BCBS Louisiana Medical Policy Updates – December 2018

December 2018 BCBS Louisiana Medical Policy Updates:

• Ablation Procedures for Peripheral Neuromas
• Acoustic Cardiography-Archived Policy
• Aimovig  (erenumab-aooe)
• Alternative Treatments of Benign Prostatic Hypertrophy – Archived Policy
• anakinra (Kineret)
• Analysis of Human DNA in Stool Samples as a Technique for Colorectal Cancer Screening
• Autonomic Nervous System Testing
• avatrombopag (Doptelet )
• Bisphosphonates (Oral)
• Bone Growth Stimulation
• Bone Mineral Density Studies – Archived Policy
• Breast Duct Endoscopy – Archived Policy
• Bronchial Valves
• C1 Esterase Inhibitor (Berinert)
• C1 esterase inhibitor [recombinant] (Ruconest)
• Cardiopulmonary Exercise Stress Test (CPET) – Archived Policy
• Catheter Ablation as Treatment for Atrial Fibrillation
• cholic acid capsules (Cholbam)
• Cialis (tadalafil)
• Closure Devices for Patent Foramen Ovale and Atrial Septal Defects
• Combined Androgen Blockade for the Treatment of Metastatic Prostate Cancer – Archived Policy
• Conjunctival Incision with Posterior Juxtascleral Placement of Anecortave Acetate Depot Suspension – Archived Policy
• Corneal Collagen Cross-linking
• Coronary Computed Tomography Angiography With Selective Noninvasive Fractional Flow Reserve
• Cytochrome p450 Genotyping
• Decompression of the Intervertebral Disc Using Laser Energy (Laser Discectomy) or Radiofrequency Coblation (Nucleoplasty)
• Diabetic Test Strips
• Donor Leukocyte Infusion for Malignancies Treated with an Allogeneic Hematopoietic Cell Transplant- Archived
• Drug Testing in Pain Management and Substance Abuse Treatment
• Dynamic Spinal Visualization
• emicizumab (Hemlibra)
• Endovascular Stent Grafts for Disorders of the Thoracic Aorta
• Epithelial Cell Cytology in Breast Cancer Risk Assessment and High-Risk Patient Management Ductal Lavage and Fiberoptic Ductoscopy – Archived Policy
• etanercept (Enbrel)
• Evzio (naloxone auto-injector)
• Facet Radiofrequency Denervation
• Fecal Analysis in the Diagnosis of Intestinal Dysbiosis- Archived Medical Policy
• Fecal Microbiota Transplantation
• Gait Analysis-Archived
• Gamma Interferon Blood Test for Diagnosis of Latent Tuberculosis – Archived Policy
• Gas Permeable Scleral Contact Lens Archived Medical Policy
• Gene Expression-Based Assays for Cancers of Unknown Primary
• Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer
• Genetic Testing for Alzheimer’s Disease
• Genetic Testing for CHARGE Syndrome
• Genetic Testing for Developmental Delay/Intellectual Disability, Autism Spectrum Disorder, and Congenital Anomalies
• Genetic Testing for Familial Cutaneous Malignant Melanoma
• Genetic Testing for Germline Mutations of the RET Proto-Oncogene in Medullary Carcinoma of the Thyroid – Archived Policy
• Genetic Testing for Hereditary Hemochromatosis
• Genetic Testing for Hereditary Pancreatitis
• Genetic Testing for Li-Fraumeni Syndrome
• Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes
• Genetic Testing for Marfan Syndrome, Thoracic Aortic Aneurysms and Dissections, and Related Disorders
• Genetic Testing for Tamoxifen Treatment
• Gocovri (amantadine extended release)
• Hematopoietic Cell Transplantation for Acute Myeloid Leukemia
• Hematopoietic Cell Transplantation for Primary Amyloidosis or Waldenstrom’s Macroglobulinemia
• Hematopoietic Cell Transplantation in the Treatment of Germ-Cell Tumors
• Hematopoietic Stem Cell Transplantation for Breast Cancer- Archived Policy
• Hematopoietic Stem-Cell Transplantation for Non-Hodgkin Lymphomas
