Medical Policy and Clinical Guideline Updates The Medical Policy and Technology Assessment Committee has adopted the following new and/or revised Medical Policies and Clinical Guidelines. Some may have expanded rationales, medical necessity indications or criteria and some may involve changes to policy position statements that might result in services that previously were covered being found to be either not medically necessary or investigational/experimental. All BCBSGa Medical Policies and Clinical Guidelines are available at bcbsga.com (Providers > Choose Medical Policies). Nationally recommended Clinical Practice Guidelines for Attention Deficit/Hyperactivity Disorder (ADHD), Depression, and Substance Use Disorders are available by selecting Provider>Quality Program Information>Clinical Practice Guidelines. Effective Dates are as follows: August 23, 2007: o ADMIN.00002 Preventive Health Guideline o CG-TRANS-02 Kidney Transplantation o BEH.00004 Treatment of Autism, Asperger s Syndrome, Rett Syndrome, Childhood Disintegrative Disorder, and Pervasive Development Disorder Not Otherwise Specified (NOS) o New Pharmacology Toolkits September 21, 2007 - GENE.00011 Gene Expression Profiling for Breast Cancer October 15, 2007: All other Medical Policies and Adopted Clinical UM Guidelines If you do not have access to the Internet, you may request a hard copy of a specific Medical or Behavioral Health Policy or Clinical Guideline by calling our Customer Care Center at (800) 241-7475 Monday through Friday from 7 AM to 9 PM or send written requests (specifying the medical policy or guideline of interest, your name and address to where the information should be sent) to: Blue Cross Blue Shield of Georgia Blue Cross Blue Shield Healthcare Plan of Georgia Attention: Prior Approval, Mail Code GAG009-0002 3350 Peachtree Road NE Atlanta, GA 30326
ADMIN.00002 Preventive Health Guidelines ANC.00006 Biomagnetic Therapy BEH.00004 Treatment of Autism, Asperger's Syndrome, Rett Syndrome, Childhood Disintegrative Disorder, and Pervasive Development Disorder (NOS) DME.00004 Electrical Bone Growth Stimulation DME.00009 Vacuum Assisted Wound Therapy in the Outpatient Setting DME.00019 Continuous Passive Motion Devices DME.00023 ibot Mobility System DME.00024 Transtympanic Micropressure for the Treatment of Meniere's Disease (including Meniett device) DME.00028 Stretching Devices for the Treatment of Joint Stiffness and Contracture DME.00030 Altered Auditory Feedback (AAF) Devices for the Treatment of Stuttering DME.00033 TempTouch Dermal Thermometer DRUG.00004 Prostacyclin Infusion Therapy for Treatment of Pulmonary Hypertension (Epoprostenol [Flolan ], Treprostinil [Remodulin ]) DRUG.00009 Growth Hormone DRUG.00015 Prevention of Respiratory Syncytial Virus Infections DRUG.00024 Omalizumab (Xolair ) for Treatment of Asthma DRUG.00028 Treatment for Age Related Macular Degeneration DRUG.00029 Nebulized Corticosteroids for the Treatment of Nasal Polyps DRUG.00030 Histamine Desensitization Therapy DRUG.00031 Hormone Replacement Implants DRUG.00032 Fluocinolone Acetonide Intravitreal Implant GENE.00002 Preimplantation Genetic Diagnosis Testing GENE.00011 Gene Expression Profiling for Managing Breast Cancer Treatment LAB.00016 Fecal Analysis in the