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BCBS Kansas City Medical Policy Updates – February 2024
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February 2024 BCBS Kansas City Medical Policy Updates:
- February 2024 EHB Rx policies
- Ilaris (canakinumab)
- February 2024 Pharmacy Administrative Policies
- Head Imaging Guidelines
- Tepezza (teprotumumab-trbw) – MA Only
- Pelvis Imaging Guidelines
- Cosentyx IV (secukinumab)
- Breast Imaging Guidelines
- Chimeric Antigen Receptor Therapy for Leukemia and Lymphoma
- Yervoy (ipilimumab)
- Rybrevant (amivantamab-vmjw)
- Molecular Testing for Cutaneous Melanoma
- Coronavirus Testing in an Outpatient Setting
- Biomarkers for Myocardial Infarction and Chronic Heart Failure
- Oral Cancer Screening and Testing
- Prenatal Screening (Genetic)
- Testing for Colorectal Cancer Management
- Serum Testing for Evidence of Mild Brain Injury
- Hematopoietic Stem Cell Transplantation for Acute Myeloid Leukemia
- Buprenorphine Implant for Treatment of Opioid Dependence Medicare Advantage Only
- Genetic Testing for Alpha- and Beta-Thalassemia
- Radicava (edaravone) Medicare Advantage Only
- Omidubicel as Adjunct Treatment for Hematologic Malignancies
- Testing for Vector-Borne Infections
- Prenatal Screening (Nongenetic)
- Immune Prophylaxis for Respiratory Syncytial Virus (RSV) Medicare Advantage Only
- Cablivi (caplacizumab-yhdp)_2
- Vyepti (eptinezumab-jjmr)
- Rituxan (rituximab) and Biosimilars
- Gene Therapies for Treatment of Wounds in Dystrophic Epidermolysis Bullosa – Vyjuvek
- Brineura (cerliponase alfa)_2
- Gene Therapies for Congenital Hemophilia A or B
- Opdualag (nivolumab and relatlimab-rmbw)
- Islet Transplantation for Chronic Pancreatitis and Donislecel-jujn for Type 1 Diabetes
- Evenity (romosozumab-aqqg)- Medicare Advantage Only
- Remote Electrical Neuromodulation for Migraines
- Immune Globulin Therapy MA Only
- Percutaneous Electrical Nerve Stimulation and Percutaneous Neuromodulation Therapyand Restorative Neurostimulation Therapy
- Danyelza (naxitamab-gqgk) MA Only
- Digital Health Technologies Therapeutic Applications
- Cosela (trilaciclib) MA Only
- Syfovre (pegcetacoplan) MA Only
- Reblozyl (luspatercept-aamt) MA Only
- Percutaneous Balloon Kyphoplasty and Mechanical Vertebral Augmentation
- Patient-Specific Instrumentation (egCutting Guides) for Joint Arthroplasty
- Leqembi (lecanemab-irmb) – MA
- Istodax (romidepsin) MA Only
- Margenza (mergetuximab-cmkb) MA Only
- Ultomiris (ravulizumab-cwvz)
- Hematopoietic Stem Cell Transplantation for Chronic Lymphocytic Leukemia and Small Lymphocytic Lymphoma
- Acupuncture for Pain ManagementNausea and Vomitingand Opioid Dependence
- Postsurgical Outpatient Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis
- Transcranial Magnetic Stimulation and Cranial Electrical Stimulation (CES) as a Treatment of Depression and Other Psychiatric Neurologic Disorders
- Radioembolization for Primary and Metastatic Tumors of the Liver
- Lemtrada (alemtuzumab) MA Only
- Pepaxto (melphalan flufenamide) MA
- Ilaris (canakinumab) MA Only
- Genetic Testing for Familial Alzheimer Disease
- Digital Health Technologies Diagnostic Applications
- Crysvita (burosumab-twza) MA Only
- Kalbitor (ecallantide injection for subcutaneous use) MA Only
- Adstiladrin – (nadofaragene firadenovec-vncg)
- Evkeeza (evinacumb-dgnb) MA Only
- Laboratory Procedures Reimbursement Policy
- Brineura (cerliponase alfa)
- Vertebral Fracture Assessment with Densitometry
- Monjuvi (tafasitamab-cxix)
- Pediatric Cardiac Imaging Guidelines
- Manipulations and Chiropractic Care
- Spine Imaging Guidelines
