Blues highlight medical, benefit policy changes

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Basic benefit and medical policy

Lung and lobar lung transplant

The safety and effectiveness of lung or lobar lung transplantation have been established. It may be considered a useful therapeutic option for carefully selected adults, children and adolescents with irreversible, progressively disabling, primary or secondary end-stage pulmonary disease. It is a useful therapeutic option for patients meeting patient selection guidelines.

The safety and effectiveness of lobar lung retransplantation have been established. It may be considered a useful therapeutic option for carefully selected adults, children and adolescents following an initial, failed lung or lobar lung transplantation and who meet criteria for lung transplantation. It is a useful therapeutic option for patients meeting patient selection guidelines.

Lung or lobar lung transplantation is considered experimental/investigational in all other situations. This policy is effective Sept. 1, 2015.

Inclusions:
Lung-specific-background information: Bilateral lung transplantation is typically required when chronic lung infection disease is present; i.e., associated with cystic fibrosis and bronchiectasis. Some, but not all, cases of pulmonary hypertension will require bilateral lung transplantation. Bronchiolitis obliterans is associated with chronic lung transplant rejection, and thus may be the etiology of a request for lung retransplantation.

Indications for lung and lobar lung transplantation include, but are not limited to, irreversible, chronic lung diseases for which there is no further medical or surgical therapy available and survival is limited. Lung transplantation is rarely an option for acutely, critically ill patients. The most common illnesses which may result in irreversible, progressively disabling, primary or secondary end-stage pulmonary disease include but are not limited to:

• Alpha-1 antitrypsin deficiency     
• Asbestosis
• Benign hypertensive heart disease without congestive heart failure      
• Bilateral bronchiectasis
• Bronchiolitis obliterans
• Bronchopulmonary dysplasia
• Chronic airway obstruction, not elsewhere classified
• Chronic obstructive pulmonary disease
• Chronic respiratory conditions due to fumes and vapors
• Chronic respiratory disease arising in the perinatal period
• Coal workers’ pneumoconiosis
• Congenital bronchiectasis
• Cystic fibrosis with meconium ileus (double lung transplanted)
• Cystic fibrosis without mention of meconium ileus (double lung transplanted)
• Eisenmenger’s syndrome
• Emphysema
• Eosinophilic granuloma
• Idiopathic pulmonary fibrosis
• Idiopathic fibrosing alveolitis
• Interstitial pulmonary fibrosis
• Lung involvement in other diseases classified elsewhere
• Lymphangiomyomatosis
• Neoplasm of uncertain behavior of trachea, bronchus and lung
• Other chronic bronchitis
• Other deficiencies of circulating enzymes
• Other emphysema
• Other specified disorders of metabolism
• Pneumoconiosis due to other inorganic dust
• Pneumoconiosis due to other silica or silicates
• Pneumoconiosis, unspecified
• Pneumonopathy due to inhalation of other dust
• Postinflammatory pulmonary fibrosis
• Primary pulmonary hypertension
• Pulmonary fibrosis
• Pulmonary embolism and infraction
• Pulmonary hypertension due to cardiac disease
• Recurrent pulmonary embolism
• Sarcoidosis
• Scleroderma
• Systemic sclerosis
• Tuberculosis fibrosis of lung
• Ventricular septal defect

General exclusions (contraindications):

Potential contraindications are subject to the judgment of the transplant center:

• Known current malignancy, including metastatic cancer
• Recent malignancy with high risk of recurrence
• Untreated systemic infection making immunosuppression unsafe, including chronic infection
• Other irreversible end-stage disease not attributed to heart or lung disease
• History of cancer with a moderate risk of recurrence
• Stable systemic disease that could be exacerbated by immunosuppression
• Psychosocial conditions or chemical dependency affecting ability to adhere to therapy

Policy specific:

• Coronary artery disease not amenable to percutaneous intervention or bypass grafting, or associated with significant impairment of left ventricular function* or
• Colonization with highly resistant or highly virulent bacteria, fungi or mycobacteria.

Patients must meet United Network for Organ Sharing guidelines for lung allocation score greater than zero.

Exclusions: Patients not meeting the above inclusionary guidelines.

J3490

Basic benefit and medical policy

Effective Feb. 25, 2015, Avycaz™ (ceftazidime-avibactam) is covered under this code for the treatment of adults with complicated intra-abdominal or urinary tract infections, including kidney infections (pyelonephritis), who have limited or no alternative treatment options.

Indications and usage:
Complicated intra-abdominal infections
Avycaz, in combination with metronidazole, is indicated for the treatment of complicated intra-abdominal infections caused by the following susceptible microorganisms: escherichia coli, klebsiella pneumoniae, proteus mirabilis, providencia stuartii, enterobacter cloacae, lebsiella oxytoca and pseudomonas aeruginosa in patients 18 years or older.

Complicated Urinary Tract Infections, including Pyelonephritis
Avycaz is indicated for the treatment of complicated urinary tract infections, including pyelonephritis, caused by the following susceptible microorganisms:  escherichia coli, klebsiella pneumoniae, citrobacter koseri, enterobacter aerogenes, enterobacter cloacae, Citrobacter freundii, proteus spp. and pseudomonas aeruginosa in patients 18 years or older.

Usage
To reduce the development of drug-resistant bacteria and maintain the effectiveness of Avycaz and other antibacterial drugs, Avycaz should be used only to treat infections that are proven or strongly suspected to be caused by susceptible bacteria.

