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BCBS Michigan Medical Policy Updates – February 2024
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February 2024 BCBS Michigan Medical Policy Updates:
- GT-SOMATIC BIOMARKER TESTING FOR IMMUNE CHECKPOINT INHIBITOR THERAPY (BRAF, MSI/MMR, PD-L1, TMB)
- MATERNAL SERUM BIOMARKERS FOR PREDICTION OF ADVERSE OBSTETRIC OUTCOMES
- GENETIC TESTING FOR BRCA1 OR BRCA2 FOR HEREDITARY BREAST/OVARIAN CANCER SYNDROME AND OTHER HIGH-RISK CANCERS
- HYPERTHERMIC INTRAPERITONEAL CHEMOTHERAPY FOR SELECT INTRA ABDOMINAL AND PELVIC MALIGNANCIES
- INTRAVENOUS ANESTHETICS FOR THE TREATMENT OF CHRONIC PAIN AND PSYCHIATRIC DISORDERS
- LYMPHEDEMA-SURGICAL TREATMENTS
- MULTI-BIOMARKER DISEASE ACTIVITY (MBDA) LABORATORY TESTING (E.G., VECTRA DA BLOOD TEST) FOR RHEUMATOID ARTHRITIS
- LIPEDEMA-SURGICAL TREATMENTS
- INFERTILITY DIAGNOSIS
- ISLET CELL AUTOANTIBODY TESTING
- MAGNETIC PELVIC FLOOR STIMULATION AS A TREATMENT OF URINARY INCONTINENCE
- LOW LEVEL LASER THERAPY
- ENTYVIO (VEDOLIZUMAB) MEDICARE ONLY
- SOMATIC BIOMARKER TESTING (INCLUDING LIQUID BIOPSY) FOR TARGETED TREATMENT AND IMMUNOTHERAPY IN METASTATIC COLORECTAL CANCER (KRAS, NRAS, BRAF, MMR/MSI, HER2, AND TMB)
- LEADLESS CARDIAC PACEMAKERS
- SOMATOSTATIN ANALOGS
- MAGNETIC RESONANCE ANGIOGRAPHY AND MAGNETIC RESONANCE VENOGRAPHY
- CORTROPHIN GEL (REPOSITORY CORTICOTROPHIN)
- LUTATHERA (LUTETIUM LU 177 DOTATATE)
- AZEDRA
- MEDICAL POLICY- IMMUNE GLOBULIN REPLACEMENT THERAPY MEDICATION USE GUIDELINES
- RETHYMIC (ALLOGENIC PROCESSED THYMUS TISSUE-AGDC)
- BREYANZI (LISOCABTAGNE MARALEUCEL)
- INTERMITTENT (72 HOURS OR GREATER) OR CONTINUOUS INVASIVE GLUCOSE MONITORING
- TZIELD (TEPLIZUMAB-MZWV)
- AMBULATORY EVENT MONITORS AND MOBILE CARDIAC OUTPATIENT TELEMETRY
- TRANSESOPHAGEAL ENDOSCOPIC THERAPIES FOR GASTROESOPHAGEAL REFLUX DISEASE (GERD)
- XOFIGO (RADIUM RA 223 DICHLORIDE)
- POSITRON EMISSION TOMOGRAPHY (PET) FOR ONCOLOGIC CONDITIONS
- SPRAVATO (ESKETAMINE)
- MAGNETIC RESONANCE IMAGING FOR DETECTION AND DIAGNOSIS OF BREAST CANCER
- INTERSPINOUS / INTERLAMINAR STABILIZATION / DISTRACTION DEVICES (SPACERS)
- RADICAVA (EDARAVON)
- MEASUREMENT OF EXHALED NITRIC OXIDE AND EXHALED BREATH CONDENSATE IN THE DIAGNOSIS AND MANAGEMENT OF RESPIRATORY DISORDERS
- ORENCIA (ABATACEPT)
- GENETIC TESTING MICROARRAY TESTING FOR CANCERS OF UNKNOWN PRIMARY (CUP) ORIGIN
- HOLOTRANSCOBALAMIN AS A MARKER OF VITAMIN B12 (COBALAMIN) STATUS
- GIVLAARI (GIVOSIRAN)
- EXTRACORPOREAL MEMBRANE OXYGENATION
- GENETIC TESTING – PREIMPLANTATION
- EYELID THERMAL PULSATION AND INTERFEROMETRIC COLOR ASSESSMENT OF THE TEAR FILM FOR THE DIAGNOSIS AND TREATMENT OF DRY EYE SYNDROME