- Cryoablation of Tumors Located in the KidneyLungBreastPancreasor Bone
- Tumor-Informed Circulating Tumor DNA Testing for Cancer Management
- Oxlumo (Lumasiran)
- Herceptin (trastuzumab) and Biosimilars
- Epithelial Cell Cytology in Breast Cancer Risk Assessment
- Lynch Syndrome
- Progenitor Cell Therapy for the Treatment of Damaged Myocardium Due to Ischemia
- Interferential Current Stimulation
- Mepsevii (vestronidase-aslfa-vjbk)
- General Genetic TestingGermline Disorders
- Helicobacter Pylori Testing
- IMFINZI (durvalumab)
- Ultrasonographic Measurement of Carotid Intimal-Medial Thickness as an Assessment of Subclinical Atherosclerosis
- Air Ambulance
- Zokinvy (lonafarnib)
- Orthoptic Training for the Treatment of Vision or Learning Disabilities
- Whole Gland Cryoablation of Prostate Cancer
- Clotting Factors and Coagulant Blood Products
- Catheter Ablation as Treatment for Atrial Fibrillation
- Actigraphy
- Vimizim (elosulfase alfa)
- Elzonris (tagraxofusp-erzs)
- Nexviazyme (avalglucosidase alfa-ngpt)
- Trodelvy (sacituzumab govitecan-hziy)
- Fyarro (sirolimus)
- Prescription Medication and Illicit Drug Testing in the Outpatient Setting
- Ilumya (tildrakizumab-asmn)
- Coronary Computed Tomography Angiography With Selective Noninvasive Fractional Flow Reserve
- Zulresso (brexanolone) -MA Only
- Peripheral Subcutaneous Field Stimulation
- Magnetic Resonance‒Guided Focused Ultrasound
- Cellular Immunotherapy for Prostate Cancer
- Zinplava (bezlotoxumab)
- Saphnelo (anifrolumab-fnia)
- Arcalyst (rilonacept)
- Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer
- Cervical Cancer Screening
- Focal Treatments for Prostate Cancer
- Intraocular Radiotherapy for Age-Related Macular Degeneration
- Immunopharmacologic Monitoring of Therapeutic Serum Antibodies
- Adoptive Immunotherapy
- Chemical Peels
- Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers
- Measurement of Exhaled Nitric Oxide and Exhaled Breath Condensate in the Diagnosis and Management of Respiratory Disorders
- Fecal Analysis in the Diagnosis of Intestinal Dysbiosis and Fecal Microbiota Transplant Testing
- Thyroid Disease Testing
- Treatment of Tinnitus
- Cablivi (caplacizumab-yhdp)
- Aldurazyme (laronidase)
- Dopamine Transporter Imaging with Single Photon Emission Computed Tomography DATSPECT
- Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence
- Tepezza (teprotumumab-trbw)
- Panniculectomy and Abdominoplasty
- Stelara (ustekinumab)
- Cimzia (certolizumab pegol) MA Only
- Percutaneous Vertebroplasty and Sacroplasty
- Genetic Testing for Lipoprotein(a) Variant(s) as a Decision Aid for Aspirin Treatment and or CVD Risk Assessment
- Genetic Testing for Hereditary Pancreatitis
- Diabetes Mellitus Testing
- Elahere (mirvetuximab soravtansine)
- Patient Controlled End Range Motion Stretching Devices
- Vascular Endothelial Growth Factor Inhibitors for Sickle Cell Retinopathy
- Lyme Disease Testing
- Lytgobi (futibatinib)
- Remote Patient Monitoring (RPM) and Remote Therapeutic Monitoring (RTM)
- Diagnostic and Therapeutic Infertility Services
- Hemlibra (emicizumab-kxwh) MA Only
- Hepatitis Testing
- Intensity-Modulated Radiotherapy (IMRT) Prostate
- Reconstructive Breast Surgery Management of Breast Implants
- Human Immunodeficiency Virus (HIV)
- Orencia (abatacept) MA Only
- Endovascular Grafts for Abdominal Aortic Aneurysms
- Genetic Cancer Susceptibility Panels using Next Generation Sequencing
- Hematopoietic Cell Transplantation for Non-Hodgkin’s Lymphomas
- Nasal Valve Collapse
- Lunsumio (mosunetuzumab)
- Entyvio (vedolizumab) MA Only
- Poteligeo (mogamulizmuab-kpkc)
- Testing for Targeted Therapy of Non-Small-Cell Lung Cancer
- Fibromyalgia Testing
