebral Artery Disease Reference added. Specialty Matched Consultant Advisory Panel review 5/19/2021.
Epidural Steroid Injections for Back Pain Policy guidelines updated. References added. Specialty Matched Consultant Advisory Panel review 4/2021. Medical Director review 4/2021. No change to policy statement.
Esophageal pH Monitoring References updated. Specialty Matched Consultant Advisory Panel 5/2021. Medical Director review 5/2021.
Evaluation and Management Services New policy developed. Blue Cross Blue Shield North Carolina (Blue Cross NC) will limit reimbursement for E&M services according to the guidelines outlined in this policy. Medical Director review 3/2021. Policy noticed 3/31/2021 for effective date 6/1/2021.
Facet Joint Denervation When not covered section updated to include “cooled radiofrequency ablation (e.g., COOLIEF) “. Medical Director review. Notification 3/31/2021 for effective date 6/1/2021
Fecal Analysis in the Diagnosis of Intestinal Dysbiosis and Fecal Microbiota Transplant Testing AHS – G2060 Specialty Matched Consultant Advisory Panel review 5/2021. Medical Director review 5/2021.
Gastric Electrical Stimulation References updated. Specialty Matched Consultant Advisory Panel 5/2021. Medical Director review 5/2021.
Helicobacter Pylori Testing AHS – G2044 Specialty Matched Consultant Advisory Panel review 5/2021. Medical Director review 5/2021
Image-Guided Minimally Invasive Decompression (IG-MLD) for Spinal Stenosis Reference added. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 5/19/2021.
Interspinous Fixation (Fusion) Devices Reference added. Specialty Matched Consultant Advisory Panel review 5/19/2021.
Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers) Reference added. Related policy added. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 5/19/2021
Intraoperative Neurophysiologic Monitoring Reference added. When Covered section updated for additional clarity regarding Practice Standards. When Not Covered section updated for additional clarity regarding not medically necessary uses. Specialty Matched Consultant Advisory Panel review 5/19/2021.
Investigational (Experimental) Services COVID-19 related changes extended “effective from March 6, 2020 through December 31, 2021. We will reevaluate if an additional extension is needed as we approach December 31.”
Lumbar Spine Fusion Surgery Reference added. Related Policies updated. Specialty Matched Consultant Advisory Panel review 5/19/2021.
Magnetic Resonance Spectroscopy Description Guidelines updated. References added. Specialty Matched Consultant Advisory Panel review 5/2021. No change to policy statement.
Modifier Guidelines Updated modifier 25 to redirect to Evaluation and Management Services policy.
MRI-Guided Focused Ultrasound (MRgFUS) Reference added. Specialty Matched Consultant Advisory Panel review 5/2021. Medical Director review. No change to policy statement.
Myocardial Sympathetic Innervation Imaging Reference added. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 5/2021. Medical Director review. No change to policy statement.
Noninvasive Respiratory Assist Devices Description section updated. Specialty Matched Consultant Advisory Panel review 3/2021. Medical Director review 4/2021.
Occipital Nerve Stimulation Reference added. Related policy added. Specialty Matched Consultant Advisory Panel review 5/19/2021.
Pancreas Transplant Description section and references updated. Specialty Matched Consultant Advisory Panel 5/2021. Medical Director review 5/2021.
Pancreatic Enzyme Testing for Acute Pancreatitis AHS – G2153 Specialty Matched Consultant Advisory Panel review 5/2021. Medical Director review 5/2021
Peroral Endoscopic Myotomy for Treatment of Esophageal Achalasia References updated. Specialty Matched Consultant Advisory Panel 5/2021. Medical Director review¬ 5/2021.
Positional Magnetic Resonance Imaging (MRI) References added. Specialty Matched Consultant Advisory Panel review 5/2021. Medical Director review 5/2021. No change in policy statement.
Screening for Vertebral Fracture with Dual X-ray Absorptiometry (DXA) Reference added. Specialty Matched Consultant Advisory Panel review 5/2021. Medical Director review 5/2021. No change to policy statement.
Serum Testing for Hepatic Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease AHS – G2110 Specialty Matched Consultant Advisory Panel review 5/2021. Medical Director review 5/2021.
Skin and Soft Tissue Substitutes When covered section “Dural Reconstruction/Repair” updated for clarity and added spinal to criteria. Medical Director review.
Small Bowel, Small Bowel with Liver, or Multivisceral Transplant References updated. Specialty Matched Consultant Advisory Panel 5/2021. Medical Director review 5/2021.
Therapeutic Radiopharmaceuticals in Oncology Reference added. Specialty Matched Consultant Advisory Panel review 5/2021. Medical Director review.