- FOCAL TREATMENTS FOR PROSTATE CANCER
- GENETIC AND LABORATORY TESTING FOR USE OF 5-FLUOROURACIL IN PATIENTS WITH CANCER
- FACET ARTHROPLASTY
- DEEP BRAIN STIMULATION
- DIGITAL BREAST TOMOSYNTHESIS (3D MAMMOGRAPHY)
- CLOSURE DEVICES FOR PATENT FORAMEN OVALE AND ATRIAL SEPTAL DEFECTS
- CHARGED-PARTICLE (PROTON OR HELIUM ION) RADIATION THERAPY FOR NEOPLASTIC CONDITIONS
- DUAL ENERGY X-RAY ABSORPTIOMETRY (DXA) AND BIOELECTRICAL IMPEDANCE ANALYSIS (BIA) TO DETERMINE BODY COMPOSITIO
- BRONCHIAL THERMOPLASTY FOR THE TREATMENT OF ASTHMA
- CRYOSURGICAL ABLATION OF PRIMARY OR METASTATIC LIVER TUMORS
- BALLOON DILATION OF THE EUSTACHIAN TUBE (BDET)
- CORNEAL COLLAGEN CROSS-LINKING
- EXTRACORPOREAL SHOCK WAVE TREATMENT OF WOUNDS
- GENE EXPRESSION PROFILE ANALYSIS FOR RISK STRATIFICATION FOR PROSTATE CANCER MANAGEMENT
- TRANSCATHETER AORTIC VALVE IMPLANTATION FOR AORTIC STENOSIS
- GERMLINE AND SOMATIC BIOMARKER TESTING (INCLUDING LIQUID BIOPSY) FOR TARGETED TREATMENT IN PROSTATE CANCER (BRCA1/2, HOMOLOGOUS RECOMBINATION REPAIR GENE ALTERATIONS)
- TRANSPLANT-PANCREAS (ALLOGENEIC)
- WAINUA (EPLONTERSEN) MEDICARE ONLY
- 90589-CHIKUNGUNYA VIRUS VACCINE
- LANTIDRA (DONISLECEL-JUJN)
- TALVEY (TALQUETAMAB-TGVS)
- EYLEA (AFLIBERCEPT)
- REBYOTA (FECAL MICROBIOTA, LIVE – JSLM)
- CARVYKTI (CILTACABTAGENE AUTOLEUCEL)
- NEUROFEEDBACK
- H.P. ACTHAR GEL (REPOSITORY CORTICOTROPIN INJECTION)
- CIRCULATING TUMOR DNA AND CIRCULATING TUMOR CELLS FOR CANCER MANAGEMENT (LIQUID BIOPSY)
- RECONSTRUCTIVE BREAST SURGERY/MANAGEMENT OF BREAST IMPLANTS
- LYFGENIA (LOVOTIBEGLOGENE AUTOTEMCEL)
- TREATMENT OF HYPERHIDROSIS, EXCLUDING BOTULINUM
- GENETIC TESTING-ASSAYS OF GENETIC EXPRESSION IN TUMOR TISSUE AS A TECHNIQUE TO DETERMINE PROGNOSIS IN PATIENTS WITH BREAST CANCER
- BCBSM ONLY: PROVIDER SELF TREATMENT AND TREATMENT OF IMMEDIATE FAMILY MEMBERS
- VERTICAL EXPANDABLE PROSTHETIC TITANIUM RIB
- BCBSM ONLY: TRANSPLANT CENTERS
- BCBSM ONLY: CLINICAL SUPERVISION OF NON-PHYSICIAN MENTAL HEALTH PROVIDERS
- HYPERBARIC OXYGEN THERAPY, SYSTEMIC AND TOPICAL
- SPINAL SURGERY AUTOMATED PERCUTANEOUS AND ENDOSCOPIC DISCECTOMY
- PROSTHETIC DEVICES
- AUTOGRAFTS AND ALLOGRAFTS IN THE TREATMENT OF FOCAL ARTICULAR CARTILAGE LESIONS
- PERCUTANEOUS ELECTRICAL NERVE STIMULATION (PENS) AND PERCUTANEOUS NEUROMODULATION THERAPY (PNT)
- RETINAL PROSTHESIS
- DURABLE MEDICAL EQUIPMENT
- SPINAL SURGERY: PERCUTANEOUS DISC DECOMPRESSION USING LASER ENERGY OR RADIOFREQUENCY ABLATION (DISC NUCLEOPLASTY)
- ISLET TRANSPLANTATION
- ARTIFICIAL INTERVERTEBRAL DISC: CERVICAL SPINE
- BMT – HEMATOPOIETIC CELL TRANSPLANTATION FOR PLASMA CELL DYSCRASIAS, INCLUDING MULTIPLE MYELOMA AND POEMS SYNDROME
- INHALED NITRIC OXIDE (INO)