• Hip Resurfacing
• Hippotherapy
• HIV Genotyping and Phenotyping- Archived Medical Policy
• HMG-CoA Reductase Inhibitors and HMG-CoA Reductase Inhibitor Combination Drugs
• Home Phototherapy for Neonatal Jaundice – Archived Policy
• Home Prothrombin Time Monitoring-Archived Policy
• Hysteroscopic Placement of Micro-inserts in the Fallopian Tubes as a Form of Permanent Sterilization – Archived Policy
• Identification of Microorganisms Using Nucleic Acid Probes
• Implantable Bone Conduction and Bone-Anchored Hearing Aids
• Implantable Sinus Stents for Postoperative Use Following Endoscopic Sinus Surgery and for Recurrent Sinus Disease
• In Vivo Colorectal Polyp Analysis – Archived Policy
• Injectable Bulking Agents for the Treatment of Urinary and Fecal incontinence
• Inpatient Intestinal Rehabilitation Therapy – Archived Policy
• Intra-arterial Brachytherapy for the Management and Treatment of Restenosis after Percutaneous Transluminal Angioplasty (PTA) – Archived Policy
• Intra-operative Neurophysiologic Monitoring (Sensory-evoked Potentials, Motor-evoked Potentials, EEG Monitoring) – Archived Policy
• Islet Transplantation
• itraconazole (Onmel)
• ivacaftor (Kalydeco)
• JAK2, MPL, and CALR Testing for Myeloproliferative Neoplasms
• Keratolimbal Allograft and Amniotic Membrane Transplant – Archived Policy
• Laparoscopic and Percutaneous Techniques for the Myolysis of Uterine Fibroids
• Laser Treatment of Congenital Port Wine Stain Hemangiomas – Archived Policy
• Light Therapy for Psoriasis
• Local or Whole Body Hyperthermia – Archived Policy
• Lucemyra  (lofexidine)
• lumacaftor/ivacaftor (Orkambi)
• Lung and Lobar Lung Transplant
• Lung Volume Reduction Surgery for Severe Emphysema – Archived Policy
• lusutrombopag (Mulpleta )
• Lymphedema Pumps – Archived Policy
• Magnetic Resonance Imaging Targeted Biopsy of the Prostate-Archived Medical Policy
• Magnetic Resonance-Guided Focused Ultrasound
• Metformin and Metformin Containing Products
• Microarray-Based Gene Expression Profile Testing for Multiple Myeloma Risk Stratification
• mifepristone (Korlym)
• Miscellaneous Genetic and Molecular Diagnostic Tests
• Monitoring of Regional Cerebral Blood Flow Using an Implanted Cerebral Thermal Perfusion Probe – Archived Policy
• Naltrexone Implants/Pellets
• nesiritide (Natrecor) – Archived Policy
• nitisinone (Orfadin, Nityr)
• Nonmyeloablative Allogeneic Transplants of Hematopoietic Stem Cells for Treatment of Malignancy – Archived Policy
• Nutrient/Nutritional Panel Testing
• obeticholic acid (Ocaliva)
• Oncologic Applications of Photodynamic Therapy, Including Barrett’s Esophagus
• Opioid Antagonists Under Heavy Sedation or General Anesthesia as a Technique of Opioid Detoxification-Archived Medical Policy
• Opioid Management/Long Acting Oral Opioid Step Therapy
• Optical Diagnostic Devices for Evaluating Skin Lesions Suspected of Malignancy- Archived Policy
• Parenteral Therapy for Osteoporosis
• Partial Coherence Interferometry as a Technique to Measure the Axial Length of the Eye – Archived Policy
• pegvaliase-pqpz (Palynziq )
• Pegylated Interferons (Pegasys, PegIntron) for Other (Non-Hepatitis C) Uses- Archived Policy
• Percutaneous Electrical Nerve Stimulation (PENS) and Percutaneous Neuromodulation Therapy (PNT)
• Percutaneous Left-Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation
• Pharmacogenomic and Metabolite Markers for Patients Treated with Thiopurines
• Phosphate Binders
• Photodynamic Therapy for Choroidal Neovascularization
