BCBS South Carolina Medical Policy Updates – June 2018

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June 2018  Medical Policy Updates:

• Abatacept (Orencia®)
• Abdominoplasty, Panniculectomy and Lipectomy
• Acupuncture and Dry Needling
• Blepharoplasty (Upper and Lower)
• Brachytherapy for Clinically Localized Prostate Cancer Using Permanently Implanted Seeds
• Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting
• Catheter Ablation for Cardiac Arrhythmias
• Cellular Immunotherapy for Prostate Cancer
• Chiropractic Services
• Cimzia® (certolizumab pegol)
• Cosmetic/Reconstructive Services
• Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome
• Electronic Brachytherapy for Nonmelanoma Skin Cancer
• Endobronchial Brachytherapy
• Facet Arthroplasty
• Focal Treatments for Prostate Cancer
• Genetic Testing for Hereditary Breast and/or Ovarian Cancer Syndrome (BRCA1/BRCA2)
• Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia
• Hematopoietic Colony-Stimulating Factors (CSFs)
• Hematopoietic Stem-Cell Transplantation for Solid Tumors of Childhood
• Homocystinuria
• Human Antihemophilic Factor (AHF)
• Human Leukocyte Antigen (HLA) Testing for Celiac Disease
• Hypnosis
• Inflectra™ (infliximab-dyyb)
• Infliximab
• Inpatient Rehabilitation
• Intensity-Modulated Radiation Therapy (IMRT): Abdomen and Pelvis
• Laser Treatment of Onychomycosis
• Light Therapy for Vitiligo and Alopecia Areata
• Marfan Syndrome Testing
• Medical Records Documentation Standards
• Negative Pressure Wound Therapy in the Outpatient Setting
• Nerve Graft with Radical Prostatectomy
• Neuromuscular Electrical Stimulation (NMES)
• Nivolumab (Opdivo)
• Occupational Therapy
• Orthopedic Applications of Platelet-Rich Plasma
• Pain Management Services (Chronic Pain and Rehabilitation Therapies)
• Pancreatic Enzyme Testing for Acute Pancreatitis
• Patient-Specific Cutting Guides and Custom Knee Implants
• Physical Therapy
• Positional Magnetic Resonance Imaging (MRI)
• Serum Testing for Evidence of Mild Traumatic Brain Injury
• SIMPONI ARIA (golimumab injection for intravenous use)
• Speech Therapy
• Stereotactic Radiofrequency Pallidotomy for the Treatment of Parkinson’s Disease
• Surgery for Athletic Pubalgia
• Surgical Ventricular Restoration
• TECENTRIQ™ (atezolizumab)
• Three-Dimensional Printed Orthopedic Implants
• Tocilizumab (Actemra®)
• Total Parenteral Nutrition and Enteral Nutrition in the Home
• Treatment of Hyperhidrosis
• Treatment of Tinnitus
• Tumor Treatment Fields Therapy for Glioblastoma
• Unicompartmental and Bicompartmental Knee Arthroplasties
• Use of Magnetic Resonance Imaging to Monitor Integrity of Silicone Gel-Filled Breast Implants
• ustekinumab (Stelara™)
• Vedolizumab (Entyvio™)
• Vertical Expandable Prosthetic Titanium Rib
• Virtual Colonoscopy/CT Colonography
• Visual and Auditory Evoked Potentials
• Whole Gland Cryoablation of Prostate Cancer

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