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BCBS Horizon

BCBS Horizon Medical Policy Updates – December 2018

Click here to view the Blue Cross Blue Shield Horizon Medical Policy Updates »

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


Click here to view the Blue Cross Blue Shield Horizon Medical Policy Updates »


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