Commercial Medical Policy Update for July 1, 2024

Policy retitled to Ambulatory Event Monitors and Outpatient Cardiac Telemetry.  Policy statement updated: “BCBSNC will provide coverage for Ambulatory Event Monitors and Outpatient Cardiac Telemetry (also known as mobile cardiac outpatient telemetry or MCOT) when it is determined to be medically necessary because the medical criteria and guidelines shown below are met.” When Covered and Not Covered sections updated to include coverage criteria for outpatient cardiac telemetry. Minor edits for clarity made to remaining criteria in When Covered section. Description, Policy Guidelines and References updated. Added reimbursement policy “Maximum Units of Service” to Related Policies section. Specialty Matched Consultant Advisory Panel review 6/2024. Medical Director review 6/2024.

Medical Director Review. References added. Policy guidelines updated and returned to active review.  Policy noticed 05/01/24 for effective date 07/01/24.

Specialty Matched Consultant Advisory Panel review 5/2024.  Medical Director review 5/2024.  Policy archived with annual review.

Description, Policy Guidelines and References updated. Added statement to Not Covered section: “The Aveir™ DR dual-chamber pacing system is considered investigational for all indications.” Code C1605 added to the Billing/Coding section effective 7/1/24. Specialty Matched Consultant Advisory Panel review 6/2024. Medical Director review 6/2024.

Under “Billing/Coding” section, deleted CPT code 0204U per code set update, effective 7/1/24.

Added CPT code 0882T, 0883T to Section II Billing/Coding section, effective 7/1/2024.

Added coverage criteria for Custom Knee Braces to when covered section. Updated Policy Guidelines to add section for Knee Braces. Updated References.  Medical Director Review 4/2024. Policy noticed 05/01/24 for effective date 07/01/24.

Policy archived.

Specialty Matched Consultant Advisory Panel review 5/15/2024. Per Medical Director/ CAP review: updated description and policy guidelines. References added. No change to policy statement. Policy title changed from: “Charged Particle Radiotherapy” to “Proton Beam Therapy.” 

New policy developed. BCBSNC will provide coverage for Psychiatric Intensive Outpatient Programs (IOP) when it is determined to be medically necessary because the medical criteria and guidelines listed within the policy are met. Medical Director review 3/2024. Notification given on 4/1/2024 for effective date 7/1/2024.

New policy developed. BCBSNC will provide coverage for Psychiatric Partial Hospitalization Programs (PHP) when it is determined to be medically necessary because the medical criteria and guidelines listed within the policy are met. Medical Director review 3/2024. Notification given on 4/1/2024 for effective date 7/1/2024.

Specialty Matched Consultant Advisory Panel review 5/15/2024. Per Medical Director/CAP review: Under “When Covered” section, pg.5 section B.2.a, added medical necessity coverage for high-risk; section C. statement related to fractionation removed for clarity. Under policy guidelines, Fractionation section, clarified SRS is single-fraction treatment. Reference added.

Reinstated medical policy. Updated definition of residential treatment to include “is licensed under applicable state laws to provide the services for which authorization or coverage is being requested.” Updated related policies. Updated coverage criteria, description, and references based on updated literature and current standards of care. Medical director review 3/2024. Notification given 4/1/2024 for effective date 7/1/2024.

Added HCPCS codes Q4311, Q4312, Q4313, Q4314, Q4315, Q4316, Q4317, Q4318, Q4319, Q4320, Q4321, Q4322, Q4323, Q4324, Q4325, Q4326, Q4327, Q4328, Q4329, Q4330, Q4331, Q4332, Q4333 to Billing/Coding section, effective 7/1/2024.

Policy titled “Speech Generating Devices” reinstated. BCBSNC will provide coverage for Speech Generating Devices when it is determined to be medically necessary because the medical criteria and guidelines are met. Specialty Matched Consultant Advisory Panel review 3/2024. Medical Director review 3/2024. Notification given 5/1/24 for effective date 7/1/24.

New policy developed. BCBSNC will provide coverage for Intensive Outpatient Programs (IOP) for Substance Use Disorder when it is determined to be medically necessary because the medical criteria and guidelines listed within the policy are met. Medical Director review 3/2024. Notification given on 4/1/2024 for effective date 7/1/2024.