Diagnosis of Intestinal Dysbiosis MED.00002 Diagnosis of Sleep Disorders MED.00004 Technologies for the Evaluation of Skin Lesions (including Dermatoscopy, Epiluminesence Microscopy, Videomicroscopy, Ultrasonography) MED.00008 Ultraviolet Light, Including Laser Therapy, for the Treatment of Skin Disorders MED.00017 Photodynamic Therapy MED.00041 Microvolt T-Wave Alternans Testing MED.00045 Wireless Esophageal ph Monitoring MED.00054 Treatment for Obstructive Sleep Apnea in Adults MED.00055 Wearable Cardioverter Defibrillators MED.00065 Hepatic Activation Therapy (CIIIT/PIVIT)
MED.00067 Dry Hydrotherapy (Hydromassage) MED.00068 Electrical Stimulation for the Treatment of Facial Palsy MED.00069 Carotid Intimal Medial Thickness Measurement MED.00070 Nocturnal Enuresis Correction Interventions MED.00072 Rhinomanometry and Acoustic Rhinometry MED.00073 Treatment of Tinnitus MED.00075 Correlated Audioelectric Cardiography MED.00077 Fiberoptic Analysis of Colorectal Polyps MED.00078 Cutaneous Electrogastrography MED.00079 Spinal Manipulation Under Anesthesia MED.00080 Cryopreservation of Oocytes or Ovarian Tissue MED.00081 Cognitive Rehabilitation MED.00083 Melanoma Vaccines MED.00084 Intradialytic Parenteral Nutrition and Intraperitoneal Nutrition MED.00085 Antineoplaston Therapy RAD.00004 Peripheral Bone Mineral Density Measurement and Screening for Vertebral Fractures Using Dual Energy X-Ray Absorptiometry RAD.00030 Wireless Capsule Endoscopy for Esophageal and Small Bowel Imaging and the Patency Capsule RAD.00034 Dynamic Spinal Visualization (Including Digital Motion X-ray and Cineradiography/Videofluoroscopy) RAD.00042 SPECT/CT Fusion Imaging RAD.00045 Cerebral Perfusion Imaging using Computed Tomography RAD.00046 Cerebral Perfusion Studies using Diffusion and Perfusion Magnetic Resonance Imaging SURG.00005 Partial Left Ventriculectomy SURG.00020 Implantable Bone Conduction Hearing Aids SURG.00023 Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures SURG.00024 Surgery for Clinically Severe Obesity SURG.00033 Implantable Cardioverter-Defibrillator (ICD) SURG.00049 Mandibular/Maxillary (Orthognathic) Surgery SURG.00051 Hip Resurfacing SURG.00055 Artificial Intervertebral Discs SURG.00064 Cardiac Resynchronization Therapy (CRT) with or without an Implantable Cardioverter Defibrillator (CRT/ICD) for the Treatment of Heart Failure SURG.00068 Implantable Infusion Pumps SURG.00074 Nasal Surgery for the Treatment of Obstructive Sleep Apnea (OSA) (Including Radiofrequency Ablation of Nasal Turbinates for Nasal Obstruction with or without OSA)
SURG.00075 Intervertebral Stabilization Devices (Dynesys Spinal System, SATELLITE Spinal System) SURG.00076 Nerve Graft After Prostatectomy SURG.00077 Laparoscopic and Percutaneous MRI-Image Guided Techniques for Myolysis as a Treatment of Uterine Fibroids SURG.00080 Implanted Cerebral Thermal Perfusion Probe for Monitoring Regional Cerebral Blood Flow SURG.00082 Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedures SURG.00084 Semi-Implantable Middle Ear Hearing Aids SURG.00085 Mastectomy for Gynecomastia SURG.00086 Reduction Mammaplasty SURG.00090 Radiofrequency Ablation for Trigeminal Neuralgia SURG.00092 Interspinous Vertebral Devices for Treatment of Spinal Stenosis SURG.00095 