Notification of Policy Revisions Effective November 15, 2022 (Posted September 13, 2022)

Medical Policy	Revision
Adaptive Behavioral Treatment for Autism Spectrum Disorders	Added the following statement to When Covered Section: “There is an established DSM-5 diagnosis of Autism Spectrum Disorder diagnosed by a psychiatrist, psychologist, neurologist, developmental pediatrician, or other licensed physician experienced in the diagnosis and treatment of autism. Medical Director review 8/2022. Notification given 9/13/2022 for effective date 11/15/2022.
Breast Surgeries	Section V Surgical Management of Breast Implants description updated. Section V When Covered section updated to include the following statement: “Removal of breast implants with capsulectomy/capsulotomy is considered medically necessary when the following criteria has been met (See Policy Guidelines): Baker Class III contractures (only if the initial implant was for reconstructive purposes), Baker Class IV contracture.” And “Removal of a breast implant and capsulectomy is covered, regardless of the indication for the initial implant placement, for: Treatment of Anaplastic Lymphoma of the breast when there is pathologic confirmation of the diagnosis by cytology or biopsy; or Individuals with an increased risk of implant-associated Anaplastic Lymphoma of the breast due to use of Allergan BIOCELL textured breast implants and tissue expanders.” Section V When not Covered section updated to include the following statement: “Removal of breast implants with capsulectomy/capsulotomy is not covered for Baker Class III contractures in patients with implants for cosmetic purposes.” Section V Policy Guidelines Updated to include Baker Classification System. Added codes 19370 and 19371 to Section V Billing/Coding Section, References updated. Medical Director Review 8/2022. Specialty Matched Consultant Advisory Panel review 8/2022. Notification given 9/13/2022 for effective date 11/15/2022.
Coronavirus Testing in the Outpatient Setting AHS-G2174	New policy developed. BCBSNC will provide coverage for Coronavirus Testing in the Outpatient Setting when medical criteria and guidelines outlined in the policy are met. Medical Director review 7/2022. Notification give 9/13/2022 for effective date 11/15/2022.
Genetic Testing for Mental Health Disorders M2084	New policy developed. Genetic Testing for Mental Health Disorders is considered investigational for all applications. BCBSNC does not provide coverage for investigational services or procedures. Medical Director review 7/2022. Notification given 9/13/2022 for effective date 11/15/2022.

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