Download A. Cosmetic Procedures vs. Reconstructive Procedure

BCNEPA Medical Policy Updates effective June 1, 2005
Bone Mineral Density Studies
BCNEPA shall provide coverage for ultrasound of the heel for the diagnosing of osteoporosis and
selecting patients for pharmacologic treatment.
Experimental/Investigational
BCNEPA shall not provide coverage for the following services since they are considered
experimental/investigative:
A. Cosmetic Procedures vs. Reconstructive Procedure:
1. In patients with documented reflux of the saphenofemoral junction or reflux isolated to the
perforator veins of the upper thigh, sclerotherapy of varicose tributaries when performed
without associated treatment of the source of reflux. Procedure codes 36470, injection of
sclerosing solution and 36471, multiple veins.
2. Subfascial endoscopic perforator surgery as a treatment of chronic venous insufficiency.
Procedure code 37500 vascular endoscopy surgical with ligation of perforator veins,
subfascial (SEPS).
3. Laser ablation of the saphenous vein as an alternative to saphenous vein ligation and
stripping.
B. Electrical/Neuromuscular Stimulator
1. Deep Brain Stimulation for the treatment of chronic cluster headaches.
2. Electrophrenic pacemaker for the following conditions:
a. Chronic Obstructive Pulmonary Disease (COPD)
b. Young children and infants
c. Treatment of hiccups
C. Medicine
1. Intracranial percutaneous transluminal angioplasty with or without stenting.
2. Quantitative sensory testing including current perception threshold testing and pressurespecified sensory device testing.
D. Outpatient Therapies
1. Low Level Laser Therapy as a Treatment of Carpal Tunnel Syndrome. Procedure code
S8948, application of a modality (requiring constant provider attendance) to one or more
area; low level laser.
E. Pathology/Laboratory
1. Assays of genetic expression in tumor tissue as a technique to determine prognosis in
patients with breast cancer.
2. Combined genotypng and phenotyping for HIV. Procedure codes 87901, infectious agent
genotype analysis by nucleic acid (DNA or RNA) HIV 1, reverse transcriptase and
protease; 87903, infectious agent phenotype analysis by nucleic acid (DNA or RNA) with
drug resistance tissue culture analysis, HIV 1, up to 10 drugs; 87904, each additional 1
through 5 drugs tested.
F. Surgery
1. Deep brain stimulation for the treatment of cluster headaches.
2. Electrophrenic pacemaker for the following conditions:
a. Chronic Obstructive Pulmonary Disease (COPD)
b. Young children and infants
c. Treatment of hiccups.
3. The use of Automatic Implantable Cardioverter Defibrillator (AICD) in primary patients
who:
a. Have had an acute myocardial infarction (i.e. less than 40 days before AICD
treatments;
b. Have New York Heart Association (NYHA) class IV congestive heart failure
(unless patient is eligible to receive a combination cardiac resynchronization
therapy ICD device;
c. Have had cardiac revascularization procedure in past 3 months (coronary artery
bypass great (CABG) or percutaneous transluminal coronary angioplasty (PTCA)
or are candidates for a cardiac revascularization procedures;
d. Have non-cardiac disease that would be associated with life expectancy less
than one (1) year.
4. Total hip resurfacing.
G. Therapy
1. Intradyalitic parenteral nutrition in those patients who would not otherwise be considered
candidates for TPN.
2. Interleukin-2 therapy as a treatment of HIV.
3. Other applications of nonmyeloablative allogeneic stem-cell transplantation, including its
use in patients who do not meet criteria for high dose chemotherapy and allogeneic stemcell transplantation due to either age or comorbidities, or as a treatment of other
malignancies, including, but not limited to, multiple myeloma, renal cell carcinoma, other
solid tumors or au to immune disease.
If you have questions regarding coverage/authorization, please contact 1-888-827-7117 for
questions on Blue Cross Traditional coverage, 1-866-262-5635 for questions on Access Care II
coverage or 1-800-822-8752 to reach the Provider Services Unit with questions on First Priority
Health coverage. PLEASE NOTE: Procedure Codes are subject to change without written
notification. Medical policy is not an authorization, certification, explanation of benefits or a
contract. Benefits and eligibility are determined before medical policy and claims payment policy
are applied. This document is provided for informational purposes only and is based on research
of current medical literature and review of common medical practices in the treatment and
diagnosis of disease. Medical practices and information are constantly changing and BCNEPA
reserves the right to review and revise its medical policies periodically