- CONTINUOUS SUBCUTANEOUS INSULIN INFUSION (CSII) (INSULIN PUMPS) AND TRANSDERMAL INSULIN DELIVERY SYSTEMS
- ABDOMINOPLASTY
- SALIVARY TESTING FOR HORMONE LEVELS
- DENTAL ANESTHESIA
- CONTRACEPTION AND VOLUNTARY STERILIZATION
- XOLAIR (OMALIZUMAB)
- OPHTHALMOLOGIC TECHNIQUES THAT EVALUATE THE POSTERIOR SEGMENT FOR GLAUCOMA
- OBSTRUCTIVE SLEEP APNEA AND SNORING – SURGICAL TREATMENT
- IMPLANTABLE BONE-CONDUCTION AND BONE-ANCHORED HEARING DEVICES
- SEMI-IMPLANTABLE AND FULLY IMPLANTABLE MIDDLE EAR HEARING AIDS
- REFRACTIVE KERATOPLASTIES, PHOTOTHERAPEUTIC KERATECTOMY AND IMPLANTATION OF INTRASTROMAL CORNEAL RING SEGMENTS
- LUNG AND LOBAR LUNG TRANSPLANT
- IMPLANTABLE CARDIOVERTER DEFIBRILLATOR (ICD), INCLUDING SUBCUTANEOUS ICD)
- ORTHOTIC DEVICES
- SURGICAL TREATMENT FOR MALE GYNECOMASTIA
- RADIOFREQUENCY ABLATION OF PRIMARY OR METASTATIC LIVER TUMORS
- BREAST REDUCTION FOR BREAST-RELATED SYMPTOMS
- INTRAOCULAR LENS IMPLANT FOR MYOPIA (NEARSIGHTEDNESS)
- SMALL BOWEL/LIVER AND MULTIVISCERAL TRANSPLANT
- HOME SPIROMETRY
- LIVER TRANSPLANT
- INTRADIALYTIC PARENTERAL NUTRITION (IDPN)
- GASTRIC ELECTRICAL STIMULATION
- HOME CARDIORESPIRATORY MONITORING FOR PEDIATRICS
- EXTRACORPOREAL SHOCK WAVE THERAPY FOR TREATMENT OF PLANTAR FASCIITIS AND OTHER MUSCULOSKELETAL DISORDERS
- PREGNANCY TERMINATIONS – MEDICAL AND SURGICAL
- COCHLEAR IMPLANT
- ALLERGY TESTING AND IMMUNOTHERAPY
- AUDITORY BRAIN STEM IMPLANT
- COMPUTER-ASSISTED MUSCULOSKELETAL SURGICAL NAVIGATIONAL ORTHOPEDIC PROCEDURE – EFFECTIVE 3/01/2024
- SERUM MARKERS FOR THE DIAGNOSIS OF INFLAMMATORY BOWEL DISEASE
- AMBULATORY BLOOD PRESSURE MONITORING FOR SCREENING AND DIAGNOSIS OF HYPERTENSION
- POSITRON EMISSION TOMOGRAPHY (PET) FOR ONCOLOGIC CONDITIONS – EFFECTIVE 03/01/2024
- GERMLINE AND SOMATIC BIOMARKER TESTING (INCLUDING LIQUID BIOPSY) FOR TARGETED TREATMENT IN OVARIAN CANCER (BRCA1, BRCA2, HOMOLOGOUS RECOMBINATION DEFICIENCY) – EFFECTIVE 3/01/2024
- GERMLINE GENETIC TESTING FOR BRCA1, BRCA2, AND PALB2 FOR HEREDITARY BREAST/OVARIAN CANCER SYNDROME AND OTHER HIGH-RISK CANCERS – EFFECTIVE 03/01/2024
- CHARGED-PARTICLE (PROTON OR HELIUM ION) RADIATION THERAPY – EFFECTIVE 03/01/2024
- CONTINUOUS INVASIVE GLUCOSE MONITORING – EFFECTIVE 03/01/2024
- RECONSTRUCTIVE BREAST SURGERY AND MANAGEMENT OF BREAST IMPLANTS (EST) – EFFECTIVE 03/01/2024
- FOCAL TREATMENTS FOR PROSTATE CANCER – EFFECTIVE 03/01/2024
- BALLOON DILATION OF THE EUSTACHIAN TUBE (BDET) (MXD) – EFFECTIVE 03/01/2024
- AMBULATORY EVENT MONITORS AND MOBILE CARDIAC OUTPATIENT TELEMETRY – EFFECTIVE 03/01/2024
- INTERSPINOUS/INTERLAMINAR STABILIZATION/DISTRACTION DEVICES (SPACERS)- EFFECTIVE 03/01/2024
- TRANSCATHETER AORTIC VALVE IMPLANTATION FOR AORTIC STENOSIS – EFFECTIVE 03/01/2024
