Medical Policy Updates

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Blue Cross and Blue Shield of North Carolina Medical Policy Update August 10, 2021

Medical Guidelines Reason for Update
DNA Ploidy Cell Cycle Analysis AHS – M2136 Reviewed by Avalon 2nd Quarter 2021 CAB. Updated Description and Policy Guidelines. References added. Medical Director review 7/2021.
Extracorporeal Shock Wave Treatment for Musculoskeletal Conditions and Wound Healing References added. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 6/16/2021
Facet Joint Denervation Policy Guidelines item 5 updated with “Prior success is defined as 50% or more pain relief documented in medical record”. References added. Code 64625 added to Billing/Coding section. Specialty Matched Consultant Advisory Panel review 4/2021. Medical Director review 4/2021. Notification 6/1/2021 for effective date 8/10/2021.
Folate Testing AHS – G2154 Reviewed by Avalon 2nd Quarter 2021 CAB. Updated Description and policy guidelines. Added references. Medical Director review 7/2021.
General Inflammation Testing AHS – G2155 Reviewed by Avalon 2nd Quarter 2021 CAB. Updated Description, Policy Guidelines and Reference sections. Medical Director review 7/2021.
Immunohistochemistry AHS – P2018 Specialty Matched Consultant Advisory Panel 02/17/2021. Medical Director review 7/21/2017. Wording in policy, Indication and/or limitations of coverage, updated for clarifications of coverage for code 88341 and 88342.
Interferential Stimulation Reference added
Multigene Expression Assay for Predicting Colon Cancer Recurrence AHS-M2111 Reviewed by Avalon 2nd Quarter 2021 CAB. Updated Description and Policy Guidelines. Added related policies section. Updated references. Medical Director review 7/2021.
Navigated Transcranial Magnetic Stimulation (nTMS) Reference added. Policy Guidelines updated.
Neurostimulation, Electrical Additional sections titled “Peripheral Subcutaneous Field Stimulation” and “Threshold Electrical Stimulation” added to policy. Related policies updated. Policy statement updated to read “Functional Neuromuscular Electrical Stimulation, Peripheral Subcutaneous Field Stimulation, Neuromuscular Electrical Stimulation, and Threshold Electrical Stimulation are considered investigational for all applications”. Medical Director review. Policy noticed 6/1/2021 for effective date 8/10/2021.
Pancreatic Cancer Risk Testing Using Molecular Classifier in Pancreatic Cyst Fluid AHS-M2114 Reviewed by Avalon 2nd Quarter 2021 CAB. Updated Description and added references. Medical Director review 7/2021.
Polysomnography for Non‒Respiratory Sleep Disorders Reference added.
Quantitative Sensory Testing References added. Related policy removed.
Skin and Soft Tissue Substitutes Added information to When Skin and Soft Tissue Substitutes are covered criteria to include clarification of 2nd and 3rd degree burn products. Also added PuraPly® and StrataGraft® to products that are covered.