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BCBS Tennessee Medical Policy Updates – November 2024
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Click here to view the Blue Cross Blue Shield BCBS Tennessee Medical Policy Updates »
November 2024 BCBS Tennessee Medical Policy Updates:
- Abatacept
- Abbreviated Daytime Sleep Study (e.g. PAP-NAP)
- Ablation Procedure for Peripheral Neuromas
- AbobotulinumtoxinA
- Absorbable Nasal Implant for the Treatment of Nasal Valve Collapse
- Actigraphy
- Acupuncture
- Adipose-Derived Stem Cells in Autologous Fat Grafting to the Breast
- Adoptive Immunotherapy
- Ado-Trastuzumab Emtansine
- Aducanumab-avwa (Aduhelm™)
- Aflibercept
- Agalsidase Beta
- Aldesleukin
- Alemtuzumab
- Alglucosidase Alfa
- Allogeneic Processed Thymus Tissue-agdc (Rethymic®)
- Alpha1-Proteinase Inhibitor Therapy
- Amivantamab-vmjw (Rybrevant™)
- Angioplasty or Stenting for Intracranial Arterial Disease (Atherosclerosis and Aneurysms)
- Anifrolumab-fnia (Saphnelo™)
- Aqueous Shunts and Stents for Glaucoma
- Artificial Intervertebral Disc
- Asparaginase Erwinia chrysanthemi (recombinant)-rywn (Rylaze™)
- Atezolizumab
- Atidarsagene Autotemcel (Lenmeldy™)
- Auricular Electrostimulation
- Autologous Chondrocyte Implantation (ACI)
- Automated Percutaneous and Endoscopic Discectomy
- Autonomic Nervous System Testing
- Avacincaptad Pegol (Izervay™)
- Avalglucosidase Alfa-ngpt (Nexviazyme™)
- Avelumab
- Axicabtagene Ciloleucel
- Azacitidine
- Balloon and Self-Expanding Absorptive Ostial Dilation for Treatment of Chronic Sinusitis
- Balloon Dilation of the Eustachian Tube
- Belimumab
- Belinostat
- Bendamustine HCl (Treanda®)
- Benralizumab
- Beremagene Geperpavec-svdt (Vyjuvek™)
- Betibeglogene autotemcel (Zynteglo®)
- Bevacizumab for the Treatment of Neoplastic Disease
- Bioengineered Skin and Soft Tissue Substitutes
- Biofeedback and Neurofeedback
- Bioidentical Compounded Hormone Therapy
- Bioimpedance Devices for Detection of Lymphedema
- Blinatumomab
- Bortezomib
- Breast Augmentation / Mammaplasty (Non-Cancerous)
- Breast Cancer Gene Expression Assays
- Breast Implant Removal
- Breast Reconstructive and Symmetry Surgery Following Mastectomy
- Brentuximab Vedotin
- Brexucabtagene Autoleucel
- Brolucizumab-dbll
- Browplasty
- Bulking Agents for the Treatment of Vesicoureteral Reflux (VUR) and Incontinence
- Burosumab-twza
- C1 Esterase Inhibitor (Berinert®)
- C1 Esterase Inhibitor (Human) – Cinryze®
- C1 Esterase Inhibitor (recombinant) – Ruconest®
- C1 Esterase Inhibitor Subcutaneous (Human) (Haegarda®)
- Cabazitaxel
- Calaspargase Pegol-mknl
- Canakinumab
- Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting
- Carfilzomib
- Casimersen (Amondys 45™)
- Cemiplimab-rwlc
- Cerliponase Alfa
- Certolizumab Pegol
- Cervical Traction Devices for Home Use
- Cetuximab
- Chelation Therapy
- Chromosomal Microarray Analysis for Evaluation of Pregnancy Loss
- Chronic Intermittent Intravenous Insulin Therapy
- Ciltacabtagene Autoleucel (Carvykti™)
- Cipaglucosidase Alfa-atga (Pombiliti™)
- Collagenase (Xiaflex®)
- Complementary and Alternative Medicine
- Computer Assisted Surgical Navigation for Orthopedic Procedures
- Computerized 2-lead Resting Electrocardiogram Analysis for the Diagnosis of Coronary Artery Disease
- Continuous Home Pulse Oximetry
- Continuous Passive Motion (CPM) Device in the Home Setting
- Copanlisib
- Corneal Collagen Cross-Linking
- Coronary Computed Tomography Angiography (CCTA)
- Corticotropin Therapy
- Crizanlizumab-tmca
- Cutaneous Electrogastrography (EGG)
- Cytochrome p450 Genotyping
- Daratumumab
- Daratumumab and hyaluronidase-fihj
- Darbepoetin Alfa (Aranesp®)
- Daunorubicin and Cytarabine, Liposome (Vyxeos®)
- DaxibotulinumtoxinA-lanm (Daxxify™)
- Degarelix
- Delandistrogene moxeparvovec-rokl (Elevidys®)
- Denosumab (Prolia®)
- Denosumab (Xgeva®)