- Thermography and Temperature Gradient Studies
- Intravenous Anesthetics for the Treatment of Chronic Pain
- Percutaneous Electrical Nerve Field Stimulation for Irritable Bowel Syndrome
- Mozobil (plerixafor)
- Genetic Testing for Neurofibromatosis and Related Disorders
- Eyelid Thermal Pulsation for the Treatment of Dry Eye Syndrome
- Fecal Calprotectin Testing
- Keratoprosthesis (Artficial Cornea)
- Bone Morphogenetic Protein
- Transcatheter Pulmonary Valve Implantation
- Vyxeos (daunorubicin and cytarabine)
- Genetic Testing for FMR1 Mutations
- Isturisa (osilodrostat)
- Chest Imaging Guidelines
- Closure Devices for Patent Foramen Ovale and Atrial Septal Defects
- Genetic Testing for Connective Tissue Disorders
- Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors in Adults
- Genetic Markers for Assessing Risk of Cardiovascular Disease
- Isolated Small Bowel Transplant
- Urine Culture Testing for Bacteria
- In Vitro Chemoresistance and Chemosensitivities Assays
- Opdivo (nivolumab)
- Tezspire (tezepelumab-ekko)
- Electronic Brachytherapy for Nonmelanoma Skin Cancer
- Laparoscopic and Percutaneous Techniques for the Myolysis of Uterine Fibroids
- Pediatric Chest Imaging Guidelines
- Cardiac Imaging Guidelines
- Rydapt (midostaurin)
- Measurement of Thromboxane Metabolites for ASA Resistance
- Identification of Microorganisms using Nucleic Acid Probes
- Revcovi (elapegademase-lvlr)
- VPRIV (velaglucerase alfa)
- Intraoperative Neurophysiologic Monitoring (Sensory Evoked PotentialsMotor Evoked Potentialsetc)
- Kidney Transplant
- Pemazyre (pemigatinib)
- Pathogen Panel Testing
- Chronic Intermittent Intravenous Insulin Therapy (CIIIT)
- Radiofrequency Coblation Tenotomy for Musculoskeletal Conditions
- Temporomandibular Joint Dysfunction Non Surgical Care
- Reconstructive Breast Surgery and Management of Breast Implants
- Onychomycosis Testing
- Bioimpedance Devices for Detection and Management of Lymphedema
- Hemlibra (emicizumab-kxwh)
- Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome
- Biofeedback as a Treatment of Headache
- Botulinum Toxin
- Continuous Passive Motion in the Home Setting
- Hematopoietic Cell Transplantation for Germ Cell Tumors (GCT)
- Cinqair (reslizumab)
- Fecal Microbiota Transplantation
- Celiac Disease Testing
- Endovascular Procedures (Angioplasty and or Stenting) for Intracranial Arterial Disease (Atherosclerosis and Aneurysms)
- Istodax (romidepsin)
- Genetic Testing for Li-Fraumeni Syndrome
- Benlysta (belimumab)
- Extracorporeal Photopheresis
- Pancreatic Enzyme Testing for Acute Pancreatitis
- Takhzyro (lanadelumab)
- Maternal Serum Biomarkers for Prediction of Adverse Obstetric Outcomes
- Gene Therapy for Inherited Retinal Dystrophy
- Dry Needling and Trigger Point Injections for Myofascial Pain
- Genetic Testing for PTEN Hamartoma Tumor Syndrome
- Intradialytic Parenteral Nutrition
- Extracorporeal Shock Wave Therapy for Plantar Fasciitis and Other Musculoskeletal Conditions
- Liposuction for Lipedema and Lymphedema
- Transcatheter Mitral Valve Repair
- Lupkynis (voclosporin)
- Formulary Non-Covered Drugs
- Hepatitis C Viremic Organs for Transplantation to Non-Viremic Patients
- Surgical Ventricular Restoration
- Bevacizumab products
- Radiofrequency Ablation of the Renal Sympathetic Nerves as a Treatment for Resistant Hypertension
- Cerezyme (imiglucerase)
- Subtalar Arthroereisis
- Evkeeza (evinacumab-dgnb)
- Genetic Testing for Hereditary Hearing Loss
- Fasenra (benralizumab)
- Immune Cell Function Assay
- Observation Room Services
- Recorlev (levoketoconazole)
- Biochemical Markers of Alzheimer Disease and Dementia
- Synthetic Cartilage Implants for Joint Pain