- SACROILIAC JOINT FUSION FOR LOW BACK PAIN (EST) – EFFECTIVE 03/01/2024
- MAGNETIC RESONANCE ANGIOGRAPHY AND MAGNETIC RESONANCE VENOGRAPHY – EFFECTIVE 03/01/2024
- MAGNETIC RESONANCE IMAGING FOR BREAST CANCER – EFFECTIVE 03/01/2024
- GENE EXPRESSION PROFILE ANALYSIS FOR RISK STRATIFICATION FOR PROSTATE CANCER MANAGEMENT – EFFECTIVE 03/01/2024
- TRANSPLANT-PANCREAS (ALLOGENEIC) – EFFECTIVE 03/01/2024
- MATERNAL SERUM BIOMARKERS FOR PREDICTION OF ADVERSE OBSTETRIC OUTCOMES – EFFECTIVE 03/01/2024
- GT-SOMATIC BIOMARKER TESTING FOR IMMUNE CHECKPOINT INHIBITOR THERAPY (BRAF, MSI/MMR, PD-L1, TMB) – EFFECTIVE 03/01/2024
- GENETIC TESTING – PREIMPLANTATION – EFFECTIVE 03/01/2024
- NEUROFEEDBACK (I.E. EEG BIOFEEDBACK) EFFECTIVE 03/01/2024
- GERMLINE AND SOMATIC BIOMARKER TESTING (INCLUDING LIQUID BIOPSY) FOR TARGETED TREATMENT IN PROSTATE CANCER (BRCA1/2, HOMOLOGOUS RECOMBINATION REPAIR GENE ALTERATIONS) – EFFECTIVE 03/01/2024
- PLACENTAL AND UMBILICAL CORD BLOOD COLLECTION AND STORAGE – EFFECTIVE 03/01/2024
- TEMPORARILY IMPLANTED PROSTATIC STENTS FOR BENIGN PROSTATIC HYPERPLASIA (E.G., NITINOL DEVICE [ITIND], SPANNERTM)
- VEOPOZ (POZELIMAB-BBFG)
- ELREXFIO (ELRANATAMAB-BCMM)
- RYSTIGGO (ROZANOLIXIZUMAB-NOLI)
- ROCTAVIAN (VALOCTOCOGENE ROXAPARVOVEC)
- COLUMVI (GLOFITAMAB-GXBM)
- EPKINLY (EPCORITAMAB-BYSP)
- IZERVAY (AVACINCAPTAD PEGOL)
- INTRAVENOUS IRON REPLACEMENT
- ELEVIDYS (DELANDISTROGENE MOXEPARVOVEC-ROKL)
- ZYNYZ (RETIFANLIMAB-DLWR)
- OMISIRGE (OMIDUBICEL-ONLV)
- ENZYME REPLACEMENT THERAPY FOR FABRY DISEASE
- VYJUVEK (BEREMAGENE GEPERPAVEC)
- QALSODY (TOFERSEN)
- SYFOVRE (PEGCETACOPLAN)
- LAMZEDE (VELMANASE ALFA-TYCV)
- LUNSUMIO (MOSUNETUZUMAB-AXGB)
- BRIUMVI (UBLITUXIMAB-XIIY)
- LEQEMBI (LECANEMAB)
- Respiratory Syncytial Virus Vaccine (RSVpreF)
- ADSTILADRIN (NADOFARAGENE FIRADENOVEC-VNCG)
- ENDOTHELIAL KERATOPLASTY
- REMOTE ELECTRICAL NEUROMODULATION FOR MIGRAINES
- ZYNTEGLO (BETIBEGLOGENE AUTOTEMCEL)
- SKYSONA (ELIVALDOGENE AUTOTEMCEL)
- TECVAYLI (TECLISTAMAB-CQYV)
- SAPHNELO (ANIFROLUMAB-FNIA)
- SPEVIGO (SPESOLIMAB-SBZO)
- XENPOZYME (OLIPUDASE ALFA)
- PULMONARY ARTERIAL HYPERTENSION PRODUCTS MEDICARE ONLY
- SKYRIZI IV (RISANKIZUMAB-RZAA)
- ITCA 650 (EXENATIDE) – RETIRED AS OF 06/09/2022
- PLUVICTO (LUTETIUM LU 177 VIPIVOTIDE TETRAXETAN)
- ENJAYMO (SUTIMLIMAB INTRAVENOUS INJECTION)
- PROPRIETARY LABORATORY ANALYSES (PLA) CODES
- TEMPOROMANDIBULAR JOINT DISORDER
- GENETIC TESTING FOR LI-FRAUMENI SYNDROME
- TEZSPIRE (TEZEPELUMAB-EKKO)
- COMPLEMENTARY AND ALTERNATIVE MEDICINE (CAM)
- KIDNEY TRANSPLANTATION
- PCSK9 INHIBITORS
- VABYSMO (FARICIMAB-SVOA)
- VYVGART (EFGARTIGIMOD ALFA-FCAB)
- AIM IMFINZI (DURVALUMAB)