- Dexamethasone Intravitreal Implant
- Diabetes Management
- Diagnosis and Treatment of Sacroiliac Joint Pain
- Digital Breast Tomosynthesis (3D Mammogram)
- Digital Health Technologies: Diagnostic Applications
- Digital Health Therapies for Substance Use Disorders
- Donor Lymphocyte Infusion for Hematologic Malignancies Treated with an Allogeneic Hematopoietic Stem Cell Transplant
- Dostarlimab-gxly (Jemperli®)
- Durvalumab
- Dynamic Posturography in the Assessment of Balance
- Dynamic Spinal Visualization
- Ecallantide
- Eculizumab
- Edaravone
- Efgartigimod Alfa-fcab and Hyaluronidase-qvfc (Vyvgart®Hytrulo)
- Eflapegrastim-xnst (Rolvedon™)
- Elapegademase-lvlr
- Electrical Impedance Scanning of the Breast
- Electrical Stimulation and Electromagnetic Therapy for the Treatment of Wounds
- Electrical Stimulation for the Treatment of Arthritis
- Electromyography and Nerve Conduction Studies (Electrodiagnostic Assessment)
- Electronic Brachytherapy for Non-Melanoma Skin Cancer
- Elivaldogene Autotemcel (Skysona®)
- Elosulfase Alfa
- Elotuzumab
- Elranatamab-bcmm (Elrexfio™)
- Emapalumab-lzsg
- End Diastolic Pneumatic Compression Boot as a Treatment of Peripheral Vascular Disease or Lymphedema
- Endometrial Ablation
- Endothelial Function Assessment
- Endothelial Keratoplasty
- Endovascular Therapies for Extracranial Vertebral Artery Disease
- Enfortumab Vedotin-ejfv
- Epcoritamab-bysp (Epkinly™)
- Epidural Steroid Injections for Treatment of Back Pain
- Epoetin Alfa Products (Epogen®, Procrit®, Retacrit®)
- Epoprostenol
- Eptinezumab-jjmr
- Eribulin Mesylate
- Error
- Eteplirsen
- Etranacogene Dezaparvovec-drlb (Hemgenix®)
- Evinacumab-dgnb (Evkeeza™)
- Exagamglogene Autotemcel (Casgevy™)
- Expanded Molecular Panel Testing of Cancers to Identify Targeted Therapies
- Extracorporeal Shock Wave Therapy for Wounds
- Eyelid Thermal Pulsation
- Facelift, Facial Thread Lift
- Facet Joint Injections
- Facet Joint Neurotomy
- Fam-trastuzumab Deruxtecan-nxki
- Faricimab-svoa (Vabysmo™)
- Fetal Surgery for Prenatally Diagnosed Malformations
- Fidanacogene Elaparvovec-dzkt (Beqvez™)
- First-Trimester Detection of Down Syndrome Using Fetal Ultrasound Markers Combined with Maternal Serum Assessment
- Fluocinolone Acetonide Implant (Iluvien®)
- Fluocinolone Acetonide Implant (Retisert®)
- Fluocinolone Acetonide Implant (Yutiq™)
- Fosdenopterin (Nulibry™)
- Fractional Laser Treatment of Vulvovaginal Atrophy
- Functional Neuromuscular Electrical Stimulation
- Galsulfase (Naglazyme®)
- Gemtuzumab Ozogamicin
- Gender Reassignment Surgery
- Gene Expression Profile Analysis for Prostate Cancer Management
- Genetic (Human Leukocyte Antigen) Testing for Celiac Disease
- Genetic Testing for CHARGE Syndrome
- Genetic Testing for CHEK2 Mutations for Breast Cancer
- Genetic Testing for Facioscapulohumeral Muscular Dystrophy
- Genetic Testing for Lipoprotein(a) Variant(s) as a Decision Aid for Aspirin Treatment
- Genetic Testing for Macular Degeneration
- Genetic Testing for Mental Health Conditions
- Genetic Testing for Mitochondrial Disorders
- Genetic Testing for Warfarin Dose
- Genotyping for 9p21 Single Nucleotide Polymorphisms to Predict Risk of Cardiovascular Disease or Aneurysm
- Givosiran
- Glofitamab-gxbm (Columvi™)
- Golimumab for Intravenous Infusion
- Golodirsen
- Goserelin Acetate Implant
- Hair Removal
- Hair Transplantation
- Hand and/or Face Transplantation (Composite Tissue Allotransplantation)
- Hematopoietic Progenitor Cell (HPC) Boost
- Hematopoietic Stem Cell Transplantation for Central Nervous System Embryonal and Ependymoma Tumors
- Hematopoietic Stem-Cell Transplantation for Malignant Astrocytomas and Gliomas
- Hematopoietic Stem-Cell Transplantation for Miscellaneous Solid Tumors in Adults
- Hemodialysis in the Home
- Hippotherapy
- Histrelin (Supprelin® LA)