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Basic medical and benefit policy
Following breast-conserving surgery for early stage breast cancer:

• Accelerated whole breast irradiation and interstitial or balloon brachytherapy may be considered established for patients who meet inclusionary guidelines. These procedures are useful therapeutic options for patients meeting selection criteria.
• Accelerated whole breast irradiation is considered experimental in all other situations.
• Accelerated partial breast irradiation, including interstitial APBI, balloon APBI, external beam APBI, noninvasive brachytherapy using Accuboost®, and intra-operative APBI, is considered experimental.
• Noninvasive brachytherapy using Accuboost® for patients undergoing initial treatment for stage 1 or 2 breast cancer when used as local boost irradiation in patients who are also treated with BCS and whole breast external-beam radiotherapy is considered experimental.
• Local boost irradiation when combined with whole-breast radiotherapy but without surgical excision is considered experimental. There is a lack of published data to validate the efficacy of brachytherapy without surgical excision of the tumor. 

Inclusionary and exclusionary criteria have been updated, effective Sept. 1, 2015.

Inclusionary guidelines:
Following breast-conserving surgery for early stage breast cancer:

• Accelerated whole breast irradiation for patients who meet the following conditions:
• Invasive carcinoma of the breast. Exclude disease involving the margins of excision; tumors >5 cm in diameter; breast width >25 cm at posterior border of medial and lateral tangential beams.
• Negative lymph nodes
• Technically clear surgical margins
• Interstitial or balloon brachytherapy may be considered established for patients undergoing initial treatment for stage I or II breast cancer when used as local boost irradiation in patients who are also treated with breast-conserving surgery and whole-breast external-beam radiotherapy.

Exclusionary guidelines:

• Accelerated whole breast irradiation for patients not meeting the above inclusions.
• Accelerated partial breast irradiation, including interstitial APBI, balloon APBI, external beam APBI, noninvasive brachytherapy using Accuboost® and intra-operative APBI.
• Interstitial or balloon brachytherapy in all other situations not specified under the inclusions.
• Noninvasive brachytherapy using Accuboost® for patients undergoing initial treatment for stage 1 or 2 breast cancer when used as local boost irradiation in patients who are also treated with BCS and whole breast external-beam radiotherapy.

Local boost irradiation when combined with whole-breast radiotherapy but without surgical excision.

86294*, 86386*, 88120, 88121

Not covered:
81479

Basic benefit and medical policy
The safety and effectiveness of urinary tumor markers for bladder cancer have been established. It may be considered a useful diagnostic option when used as an adjunct to cytology and cystoscopy. Policy updates are effective Aug. 1, 2015.

Payment policy
Procedure codes *86294 and 86386 will be removed from the Physician Office Laboratory List, effective Aug. 1, 2015, and will not be payable if provided in an office location.

Inclusionary guidelines:
The assessment of urinary tumor markers for bladder cancer, as an adjunct to cytology and cystoscopy, is indicated in:

• The diagnosis of urinary bladder malignancy in members at very high risk
• The follow-up of members with a history of urinary bladder malignancy when the measurements of these markers is deemed essential in making management decisions

Exclusionary guidelines:
All other indications

91110

Experimental:
91111
0355T

Basic benefit and medical policy

Wireless capsule endoscopy as a diagnostic technique in disorders of the small bowel, esophagus and colon

The criteria for wireless capsule endoscopy as a diagnostic technique in disorders of the small bowel, esophagus and colon policy have been updated. This policy is effective Sept. 1, 2015.

Wireless capsule endoscopy has been proven to be safe and effective. It is a useful therapeutic option for patients meeting patient selection criteria.

Inclusions:

• Initial diagnosis in patients with suspected Crohn’s disease without evidence of disease on conventional diagnostic tests such as small-bowel follow-through and upper and lower endoscopy
• In patients with an established diagnosis of Crohn’s disease, when there are unexpected change(s) in the course of disease or response to treatment, suggesting the initial diagnosis may be incorrect and re-examination may be indicated.
• Evaluation for the extent of involvement and/or management of known Crohn’s disease
• Obscure gastrointestinal, or GI, bleeding suspected of being of small bowel origin, as evidenced by prior inconclusive upper and lower gastrointestinal endoscopic studies
• For surveillance of the small bowel in patients with hereditary GI polyposis syndromes, including familial adenomatous polyposis and Peutz-Jeghers syndrome

Exclusions:

• Evaluation for the extent of involvement or management of known ulcerative colitis
• Evaluation of the esophagus, in patients with gastroesophageal reflux or other esophageal pathologies
• Evaluation of other gastrointestinal diseases not presenting with GI bleeding including, but not limited to, celiac sprue, irritable bowel syndrome, Lynch syndrome, portal hypertensive enteropathy, small bowel neoplasm and unexplained chronic abdominal pain
• Evaluation of the colon, including but not limited to, detection of colonic polyps or colon cancer
• Initial evaluation of patients with acute upper GI bleeding
• The patency capsule, when used to evaluate patency of the gastrointestinal tract before wireless capsule endoscopy
• Use of wireless capsule for routine colorectal cancer screening, confirmation of lesions or pathology normally within the reach of upper or lower endoscopes
• In patients with known or suspected gastrointestinal obstruction, strictures or fistulas

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Basic benefit and medical policy

Leadless permanent cardiac pacemakers
The insertion of leadless permanent cardiac pacemakers is experimental. There is insufficient evidence in published, peer-reviewed medical literature regarding the safety and efficacy of these devices. They have not been scientifically demonstrated to improve patient clinical outcomes. In addition, there are no leadless cardiac pacemakers that have received FDA approval at this time.

This policy is effective Sept. 1, 2015.

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Basic benefit and medical policy
The peer reviewed medical literature has not demonstrated the clinical utility of gene expression profiling for uveal melanoma. Therefore, this service is experimental policy, effective Sept. 1, 2015.