- AIM JEMPERLI (DOSTARLIMAB-GXLY)
- TANEZUMAB SUBCUTANEOUS INJECTION – RETIRED AS 04/14/2022
- AIM PEPAXTO ( Retired as of 12/9/2022 MLackley)
- RADIOFREQUENCY ABLATION OF BASIVERTEBRAL NERVE FOR LOW BACK PAIN (I.E. INTRACEPT)
- OXLUMO (LUMASIRAN)
- ILUMYA (TILDRAKIZUMAB-ASMN)
- MEDICAL POLICY- J0693 FETROJA® (CEFIDEROCOL)
- ENZYME REPLACEMENT THERAPY FOR MUCOPOLYSACCHARIDOSIS ALDURAZYME, ELAPRASE, MEPSEVII, NAGLAZYME, VIMIZIM (J1743) (J3397) (J1458) (J1322)
- ENZYME REPLACEMENT THERAPY FOR GAUCHER’S DISEASE CEREZYME, ELELYSO, VPRIV (J1786) (J3060) (J3385)
- KANUMA (SEBELIPASE ALFA)
- MARQIBO (VINCRISTINE SULFATE LIPOSOME)
- BRINEURA (CERLIPONASE ALFA)
- ANNULAR CLOSURE DEVICES (E.G., BARRICAID, XCLOSE, INCLOSE)
- PHRENIC NERVE STIMULATION FOR CENTRAL SLEEP APNEA
- GASTRIC BYPASS SURGERY FOR GASTROPARESIS
- ALTERNATIVE PHYSICAL THERAPY MODALITIES-EXPERIMENTAL/INVESTIGATIONAL
- ENZYME REPLACEMENT THERAPY FOR POMPE DISEASE
- TELEMEDICINE SERVICES
- BARHEMSYS ( retired 4/8/2021)
- ANJESO (retired 04/08/2021)
- TEPEZZA (TEPROTUMUMAB-TRBW)
- GROUND AMBULANCE SERVICES
- JYNNEOS (SMALLPOX AND MONKEYPOX, LIVE, NON-REPLICATING VACCINE) policy retired as of 12/3/2020.
- REBLOZYL (LUSPATERCEPT-AAMT)
- SELF ADMINISTERED DRUGS (retired as of 10/7/2021)
- ERVEBO (RETIRED AS OF 02/14/2021)
- ADAKVEO (CRIZANLIZUMAB-TMCA)
- HYALURONIC ACID INTRA-ARTICULAR INJECTIONS
- IN-OFFICE NEEDLE ARTHROSCOPY (E.G., MI-EYE?, VISIONSCOPE¿)
- HEART-KIDNEY TRANSPLANT COMBINED
- LUNG/DOUBLE LUNG AND LIVER TRANSPLANT COMBINED
- RISANKIZUMAB-RZAA: SKYRIZI (J3590)
- PNEUMATIC COMPRESSION PUMPS AND APPLIANCES FOR VENOUS ULCERS
- AIM (PEANUT IMMUNOTHERAPY TRANSDERMAL PATCH) VIASKIN PEANUT¿ J3490
- NON AIM SCENESSE (AFAMELANOTIDE INJECTABLE IMPLANT) J3490
- MEDICAL POLICY DETERMINATION – 90689 FLUAD QUADRIVALENT PEDIATRIC®
- ASPARLAS (RETIRED AS OF 02/4/2021)
- AMNIOTIC MEMBRANE AND AMNIOTIC FLUID
- GENICULAR NERVE BLOCKS
- ELZONRIS (RETIRED AS OF 2/4/2021)
- ULTOMIRIS (RAVULIZUMAB-CWVZ)
- CORONARY COMPUTED TOMOGRAPHY ANGIOGRAPHY WITH SELECTIVE NONINVASIVE FRACTIONAL FLOW RESERVE (FFRCT)
- MEDICAL FORMULA FOR INBORN ERRORS OF METABOLISM
- AIM MOXETUMOMAB PASUDOTOX-TDFK: LUMOXITI (J9999, C9045) (J9313)
- GENETIC TESTING-BRAF MUTATION IN SELECTING MELANOMA PATIENTS FOR TARGETED THERAPY
- CPT CATEGORY III CODES- NON-COVERED SERVICES
- POLYMERASE CHAIN REACTION (PCR) TESTING IN THE DIAGNOSIS OF ONYCHOMYCOSIS
- SPHENOPALATINE GANGLION BLOCK FOR HEADACHE
- PNEUMATIC COMPRESSION PUMPS AND APPLIANCES (E.G., FLECITOUCH? SYSTEM) FOR LYMPHEDEMA
- PERIRECTAL SPACER FOR RADIATION THERAPY TREATMENT OF PROSTATE CANCER (SPACEOAR)
- RADIOFREQUENCY ABLATION OF PERIPHERAL NERVES TO TREAT PAIN INCLUDING COOLIEF COOLED RF
