BCBS Massachusetts Medical Policy Updates – June 2018

June 2018 Medical Policy Updates:

• 004 Immune Modulating Drugs
• 024 Vestibular Function Testing prn
• 033 Med UM Policy
• 046 Hip Resurfacing
• 051 Pharmacy Specialty List
• 090 Intensity Modulated Radiation Therapy – IMRT – of the Prostate
• 097 Bone Morphogenetic Protein
• 110 Meniscal Allografts and Other Meniscal Implants
• 111 Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions
• 133 Microprocessor Controlled Prostheses for the Lower Limb
• 145 Surgical Treatment of Femoroacetabular Impingement
• 153 Sacral Nerve Neuromodulation-Stimulation
• 161 Reverse Shoulder Arthroplasty
• 163 Intensity-Modulated Radiation Therapy – IMRT – of the Breast and Lung
• 164 Intensity-Modulated Radiation Therapy – IMRT – Cancer of the Head and Neck or Thyroid
• 165 Intensity-Modulated Radiation Therapy – IMRT – Abdomen and Pelvis
• 172 Percutaneous Electrical Nerve Stimulation – PENS – and Percutaneous Neuromodulation Therapy – PNT
• 178 Complementary Medicine
• 183 Prolotherapy
• 195 Dynamic Spinal Visualization 
• 211 Intraoperative Neurophysiologic Monitoring (Sensory-Evoked Potentials, Motor-Evoked Potentials, EEG Monitoring)
• 219 Carotid, Vertebral and Intracranial Artery Stent Placement with or without Angioplasty
• 320 Diagnosis and Treatment of Sacroiliac Joint Pain
• 325 Request for Clinical Exception to BCBSMA Intensity Modulated Radiation Therapy – IMRT – Policy and Notification
• 357 Genetic Testing of CADASIL Syndrome
• 363 Psychological Testing
• 374 Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions
• 406 Treatment of Hyperhidrosis
• 423 Outpatient Psychotherapy
• 436 Interspinous Fixation – Fusion Devices
• 447 Whole-Body Computed Tomography Scan as a Screening Test
• 452 Genetic Testing for Hereditary Hearing Loss
• 455 Adoptive Immunotherapy including CAR T-Cell therapy
• 457 Whole Exome Sequencing
• 474 Vagus Nerve Stimulation
• 484 Percutaneous Vertebroplasty and Sacroplasty
• 485 Percutaneous Balloon Kyphoplasty, Radiofrequency Kyphoplasty and Mechanical Vertebral Augmentation
• 498 Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures
• 580 Genetic Testing for Familial Alzheimers Diseases
• 582 Balloon Sinuplasty for Treatment of Chronic Sinusitis
• 585 Artificial Intervertebral Disc – Cervical Spine
• 590 Nerve Graft in Association with Radical Prostatectomy
• 592 Artificial Intervertebral Disc – Lumbar Spine
• 592 Artificial Intervertebral Disc – Lumbar Spine
• 643 Amniotic Membrane and Amniotic Fluid
• 701 Electromyography and Nerve Conduction Studies
• 709 Proteomic Testing for Systemic Therapy in Non-Small-Cell Lung Cancer
• 712 Miscellaneous Genetic and Molecular Diagnostic Tests
• 716 Responsive Neurostimulation for the Treatment of Refractory Focal Epilepsy
• 790 Expanded Molecular Panel Testing of Cancers to Identify Targeted Therapies
• 833 Computed Tomography (CT) Cardiac (Structure)
• 910 Intensity Modulated Radiation Therapy – IMRT – Central Nervous System Tumors
• 925 Preauthorization Request Form for Kymriah Therapy
• 927 Preauthorization Request Form for Diagnosis and Treatment of Sacroiliac Joint Pain for MP 320

Added 6/29/2018;

• 070 Implantable Cardioverter Defibrillator
• 006 Botulinum Toxin Injection
• 033 Med UM Policy
• 037 Phototherapy Light for the Treatment of Seasonal Affective – SAD – and Other Depressive Disorders
• 039 Neuropsychological Testing
• 042 Wearable Cardioverter Defibrillators
• 068 Plastic Surgery
• 098 Endovascular Grafts for Abdominal Aortic Aneurysms
• 100 Inhaled Nitric Oxide as a Treatment of Hypoxic Respiratory Failure in Neonates
• 123 Catheter Ablation for Cardiac Arrhythmias
• 129 KIF6 Genotyping for Predicting Cardiovascular Risk and or Effectiveness of Statin Therapy
• 136 Outpatient Pulmonary Rehabilitation
• 141 Catheter Ablation as Treatment for Atrial Fibrillation
• 200 Transanal Endoscopic Microsurgery
• 223 Aqueous Shunts and Stents for Glaucoma
• 223 Aqueous Shunts and Stents for Glaucoma
• 229 Positron Emission Tomography, Other PET Applications, Including Oncologic Tumor Imaging
• 251 Drug Management and Prior Authorization
• 274 Methadone Treatment and Intensive Detoxification or Ultra-Rapid Detoxification for Opiate Addiction
• 277 Stereotactic Radiosurgery and Stereotactic Body Radiotherapy
• 297 Repetitive Transcranial Magnetic Stimulation – rTMS
• 319 Outpatient Electroconvulsive Therapy
• 326 Accelerated Breast Irradiation and Brachytherapy Boost After Breast-Conserving Surgery for Early Stage Breast Cancer
• 363 Psychological Testing
• 408 Drugs for Cystic Fibrosis
• 423 Outpatient Psychotherapy
• 433 Noncovered Drug List
• 572 Drugs for Weight Loss
• 578 Computer-Aided Evaluation of Malignancy with Magnetic Resonance Imaging of the Breast
• 594 Computer-Assisted Navigation Orthopedic Procedure
• 595 Baroreflex Stimulation Devices
• 596 Navigated Transcranial Magnetic Stimulation
• 606 Retinal Prosthesis
• 610 Intraocular Radiation Therapy for Age-Related Macular Degeneration
• 613 Eyelid Thermal Pulsation for the Treatment of Dry Eye Syndrome
• 644 Vagus Nerve Blocking Therapy for Treatment of Obesity
• 652 Progenitor Cell Therapy for the Treatment of Damaged Myocardium Due to Ischemia
• 674 Drug Testing in Pain Management and Substance Use Disorder Treatment
• 727 Quality Care Dosing Guidelines Drug List
• 730 Endovascular Therapies for Extracranial Vertebral Artery Disease
• 737 Orthopedic Applications of Platelet-Rich Plasma
• 739 Electronic Brachytherapy for Nonmelanoma Skin Cancer
• 740 Blepharoplasty Blepharoptosis repair and Brow ptosis repair
• 746 Testing Serum Vitamin D Levels
• 769 CT MR Angiography (CTA MRA) Neck
• 784 Magnetic Resonance Imaging (MRI) Upper Extremity (Any Joint)
• 785 Magnetic Resonance Imaging (MRI) Upper Extremity (Non-Joint)
• 797 Circulating Tumor DNA and Circulating Tumor Cells for Cancer
• 797 Circulating Tumor DNA and Circulating Tumor Cells for Cancer
• 905 Corneal Collagen Cross-linking
• 913 Molecular Markers in Fine Needle Aspirates of the Thyroid

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

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