- Trigger Point and Tender Point Injections
- Gamifant (emapalumab-lzsg)
- Fabrazyme (agalsidase beta)
- Negative Pressure Wound Therapy in the Outpatient Setting
- Genetic Testing for Acute Myeloid Leukemia
- Ocrevus (ocrelizumab)
- Minimally Invasive Ablation Procedures for Morton and Other Peripheral Neuromas
- Intracellular Micronutrient Analysis
- Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia
- BCR – ABL 1 Testing
- Transplant Rejection Testing
- Jynarque (tolvaptan)
- Total Artificial Hearts and Implantable Ventricular Assist Devices
- Aducanumab for Alzheimer Disease
- Tivdak (tisotumab vedotin-tftv)
- Dry Hydrotherapy for Chronic Pain Conditions
- Bavencio (avelumab)
- Oncologic Applications of Photodynamic TherapyIncluding Barrett’s Esophagus
- Genetic Testing for Polyposis Syndromes
- Orthopedic Applications of Stem Cell Therapy (Including Allografts and Bone Substitutes Used With Autologous Bone Marrow)
- Flow Cytometry
- Transcatheter Arterial Chemoembolization to Treat Primary or Metastatic Liver Malignancies
- Bone Mineral Density Studies
- Steroid-Eluting Sinus Stents
- Genetic Testing of Mitochondrial Disorders
- Oncology Imaging Guidelines
- Vertebral Axial Decompression
- Minimal Residual Disease
- Balversa (erdafitinib)
- Gender Affirmation Services
- Genetic Testing for Epilepsy
- Mylotarg (gemtuzumab ozogamicin)
- Nutrient Nutritional Panel Testing
- Liquid Biopsy
- Genetic Testing for Hereditary Hemochromatosis
- General Genetic TestingSomatic Disorders
- Reconstructive and Cosmetic Services
- Cooling Devices Used in the Outpatient Setting
- Biofeedback as a Treatment of Urinary Incontinence in Adults
- Asparlas (calaspargase pegol-mknl)
- Prostate Biopsies
- Genetic Testing and Genetic Expression Profiling in Patients with Uveal Melanoma
- Mandibular Maxillary (Orthognathic) Surgery
- Nplate (romiplostim)
- Periureteral Bulking Agents as a Treatment of Vesicoureteral Reflux (VUR)
- Ambulance Supplies
- Serum Biomarker Panel Testing for Systemic Lupus Erythematosus and Other Connective Tissue Diseases
- Genetic Testing for Neurodegenerative Disorders
- Brexanolone for Postpartum Depression
- Nucala (mepolizumab)
- Cryoablation Radiofrequency Ablation and Laser Ablation for Treatment of Chronic Rhinitis
- Intracavitary Balloon Catheter Brain Brachytherapy for Malignant Gliomas or Metastasis to the Brain
- Genetic Testing for CHARGE Syndrome
- Endobronchial Ultrasound for Diagnosing and Staging of Lung Cancer
- Microprocessor Controlled Prostheses for the Lower Limb
- Diagnosis of Idiopathic Environmental Intolerance
- Sensory Integration Therapy and Auditory Integration Therapy
- Alpha-1 Proteinase Inhibitors
- Non-Invasive Tests for the Detection of Fetal Membrane Rupture
- Ablation of Peripheral Nerves to Treat Pain
- Esophageal Pathology Testing
- Radicava (edaravone)
- Outpatient Pulmonary Rehabilitation
- Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Disorders
- Small Bowel – Liver and Multivisceral Transplant
- Meniscal Allografts and Other Meniscus Implants
- Leadless Cardiac Pacemakers
- Home Cardiorespiratory Monitoring
- Biofeedback as a Treatment of Fecal Incontinence or Constipation
- Microsatellite Instability and Tumor Mutational Burden Testing
- Molecular Analysis for Gliomas
- Strensiq (asfotase alfa)
- Proteogenomic Testing of Individuals with Cancer
- Autonomic Nervous System Testing
- Allergen Testing
- Immune Globulin Therapy
- Phesgo (pertuzumabtrastuzumaband hyaluronidase-zzxf)
- Pharmacogenetic Testing
- Amniotic Membrane and Amniotic Fluid
- Elelyso (taliglucerase alfa) MA Only
- Elitek (rasburicase) MA Only