- MOLECULAR TESTING IN THE MANAGEMENT OF PULMONARY NODULES
- AUTOGRAFTS AND ALLOGRAFTS FOR NERVE REPAIR
- GENETIC, MOLECULAR AND OTHER TESTS – EXPERIMENTAL/INVESTIGATIONAL STATUS
- MEDICAL POLICY – GIAPREZA (retired 4/08/2021)
- CRYSVITA (BUROSUMAB-TWZA)
- TROGARZO (IBALIZUMAB-ULYK)
- AIM INOTUZUMAB OZOGAMICIN: BESPONSA (J9229)
- OCREVUS (OCRELIZUMAB)
- AIM DINUTUXIMAB: UNITUXIN (J9999) (J3490) (J3590) (C9399)
- CRYOABLATION OF PERIPHERAL NERVES
- FETAL MAGNETOCARDIOGRAPHY
- RETINAL POLARIZATION SCAN (RETINAL BIREFRINGENCE SCANNING)
- MIRCERA (retired as of 06/10/2021)
- FASENRA (BENRALIZUMAB)
- POLYMETABOLITE URINE TESTING FOR ADENOMATOUS POLYPS
- AIM CABAZITAXEL: JEVTANA (J9043)
- INTRAVITREAL INJECTIONS FOR RETINAL CONDITIONS
- STELARA (USTEKINUMAB)
- ARTIFICIAL PANCREAS DEVICE SYSTEMS
- PULMONARY ARTERIAL HYPERTENSION PRODUCTS (policy retired as of 10/7/2021 – mlackley)
- AIM BLINATUMOMAB: BLINCYTO (J9039)
- AIR AMBULANCE SERVICES
- AIM BEVACIZUMAB POLICY
- H-WAVE STIMULATION
- AIM BENDAMUSTINE PRODUCTS
- SCINTIMAMMOGRAPHY AND GAMMA IMAGING OF THE BREAST AND AXILLA
- NUCALA (MEPOLIZUMAB)
- VERTEBRAL BODY TETHERING AND/OR STAPLING FOR SCOLIOSIS
- MYOELECTRIC PROSTHETIC AND ORTHOTIC COMPONENTS FOR THE UPPER LIMB
- AIM SIPULEUCEL-T: PROVENGE (Q2043)
- AIM ARZERRA
- AIM ERIBULIN MESYLATE: HALAVEN (J9179)
- AIM KYPROLIS (CARFILZOMIB) (retired as of 10/06/2022)
- GENETIC TESTING – BCR-ABL1 TESTING IN CHRONIC MYELOGENOUS LEUKEMIA AND ACUTE LYMPHOBLASTIC LEUKEMIA
- NONINVASIVE MEASUREMENT OF CENTRAL BLOOD PRESSURE (SPHYGMOCOR SYSTEM, VICORDER, PULSE WAVE VELOCITY, PHYSIOWAVE)
- INFLIXIMAB POLICY
- BCBSM ONLY: THERAPEUTIC MASSAGE
- ORTHOPEDIC APPLICATIONS OF PLATELET-RICH PLASMA
- GENDER AFFIRMING SERVICES
- CAR-T CLASS POLICY (policy retired as of 8/12/2021 ML)
- BCBSM ONLY: DENTAL MEDICAL-SURGICAL TREATMENT
- HOME MONITORING DEVICE FOR AGE-RELATED MACULAR DEGENERATION
- GENETIC TESTING NONINVASIVE PRENATAL SCREENING FOR FETAL ANEUPLOIDIES AND MICRODELETIONS USING CELL-FREE FETAL DNA
- GENETIC TESTING FOR SPECIFIED CONDITIONS USING TESTING PANELS
- PROSTATIC URETHRAL LIFT PROCEDURE FOR THE TREATMENT OF BPH
- GENETIC TESTING-CHROMOSOMAL MICROARRAY TESTING FOR THE EVALUATION OF EARLY PREGNANCY LOSS AND INTRAUTERINE FETAL DEMISE
- GENETIC TESTING – GENE EXPRESSION PROFILING FOR UVEAL MELANOMA
- GENETIC TESTING – JAK2, MPL AND CALR TESTING FOR MYELOPROLIFERATIVE NEOPLASMS
- INTRAVENOUS BISPHOSPHONATES (retired 04/08/2021)
- INTENSITY-MODULATED RADIATION THERAPY (IMRT) OF THE PROSTATE
- INTENSITY MODULATED RADIATION THERAPY (IMRT) OF THE BREAST AND LUNG
- GENETIC TESTING – NGS OF MULTIPLE GENES (PANEL) FOR MALIGNANT CONDITIONS.
