Revised CareFirst Procedure Determinations

CareFirst BlueCross BlueShield shared the following updates with the Medical Society.

• A gene expression profile for breast cancer management is considered medically necessary (MN) for patients with breast cancer stages 1 and 2, who are node-negative and estrogen-receptor positive and will receive tamoxifen. HCPCS reporting code S3854.
• Botulinum toxin A injection for certain disorders of the urinary system is considered MN for neurogenic or idiopathic detrusor over-activity disorder where conventional treatment including anticholinergics have failed; considered experimental/investigational (E/I) for other urinary tract disorders, including, but not limited to, sphincter-detrusor dyssynergia, benign prostates hypertrophy, and interstitial cystitis. CPT reporting code 53899, HCPCS reporting code J0585.
• Botulinum toxin A injection for chronic headache disorders is considered E/I. CPT reporting code 64699, HCPCS reporting code J0585.
• Cryoablation for renal cell carcinoma is considered E/I. CPT reporting codes 50250 (open), 50542 (laparoscopic) or 0135T (percutaneous).
• Wireless capsule endoscopy is considered MN for surveillance of hereditary familial polyposis syndromes, e.g. Peutz-Jeghers syndrome and E/I for assessing disorders of the esophagus. CPT reporting code 91110.