Effective: December 1, 2015
Service Categories Most Frequently Requiring Medical Record Submissions
Genetic tests
Genetic testing may be considered medically necessary; however, the following criteria must be met. Please submit information to assure payment. Genetic testing is considered medically necessary if the following information is provided to the plan:
1. Did the testing of an affected (symptomatic) member using individual germline DNA benefit the member? Extended genetic panel testing is not covered.
2. Did testing of DNA from cancer cells of an affected (symptomatic) member benefit the individual or define treatment options? Genetic testing is not clinically appropriate when it will not change the diagnosis and/or medical management.
3. Did the genetic test determine the future risk of disease in an asymptomatic individual to who is at-risk? If a clinical diagnosis can be made without the use of a genetic test, the test is not covered. Tests are not covered for non-medical issues or as a convenience.
4. Did the genetic test of an affected individual’s germline DNA benefit family member(s)?
Please refer to the medical policy: https://www.bcbsnc.com/assets/services/public/pdfs/medicalpolicy/general_approach_to_genetic_testing.pdf
Noninvasive Prenatal Testing for Fetal Aneuploidies Using Cell-Free Fetal DNA
Nucleic acid sequencing-based testing of maternal plasma for trisomy 21 may be considered medically necessary in women with high-risk singleton pregnancies. A high-risk singleton pregnancy is defined by the American College of Obstetricians and Gynecologists (ACOG) as follows:
· Maternal age 35 years or older at delivery;
· Fetal ultrasonographic findings indicating increased risk of aneuploidy;
· History of previous pregnancy with a trisomy;
· Standard serum screening test positive for aneuploidy; or
· Parental balanced robertsonian translocation with increased risk of fetal trisomy 13 or trisomy 21.
· Concurrent nucleic acid sequencing-based testing of maternal plasma for trisomy 13, 18, and/or fetal sex chromosome aneuploidies may be considered medically necessary in women who are eligible for and are undergoing nucleic acid sequencing-based testing of maternal plasma for trisomy 21.
Please refer to the medical policy: https://www.bcbsnc.com/assets/services/public/pdfs/medicalpolicy/noninvasive_prenatal_testing_for_trisomy_21_using_cell_free_fetal_dna.pdf
Aqueous Shunts and Devices for Glaucoma
Aqueous Shunts and Devices for Glaucoma may be considered medically necessary; however, the following documentation must be submitted for review: The physician/nursing/office notes, medication record, operative report and history & physical.
Please refer to the medical policy: https://www.bcbsnc.com/assets/services/public/pdfs/medicalpolicy/aqueous_shunts_and_devices_for_glaucoma.pdf
Bioengineered skin grafts
Bioengineered skin grafts may be considered medically necessary; including all FDA approved graft products used for the treatment of burns.
Only Apligraf® and Oasis® Wound Matrix are covered for the treatment of chronic, noninfected, partial- or full-thickness lower-extremity vascular ulcers, which have not adequately responded following a 1-month period of conventional ulcer therapy.
Only Dermagraft®, Epifix® and Apligraf are covered for the treatment of chronic, non-infected full-thickness diabetic or neuropathic lower extremity ulcers.
***Applications will be limited to no more than the following weekly applications per wound when the above criteria are met:
· Apligraf: 4 applications.
· Dermagraft: 8 applications.
· Epifix: 5 applications.
· Breast reconstructive surgery using allogeneic acellular dermal matrix products (ie, AlloDerm®, AlloMax™, DermaMatrix™, FlexHD®, GraftJacket®) may be considered medically necessary.
Please refer to the medical policy: https://www.bcbsnc.com/assets/services/public/pdfs/medicalpolicy/bioengineered_skin_and_tissue.pdf
Ambulance and Medical Transport Services
Ambulance and Medical Transport Services may be considered medically necessary; however, the criteria outlined in the medical policy must be documented, to include the transport log and the rationale to support a hospital to hospital transfer.
Please refer to the medical policy: https://www.bcbsnc.com/assets/services/public/pdfs/medicalpolicy/ambulance_and_medical_transport_services.pdf
Specialty Drugs Requiring Prior Plan Approval (PPA)
Many specialty drugs require an approval by BCBSNC prior to dispensing the drug. However, there may be occasions when the approval was not obtained. A review for the medical necessity of that prescription must be still completed even after the medication has been dispensed. BCBSNC provides checklists online that may be completed for specialty drugs when the PPA requirement was not completed.
Please refer to bcbsnc.com for complete information: http://www.bcbsnc.com/content/providers/ppa/prescriptions.htm