Download Provider Bulletin August 2005 Issue BCNEPA Medical Policy

Provider Bulletin August 2005 Issue
BCNEPA Medical Policy Updates Effective September 1, 2005
Cosmetic Procedures vs. Reconstructive Procedures
BCNEPA shall provide coverage for the treatment of varicose veins where the following criteria are met:
Sclerotherapy, stripping, ligation or transilluminated powered phlebectomy system (TPPS) of varicose leg
veins may be considered medically necessary and, therefore, eligible for payment for those patients who
meet all of the following criteria:
1. The patient must be symptomatic with pain, burning or severe itching or there must be documented
chronic skin changes, edema, ulceration or bleeding;
2. The veins are bulging above the skin’s surface;
3. The varicosities are at least 5mm in size;
4. Medical management, including simple analgesics, compression therapy, modified activity, and
elevation, and have not provided improvement of signs and symptoms over a six- (6) week period of
time; and
5. There is no sapheno-femoral insufficiency or disease/occlusion of the deep venous system as
evidenced by Doppler studies.
Ligation, radiofrequency ablation or laser ablation of the greater saphenous vein may be considered
medically necessary and, therefore, eligible for payment in patients who meet all of the following criteria:
1. The patient must be symptomatic with pain, burning, or heaviness of the leg not responding to
simple analgesics;
2. There must be documented skin changes, edema, or enlargement of the extremity or documentation
of at least one episode of phlebitis, or two episodes of minor bleeding or one episode of major
bleeding evidenced by the drop in hemoglobin of 2g or the need for a blood transfusion;
3. Conservative treatment such as compression therapy, modified activity and elevation have not
provided improvement of signs and symptoms over a six- (6) week period of time; and
4. There is demonstrated sapheno- femoral insufficiency by ultrasound.
Experimental/Investigative Services
BCNEPA shall not provide coverage for the following services because they are considered
experimental/ investigative:
A. Obstetrical/Gynecological
The daily use of a home uterine activity monitor (HUAM) alone is considered investigational as
secondary prevention in women at high risk for experiencing preterm birth who have not experienced
preterm labor in the current pregnancy.
The use of daily nursing contact alone is considered investigational as secondary prevention in women at
high risk for experiencing preterm birth who have not experienced preterm labor in the current pregnancy.
The daily use of the HUAM device in combination with nursing contact is considered investigational as
secondary prevention in women at high risk for experiencing preterm birth who have not experienced
preterm labor in the current pregnancy.
The use of a HUAM device, with or without nursing contact is considered investigational in tertiary
prevention of preterm birth, defined as monitoring of patients who have already experienced preterm
labor in the current pregnancy, and have experienced successful arrest of labor with tocolytic drugs.
Serial monitoring of salivary estriol levels as a technique of risk assessment for preterm labor or
delivery.
B. Pathology/Laboratory
Analysis of proteomic patterns in serum for screening and detection of cancer.
Provider Bulletin August 2005 Issue
C. Radiology
Wireless capsule endoscopy of the esophagus.
D. Therapy
Transcatheter hepatic arterial chemoembolization as a bridge to liver transplantation in patients with
hepatocellular cancer.
Hyperbaric Oxygen (HBO) Therapy
BCNEPA shall not provide coverage for systemic hyperbaric oxygenation for the following indications as
these are listed as investigational:
1. As an adjunct to percutaneous coronary interventions;
2. Acute ischemic stroke; and
3. Idiopathic sudden sensorineural hearing loss.
Photodynamic Therapy
BCNEPA shall provide coverage for photodynamic therapy with methyl aminolevulinate and exposure to
red light as a treatment of non-hyperkeratotic actinic keratoses of the face and scalp.
BCNEPA shall provide coverage for photodynamic therapy with topical ALA and exposure to blue light
as a treatment of non-hyperkeratotic actinic keratoses of the face and scalp.
BCNEPA shall consider photodynamic therapy with topical ALA and exposure to blue light investigational
for other dermatological applications, including, but not limited to squamous carcinoma, basal carcinoma,
hidradenitis suppurativa, or Bowen’s disease.
BCNEPA shall not provide coverage for photodynamic therapy with methyl aminolevulinate and
exposure to red light for the treatment of other dermatologic applications, including, but not limited to,
basal cell carcinomas, Bowen’s disease, acne vulgaris, mycoses, or squamous carcinoma because
these are considered investigational.
Morbid Obesity
Documentation of repeated failure of multiple (at least three) rigorous and supervised weight loss
attempts of at least six-month’s duration each, for example, Weight Watchers, Jenny Craig or a physiciansupervised weight loss program.
Sleep Disorder Services
Clinically significant upper airway resistance syndrome (UARS) is defined as:
1. Greater than 10 alpha EEG arousals per minute. The presence of abnormally negative intrathoracic
pressure (i.e., more negative than 10 cm) in conjunction with the EEG arousals supports the
diagnosis. The measurement of intrathoracic pressures requires the use of an esophageal
manometer as an adjunct to a polysomnogram.
2. Objective evidence of hypopharyngeal obstruction is documented by either:
a) Fiberoptic endoscopy; or
b) Cephalometric radiographs.
BCNEPA shall not provide coverage for the following indications because they are considered
investigational/ experimental:
1. Palatal stiffening procedures including, but not limited to, cautery-assisted palatal stiffening operation
and the implantation of palatal implants as a treatment for upper airway resistance syndrome or
obstructive sleep apnea.
Surgery
BCNEPA shall provide coverage for minimally invasive hip replacement surgery.
Transplant
Provider Bulletin August 2005 Issue
BCNEPA shall provide coverage for the following transplants based on medical necessity:
1. Ventricular assist devices with FDA-approved or cleared devices as a bridge to heart transplantation
for patients who are currently listed as heart transplantation candidates;
2. Total artificial hearts with FDA approval or clearance devices as a bridge to heart transplantation for
patient with biventricular failure, who are currently listed as heart transplantation candidates and who
are not candidates for a left ventricular assist device;
3. Ventricular assist devices with FDA approval or cleared devices in the post-cardiotomy setting in
patients who are unable to be weaned off cardiopulmonary bypass;
4. Ventricular assist devices with FDA approval or cleared devices as destination therapy with end
stage heart failure who are ineligible for human heart transplant and who meet the following criteria:
a) New York Heart Association (NYHA) class IV heart failure for >=60 days, OR patients in NYHA
class II/IV for 28 days received >=14 days support with intra-aortic balloon pump or dependent on
IV inotropic agents, with failed weaning attempts; and
b) b) Peak 0-2 consumption =<14 ml/kg.
In addition, patients must not be candidates for human heart transplant for one or more of the following
reasons:
1. Age > 65 years; or
2. Insulin-dependent diabetes mellitus with end organ damage; or
3. Chronic renal failure (serum Creatinine > 2.5 mg/dl for >=90 days); or
4. Presence of other clinically significant condition.
Wound Care
BCNEPA shall provide coverage for vacuum-assisted closure of chronic wounds (VAC system). This will
be applied toward the Durable Medical Equipment benefit limit.
-REMINDERPhotochemotherapy
Alopecia areata, 704.01, is a non-covered diagnosis code.
If you have questions regarding coverage/authorization, please contact 1-888-827-7117 about
BlueCare Traditional coverage, 1-866-262-5635 about BlueCare PPO coverage or 1-800-8228752 to reach the Provider Services Unit about BlueCare HMO and BlueCare POS 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. (Policy Update 0708004)