BCBS Massachusetts Medical Policy Updates – February 2019

February 2019 Medical Policy Updates:

• Adoptive Immunotherapy including CAR T-Cell therapy
• Alphabetical Index of Policies
• Alpha-Fetoprotein-L3 for Detection of Liver Cancer
• Analysis of Human DNA in Stool Samples as a Technique for Colorectal Cancer Screening
• Analysis of Proteomic Patterns for Early Detection of Cancer
• Anesthetics for the Treatment of Chronic Pain and Depression
• Applied Behavioral Analysis Service Request Form
• Assisted Reproductive Services Infertility Services
• Automated Percutaneous and Percutaneous Endoscopic Discectomy
• Autonomic Nervous System Testing
• Baroreflex Stimulation Devices
• Bi-Level Positive Airway Pressure – BPAP Devices
• Biofeedback as a Treatment of Chronic Pain
• Biofeedback as a Treatment of Fecal Incontinence or Constipation
• Biofeedback for Miscellaneous Indications
• Biofeedback for the Treatment of Headache
• Bone Turnover Markers for Diagnosis and Management of Osteoporosis and Diseases Associated with High Bone Turnover
• Cardiovascular Risk Panels
• Cerebrospinal Fluid and Urinary Biomarkers of Alzheimer Disease
• Charged-Particle – Proton or Helium Ion – Radiation Therapy
• Chemical Peels
• Chromoendoscopy as an Adjunct to Colonoscopy
• CNS Stimulants and Psychotherapeutic Agents
• Computed Tomographic Angiography Coronary Arteries (CCTA)
• Computed Tomography (CT) Abdomen
• Computed Tomography (CT) Abdomen and Pelvis Combination
• Computed Tomography (CT) Cervical Spine
• Computed Tomography (CT) Chest
• Computed Tomography (CT) CT Colonography (Virtual Colonoscopy)
• Computed Tomography (CT) Head
• Computed Tomography (CT) Lower Extremity
• Computed Tomography (CT) Lumbar Spine
• Computed Tomography (CT) Neck for Soft Tissue Evaluation
• Computed Tomography (CT) Orbit, Sella Turcica, Posterior Fossa, Temporal Bone, including Mastoids
• Computed Tomography (CT) Paranasal Sinus & Maxillofacial Area
• Computed Tomography (CT) Thoracic Spine
• Computed Tomography (CT) Upper Extremity
• Computer-Aided Evaluation as an Adjunct to Magnetic Resonance Imaging of the Breast
• Computer-Assisted Navigation Orthopedic Procedure
• Confocal Laser Endomicroscopy
• Continuous or Intermittent Monitoring of Glucose in Interstitial Fluid
• Corneal Collagen Cross-linking
• CT Angiography (CTA) Abdomen and Pelvis Combination
• CT Angiography (CTA) Abdominal Aorta and Bilateral Iliofemoral Lower Extremity
• CT Angiography (CTA) and MR Angiography (MRA) Abdomen
• CT Angiography (CTA) and MR Angiography (MRA) Lower Extremity
• CT Angiography (CTA) and MR Angiography (MRA) Pelvis
• CT Angiography (CTA) and MR Angiography (MRA) Upper Extremity
• CT Angiography (CTA) Chest (Non Coronary)
• CT MR Angiography (CTA MRA) Head Cerebrovascular
• CT MR Angiography (CTA MRA) Neck
• Dermatologic Applications of Photodynamic Therapy
• Diagnosis and Treatment of Sacroiliac Joint Pain
• Directory of Documents, 411
• Drug Management and Prior Authorization
• Drug Testing in Pain Management and Substance Use Disorder Treatment
• Duchenne Muscular Dystrophy (DMD) Medications
• Dynamic Spinal Visualization and Vertebral Motion Analysis
• Electronic Brachytherapy for Nonmelanoma Skin Cancer
• Endoscopic Radiofrequency Ablation or Cryoablation for Barretts Esophagus
