BCBS Louisiana Medical Policy Updates – August 2022

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

August 2022 BCBS Louisiana Medical Policy Updates:

• Abrocitinib (Cibinqo™)
• Allogeneic Hematopoietic Cell Transplantation for Genetic Diseases and Acquired Anemias
• Allogeneic Hematopoietic Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms
• Amikacin Suspension (Arikayce®)
• Amniotic Membrane and Amniotic Fluid
• Auditory Brainstem Implant
• Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions
• Bioengineered Skin and Soft Tissue Substitutes
• Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment and Immunotherapy in Metastatic Colorectal Cancer
• Budesonide Delayed Release (Tarpeyo™)
• carbinoxamine 6 mg tablets (Ryvent™, generics)
• Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting
• Chimeric Antigen Receptor T-cell (CAR-T) Therapy
• Chromosomal Microarray Testing for the Evaluation of Pregnancy Loss
• Circulating Tumor DNA and Circulating Tumor Cells for Cancer Management (Liquid Biopsy)
• Cognitive Rehabilitation
• Comprehensive Genomic Profiling for Selecting Targeted Cancer Therapies
• Continuous Glucose Monitoring
• Contrast-Enhanced Coronary Computed Tomography Angiography (CCTA) for Coronary Artery Evaluation
• Cromolyn Oral Solution (Gastrocrom®, generics)
• Cryoablation of Tumors Located in the Kidney, Lung, Breast, Pancreas, or Bone
• Cryosurgical Ablation of Primary or Metastatic Liver Tumors
• Cysteamine Delayed Release Capsules, Oral Granules (Procysbi®)
• Daxbia™ (cephalexin)
• droxidopa (Northera®, generics)
• Ecallantide (Kalbitor®)
• Elapegademase-lvlr (Revcovi™)
• emapalumab-lzsg (Gamifant™)
• emtricitabine/tenofovir Branded Products (Descovy® ,Truvada®)
• End-Diastolic Pneumatic Compression Boot as a Treatment of Peripheral Vascular Disease or Lymphedema
• Endovascular Procedures for Intracranial Arterial Disease (Atherosclerosis and Aneurysms)
• evinacumab-dgnb (Evkeeza™)
• Exon Skipping Therapies for Duchenne Muscular Dystrophy
• Experimental-Investigational Services
• Extracranial Carotid Angioplasty/Stenting
• Facet Radiofrequency Denervation
• Fentanyl Oral Transmucosal and Nasal Opioid Analgesics
• Functional Endoscopic Sinus Surgery for Chronic Rhinosinusitis
• Functional Neuromuscular Electrical Stimulation
• Gender Reassignment Surgery
• Gene Expression Profiling and Protein Biomarkers for Prostate Cancer Management
• Genetic Testing for Dilated Cardiomyopathy
• Genetic Testing for Duchenne and Becker Muscular Dystrophy
• Genetic Testing for Epilepsy
• Genetic Testing for Hereditary Hearing Loss
• Genetic Testing for Heterozygous Familial Hypercholesterolemia
• Genetic Testing for Limb-Girdle Muscular Dystrophies
• Genetic Testing for Lipoprotein(a) Variant(s) as a Decision Aid for Aspirin Treatment
• Genetic Testing for Neurofibromatosis
• Genetic Testing of CADASIL Syndrome
• Genotyping for 9p21 Single Nucleotide Polymorphisms to Predict Risk of Cardiovascular Disease or Aneurysm
• Germline and Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment and Immunotherapy in Breast Cancer
• Hematopoietic Cell Transplantation for Central Nervous System Embryonal Tumors and Ependymoma
• Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer
• Hematopoietic Cell Transplantation for Solid Tumors of Childhood
• Hyperbaric Oxygen Pressurization (HBO)
• Icatibant (Firazyr®, generics)
• Immune Globulin Therapy
• Ingestible pH and Pressure Capsule
• Liver Transplant and Combined Liver-Kidney Transplant
• Mannitol (Bronchitol®)
• Mechanical Stretch Devices for Joint Stiffness and Contractures
• Metformin and Metformin Containing Products
• Metreleptin (Myalept)
• Microprocessor-Controlled Prostheses for the Lower Limb
• Mitapivat (Pyrukynd®)
• Molecular Analysis (Including Liquid Biopsy) for Targeted Therapy or Immunotherapy of Non-Small-Cell Lung Cancer
• Myocardial Strain Imaging
• Myoelectric Prosthetic and Orthotic Components for the Upper Limb
• Nexiclon™ XR (clonidine extended release tablets)
• Noninvasive Prenatal Screening for Fetal Aneuploidies and Microdeletions, and Twin Zygosity Using Cell-Free Fetal DNA
• Occipital Nerve Stimulation
• Oral Non-Sedating Antihistamines and Singulair® Products (Branded)
• Orilissa™ (elagolix)
• Outpatient Pulmonary Rehabilitation
• Parenteral Nutrition and Enteral Nutrition Therapy in the Home
• Plasminogen, human-tvmh (Ryplazim )
• Remote Electrical Neuromodulation for Migraines
• Sutimlimab-jome (Enjaymo )
• Verkazia  (cyclosporine ophthalmic emulsion)
• Percutaneous Electrical Stimulation PENS and Percutaneous Neuromodulation Therapy (PNT)
• Percutaneous Tibial Nerve Stimulation
• Peripheral Subcutaneous Field Stimulation
• Pharmacogenetic Testing for Pain Management
• Postsurgical Home Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis
• pramlintide (Symlin®
• Progenitor Cell Therapy for the Treatment of Damaged Myocardium due to Ischemia
• Prolotherapy
• Pyrimethamine (Daraprim®, generic)
• Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors
• Repository Corticotropin Injection
• Reslizumab (Cinqair®)
• Responsive Neurostimulation for the Treatment of Refractory Partial Epilepsy
• Sacral Nerve Neuromodulation/Stimulation
• Select Anti-Epileptic Drugs
• Select Drugs for Attention Deficit Hyperactivity Disorder (ADHD)
• Select Drugs for Constipation
• Selective Serotonin Reuptake Inhibitors (SSRIs)/SerotoninNorepinephrine Reuptake Inhibitors (SNRIs)
• Soaanz® (torsemide tablets)
• Stem Cell Therapy for Peripheral Arterial Disease
• Subtalar Arthroereisis
• teduglutide [rDNA origin] (Gattex®)
• teprotumumab-trbw (Tepezza™)
• tesamorelin (Egrifta®)
• Topical Acne Products
• Topical Treatments for Dry Eye Disease
• Topical, Nasal, and Oral Testosterone Products
• tralokinumab-ldrm (Adbry™)
• Treatment for Spinal Muscular Atrophy
• Tumor-Informed Circulating Tumor DNA Testing for Cancer Management
• upadacitinib (Rinvoq™)
• vedolizumab (Entyvio®)
• Verquvo™ (vericiguat)
• Vertebral Axial Decompression
• Vesicular Monoamine Transporter Type 2 Inhibitors: deutetrabenazine (Austedo™), tetrabenazine (Xenazine®), valbenazine (Ingrezza™)
• Viscocanalostomy and Canaloplasty
• Xyosted™ (testosterone enanthate auto-injection)

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

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