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Medical Policy Update for December 31, 2024
| Medical Guidelines | Reason for Update |
|---|---|
| Ablation and Neural Therapy Procedures for Headache and Pain Management (PDF) | Codes C9807, and C9808 added to Billing/Coding section effective 1/1/25. |
| Ambulatory Event Monitors and Outpatient Cardiac Telemetry (PDF) | Codes 0937T, 0938T, 0939T and 0940T added to Billing/Coding section, effective 1/1/2025. |
| Bioimpedance Devices for Detection of Lymphedema (PDF) | Reference added. Policy Guidelines updated with results of PREVENT RTC. Specialty Matched Consultant Advisory Panel review 11/2024. Medical Director review 11/2024. |
| Biomarker Testing for Autoimmune Rheumatic Disease AHS – G2022 (PDF) | Updated Billing/Coding section to add CPT code 0521U, effective 1/1/2025. |
| Cardiac Monitoring Devices in the Outpatient Setting (PDF) | Codes 0933T, 0934T and G0555 added to Billing/Coding section, effective 1/1/2025. |
| Continuous Monitoring of Glucose in the Interstitial Fluid (PDF) | Updated Billing/Coding section to add G0564, G0565, effective 1/1/2025. |
| Diagnosis of Vaginitis AHS – M2057 (PDF) | Added 81515 to Billing/Coding section, effective 1/1/2025. |
| Electrostimulation and Electromagnetic Therapy for Wounds (PDF) | Reference added. Specialty Matched Consultant Advisory Panel review 11/2024. Medical Director Review 11/2024. |
| Facility Based Crisis Services (PDF) | New policy developed. Facility Based Crisis Services are considered medically necessary when the criteria above are met. Medical Director review 9/2024. Notification given 10/1/2024 for effective date 12/31/2024. |
| General Genetic Testing, Somatic Disorders AHS - M2146 (PDF) | Code 0523U added to Billing/Coding section, effective 1/1/2025. |
| Genetic Testing for Breast, Ovarian, Pancreatic and Prostate Cancers (BRCA) AHS - M2003 (PDF) | Deleted CPT code 81433 from Billing/Coding section for 1/1/25 code update. |
| Genetic Testing for Inherited Cardiomyopathies and Channelopathies AHS – M2025 (PDF) | Annual policy review. No updates from lab benefit manager, no change to policy statement. |
| Genomic Testing for Hematopoietic Neoplasms AHS - M2182 (PDF) | Added CPT code 81195 to Billing/Coding section for 1/1/25 code update. |
| Growth Factors in Wound Healing (PDF) | Criteria for Neuropathic Diabetic Ulcers and Pressure Ulcers moved from policy guidelines to When Growth Factors in Wound Healing are covered section. No change to policy intent. References added. Specialty Matched Consultant Advisory Panel review 11/2024. Medical Director review 11/2024. |
| Handheld Radiofrequency Spectroscopy for Intraoperative Assessment of Surgical Margins during Breast-Conserving Surgery (PDF) | References added. Specialty Matched Consultant Advisory Panel review 11/2024. Medical Director review 11/2024. |
| Helicobacter Pylori Testing AHS – G2044 (PDF) | Code 87513 added to Billing/Coding section, effective 1/1/2025. |
| In Vitro Chemoresistance and Chemosensitivity Assays AHS - G2100 (PDF) | Added PLA code 0525U to Billing/Coding section for 1/1/25 code update. |
| Laboratory Procedures Medical Policy AHS - R2162 (PDF) | Codes 0522U, 0524U, 0526U and 0527U added to Billing/Coding section, effective 1/1/2025. |
| Lynch Syndrome AHS - M2004 (PDF) | Deleted CPT codes 81436 and 96040 from “Billing/Coding section for 1/1/25 code update. |
| Magnetic Esophageal Sphincter Augmentation to Treat Gastroesophageal Reflux Disease (GERD) (PDF) | Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 11/2024. Medical Director review 11/2024. |
| Microarray-Based Gene Expression Profile Testing for Multiple Myeloma Risk Stratification AHS - B0002 (PDF) | Updated references. No change to policy statement. |
| Microsatellite Instability and Tumor Mutational Burden Testing AHS - M2178 (PDF) | Added PLA code 0530U and deleted 0428U to Billing/Coding section for 1/1/25 code update. |
| MRI-Guided Focused Ultrasound (MRgFUS) (PDF) | Updated Billing/Coding section to remove 0398T and add 0947T and 61715, effective 1/1/2025. |
| Neurostimulation, Electrical (PDF) | Added HCPCS code C9807 to Section II Billing/Coding section, effective 1/1/2025. |
| Non-Contact Ultrasound Treatment for Wounds (PDF) | References added. Update regulatory section to indicate Sanuwave acquired related UltraMIST System assets. Specialty Matched Consultant Advisory Panel review 11/2024. Medical Director review 11/2024. |
| Non-Hospital Medical Detox (PDF) | New policy developed. Non-Hospital Medical Detox may be medically necessary when the medical criteria and guidelines above are met. Medical Director review 9/2024. Notification given 10/1/24 for effective date 12/31/24. |