• Endovascular Therapies for Extracranial Vertebral Artery Disease
• Epidural Steroid Injections for Neck and Back Pain
• Esophageal pH Monitoring
• Expanded Molecular Panel Testing of Cancers to Identify Targeted Therapies
• Eyelid Thermal Pulsation for the Treatment of Dry Eye Syndrome
• Facet Joint Denervation
• Fecal Analysis in the Diagnosis of Intestinal Dysbiosis
• Fecal Microbiota Transplantation
• Fetal MRI
• Functional Magnetic Resonance Imaging (fMRI) Brain
• Gender Affirming Services (Transgender Services)
• Genetic Testing for Commercial and Medicare Advantage
• Hematopoietic Cell Transplantation for Plasma Cell Dyscracias, Including Multiple Myeloma and POEMS Syndrome
• Hematopoietic Stem-Cell Transplantation for Waldenstrom Macroglobulinemia
• Homocysteine Testing in the Screening, Diagnosis, and Management of Cardiovascular Disease and Venous Thromboembolic Disease
• Human Anti hemophilic Factor
• Identification of Microorganisms Using Nucleic Acid Probe
• Immune Cell Function Assay in Solid Organ Transplantation
• Immunomodulators for Skin Conditions
• Implantable Miniature Telescope – IMT
• Ingestible pH and Pressure Capsule
• Injections for Osteroarthritis
• Intensity-Modulated Radiation Therapy – IMRT – Abdomen and Pelvis
• Intensity-Modulated Radiation Therapy – IMRT – Cancer of the Head and Neck or Thyroid
• Interspinous and Interlaminar Stabilization-Distraction Devices – Spacers
• Intracellular Micronutrient Analysis
• Intraocular Radiation Therapy for Age-Related Macular Degeneration
• Intraoperative Neurophysiologic Monitoring (Sensory-Evoked Potentials, Motor-Evoked Potentials, EEG Monitoring)
• Laboratory Testing for HIV Tropism
• Laser Treatment of Onychomycosis
• Lysis of Epidural Adhesions
• Magnetic Resonance Imaging (MRI) Abdomen – Cholangiopancreatography (MRCP) Abdomen
• Magnetic Resonance Imaging (MRI) Breast
• Magnetic Resonance Imaging (MRI) Cardiac
• Magnetic Resonance Imaging (MRI) Cervical Spine
• Magnetic Resonance Imaging (MRI) Chest
• Magnetic Resonance Imaging (MRI) Head Brain
• Magnetic Resonance Imaging (MRI) Lumbar Spine
• Magnetic Resonance Imaging (MRI) of the Lower Extremity Joint and Non-Joint
• Magnetic Resonance Imaging (MRI) Orbit, Face & Neck (Soft Tissues)
• Magnetic Resonance Imaging (MRI) Pelvis
• Magnetic Resonance Imaging (MRI) Temporomandibular Joint (TMJ)
• Magnetic Resonance Imaging (MRI) Thoracic Spine
• Magnetic Resonance Spectroscopy
• Management of Obstructive Sleep Apnea – OSA Oral Appliances
• Management of Obstructive Sleep Apnea APAP and CPAP Devices
• Measurement of Exhaled Nitric Oxide and Exhaled Breath Condensate in the Diagnosis and Management of Respiratory Disorders
• Measurement of Lipoprotein-Associated Phospholipase A2 – Lp-PLA2 – in the Assessment of Cardiovascular Risk
• Measurement of Serum Antibodies to Infliximab and Adalimumab
• MED UM Drug List
• Med UM Policy
• Medical Policies
• Medical Policy Updates
• Medical Policy Updates April 2019
• Medical Policy Updates February 2019
• Medical Technology Assessment NonCovered Services
• Mineral Density Studies
• Molecular Testing in the Management of Pulmonary Nodules
• Monitored Anesthesia Care – MAC
• MRI-Guided Focused Ultrasound – MRgFUS
• Multimarker Serum Testing Related to Ovarian Cancer