Canaloplasty SURG.00100 Cryoablation for Plantar Fasciitis and Plantar Fibroma CG - ANC - 03 Acupuncture CG - DME - 03 Neuromuscular Stimulation in the Treatment of Muscle Atrophy CG - DME - 04 Electrical Nerve Stimulation, Transcutaneous, Percutaneous CG - DME - 05 Cervical Traction Devices for Home Use CG - DME - 06 Pneumatic Compression Devices CG - DME - 07 Augmentative and Alternative Communication (AAC) Devices/Speech Generating Devices (SGD) CG - DME - 08 Infant Home Apnea Monitors CG - DME - 15 Hospital Beds and Accessories CG - DME - 27 Non-Invasive Positive Pressure Respiratory Assist Devices (BiPAP ) CG - DME - 32 Continuous Positive Airway Pressure (CPAP) and Related Devices for the Treatment of Obstructive Sleep Apnea in Adults CG - DRUG - 03 Beta Interferons (interferon beta-1a [Avonex, Rebif ], interferon beta 1-b [Betaseron ]) or Glatiramer Acetate [Copaxone ] for Treatment of Multiple Sclerosis CG - DRUG - 07 Hepatitis C Pegylated Interferon Antiviral Therapy CG - DRUG - 10 Live Attenuated Influenza Vaccine/FluMist CG - DRUG - 17 Natalizumab (Tysabri ) CG LAB - 01 High Sensitivity C-Reactive Protein CG - MED - 01 Polysomnography Studies in Adults and Children CG - MED - 05 Ketogenic Diet for Intractable Seizure Disorder CG - MED - 06 Intraoperative Neurophysiological Monitoring and Non-Operative Neurophysiological Testing. CG - MED - 07 Upper Gastrointestinal Endoscopy CG - MED - 09 Vision Therapy
CG - MED - 10 Measurement of Intermediate Density Lipoproteins CG - MED - 11 Lipoprotein-Associated Phospholipase A2 CG - MED - 12 Lipoprotein Size and Concentration in Cardiac Risk Assessment and Management CG - MED - 13 Cardiopulmonary Exercise Testing CG - MED - 14 Serum Antibodies for the Diagnosis of Inflammatory Bowel Disease and Celiac Disease CG - MED - 16 Amnioreduction and/or Fetoscopic Laser Therapy for Interfetal Transfusion Syndrome CG - MED - 18 Electroencephalography (EEG) Testing: Ambulatory and Video CG - MED - 22 Neuropsychological Testing CG - MED - 23 Home Health CG - MED - 31 Skilled Nursing Facility CG - MED - 34 Anesthesia Services for Gastrointestinal Endoscopic Procedures CG - RAD - 01 Ultrasound Evaluation of Breast Disease CG - RAD - 02 Endoscopic Ultrasonography (EUS) CG - RAD - 04 Ultrasound in Maternity Care CG - RAD - 18 Central (Hip or Spine) Bone Density Measurement CG - REHAB - 03 Pulmonary Rehabilitation CG - REHAB - 04 Physical Therapy CG - REHAB - 05 Occupational Therapy CG - REHAB - 09 Acute Inpatient Rehabilitation CG - SURG - 05 Maze Procedure CG - SURG - 07 Vertical Expandable Prosthetic Titanium Rib (VEPTR) CG - SURG - 08 Sacral Nerve Stimulation as a Treatment of Neurogenic Bladder Secondary to Spinal Cord Injury CG - SURG - 23 Arthroscopic Lavage and Arthroscopic Debridement as a Treatment for Osteoarthritis of the Knee CG - SURG-24 Functional Endoscopic Sinus Surgery (FESS) CG - TRANS - 02 Kidney Transplantation Toolkit - Abraxane, Paclitaxel Toolkit - Alemtuzumab, Campath Toolkit - Alpha 1 Proteinase Inhibitor Toolkit - Amifostine, Ethyol Toolkit - Arsenic Trioxide, Trisenox Toolkit - Bleomycin Sulfate, Blenoxane, Bleo Toolkit - Busulfan Busulfex, Myleran Toolkit - Carboplatin, Paraplatin, Paraplatin-AQ