- Besponsa (inotuzumab ozogamicin) MA Only
- Poteligeo (mogamulizmuab-kpkc) MA Only
- Tecvayli
- Naglazyme (galsulfase) MA Only
- Polivy (polatuzumab vedotin piiq)
- Mobile Cardiac Outpatient Telemetry
- Axillary Reverse Mapping for Prevention of Breast Cancer-Related Lymphedema
- Stelara (ustekinumab) MA Only
- Intra-articular Hyaluronan Injections for Osteoarthritis MA Only
- Zaltrap (ziv-aflibercept) MA Only
- Scalp Hypothermia During Chemotherapy to Prevent Hair Loss
- Cladribine IV MA Only
- Percutaneous Intradiscal Electrothermal AnnuloplastyRadiofrequency AnnuloplastyBiacuplasty and Intraosseous Basivertebral Nerve Ablation
- Testosterone
- Pediatric Musculoskeletal Imaging Guidelines
- Adcetris (brentuximab vedotin) MA Only
- Bevacizumab (oncology) MA Only
- Thrombate III [Antithrombin III (Human)] MA Only
- Gene Expression Profiling and Protein Biomarkers for Prostate Cancer
- Prevymis (letermovir)
- Takhzyro (lanadelumab-flyo) MA Only
- Azacitidine MA Only
- Alpha Proteinase Inhibitors MA Only
- Ibandronate injection MA Only
- Genetic Testing for Familial Hypercholesterolemia
- Mavenclad (cladribine)
- Lung Volume Reduction Surgery for Severe Emphysema
- Bimatoprost Implant (Durysta™)
- C1 Esterase Inhibitors
- Soliris (eculizumab)
- Aqueous Shunts and Stents for Glaucoma
- Pediatric Preventive Screening
- Influenza Therapies
- Keveyis (dichlorphenamide)
- Pharmacy Copay Waiver Policy
- Monjuvi (tafasitamab-cxix) MA Only
- Icatibant for Hereditary Angioedema
- Surgical Treatments for Breast Cancer-Related Lymphedema
- DuchenneBeckerFacioscapulohumeraland Limb-Girdle Muscular Dystrophies
- Temporarily Implanted Nitinol Device (iTind) for Benign Prostatic Hyperplasia
- Vyxeos (daunorubicin-cytarabine) MA Only
- Apretude (cabotegravir injection)
- Peripheral Nerve Disorders (PND) Imaging Guidelines
- Prenatal Testing for Fetal Aneuploidy
- Fotivda (tivozanib)
- Enspryng (satralizumab-mwge)
- Biofeedback as a Treatment of Chronic Pain
- Musculoskeletal Imaging Guidelines
- Plugs for Anal Fistula Repair
- Gait Analysis
- Ilumya (tildrakizumab-asmn) MA Only
- Advanced Therapies for Pharmacological Treatment of Pulmonary Arterial Hypertension – MA Only
- Diagnostic Testing of Common Sexually Transmitted Infections
- Intensity-Modulated Radiotherapy (IMRT) AbdomenPelvis and Chest
- Cosela (Trilaciclib)
- Adipose-Derived Stem Cells in Autologous Fat Grafting to the Breast
- Treatment for Spinal Muscular Atrophy
- Pediatric Head Imaging Guidelines
- Chromoendoscopy as an Adjunct to Colonoscopy
- Implantable Peripheral Nerve Stimulation (PNS) Devices
- Intra-articular Hyaluronan Injections for Osteoarthritis
- Cryosurgical Ablation of Primary or Metastatic Liver Tumors
- Pre-Implantation Genetic Testing
- Electromagnetic Navigation Bronchoscopy
- Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting
- Jemperli (dostarlimab-gxly)
- Givlaari (givosiran)
- Hematopoietic Stem-Cell Transplantation for Plasma Cell DyscrasiasIncluding Multiple Myeloma and POEMS Syndrome
- Parathyroid HormonePhosphorusCalciumand Magnesium Testing
- Diacomit (stiripentol)
- Genetic Testing for Cystic Fibrosis
- Chromosomal Microarray
- Lumizyme (alglucosidase alfa)
- Radioactive Seed Localization of Nonpalpable Breast Lesions
- Reblozyl (luspatercept-aamt)
- Kevzara (sarilumab)
- Inqovi (decitabine and cedazuridine)
- Vonjo (pacritinib)
- Duopa (carbidopa-levodopa enteral suspension) MA Only
- Enspryng (satralizumab) MA Only
- Private Duty Nursing Service
- Stationary Ultrasonic Diathermy Devices
- Infliximab and Biosimilars MA Only
- Vitamin D Testing
- Ophthalmic VEGF Inhibitors MA Only
- Testing for Autism Spectrum Disorder and Developmental Delay