• Multiple Sleep Latency Testing – MSLT and Maintenance of Wakefulness Testing – MWT
• Multitarget Polymerase Chain Reaction Testing for Diagnosis of Bacterial Vaginosis
• Nerve Fiber Density Measurement
• Neural Therapy
• Neuropsychological and Psychological Testing
• Non pharmacologic Treatment of Rosacea
• Noninvasive Techniques for the Evaluation and Monitoring of Patients With Chronic Liver Disease
• Non-Invasive Vascular Studies – Duplex Scans
• Novel Biomarkers in Risk Assessment and Management of Cardiovascular Disease
• Nuclear Cardiology Myocardial Perfusion Imaging
• Nutrient – Nutritional Panel Testing
• Oncologic Applications of Photodynamic Therapy, Including Barretts Esophagus
• Oncology Drugs
• Ophthalmic Prostaglandins
• Ophthalmologic Techniques That Evaluate the Posterior Segment for Glaucoma
• Opioid Medication Management
• Optical Coherence Tomography of the Anterior Eye Segment
• Orthopedic Applications of Platelet-Rich Plasma
• Outpatient Electroconvulsive Therapy
• Outpatient Psychotherapy
• Percutaneous Balloon Kyphoplasty, Radiofrequency Kyphoplasty and Mechanical Vertebral Augmentation
• Percutaneous Tibial Nerve Stimulation for Voiding Dysfunction
• Percutaneous Vertebroplasty and Sacroplasty
• Peroral Endoscopic Myotomy for Treatment of Esophageal Achalasia
• Pharmacy Hepatitis C Medication Management
• Pharmacy Topical Ocular Hydrating Agents
• Phototherapy PUVA UV-B and Targeted Phototherapy
• Plasma Exchange
• Polysomnography and Home Sleep Testing
• Positron Emission Tomography (PET) Myocardial Imaging
• Positron Emission Tomography, Other PET Applications, Including Oncologic Tumor Imaging
• Prior Authorization Request  Form for Gender Affirming Services (Transgender Services)
• Prior Authorization Request Form for Electrolysis for Gender Affirming Services
• Proteomic Testing for Systemic Therapy in Non-Small-Cell Lung Cancer
• Quantitative Assay for Measurement of HER2 Total Protein Expression and HER2 Dimers
• Radiofrequency Ablation of Peripheral Nerves to Treat Pain
• Reduction Mammaplasty for Breast-Related Symptoms
• Retinal Prosthesis
• Retinal Telescreening for Diabetic Retinopathy
• Routine Foot Care and Debridement of Toenails
• Serum Biomarker Human Epididymis Protein 4 – HE4
• Serum Tumor Markers for Breast and Gastrointestinal Malignancies
• Sphenopalatine Ganglion Block for Headache
• Stereotactic Radiosurgery and Stereotactic Body Radiotherapy
• Surgical and Transesophageal Endoscopic Procedures to Treat Gastroesophageal Reflux Disease
• Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome
• Testing Serum Vitamin D Levels
• Therapeutic Radiopharmaceuticals in Oncology
• Topical Testosterone
• Transanal Endoscopic Microsurgery
• Transanal Radiofrequency Treatment of Fecal Incontinence
• Transcatheter Mitral Valve Repair
• Transcranial Magnetic Stimulation as a Treatment of Depression
• Transcutaneous Electrical Nerve Stimulation
• Transrectal Ultrasound for Staging Rectal Cancer
• Transrectal Ultrasound of the Prostate
• Transvaginal and Transurethral Radiofrequency Tissue Remodeling for Urinary Stress Incontinence
• Treatment of Varicose Veins and Venous Insufficiency
• Vagus Nerve Blocking Therapy for Treatment of Obesity

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