The Medical Policy and Technology Assessment Committee 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/not medically necessary.  Clinical Guidelines adopted by Blue Cross Blue Shield and all the Medical Policies are available at bcbsga.com/provider under “see policies and guidelines”.  Please note that our medical policies now include NOC (Not Otherwise Classified) codes to expedite the process of determining services that may require medical review. 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 UM Guideline by calling Provider Services at (800) 241-7475 Monday through Friday from 8 AM to 7 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 and Blue Cross Blue Shield Healthcare Plan of Georgia

Attention: Prior Approval, Mail Code GAG009-0002

3350 Peachtree Road NE

Atlanta, GA 30326

 

NOTE: Any Clinical Guideline included in this standard MPTAC notification is only effective for GA if included on the GA Standard Adopted Clinical Guideline List unless there is a Group-specific review requirement in which case it will be considered ‘Adopted’ for that group only and for the specific type of review required. Additionally, as part of the Pre-Payment Review Program for commercial or Federal Employee Health Benefits Program (FEHBP) plans, Clinical Guidelines approved by Medical Policy and Technology Assessment Committee (MPTAC) but not included in the GA Standard Adopted Clinical Guideline List may be used to review a provider’s claims when a provider’s billing practices are not consistent with other providers in terms of frequency or in some other manner or for provider education and are “Adopted” for those purposes.

 

Publish  Date

 

Action

 

Policy or Guideline Number

 

Policy or Guideline Title

11/1/2018

New

DRUG.00098

Lutetium Lu 177 dotatate (Lutathera®)

11/1/2018

New

CG-LAB-12   

Testing for Oral and Esophageal Cancer

11/1/2018

New

CG-MED-71

Wound Care in the Home Setting

 

 

 

 

6/28/2018

Conversion New

CG-DME-44

Electric Tumor Treatment Field (TTF)

6/28/2018

Conversion Archived

DME.00035

Electric Tumor Treatment Field (TTF)

6/28/2018

Conversion New

CG-DRUG-67

Cetuximab (Erbitux®)

6/28/2018

Conversion Archived

DRUG.00036

Cetuximab (Erbitux®)

6/28/2018

Conversion New

CG-DRUG-94

Rituximab (Rituxan®) for Non-Oncologic Indications

6/28/2018

Conversion Archived

DRUG.00041

Rituximab (Rituxan®) for Non-Oncologic Indications

6/28/2018

Conversion New

CG-DRUG-95

Belatacept (Nulojix®)

6/28/2018

Conversion Archived

DRUG.00049

Belatacept (Nulojix®)

6/28/2018

Conversion New

CG-DRUG-96

Ado-trastuzumab emtansine (Kadcyla®)

6/28/2018

Conversion Archived

DRUG.00056

Ado-trastuzumab emtansine (Kadcyla®)

6/28/2018

Conversion New

CG-DRUG-97

Rilonacept (Arcalyst®)

6/28/2018

Conversion Archived

DRUG.00073

Rilonacept (Arcalyst®)

6/28/2018

Conversion New

CG-DRUG-98

Bendamustine Hydrochloride

6/28/2018

Conversion Archived

DRUG.00079

Bendamustine Hydrochloride

6/28/2018

Conversion New

CG-DRUG-99

Elotuzumab (Empliciti™)

6/28/2018

Conversion Archived

DRUG.00083

Elotuzumab (Empliciti™)

6/28/2018

Conversion New

CG-DRUG-100

Interferon gamma-1b (Actimmune®)

6/28/2018

Conversion Archived

DRUG.00084

Interferon gamma-1b (Actimmune®)

6/28/2018

Conversion New

CG-DRUG-101

Ixabepilone (Ixempra®)

6/28/2018

Conversion Archived

DRUG.00085

Ixabepilone (Ixempra®)

6/28/2018

Conversion New

CG-DRUG-102

Olaratumab (Lartruvo™)

6/28/2018

Conversion Archived

DRUG.00097

Olaratumab (Lartruvo™)

6/28/2018

Conversion New

CG-MED-72

Hyperthermia for Cancer Therapy

6/28/2018

Conversion Archived

MED.00026

Hyperthermia for Cancer Therapy

6/28/2018

Conversion New

CG-SURG-76

Carotid, Vertebral and Intracranial Artery Stent Placement with or without Angioplasty

6/28/2018

Conversion Archived

SURG.00001

Carotid, Vertebral and Intracranial Artery Stent Placement with or without Angioplasty

6/28/2018

Conversion New

CG-SURG-77

Refractive Surgery

6/28/2018

Conversion Archived

SURG.00009

Refractive Surgery

6/28/2018

Conversion New

CG-SURG-78

Locally Ablative Techniques for Treating Primary and Metastatic Liver Malignancies

