BCBS Horizon Medical Policy Updates – December 2018

December 2018 Medical Policy Updates:

• Abdominoplasty
• Adult Abdomen Imaging Policy
• Adult Spine Imaging Policy
• Agalsidase Beta (Fabrazyme)
• Allergen Immunotherapy
• Allogeneic Pancreas Transplant
• Applied Behavior Analysis in the Treatment of Autism Spectrum Disorders (ASD)
• Autonomic Nervous System Testing
• Axicabtagene Ciloleucel (Yescarta)
• Belimumab (Benlysta)
• Bendamustine hydrochloride (Treanda Bendeka)
• Beta Amyloid Imaging with Positron Emission Tomography (PET) for Alzheimers Disease
• Bioengineered Skin and Soft Tissue Substitutes
• Biofeedback
• Bone Mineral Density Studies and Vertebral Fracture Assessment With Densitometry
• Bortezomib (Velcade)
• Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting
• Carfilzomib (Kyprolis)
• Chiropractic Review Policy
• Chromosomal Microarray Analysis for the Evaluation of Pregnancy Loss
• Circulating Tumor DNA for Management of Non-Small-Cell-Lung Cancer (Liquid Biopsy)
• Colorectal Cancer Screening
• Computed Tomography (CT) Perfusion Imaging of the Brain
• Continuous or Intermittent Monitoring of Glucose in the Interstitial Fluid
• Definition of Investigational or Experimental Procedure
• Donor Lymphocyte Infusion for Malignancies Treated with an Allogeneic Hematopoietic Stem-Cell Transplant
• Drug Therapy for Hereditary Angioedema [Cinryze Berinert Haegarda (Human C1 Inhibitor) Kalbitor (Ecallantide) Firazyr (Icatibant) Ruconest (C1 Esterase Inhibitor [Recombinant])]
• Dupilumab (Dupixent)
• Eculizumab (Soliris)
• Endobronchial Ultrasound for Diagnosis and Staging of Lung Cancer
• Erythropoietin Therapy Epoetin Alfa Darbepoetin Alfa Pegylated (PEG)-epoetin Beta and Epoetin Alfa-epbx
• Esophageal pH Monitoring
• Expanded Molecular Panel Testing of Cancers to Identify Targeted Therapies
• Fecal Microbiota Transplantation
• Focal Treatments for Prostate Cancer
• Foot Care Services
• Fulvestrant (Faslodex)
• Gaucher Disease Therapy
• Gene Expression Profiling and Protein Biomarkers for Prostate Cancer Management
• Genetic Cancer Susceptibility Panels Using Next Generation Sequencing
• Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes
• Golimumab (Simponi Aria)
• Heart Transplant
• Hematopoietic Cell Transplantation for Plasma Cell Dyscrasias Including Multiple Myeloma and POEMS Syndrome
• Ibalizumab-uiyk (Trogarzo)
• Immune Globulin Subcutaneous (Vivaglobin Hizentra Gammagard Liquid Gamunex-C or Gammaked HyQvia and Cuvitru for Subcutaneous Administration)
• Injectable Bulking Agents for the Treatment of Urinary Incontinence
• Intravenous Immunoglobulin (IVIG) Therapy
• Invasive Prenatal (Fetal) Diagnostic Testing
• Islet Transplantation
• Lemtrada (Alemtuzumab)
• Liver Transplant and Combined Liver-Kidney Transplant
• Meniscal Allografts and Other Meniscal Implants
• Microwave Tumor Ablation
• Molecular Analysis for Targeted Therapy for Non-Small-Cell Lung Cancer
• Molecular Markers in Fine Needle Aspirates of the Thyroid
• Molecular Testing for the Management of Pancreatic Cysts or Barrett Esophagus
• Multigene Expression Assay for Predicting Recurrence in Colon Cancer
• Myocardial Sympathetic Innervation Imaging in Patients with Heart Failure
• Noninvasive Prenatal Screening for Fetal Aneuploidies and Microdeletions Using Cell-Free Fetal DNA
• Ovarian and Internal Iliac Vein Embolization as a Treatment of Pelvic Congestion Syndrome
• Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence
• Percutaneous Tibial Nerve Stimulation
• Pertuzumab (Perjeta)
• Photodynamic Therapy for Choroidal Neovascularization
• Preimplantation Genetic Testing
• Radiation Therapy for Prostate Cancer
• Radiation Treatment with Lutathera (Lutetium Lu 177 dotatate)
• Radioactive Seed Localization of Nonpalpable Breast Lesions
• Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors
• Radiofrequency Ablation of the Renal Sympathetic Nerves as a Treatment for Resistant Hypertension
• Sacral Nerve Neuromodulation or Stimulation
• Sacroiliac Joint Arthrography
• Sandostatin Sandostatin LAR depot (Octreotide) Somatuline Depo (lanreotide) Signifor LAR (pasireotide)
• Septoplasty
• Site of Service for Administration for Infusion and Injectable Prescription Medications
• Sodium Hyaluronate Injections
• Surgical Interruption of Pelvic Nerve Pathways for Primary and Secondary Dysmenorrhea
• Testosterone [Implantable Testosterone Pellets (Testopel Pellets) Testosterone Undecanoate (Aveed)] Testosterone Cypionate (Depo-Testosterone) or Testosterone Enanthate (Delatestryl)]
• Thermography
• Threshold Electrical Stimulation as a Treatment of Motor Disorders
• Total Artificial Hearts and Implantable Ventricular Assist Devices
• Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease
• Ultrasound Accelerated Fracture Healing Device
• Unna Boot
• Ustekinumab (Stelara)
• Vedolizumab (Entyvio)
• Vitrectomy Chair or Vitrectomy Support System or Face-Down Positioning Device for Post-Vitrectomy Positioning
• Whole Body Dual X-Ray Absorptiometry (DEXA) to Determine Body Composition