- Onpattro (patisiran) MA Only
- Skysona
- Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions
- Corneal Topography Computer-Assisted Corneal Topography Photokeratoscopy
- Genetic Testing for Germline Mutations of the RET Proto-Oncogene
- Padcev (enfortumab vedotin-ejfv)
- Libtayo (cemiplimab-rwlc)
- Infliximab and Biosimilars
- Magnetic Resonance Imaging‒Targeted Biopsy of the Prostate
- Manipulation Under Anesthesia
- Transmyocardial Revascularization
- Nucala (mepolizumab) MA Only
- Blincyto (blinatumomab)
- Bronchial Valves
- Preface to the Imaging Guidelines
- Genetic Testing of CADASIL Syndrome
- Genetic Testing for Lactase Insufficiency
- Testing for Diagnosis of Active or Latent Tuberculosis
- Treatment of Hyperhidrosis
- Vertical Expandable Prosthetic Titanium Rib (VEPTR)
- Uplizna (inebilizumab-cdon)
- Diagnostic Testing of Iron Homeostasis & Metabolism
- Enhertu (fam-trastuzumab deruxtecan-nxki)
- Besponsa (inotuzumab ozogamicin)
- Viscocanalostomy and Canaloplasty
- Salivary Hormone Testing
- Genetic Testing for Diagnosis of Inherited Peripheral Neuropathies
- Endothelial Keratoplasty
- Nerve Fiber Density Testing
- Lipid Apheresis
- Intravitreal and Punctum Corticosteroid Implants
- Parsabiv (etelcalcetide)
- Facet Arthroplasty
- Abdomen Imaging Guidelines
- Pediatric Pelvis Imaging Guidelines
- Genetic Testing for Fanconi Anemia
- Transcatheter Aortic-Valve Implantation for Aortic Stenosis
- Cardiac Rehabilitation in the Outpatient Setting
- Molecular Profiling for Cancers of Unknown Primary Origin
- Tysabri (natalizumab)
- Immune Prophylaxis for Respiratory Syncytial Virus (RSV)
- Aliqopa (copanlisib)
- Koselugo (selumetinib)
- Serum Tumor Markers for Malignancies
- Neurofeedback
- Quantitative Sensory Testing
- Hematopoietic Cell Transplantation for Solid Tumors of Childhood
- Non-Pharmacologic Treatment of Rosacea
- Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia
- Zepzelca (lurbinectedin)
- Evenity (romosozumab-aqqg)
- Diagnostic Testing of Influenza
- Scintimammography and Gamma Imaging of the Breast and Axilla
- Absorbable Perirectal Spacer (APS)
- Simponi (golimumab)
- Germline Genetic Testing for Hereditary Diffuse Gastric Cancer (CDH1CTNNA1)
- Compounded Medications
- Serum Biomarker Testing for Multiple Sclerosis and Related Neurologic Diseases
- Human Growth Hormone
- Pegfilgrastim (Neulasta Fulphila Nyvepria Udenyca Ziextenzo)
- Topical Products for Rosacea
- Cellular Immunotherapy for Prostate Cancer – MA Only
- Stromectol (ivermectin)
- Balloon Ostial Dilation for Treatment of Chronic and Recurrent Acute Rhinosinusitis
- Molecular Testing of Pulmonary Disease
- Noninvasive Cardiovascular Risk Testing
- Contraceptives
- Sarclisa (isatuximab-irfc)
- Tepmetko (tepotinib)
- Scenesse (afamelanotide)
- Nexletol (bempedoic acid) and Nexlizet (bempedoic acid-ezetimibe)
- Surgical Treatment of Femoroacetabular Impingement
- Betibeglogene Autotemcel (Zynteglo)
- Evaluation of Dry Eyes
- Folate Testing
- Metabolite Markers of Thiopurines Testing
- Repository Corticotropin Injection -MA Only
- Prophylactic Oophorectomy
- Retinal Prosthesis
- Genetic Testing for Rett Syndrome
- Nulibry (fosdenopterin)
- Hematopoietic Cell Transplantation for Hodgkin Lymphoma
- Adcetris (brentuximab vedotin)
- Artificial Pancreas Device Systems
- Open and Thoracoscopic Approaches to Treat Atrial Fibrillation (Maze and Related Procedures)
- Laser Interstitial Thermal Therapy for Neurological Conditions
- Endoscopic Radiofrequency Ablation or Cryoablation for Barrett’s Esophagus
- Image-Guided Minimally Invasive Decompression for Spinal Stenosis
- Botulinum Toxin – MA Only