• Phototherapy Light for the Treatment of Seasonal Affective and Other Depressive Disorders – Archived Policy
• Placental and Umbilical Cord Blood as a Source of Stem Cells – Archived Policy
• Plasma Exchange (PE)
• Plasma Exchange (PE)
• Proton Beam Radiation Therapy
• Pulsed Irrigation of Fecal Impaction – Archived Policy
• Radioembolization for Primary and Metastatic Tumors of the Liver
• Radiofrequency Ablation of Primary or Metastatic Liver Tumors
• Radiofrequency Ablation of the Renal Sympathetic Nerves as a Treatment for Resistant Hypertension
• Radioimmunoscintigraphy Imaging (Monoclonal Antibody Imaging) With Indium-111 Capromab Pendetide for Prostate Cancer
• Scintimammography and Gamma Imaging of the Breast and Axilla
• Scoliosis Braces – Archived Policy
• Sensory Integration Therapy and Auditory Integration Therapy
• Serologic Diagnosis of Celiac Disease
• Serum Biomarker for Human Epididymis Protein 4 (HE4) – Archived Policy
• Siklos  (hydroxyurea)
• sipuleucel-T (Provenge)
• Small Bowel Transplant, Small Bowel/Liver Transplant and Multivisceral Transplant
• Sympathetic Therapy for the Treatment of Pain – Archived Policy
• Systems Pathology in Prostate Cancer
• Thermography – Archived Policy
• Thoracic-Lumbo-Sacral Orthosis with Pneumatics- Archived Policy
• Tilt Table Testing – Archived Policy
• tocilizumab (Actemra)
• tolvaptan (Jynarque )
• Topical and Nasal Testosterone Products
• Topical Pain Patches
• Total Artificial Hearts and Implantable Ventricular Assist Devices
• Transciliary Fistulization for the Treatment of Glaucoma – Archived Policy
• Transcoronary Ablation of Septal Hypertrophy (TASH) – Archived Policy
• Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders
• Transjugular Intrahepatic Portosystemic Shunt (TIPS) – Archived Policy
• Transpupillary Thermotherapy for Treatment of Choroidal Neovascular Conditions- Archived Policy
• Treatment of Hepatitis C with a simeprevir (Olysio) Based Regimen-Archived Medical Policy
• Treatment of Hepatitis C with a sofosbuvir (Sovaldi) Based Regimen
• Treatment of Hepatitis C with daclatasvir (Daklinza) plus sofosbuvir (Sovaldi)
• Treatment of Hepatitis C with elbasvir and grazoprevir (Zepatier)
• Treatment of Hepatitis C with glecaprevir/pibrentasvir (Mavyret)
• Treatment of Hepatitis C with ombitasvir, paritaprevir, and ritonavir (Technivie)
• Treatment of Hepatitis C with ombitasvir, paritaprevir, ritonavir, and dasabuvir (Viekira Pak/Viekira XR)
• Treatment of Hepatitis C with simeprevir (Olysio) PLUS sofosbuvir (Sovaldi) Archived Medical Policy
• Treatment of Hepatitis C with sofosbuvir/ledipasvir (Harvoni)
• Treatment of Hepatitis C with sofosbuvir/velpatasvir (Epclusa)
• Treatment of Hepatitis C with sofosbuvir/velpatasvir/voxilaprevir (Vosevi)
• Treatment of Hepatitis C with Triple Therapy (Ribavirin Plus Pegylated Interferon Alfa Plus telaprevir [Incivek] or boceprevir [Victrelis])- Archived Medical Policy
• Tumor-Treatment Fields Therapy for Glioblastoma-Retired Policy
• T-Wave Alternans- Archived Medical Policy
• Urinary Metabolite Tests for Adherence to Direct-Acting Antiviral Medications for Hepatitis C-Archived Medical Policy
• Urinary Tumor Markers for Bladder Cancer – Archived Policy
• Use of Common Genetic Variants (single nucleotide polymorphisms) to Predict Risk of Nonfamilial Breast Cancer
• Vacuum Therapy as a Treatment for Female Sexual Dysfunction – Archived Policy
• Vertebroplasty/Kyphoplasty
• Whole Gland Cryoablation of Prostate Cancer

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