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Commercial Medical Policy Update for April 1, 2024
| Medical Guidelines | Reason for Update |
|---|---|
| Ablation and Neural Therapy Procedures for Headache and Pain Management (PDF) | Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 2/2024. Medical Director Review 2/2024. |
| Ablative Techniques for the Myolysis of Uterine Fibroids (PDF) | References added. Specialty Matched Consultant Advisory Panel review 3/2024. Medical Director review 3/2024. No change to policy statement. |
| Balloon Dilation of the Eustachian Tube (PDF) | Policy statement revised as follows: “BCBSNC will provide coverage for Balloon Dilation of the Eustachian Tube when it is determined to be medically necessary because the medical criteria and guidelines shown below are met.” When Covered section revised with medically necessary criteria for BDET. When Not Covered section revised to include when BDET is investigational and not covered. Updated Description, Policy Guidelines, and References. Medical Director review 2/2024. Specialty Matched Consultant Advisory Panel review 2/2024. |
| Bone Mineral Density Studies (PDF) | Policy Guidelines updated. References updated. Specialty Matched Consultant Advisory Panel review 3/2024. Medical Director review 3/2024. No change to Policy statement. |
| Bone Morphogenetic Protein (PDF) | Removed Note: This policy only addresses Bone Morphogenetic Proteins. See the BCBSNC policies titled. “Orthopedic Applications of Stem Cell Therapy” and “Growth Factors in Wound Healing” for information regarding treatments for tissue repair and tissue substitutes. For information regarding spinal fusion procedure, please see the BCBSNC policy titled “Lumbar Spine Fusion Surgery.” Added related policies section. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 2/2024. Medical Director review 2/2024. |
| Bronchial Thermoplasty (PDF) | Description, Policy Guidelines, and References updated. Specialty Matched Consultant Advisory Panel review 3/2024. Medical Director review 3/2024. No change to policy statement. |
| Cervical Spine Procedures (PDF) | Reference added. Specialty Matched Consultant Advisory Panel review 2/2024. Medical Director review 2/2024. |
| Convection-Enhanced Delivery of Therapeutic Agents to the Brain (PDF) | Specialty Matched Consultant Advisory Panel review 3/20/2024. Updated references. No change to policy statement. |
| Cord Blood as a Source of Stem Cells (PDF) | Specialty Matched Consultant Advisory Panel review 3/20/2024. No change to policy statement. |
| Electromagnetic Navigation Bronchoscopy (PDF) | Specialty Matched Consultant Advisory Panel review 3/2024. Policy Guidelines and References updated. Medical Director review 3/2024. No change to policy statement. |
| Endobronchial Valves (PDF) | Description, Policy Guidelines, and References updated. Specialty Matched Consultant Advisory Panel review 3/2024. Medical Director review 3/2024. No change to policy statement. |
| Heart-Lung Transplantation (PDF) | Description, Regulatory Status, and Policy Guidelines updated. References added. Specialty Matched Consultant Advisory Panel review 3/2024. Medical Director review 3/2024. |
| Hormone Pellet Implantation for Treatment of Menopause Related Symptoms (PDF) | Specialty Matched Consultant Advisory Panel review 3/2024. Medical Director Review 3/2024. Removed J3490 from Billing/Coding section. No change to policy statement. |
| Infertility Diagnosis and Treatment – B0006 (PDF) | Description updated to define infertility as defined by American Society for Reproductive Medicine (ASRM). References updated. Specialty Matched Consultant Advisory Panel review 3/2024. Medical Director review 3/2024. No change to policy statement. |
| Lung and Lobar Lung Transplantation (PDF) | References added. Specialty Matched Consultant Advisory Panel review 3/2024. Medical Director review 3/2024. No change to policy statement. |
| Lung Volume Reduction Surgery (PDF) | Description and References updated. Specialty Matched Consultant Advisory Panel review 3/2024. Medical Director review 3/2024. No change to policy statement. |
| Maternal and Fetal Diagnostics (PDF) | References updated. Specialty Matched Consultant Advisory Panel review 3/2024. Medical Director review 3/2024. No change to policy statement. |
| Microprocessor-Controlled Prostheses for the Lower Limb (PDF) | Minor edits to Description Section. Deleted HCPCS codes K1014 and K1022 removed from the Billing/Coding section. Specialty Matched Consultant Advisory Panel review 2/2024. Medical Director review 2/2024. |
| Monoclonal Antibody Imaging for Prostate Cancer (PDF) | Specialty Matched Consultant Advisory Panel review 3/20/2024. Reference added. No change to policy statement. |