- Forms of Alternative Treatment
- Mutation Analysis in Myeloproliferative Neoplasms
- Topical Alpha-Adrenergic Agents for Rosacea
- Therapeutic Radiopharmaceuticals for Prostate Cancer
- Korsuva (difelikefalin)
- Adjunctive Techniques for Screening and Surveillance of Barrett Esophagus and Esophageal Dysplasia
- Pediatric Abdomen Imaging Guidelines
- Peripheral Vascular Disease (PVD) Imaging Guidelines
- Short-Acting Fentanyl
- Drug Testing in Pain Management and Substance Use Disorder Treatment
- Enjaymo (sutimlimab-jome)
- Transanal Endoscopic Microsurgery (TEM)
- Emergency Care
- Surgery for Groin Pain in Athletes
- Cerezyme (imiglucerase) MA Only
- Mozobil (plerixafor) MA Only
- Parsabiv (etelcalcetide) MA Only
- Testing of Homocysteine Metabolism-Related Conditions
- VPRIV (velaglucerase alfa) MA Only
- Lumizyme (alglucosidase alfa) MA Only
- Actemra (tocilizumab) MA Only
- Confocal Laser Endomicroscopy
- Whole Body Dual X-Ray Absorptiometry (DEXA) to Determine Body Composition
- Hippotherapy
- Non-Contact Ultrasound Treatment for Wounds
- Bone Turnover Markers Testing
- Hematopoietic Cell Transplantation for CNS Embryonal Tumors and Ependymoma
- Empaveli (pegcetacoplan)
- Laser Treatment of Onychomycosis
- Yervoy (ipilimumab) MA Only
- Aliqopa (copanlisib) MA Only
- Zinplava (bezlotoxumab) MA Only
- Nexviazyme (avalglucosidase alfa-ngpt) MA Only
- Herceptin (trastuzumab) and biosimilars MA Only
- Tysabri (natalizumab) MA Only
- Mylotarg (gemtuzumab ozogamicin) MA Only
- Fabrazyme (agalsidase beta) MA Only
- Saphnelo (anifrolumab-fnia) MA Only
- Blincyto (blinatumomab) MA Only
- Fensolvi (leuprolide acetate) MA Only
- Vimizim (elosulfase alfa) MA Only
- Rylaze (asparaginase) MA Only
- Soliris (eculizumab) MA Only
- Aldurazyme (laronidase) MA Only
- Rylaze (asparaginase)
- Clotting Factor and Coagulant Blood Products MA Only
- Nurtec (rimegepant)
- Elaprase (idursulfase) MA Only
- Orencia IV SQ (abatacept)
- Biofeedback for Miscellaneous Indications
- Allergy Testing and Allergy Immunotherapy
- Powered Exoskeleton for Ambulation in Patients with Lower Limb Disabilities
- Dynamic Posturography
- Margenza (margetuximab-cmkb)
- Gas Permeable Scleral Contact Lens
- Low-Level Laser Therapy
- Spravato (esketamine)
- Therapeutic Radiopharmaceuticals for Neuroendocrine Tumors
- Implantable Cardioverter Defibrillator (ICD)
- Interventions for Progressive Scoliosis
- Natpara (parathyroid hormone)
- Intensity Modulated Radiotherapy (IMRT) Breast and Lung
- Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions
- Dynamic Spinal Visualization
- Tymlos (abaloparatide)
- Leqvio (inclisiran)
- Digital Health Therapies for Attention Deficit Hyperactivity Disorder
- Danyelza (naxitamab-gqgk)
- Pepaxto (melphalan flufenamide)
- Genetic Testing for Inherited Cardiomyopathies and Channelopathies
- Fertility Preservation
- Adakveo (crizanlizumab-tcma)
- Keytruda (pembrolizumab) MA Only
- Briumvi (ublituximab)
- Ultomiris (ravulizumab-cwvz)_2
- Rituximab and Biosimilars MA Only
- Chimeric Antigen Receptor Therapy for Multiple Myeloma
- Uterus Transplantation for Absolute Uterine Factor Infertility
- Gamma-glutamyl Transferase
- Bio-Engineered Skin and Soft Tissue Substitutes
- Balloon Dilation of the Eustachian Tube
- Treatment for Duchenne Muscular Dystrophy MA Only
- Allogeneic Pancreas Transplant
- Benlysta (belimumab)_2
- Intensity Modulated Radiotherapy (IMRT) Central Nervous System Tumors
- C1 Esterase Inhibitors MA Only
- Diagnosis and Treatment of Sacroiliac Joint Pain
- Imjudo (tremelimumab)
- Xenpozyme (olipudase alfa)
- Molecular Diagnostics for Breast Cancer Prognosis
- Biomarker Testing for Autoimmune Rheumatic Disease