- CIMZIA (CERTOLIZUMAB PEGOL)
- SECUKINUMAB: COSENTYX (J3490 / J3590)
- GENETIC TESTING FOR BLOOM SYNDROME
- GENETIC TESTING FOR MITOCHONDRIAL DISORDERS
- LEMTRADA (ALEMTUZUMAB)
- NOVEL BIOMARKERS IN RISK ASSESSMENT AND MANAGEMENT OF CARDIOVASCULAR DISEASE
- INTENSITY-MODULATED RADIATION THERAPY (IMRT): ABDOMEN, PELVIS, AND CHEST
- INTENSITY MODULATED RADIATION THERAPY (IMRT): CENTRAL NERVOUS SYSTEM TUMORS
- GENETIC TESTING- MOLECULAR MARKERS IN FINE NEEDLE ASPIRATES (FNA) OF THE THYROID
- CARDIAC HEMODYNAMIC MONITORING FOR THE MANAGEMENT OF HEART FAILURE IN THE OUTPATIENT SETTING
- INTENSITY-MODULATED RADIATION THERAPY (IMRT): CANCER OF THE HEAD AND NECK OR THYROID
- GENETIC TESTING FOR ALPHA-1 ANTITRYPSIN DEFICIENCY
- TYSABRI (NATALIZUMAB)
- MEDICATIONS FOR HEREDITARY ANGIOEDEMA
- GENETIC TESTING – WHOLE EXOME AND WHOLE GENOME SEQUENCING FOR DIAGNOSIS OF GENETIC DISORDERS
- NAVIGATED TRANSCRANIAL MAGNETIC STIMULATION (NTMS)
- SOLIRIS (ECULIZUMAB)
- ILARIS (CANAKINUMAB)
- GOLIMUMAB: SIMPONI ARIA (GOLIMUMAB)
- GENETIC TESTING FOR PTEN HAMARTOMA TUMOR SYNDROME
- VESTIBULAR FUNCTION TESTING
- GENETIC TESTING FOR INHERITED THROMBOPHILIAS
- AIM MOZOBIL (PLERIXAFOR)
- GENETIC TESTING FOR HEREDITARY HEARING LOSS
- AQUEOUS SHUNTS AND STENTS FOR GLAUCOMA
- MAGNETIC ESOPHAGEAL SPHINCTER AUGMENTATION TO TREAT GASTROESOPHAGEAL REFLUX DISEASE (GERD)
- GENETIC CANCER SUSCEPTIBILITY PANELS USING NEXT GENERATION SEQUENCING
- PERCUTANEOUS LEFT ATRIAL APPENDAGE CLOSURE DEVICES FOR STROKE PREVENTION IN ATRIAL FIBRILLATION
- BONE GROWTH STIMULATION ELECTRICAL BONE GROWTH STIMULATION OF THE APPENDICULAR SKELETON
- POSTSURGICAL HOME USE OF LIMB COMPRESSION DEVICES FOR VENOUS THROMBOEMBOLISM PROPHYLAXIS
- MAGNETIC RESONANCE IMAGING TO MONITOR INTEGRITY OF SILICONE-GEL-FILLED BREAST IMPLANTS
- BONE GROWTH STIMULATION: ELECTRICAL STIMULATION OF THE SPINE AS AN ADJUNCT TO SPINAL FUSION PROCEDURES
- BMT – HEMATOPOIETIC STEM-CELL TRANSPLANTATION FOR NON-HODGKIN LYMPHOMAS
- BMT – HEMATOPOIETIC CELL TRANSPLANTATION FOR SOLID TUMORS OF CHILDHOOD
- LABORATORY TESTING FOR HIV TROPISM
- BMT – HEMATOPOIETIC CELL TRANSPLANTATION FOR ACUTE MYELOID LEUKEMIA
- MAGNETIC RESONANCE NEUROGRAPHY (MRN)
- BMT – HEMATOPOIETIC STEM-CELL TRANSPLANTATION FOR HODGKIN LYMPHOMA
- BMT – HEMATOPOIETIC STEM-CELL TRANSPLANTATION IN THE TREATMENT OF GERM CELL TUMORS
- BMT – HEMATOPOIETIC CELL TRANSPLANTATION FOR CHRONIC MYELOID LEUKEMIA
- DONOR LYMPHOCYTE INFUSION FOR MALIGNANCIES TREATED WITH AN ALLOGENEIC HEMATOPOIETIC STEM-CELL TRANSPLANT
- BOTULINUM TOXIN TYPE A INJECTION
- ACTEMRA
- BOTULINUM TOXIN TYPE B INJECTION (RIMABOTULINUMTOXINB)
- SYNAGIS ( PALIVIZUMAB)
- STEROID-ELUTING SINUS IMPLANTS
- MAKENA (HYDROXYPROGESTERONE CAPROATE INJECTION)