6/28/2018

Conversion Archived

SURG.00065

Locally Ablative Techniques for Treating Primary and Metastatic Liver Malignancies

6/28/2018

Conversion New

CG-SURG-79

Implantable Infusion Pumps

6/28/2018

Conversion Archived

SURG.00068

Implantable Infusion Pumps

6/28/2018

Conversion New

CG-SURG-80

Transcatheter Arterial Chemoembolization (TACE) and Transcatheter Arterial Embolization (TAE) for Treating Primary or Metastatic Liver Tumors

6/28/2018

Conversion Archived

RAD.00011

Transcatheter Arterial Chemoembolization (TACE) and Transcatheter Arterial Embolization (TAE) for Treating Primary or Metastatic Liver Tumors

 

 

 

 

6/6/2018

Revised

DRUG.00046

Ipilimumab (Yervoy®)

5/10/2018

Revised

DRUG.00047

Brentuximab Vedotin (Adcetris®)

11/1/2018

Revised

DRUG.00050

Eculizumab (Soliris®)

5/10/2018

Revised

DRUG.00053

Carfilzomib (Kyprolis®)

6/6/2018

Revised

DRUG.00071

Pembrolizumab (Keytruda®)

6/6/2018

Revised

DRUG.00075

Nivolumab (Opdivo®)

5/10/2018

Revised

DRUG.00076

Blinatumomab (Blincyto®)

6/6/2018

Revised

DRUG.00104

Nusinersen (SPINRAZA®) Previous title: Nusinersen (SPINRAZA™)

11/1/2018

Revised

DRUG.00111

Monoclonal Antibodies to Interleukin-23 Previous title: Guselkumab (Tremfya™)

6/6/2018

Revised

GENE.00012

Preconception or Prenatal Genetic Testing of a Parent or Prospective Parent

6/6/2018

Revised

GENE.00026

Cell-Free Fetal DNA-Based Prenatal Testing

5/10/2018

Revised

SURG.00026

Deep Brain, Cortical, and Cerebellar Stimulation

6/6/2018

Revised

SURG.00032

Transcatheter Closure of Patent Foramen Ovale and Left Atrial Appendage for Stroke Prevention

11/1/2018

Revised

CG-ADMIN-02

Clinically Equivalent Cost Effective Services – Targeted Immune Modulators

6/6/2018

Revised

CG-DRUG-05

Recombinant Erythropoietin Products

6/6/2018

Revised

CG-DRUG-09

Immune Globulin (Ig) Therapy

6/6/2018

Revised

CG-DRUG-16

White Blood Cell Growth Factors

11/1/2018

Revised

CG-DRUG-25

Intravenous versus Oral Drug Administration in the Outpatient and Home Setting

5/10/2018

Revised

CG-DRUG-50

Paclitaxel, protein bound (Abraxane®)

6/6/2018

Revised

CG-DRUG-60

Gonadotropin Releasing Hormone Analogs for Treatment of Oncologic Indications

6/6/2018

Revised

CG-DRUG-62

Fulvestrant (FASLODEX®)

6/6/2018

Revised

CG-DRUG-73

Denosumab (Prolia®, Xgeva®)

11/1/2018

Revised

CG-DRUG-78

Antihemophilic Factors and Clotting Factors

 

 

 

 

6/6/2018

Reviewed

DRUG.00067

Ramucirumab (Cyramza®)

6/6/2018

Reviewed

DRUG.00109

Durvalumab (Imfinzi®) Previous title: Durvalumab (Imfinzi™)

6/6/2018

Reviewed

GENE.00009

Gene-Based Tests for Screening, Detection and Management of Prostate Cancer

6/6/2018

Reviewed

GENE.00023

Gene Expression Profiling of Melanomas

6/6/2018

Reviewed

GENE.00025

Molecular Profiling for the Evaluation of Malignant Tumors

6/6/2018

Reviewed

MED.00077

In Vivo Analysis of Gastrointestinal Lesions

6/6/2018

Reviewed

OR-PR.00003

Microprocessor Controlled Lower Limb Prosthesis

6/6/2018

Reviewed

SURG.00132

Drug-Eluting Devices for Maintaining Sinus Ostial Patency

6/6/2018

Reviewed

SURG.00148

Spectral Analysis of Prostate Tissue by Fluorescence Spectroscopy

6/6/2018

Reviewed

TRANS.00031

Hematopoietic Stem Cell Transplantation for Autoimmune Disease and Miscellaneous Solid Tumors