- Xolair (omalizumab) – MA Only
- Ocrevus (ocrelizumab) MA Only
- Mepsevii (vestronidase-aslfa-vjbk) MA Only
- Fasenra (benralizumab) MA Only
- Hematopoietic Stem Cell Transplantation for Primary Amyloidosis
- Spevigo (spesolimab)
- Colorectal Cancer Screening
- General Inflammation Testing
- Prostate Specific Antigen (PSA) Testing
- Verquvo (vericiguat)
- Perjeta (pertuzumab) MA Only
- Leqembi (lecanemab-irmb)
- Cinqair (reslizumab) MA Only
- Arcalyst (rilonacept) MA Only
- Serum Testing for Hepatic Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease
- Molecular Markers in Fine Needle Aspirates of the Thyroid
- Vyvgart (efgartigimod alfa-fcab)
- Functional Neuromuscular Electrical Stimulation
- Urinary Tumor Markers for Bladder Cancer
- Crysvita (burosumab-twza)
- Testing for Alpha-1 Antitrypsin Deficiency
- Jelmyto (mitomycin)
- Hematopoietic Cell Transplantation for Autoimmune Diseases
- February 2024 Commercial Rx Policies
- Miscellaneous Investigational Procedures
- Use of Common Genetic Variants (single nucleotide polymorphisms) to Predict Risk of Non-Familial Breast Cancer
- Intensity-Modulated Radiotherapy (IMRT) HeadNeckThyroid and Brain Cancers
- Diagnosis of Vaginitis including Multi-target PCR Testing
- β-Hemolytic Streptococcus Testing
- Laboratory Testing for the Diagnosis of Inflammatory Bowel Disease
- Genetic Testing for Ophthalmologic Conditions
- Electrical Stimulation for Scoliosis
- Entyvio (vedolizumab)
- Tegsedi (inotersen)
- Actemra (tocilizumab)
- Transcutaneous Electrical Nerve Stimulation – TENS
- Elaprase (idursulfase)
- Cognitive Rehabilitation
- Kadcyla (ado-trastuzumab emtansine) – MA Only
- Allogeneic Hematopoietic Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms
- Keytruda (Pembrolizumab)
- Neck Imaging Guidelines
- Krystexxa (pegloticase)
- Venous and Arterial Thrombosis Risk Testing
- Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence
- EHB Rx policies 2024-02
- Therapeutic Drug Monitoring for 5-Fluorouracil
- Whole Genome and Whole Exome Sequencing
- Pancreatic Cancer Risk Testing Using Pancreatic Cyst Fluid
- Corneal Collagen Cross-Linking
- Paraspinal Surface Electromyography (EMG) to Evaluate and Monitor Back Pain
- Phexxi (lactic acidcitric acidand potassium bitartrate gel)
- Injectable Clostridial Collagenase for Fibroproliferative Disorders
- Kimmtrak (tebentafusp-tebn)
- Red Blood Cell Molecular Testing
- Pediatric Neck Imaging Guidelines
- Cardiovascular Disease Risk Assessment
- Immunohistochemistry
- Vitamin B12 and Methylmalonic Acid Testing
- BRCA
- Advanced Therapies for Pharmacological Treatment of Pulmonary Arterial Hypertension MA Only
- Advanced Therapies for Pharmacologic Treatment of Pulmonary Arterial Hypertension
- Treatment of Geographic Atrophy MA Only
- Treatment of Hereditary Transthyretin-Mediated Amyloidosis in Adult Patients
- Head Imaging Guidelines
- Pediatric and Special Populations Oncology Imaging Guidelines
- Cranial Electrotherapy Stimulation and Auricular Electrostimulation
- Transcutaneous Electrical Nerve Stimulation
- Pediatric Oncology Imaging Guidelines
- Pediatric and Special Populations Oncology Imaging Guidelines
- Breast Imaging Guidelines
- Pelvis Imaging Guidelines
- Pediatric Cardiac Imaging Guidelines
- Pelvis Imaging Guidelines
- Botulinum Toxin MA and ACA Only
- Cardiac Implantable Devices (CID)
- Preface to the Imaging Guidelines
- Ablations Denervations of Facet Joints and Peripheral Nerves
- Anesthesia Services for Interventional Pain Procedures
Click here to view the Blue Cross Blue Shield BCBS Kansas City Medical Policy Updates »
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