| Orthotics (PDF) | Codes E1803, E1804, E1807, E1808, E1813, E1814, E1822, E1823, E1826, E1827, E1828, and E1829 added to Billing/Coding section effective 1/1/25. |
| Pancreatic Cancer Risk Testing Using Pancreatic Cyst Fluid AHS - M2114 (PDF) | References updated. No change to policy statement. |
| Penile Prosthesis (PDF) | New policy developed. BCBSNC will provide coverage for Penile Prosthesis when it is determined to be medically necessary because the medical criteria and guidelines listed within the policy are met. Medical Director review 10/2024. Notification given on 10/30/2024 for effective date 1/1/2025. |
| Plugs for Fistula Repair (PDF) | Reference added. Specialty Matched Consultant Advisory Panel review 11/2024. Medical Director review 11/2024. |
| Postsurgical Home Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis (PDF) | References added. Minor edits throughout the policy to remove Patient and replace with Individual. In the when covered section the coverage criteria reworded for clarity and defined contraindications. No changes to the policy intent. Specialty Matched Consultant Advisory Panel review 11/2024. Medical Director review 11/2024. |
| Radiofrequency Ablation of the Renal Nerves as a Treatment of Hypertension (PDF) | Code 0339T added to Billing/Coding section. New codes 0935T, C1735, C1736 added to Billing/Coding section, effective 1/1/2025. |
| Residential Treatment (PDF) | Description updated to remove information related to non-hospital medical detox. Updated when not covered to removed criteria related to non-hospital medical detox. Related policies updated. Updated Billing/Coding section to remove H0010. Medical Director review 11/2024. |
| Sacroiliac Joint Fusion/Stabilization (PDF) | Added HCPCS code C1737 to Billing/Coding section, effective 1/1/2025. |
| Skin and Soft Tissue Substitutes (PDF) | Added the following statement to When Covered section: “Autologous cell harvesting with manual preparation is considered medically necessary for treatment of any of the following: acute partial-thickness thermal burn wounds in individuals 18 years of age and older, or; application in combination with meshed autografting for acute full-thickness thermal burn wounds in pediatric as well as adult individuals, or; full-thickness skin defects after traumatic avulsion (e.g., degloving) or surgical excision (e.g., necrotizing soft tissue infection) or resection (e.g., skin cancer) in individuals 15 years of age and older.” Updated Billing/Coding section to add HCPCS codes. Q4346, Q4347, Q4348, Q4349, Q4350, Q4351, Q4352, Q4353 and CPT codes 15011, 15012, 15013, 15014, 15015, 15016, 15017, 15018, effective 1/1/2025. Medical Director review 12/2024. |
| Surgical Treatments for Lymphedema (PDF) | Reference added. Specialty Matched Consultant Advisory Panel review 11/2024. Medical Director review 11/2024. |
| Testing for Targeted Therapy of Non-Small-Cell Lung Cancer AHS - M2030 (PDF) | Deleted PLA code 0448U from Billing/Coding section for 1/1/25 code update. |
| Transplant Rejection Testing AHS – M2091 (PDF) | Code 81558 added to Billing/Coding section, effective 1/1/2025. |
| Treatment For Opioid Use Disorder in Opioid Treatment Programs (OTPs) (PDF) | Updated Billing/Coding section to remove code span G2067-G2080 due to deletion of HCPCS codes G2070, G2071, G2072, effective 1/1/2025. Billing/Coding section now reads as follows: G1028, G2067, G2068, G2069, G2073, G2074, G2075, G2076, G2077, G2078, G2079, G2080, G2215, G2216, H0020, S0109. |
| Trigger Point and Tender Point Injections (PDF) | Policy re-titled to “Trigger Point and Tender Point Injections”. Policy statement updated to BCBSNC may provide coverage for Trigger Point and Tender Point Injections when it is determined to be medically necessary because the medical criteria and guidelines shown below are met. When covered section updated to add medical necessity criteria. Description, Policy Guidelines, and References updated. Added 20552 and 20553 to Billing/Coding section. Notification given 10/1/2024 for effective date 12/31/2024. |
| Vagus Nerve Stimulation (PDF) | When Not Covered section updated to include rheumatoid arthritis in the list conditions in which vagus nerve stimulation is considered investigational. Added the following CPT codes to the Billing/Coding section: 0908T, 0909T, 0910T, 0911T, and 0912T, effective 1/1/2025. |
| Varicose Veins of the Lower Extremities, Treatment for (PDF) | Reference added. Specialty Matched Consultant Advisory Panel review 11/2024. Medical Director review 11/2024. |
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