No change

Reviewed

CG-MED-35

Retinal Telescreening Systems

6/6/2018

Reviewed

CG-REHAB-05

Occupational Therapy

 

 

 

 Cardiology Guidelines

By AIM

AIM

 

Clinical Appropriateness Guidelines: Diagnostic Coronary Angiography

By AIM

AIM

 

Clinical Appropriateness Guidelines: Percutaneous Coronary Intervention

 

 

 

Radiology Guidelines

By AIM

AIM

 

Clinical Appropriateness Guidelines: Advanced Imaging

 

 

 

Radiation Oncology Guidelines

By AIM

AIM

 

Clinical Appropriateness Guidelines: Radiation Oncology: Proton Beam Therapy Guidelines

 

 

 

 

11/1/2018

Archived

THER-RAD.00002

Proton Beam Radiation Therapy

 

 

 

 

6/6/2018

Annual Review

DME.00022

Functional Electrical Stimulation (FES); Threshold Electrical Stimulation (TES)

6/6/2018

Annual Review

DRUG.00088

Atezolizumab (Tecentriq®)

6/6/2018

Annual Review

DRUG.00107

Avelumab (Bavencio®)

6/6/2018

Annual Review

DRUG.00110

Inotuzumab ozogamicin (Besponsa®)

6/6/2018

Annual Review

GENE.00001

Genetic Testing for Cancer Susceptibility

6/6/2018

Annual Review

GENE.00002

Preimplantation Genetic Diagnosis Testing

6/6/2018

Annual Review

GENE.00005

BCR-ABL Mutation Analysis

11/1/2018

Annual Review

GENE.00006

Epidermal Growth Factor Receptor (EGFR) Testing

6/6/2018

Annual Review

GENE.00007

Cardiac Ion Channel Genetic Testing

6/6/2018

Annual Review

GENE.00016

Gene Expression Profiling for Colorectal Cancer

6/6/2018

Annual Review

GENE.00017

Genetic Testing for Diagnosis and Management of Hereditary Cardiomyopathies (including ARVD/C)

6/6/2018

Annual Review

GENE.00031

Genetic Testing for PTEN Hamartoma Tumor Syndrome

6/6/2018

Annual Review

GENE.00038

Genetic Testing for Statin-Induced Myopathy

6/6/2018

Annual Review

GENE.00040

Genetic Testing for CHARGE Syndrome

6/6/2018

Annual Review

GENE.00045

Detection and Quantification of Tumor DNA Using Next Generation Sequencing in Lymphoid Cancers

6/6/2018

Annual Review

LAB.00003

In Vitro Chemosensitivity Assays and In Vitro Chemoresistance Assays

6/6/2018

Annual Review

LAB.00011

Analysis of Proteomic Patterns

6/6/2018

Annual Review

LAB.00015

Detection of Circulating Tumor Cells in the Blood as a Prognostic Factor for Cancer

6/6/2018

Annual Review

LAB.00025

Topographic Genotyping

6/6/2018

Annual Review

MED.00024

Adoptive Immunotherapy and Cellular Therapy

6/6/2018

Annual Review

MED.00053

Non-Invasive Measurement of Left Ventricular End Diastolic Pressure (LVEDP) in the Outpatient Setting

6/6/2018

Annual Review

MED.00087

Imaging Techniques for Screening and Identification of Cervical Cancer

6/6/2018

Annual Review

MED.00102

Ultrafiltration in Decompensated Heart Failure

6/6/2018

Annual Review

MED.00104

Non-invasive Measurement of Advanced Glycation Endproducts (AGEs) in the Skin

6/6/2018

Annual Review

MED.00105

Bioimpedance Spectroscopy Devices for the Detection and Management of Lymphedema

6/6/2018

Annual Review

MED.00111

Intracardiac Ischemia Monitoring

6/6/2018

Annual Review

MED.00112

Autonomic Testing

6/6/2018

Annual Review

MED.00118

Continuous Monitoring of Intraocular Pressure

6/6/2018

Annual Review

MED.00119

High Intensity Focused Ultrasound (HIFU) for Oncologic Indications

6/6/2018

Annual Review

MED.00124

Tisagenlecleucel (Kymriah™) 

6/6/2018

Annual Review

OR-PR.00004

Partial-Hand Myoelectric Prosthesis

6/6/2018

Annual Review

RAD.00001

Computed Tomography to Detect Coronary Artery Calcification

6/6/2018

Annual Review

RAD.00022

Magnetic Resonance Spectroscopy (MRS)