- INTRAOPERATIVE NEUROPHYSIOLOGIC MONITORING (SENSORY-EVOKED POTENTIALS, MOTOR-EVOKED POTENTIALS, EEG MONITORING)
- INTRAVITREAL AND PUNCTUM CORTICOSTEROID IMPLANTS
- SPECT/CT FUSION IMAGING
- GENETIC TESTING OF CADASIL SYNDROME
- DIALECTICAL BEHAVIOR THERAPY
- OCCIPITAL NERVE STIMULATION
- RETINAL CARE FOR DIABETIC RETINOPATHY
- PHRENIC NERVE STIMULATION AND DIAPHRAGM PACING
- GENE EXPRESSION PROFILE TESTING AND CIRCULATING TUMOR DNA TESTING FOR PREDICTING RECURRENCE IN COLON CANCER (E.G., COLOPRINT, COLON PRS, GENEFX, ONCODEFENDER, ONCOTYPE DX COLON CANCER TEST)
- BCBSM ONLY: CONTINUING COVERAGE OF CPAP MACHINES AND SUPPLIES FOR THE TREATMENT OF OBSTRUCTIVE SLEEP APNEA
- EYE MOVEMENT DESENSITIZATION AND REPROCESSING FOR POST TRAUMATIC STRESS DISORDER (PTSD)
- BMT – STEM CELL TRANSPLANT FOR WALDENSTROM’S MACROGLOBULINEMIA
- TRANSANAL HEMORRHOIDAL DEARTERIALIZATION
- BAROREFLEX STIMULATION DEVICES
- INGESTIBLE CAPSULE FOR ASSESSMENT OF GASTROINTESTINAL (MOTILITY) DISORDERS
- ASPIRIN RESISTANCE TESTING
- PERCUTANEOUS SACRAL AUGMENTATION
- GENETIC TESTING FOR MARFAN SYNDROME, EHLERS-DANLOS, THORACIC AORTIC ANEURYSMS AND DISSECTIONS, AND CONNECTIVE TISSUE RELATED DISORDERS
- CRANIAL ELECTROTHERAPY STIMULATION (CES) AND AURICULAR ELECTROSTIMULATION
- CHEMOSENSITIVITY AND CHEMORESISTANCE ASSAY, IN VITRO
- STEREOTACTIC RADIOSURGERY AND STEREOTACTIC BODY RADIOTHERAPY
- ONCOPROTEIN DES-GAMMA-CARBOXY PROTHROMBIN (DCP) IMMUNOASSAY
- GENETIC TESTING, INCLUDING CHROMOSOMAL MICROARRAY ANALYSIS AND NEXT-GENERATION SEQUENCING PANELS, FOR THE EVALUATION OF CHILDREN WITH DEVELOPMENTAL DELAY/INTELLECTUAL DISABILITY, AUTISM SPECTRUM DISORDER, AND/OR CONGENITAL ANOMALIES
- OPTICAL COHERENCE TOMOGRAPHY IMAGING, ANTERIOR EYE
- INTRAOCULAR RADIATION THERAPY FOR AGE-RELATED MACULAR DEGENERATION
- AUTOLOGOUS SERUM EYE DROPS
- GENETIC TESTING FOR HEREDITARY HEMOCHROMATOSIS
- PROCALCITONIN TESTING (PCT)
- FECAL CALPROTECTIN
- ASSISTED REPRODUCTIVE TECHNIQUES
- LIVER-KIDNEY (COMBINED) TRANSPLANT
- AUTISM SPECTRUM DISORDER SERVICES
- QUANTITATIVE SENSORY TESTING
- HEMOGLOBIN A1C TESTING DEVICE FOR HOME USE OR FOR USE AS A POINT OF CARE DEVICE
- ELECTRONIC BRACHYTHERAPY
- MAGNETIC RESONANCE GUIDED FOCUSED ULTRASOUND (MRGFUS)
- ULTRASONOGRAPHIC MEASUREMENT OF CAROTID INTIMA-MEDIAL THICKNESS AS AN ASSESSMENT OF SUBCLINICAL ATHEROSCLEROSIS
- BALLOON OSTIAL DILATION FOR TREATMENT OF CHRONIC AND RECURRENT RHINOSINUSITIS
- MAGNETIC RESONANCE IMAGING, LOW-FIELD
- CASGEVY (EXAGAMGLOGENE AUTOTEMCEL)
- RIVFLOZA (NEDOSIRAN)
- ADZYNMA (ADAMTS13, RECOMBINANT-KRHN)
Click here to view the Blue Cross Blue Shield BCBS Michigan Medical Policy Updates »
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