| Noninvasive Respiratory Assist Devices (PDF) | References added. Specialty Matched Consultant Advisory Panel review 3/2024. Medical Director review 3/2024. No change to policy statement. |
| Oncologic Applications of Photodynamic Therapy, Including Barrett’s Esophagus (PDF) | Specialty Matched Consultant Advisory Panel review 3/20/2024. References added. No change to policy statement. |
| Orthopedic Applications of Stem Cell Therapy (PDF) | References added. Minor edits to background section. Specialty Matched Consultant Advisory Panel review 2/2024. Medical Director review 2/2024. |
| Orthotics (PDF) | Removed CPT code 97762 from Billing/Coding section and added CPT code 97763 as replacement code. Reference added. Specialty Matched Consultant Advisory Panel review 2/2024. Medical Director review 2/2024. |
| Oscillatory Devices for the Treatment of Respiratory Conditions (PDF) | Policy guidelines updated for clarity. References added. Specialty Matched Consultant Advisory Panel review 3/2024. Medical Director review 3/2024. No changes to policy statement. |
| Ovarian and Internal Iliac Vein Embolization, Ablation and Sclerotherapy (PDF) | Description and Policy Guidelines updated. References added. Specialty Matched Consultant Advisory Panel review 3/2024. Medical Director Review 3/2024. No change to policy statement. |
| Percutaneous Electrical Nerve Stimulation (PENS) or Neuromodulation Therapy and Percutaneous Electrical Nerve Field Stimulation (PENFS) (PDF) | Added HCPCS code A4438 to Billing/Coding section, effective 4/1/24. |
| Phrenic Nerve Stimulation for Central Sleep Apnea (PDF) | Description and References updated. Specialty Matched Consultant Advisory Panel 3/2024. Medical Director review 3/2024. No changes to policy statement. |
| Powered Exoskeleton for Ambulation in Patients with Lower Limb Disabilities (PDF) | Updated Regulatory Status. References added. Specialty Matched Consultant Advisory Panel review 2/2024. Medical Director review 2/2024. |
| Private Duty Nursing Services (PDF) | References updated. Specialty Matched Consultant Advisory Panel review 2/2024. Medical Director review 2/2024. No change to policy statement. |
| Rehabilitative Therapies (PDF) | The following statement was added to the Billing/Coding section: “PT, OT services are each limited to one hour (4 units) for the combinations of codes submitted.” Update effective 3/27/24. |
| Skin and Soft Tissue Substitutes (PDF) | Added HCPCS codes C1762, C1763, A2026, Q4305, Q4306, Q4307, Q4308, Q4309, Q4310 to Billing/Coding section, effective 4/1/2024. |
| Sleep Apnea: Diagnosis and Medical Management (PDF) | References added. Specialty Matched Consultant Advisory Panel Review 3/2024. Medical Director Review 3/2024. Added HCPCS code K1037 to Billing/Coding section, effective date 4/1/2024. No change to policy statement. |
| Subtalar Arthroereisis (PDF) | Updated Description section to add additional FDA approved Subtalar Implant Devices. Reference added. Specialty Matched Consultant Advisory Panel review 2/2024. Medical Director review 2/2024. |
| Surgery for Obstructive Sleep Apnea and Upper Airway Resistance Syndrome (PDF) | References updated. When covered section updated for alignment with Food and Drug Administration approved indications: II.H.1 updated to include hypoglossal nerve stimulation may be considered medically necessary in individuals age ≥ 18 years; and II.H.4 updated to include hypoglossal nerve stimulation may be considered medically necessary for individuals with BMI ≤ 40 kg/m2. Billing/Coding section updated to remove deleted CPT code 41500. Specialty Matched Consultant Advisory Panel review 3/2024. Medical Director review 3/2024. No change to policy statement. |
| Synthetic Cartilage Implants for Joint Pain (PDF) | Reference added. Specialty Matched Consultant Advisory Panel review 2/2024. Medical Director review 2/2024. |
| Three Dimensional Printed Orthopedic Implants (PDF) | Reference added. Specialty Matched Consultant Advisory Panel review 2/2024. Medical Director review 2/2024. |
| Ultrasound Accelerated Fracture Healing Device (PDF) | Description Section updated with new FDA definition of Non-union. Added Information regarding The AccelStim™ Bone Growth Stimulator. Updated references. Specialty Matched Consultant Advisory Panel review 2/2024. Medical Director review 2/2024. |
| Wheelchairs (Manual and Power Operated (PDF) | Code changes effective 4/1/24: new code E2298 added and code E2300 deleted. Codes are included in code range E2201-E2398 listed under the Billing/Coding section. |
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