6/6/2018

Annual Review

RAD.00040

PET Scanning Using Gamma Cameras

6/6/2018

Annual Review

RAD.00043

Computed Tomography Scans for Lung Cancer Screening

6/6/2018

Annual Review

RAD.00054

MRI of the Bone Marrow

6/6/2018

Annual Review

RAD.00059

Transcatheter Arterial Chemoembolization (TACE) and  Transcatheter Arterial Embolization (TAE) for Malignant Lesions Outside the Liver except Central Nervous System (CNS) and Spinal Cord

6/6/2018

Annual Review

RAD.00066

Multiparametric Magnetic Resonance Fusion Imaging Targeted Prostate Biopsy

6/6/2018

Annual Review

SURG.00016

Stereotactic Radiofrequency Pallidotomy

6/6/2018

Annual Review

SURG.00022

Lung Volume Reduction Surgery

6/6/2018

Annual Review

SURG.00072

Lysis of Epidural Adhesions

6/6/2018

Annual Review

SURG.00075

Intervertebral Stabilization Devices

6/6/2018

Annual Review

SURG.00107

Prostate Saturation Biopsy

6/6/2018

Annual Review

SURG.00113

Artificial Retinal Devices

6/6/2018

Annual Review

SURG.00124

Carotid Sinus Baroreceptor Stimulation Devices

6/6/2018

Annual Review

SURG.00137

Focused Microwave Thermotherapy for Breast Cancer

6/6/2018

Annual Review

SURG.00139

Intraoperative Assessment of Surgical Margins During Breast-Conserving Surgery with Radiofrequency Spectroscopy or Optical Coherence Tomography

6/6/2018

Annual Review

SURG.00147

Synthetic Cartilage Implant for Metatarsophalangeal Joint Disorders

6/6/2018

Annual Review

SURG.00149

Percutaneous Ultrasonic Ablation of Soft Tissue

6/6/2018

Annual Review

TRANS.00016

Umbilical Cord Blood Progenitor Cell Collection, Storage and Transplantation

6/6/2018

Annual Review

TRANS.00025

Laboratory Testing as an Aid in the Diagnosis of Heart Transplant Rejection

6/6/2018

Annual Review

CG-DRUG-04

Use of Low Molecular Weight Heparin Therapy, Fondaparinux (Arixtra®), and Direct Thrombin Inhibitors in the Outpatient Setting

6/6/2018

Annual Review

CG-DRUG-08

Enzyme Replacement Therapy for Gaucher Disease

6/6/2018

Annual Review

CG-DRUG-34

Docetaxel (Docefrez™, Taxotere®)

6/6/2018

Annual Review

CG-DRUG-41

Zoledronic acid

6/6/2018

Annual Review

CG-DRUG-46

Fosaprepitant (Emend®)

6/6/2018

Annual Review

CG-DRUG-48

Azacitidine (Vidaza®)

6/6/2018

Annual Review

CG-DRUG-49

Doxorubicin Hydrochloride Liposome Injection

6/6/2018

Annual Review

CG-DRUG-51

Romidepsin (Istodax®)

6/6/2018

Annual Review

CG-DRUG-53

Drug Dosage, Frequency, and Route of Administration

6/6/2018

Annual Review

CG-MED-37

Intensive Programs for Pediatric Feeding Disorders

6/6/2018

Annual Review

CG-MED-45

Transrectal Ultrasonography

6/6/2018

Annual Review

CG-MED-50

Visual, Somatosensory and Motor Evoked Potentials

6/6/2018

Annual Review

CG-SURG-17

Trigger Point Injections

6/6/2018

Annual Review

CG-SURG-18

Septoplasty

6/6/2018

Annual Review

CG-SURG-30

Tonsillectomy for Children with or without Adenoidectomy

6/6/2018

Annual Review

CG-SURG-36

Adenoidectomy

6/6/2018

Annual Review

CG-SURG-40

Cataract Removal Surgery for Adults

6/6/2018

Annual Review

CG-SURG-46

Myringotomy and Tympanostomy Tube Insertion

6/6/2018

Annual Review

CG-SURG-55

Intracardiac Electrophysiological Studies (EPS) and Catheter Ablation

 

 

 

OrthoNet 

By OrthoNet

OrthoNet - Annual Review

 

Physical and Occupational Therapy Management Programs OrthoNet maintains 64 distinct guidelines addressing the medical necessity of physical therapy (PT) and occupational therapy (OT), which includes the following atypical guidelines; Bell’s Palsy, Congenital Infantile Muscular Torticollis, General Neuromuscular Criteria, and Vestibular Disorders.

 

CODING

 

 

 11/1/2018

Coding Update of Existing Document

CG-DRUG-89

Implantable and Extended-Release Buprenorphine-Containing Products





Featured In:
August 2018 BCBSGa Provider Newsletter