Toolkit - Carmustine, BiCNU, BCNU, Gliadel Wafer Toolkit - Caspofungin Acetate Toolkit - Cisplatin, Platinol, Platinol-AQ, CDDP, Cisplatinum Toolkit - Cladribine, Leustatin, 2-CdA Toolkit - Cyclophosphamide, Cytoxan, Neosar, CTX Toolkit - Cytarabine, Cytosar-U, ARA-C, cytosine arabinoside, Cytarabine Liposomal (Depo-Cyt ) Toolkit - Cytomegalovirus Immune Globulin (Human) CytoGam Toolkit - Dacarbazine, DTIC Dome, DTIC Toolkit - Dactinomycin, Cosmegen, Actinomycin D Toolkit - Daunorubicin, Cerubidine, DNR, Daunorubicin, Liposomal (DaunoXome ) Toolkit - Denileukin Diftitox, Ontak Toolkit - Docetaxel Toolkit - Dofetilide, Tikosyn Toolkit - Dolasetron, Anzemet Toolkit - Doxorubicin, Adriamycin, Rubex, Doxorubicin Liposomal (Doxil ) Toolkit - Epirubicin Hydrochloride, Ellence Toolkit - Etoposide, VePesis, VP-16 Toolkit - Factor IX, Complex, Recombinant and Non-Recombinant Toolkit - Factor VIIa Toolkit - Factor VIII and Recombinant Toolkit - Floxuridine, FUDR Toolkit - Fludarabine Phosphate, Fludara Toolkit - Flurouracil, Adrucil, 5FU Toolkit - Fulvestrant Toolkit - Galsulfase Toolkit - Gemcitabine, Gemzar Toolkit - Gemtuzumab Ozogamicin, Mylotarg Toolkit - Granisetron, Kytril Toolkit - Ibandronate Toolkit - Idarubicin HCL, Idamycin Toolkit - Idursulfase, Elaprase Toolkit - Ifosfamide, Ifex Toolkit - Immune Globulin Subcutaneous [Human], Vivaglobin
Toolkit - Interferon Alfa, Alferon,Intron-A,Roferon-A Toolkit - Interferon Gamma 1-b Toolkit - Irinotecan HCL, Camptosar, CPT-11 Toolkit - Leucovorin, Wellcovorin Toolkit - Mechlorethamine Hydrochloride, Nitrogen mustard, Mustine, Mustargen Toolkit - Medroxyprogesterone, Provera, Depo-Provera Toolkit - Methotrexate, Folex, Mexate, MTX Toolkit - Mitomycin, Mutamycin Toolkit - Mitoxantrone HCL, Novantrone Toolkit - Octreotide Acetate, Sandostatin, Sandostatin LAR Depot Toolkit - Oprelvekin, Neumega, IL-11 Toolkit - Oxaliplatin, Eloxatin Toolkit - Paclitaxel, Taxol Toolkit - Palonosetron Toolkit - Pamidronate Disodium, Aredia Toolkit - Pegasparaginase (Pegaspargase), Oncaspar Toolkit - Pegvisomant Toolkit - Pentostatin, Nipent Toolkit - Rituximab, Rituxan Toolkit - Sotalol (Sotalol HCL), Betapace, Betapace AF Toolkit - Streptozocin, Zanosar Toolkit - Teniposide, Vumon, VM-26 Toolkit - Terbutaline Sulfate, Brethaire, Brethine, Bricanyl Toolkit - Teriparatide Toolkit - Thiotepa, Thioplex Toolkit - Topotecan Toolkit - Trimetrexate glucoronate, Neutrexin Toolkit - Valrubicin, Valstar Toolkit - Vinblastine Sulfate, Velban, Velbe Toolkit - Vincristine Sulfate, Oncovin, Vincasar, VCR Toolkit - Vinorelbine Tartrate, Navelbine Toolkit - Von Willebrand Factor Complex Toolkit - Zoledronate, zoledronic acid, Zometa
Milliman Care Guideline - Angioplasty, Percutaneous Coronary Intervention Milliman Care Guideline - Knee Arthroscopy Milliman Care Guideline - Lumbar Fusion W0002 - Mastectomy, Modified Radical W0008 - Mastectomy, Partial (Lumpectomy) with Axillary Lymphadenectomy W0022 - Mastectomy, Modified Radical, with Insertion of Breast Prosthesis or Tissue Expander W0023 - Mastectomy, Modified Radical, with Transverse Rectus Abdominis Myocutaneous (TRAM) Flap W0024 - Mastectomy, Modified Radical, with Transverse Rectus Abdominis Myocutaneous (TRAM) Flap and Microvascular Anastomosis W0045 - Cesarean Section W0047 - Vaginal Delivery W0048 - Vaginal Delivery, Operative