BCBS Louisiana Medical Policy Updates – January 2023

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

January 2023 BCBS Louisiana Medical Policy Updates:

• Adlarity  (donepezil patch)
• Advanced Therapies for Pharmacological Treatment of Pulmonary Hypertension
• Amniotic Membrane and Amniotic Fluid
• Analysis of Human DNA in Stool Samples as a Technique for Colorectal Cancer Screening
• Applied Behavior Analysis for Autism Spectrum Disorder in Adults
• Artificial Intervertebral Disc: Lumbar Spine
• Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer
• Autonomic Nervous System Testing
• Auvi-Q® (epinephrine auto-injector)
• Baroreflex Stimulation Devices
• BCR-ABL1 Testing in Chronic Myelogenous Leukemia and Acute Lymphoblastic Leukemia
• betibeglogene autotemcel (Zynteglo )
• bimatoprost Implant (Durysta™)
• Bioengineered Skin and Soft Tissue Substitutes
• Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment and Immunotherapy in Metastatic Colorectal Cancer
• Biventricular Pacemakers (Cardiac Resynchronization Therapy) for the Treatment of Heart Failure
• Bone Growth Stimulation
• cerliponase alfa (Brineura®)
• Chronic Intermittent Intravenous Insulin Therapy (CIIIT)
• Cialis® 5 mg, generics (tadalafil)
• Circulating Tumor DNA and Circulating Tumor Cells for Cancer Management (Liquid Biopsy)
• Comprehensive Genomic Profiling for Selecting Targeted Cancer Therapies
• Continuous Glucose Monitoring
• Cytochrome P450 Genotype-Guided Treatment Strategy
• dalfampridine (Ampyra®, generics)
• Erythropoiesis-Stimulating Agents (ESA’s): epoetin alfa (Epogen® and Procrit®), epoetin alfa-epbx (Retacrit™), darbepoetin alfa (Aranesp®), and pegylated epoetin beta (Mircera®)
• Eucrisa™ (crisaborole)
• Experimental-Investigational Services
• External Insulin Pump
• Fecal Microbiota Transplantation
• Fetal Surgery for Prenatally Diagnosed Malformations
• Focal Treatments for Prostate Cancer
• Formulary Exception Process/Non-Formulary Drug Review Process Standard Criteria (Closed Formulary)
• Gene Expression Profile Testing and Circulating Tumor DNA Testing for Predicting Recurrence in Colon Cancer
• Gene Expression Profiling and Protein Biomarkers for Prostate Cancer Management
• Gene Expression Profiling for Cutaneous Melanoma
• Gene Expression Profiling for Uveal Melanoma
• Gene Expression-Based Assays for Cancers of Unknown Primary
• Gene Variants (PALB2, CHEK2 and ATM) Associated With Breast Cancer in Individuals at High Breast Cancer Risk
• Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer
• Genetic Cancer Susceptibility Panels Using Next-Generation Sequencing
• Genetic Testing for Alzheimer’s Disease
• Genetic Testing for Developmental Delay/Intellectual Disability, Autism Spectrum Disorder, and Congenital Anomalies
• Genetic Testing for Diagnosis and Management of Mental Health Conditions
• Genetic Testing for Facioscapulohumeral Muscular Dystrophy
• Genetic Testing for Familial Cutaneous Malignant Melanoma
• Genetic Testing for FLT3, NPM1, and CEBPA Variants in Cytogenetically Normal Acute Myeloid Leukemia
• Genetic Testing for Inherited Thrombophilia
• Genetic Testing for Li-Fraumeni Syndrome
• Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes
• Genetic Testing for PTEN Hamartoma Tumor Syndrome
• Genetic Testing for Rett Syndrome
• Genetic Testing to Select Melanoma or Glioma Patients for Targeted Therapy
• Germline and Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment and Immunotherapy in Breast Cancer
• Germline and Somatic Biomarker Testing Including Liquid Biopsy for Targeted
• Germline and Somatic Biomarker Testing Including Liquid Biopsy for Targeted
• Germline Genetic Testing for BRCA1 or BRCA2 for Hereditary Breast/Ovarian Cancer Syndrome and Other High-Risk Cancers
• Germline Genetic Testing for Pancreatic Cancer Susceptibility Genes
• Hematopoietic Cell Transplantation for Autoimmune Diseases
• HMG-CoA Reductase Inhibitors and HMG-CoA Reductase Inhibitor Combination Drugs
• Hydrogel Spacer use During Radiotherapy for Prostate Cancer
• Image-Guided Minimally Invasive Decompression for Spinal Stenosis
• Implantable Bone-Conduction and Bone-Anchored Hearing Aids
• Interferon gamma-1b (Actimmune®)
• Intracavitary Balloon Catheter Brain Brachytherapy for Malignant Gliomas or Metastasis to the Brain
• JAK2, MPL, and CALR Testing for Myeloproliferative Neoplasms
• Kerendia® (finerenone)
• lanadelumab-flyo (Takhzyro™)
• Magnetic Resonance-Guided Focused Ultrasound
• Magnetoencephalography/Magnetic Source Imaging
• Medical Management of Obstructive Sleep Apnea Syndrome
• Microarray-Based Gene Expression Profile Testing for Multiple Myeloma Risk Stratification
• migalastat (Galafold™)
• Minimally Invasive Treatment of Nasal Valve Collapse
• Miscellaneous Genetic and Molecular Diagnostic Tests
• Molecular Analysis (Including Liquid Biopsy) for Targeted Therapy or Immunotherapy of 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, and Solid Pancreaticobiliary Lesions
• Molecular Testing in the Management of Pulmonary Nodules
• Next-Generation Sequencing for the Assessment of Measurable Residual Disease
• Noncontact Ultrasound Treatment for Wounds
• Opioid Management/Long Acting Oral Opioid Step Therapy
• Percutaneous Electrical Stimulation PENS and Percutaneous Neuromodulation Therapy (PNT)
• Pharmacogenetic Testing for Pain Management
• Pharmacotherapy for Idiopathic Pulmonary Fibrosis and Interstitial Lung Disease
• Plasma Exchange (PE)
• Quantitative Electroencephalography as a Diagnostic Aid for Attention-Deficit/Hyperactivity Disorder
• ravulizumab (Ultomiris™)
• risankizumab-rzaa (Skyrizi™)
• Sacroiliac Joint Fusion
• sapropterin dihydrochloride (Kuvan®, generics)
• Scintimammography and Gamma Imaging of the Breast and Axilla
• Select Dexamethasone Packs
• Select Erectile Dysfunction Medications
• Select Hemophilia Products
• Select Topical Rosacea Products
• Spinal Cord and Nerve Root Stimulators
• Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy
• Sunosi™ (solriamfetol)
• tezacaftor/ivacaftor (Symdeko™)
• tildrakizumab-asmn (Ilumya™)
• tocilizumab (Actemra®)
• tolvaptan (Jynarque™)
• Topical Corticosteroids
• Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders
• Treatment of Hereditary Transthyretin-Mediated Amyloidosis in Adult Patients
• triamcinolone extended release intra-articular injection (Zilretta™)
• Tumor-Informed Circulating Tumor DNA Testing for Cancer Management
• upadacitinib (Rinvoq™)
• Use of Common Genetic Variants (Single Nucleotide Variants) to Predict Risk of Nonfamilial Breast Cancer
• Vagus Nerve Stimulation
• Vertebral Body Stapling and Vertebral Body Tethering for the Treatment of Scoliosis
• Vertebroplasty/Kyphoplasty
• Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders

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

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