- Home Apnea Monitoring / Home Cardiorespiratory Monitoring
- Home Nutritional Support (Total Parenteral / Enteral Nutrition)
- Home Spirometry
- Hospital-Grade Breast Pump
- Human Amniotic Membrane Grafts and Amniotic Fluid Injections
- Hyaluronan Derivatives for Intra-Articular Injection
- Ibalizumab-uiyk
- Icatibant
- Idecabtagene Vicleucel (Abecma®)
- Idursulfase
- Image-Guided Minimally Invasive Decompression for Spinal Stenosis
- Imetelstat (Rytelo™)
- Imiglucerase
- Implantable Hypoglossal Nerve Stimulation
- In Vitro Particle Size Measurement for Screening Hypersensitivity Reactions to Foods and Chemicals
- Inclisiran (Leqvio®)
- IncobotulinumtoxinA
- Inebilizumab-cdon (Uplizna™)
- Infliximab
- Inotersen
- Inotuzumab Ozogamicin
- Intensity-Modulated Radiotherapy (IMRT) of the Breast and Lung
- Intensive Outpatient Pediatric Feeding Program
- Interferential Current Stimulation
- Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers) – Interspinous Fixation (Fusion) Devices
- Intervertebral Disc Decompression using Radiofrequency Coblation (Nucleoplasty) or Laser Energy (Laser Discectomy)
- Intestinal Transplantation
- Intradiscal Annuloplasty and Intraosseous Radiofrequency Ablation for Treatment of Back Pain
- Intraocular Radiation Therapy for Age-Related Macular Degeneration
- Intraoperative Radiation Therapy (IORT)
- Intraoral Devices for the Treatment of Headaches
- Intrastromal Corneal Ring Segments (ICRS) for Vision Correction
- Intravenous Anesthetics for the Treatment of Chronic Pain
- Intravenous Immune Globulins
- Ipilimumab
- Irinotecan Liposome Injection
- Isatuximab-irfc
- Ixabepilone
- KIF6 Genotyping for Predicting Cardiovascular Risk and/or Effectiveness of Statin Therapy
- Kinesio Taping
- Lanadelumab-flyo
- Lanreotide
- Laparoscopic and Endoscopic Therapies for Gastroesophageal Reflux (GERD)
- Laparoscopic and Percutaneous Techniques for the Myolysis of Uterine Fibroids
- Laronidase
- Laser Assisted Uvulopalatoplasty (LAUP)
- Laser Device for Obtaining Blood Sample
- Laser Therapy for Onychomycosis and Active Acne
- LASIK (laser in situ keratomileusis)
- Lecanemab-irmb (Leqembi™)
- Leuprolide Suspension (Camcevi™)
- Leuprolide Suspension (Eligard®)
- Leuprolide Suspension (Fensolvi®)
- Leuprolide Suspension (Lupron Depot®, Leuprolide Acetate Depot)#1
- Leuprolide Suspension (Lupron Depot®, Leuprolide Acetate Depot)#2
- Leuprolide Suspension (Lupron Depot-Ped®)
- Levoleucovorin
- Lifileucel (Amtagvi)
- Lipectomy and Liposuction for Lymphedema
- Liposuction
- Lisocabtagene Maraleucel (Breyanzi®)
- Loncastuximab Tesirine-lpyl (Zynlonta™)
- Lovotibeglogene Autotemcel (Lyfgenia®)
- Lumasiran (Oxlumo®)
- Lurbinectedin (Zepzelca™)
- Luspatercept-aamt
- Lymphatic Physiologic Microsurgery for Breast Cancer-Related Lymphedema
- Lysis of Epidural Adhesions
- Mammography Screening
- Manipulation Under Anesthesia (MUA) of the Musculoskeletal System
- Mastectomy for Gynecomastia
- Measurement of Exhaled Nitric Oxide and Exhaled Breath Condensate in the Diagnosis and Management of Asthma and Other Respiratory Disorders
- Mechanized Axial Spinal Distraction Therapy Devices
- Meniscal Allografts and Synthetic Meniscus Implants
- Mentoplasty (Chin Augmentation, Genioplasty)
- Mepolizumab
- Methoxy Polyethylene Glycol-Epoetin Beta (Mircera®)
- Microarray-based Gene Expression Testing for Cancers of Unknown Primary
- Microprocessor-Controlled Prostheses for the Lower Limb
- Microwave Ablation for Oncologic Tumors
- Mirikizumab-mrkz (Omvoh)
- Mirvetuximab Soravtansine-gynx (Elahere™)
- Mitomycin Gel
- Mogamulizumab-kpkc
- Molecular Markers in Fine Needle Aspirates of the Thyroid
- Mosunetuzumab-axgb (Lunsumio™)
- Motixafortide (Aphexda™)
- Moxetumomab pasudotox-tdfk
- MRI-Guided Focused Ultrasound (MRgFUS)
- MRI-guided Laser-induced Thermotherapy for Neurological Indications
- Multi-biomarker Testing for Rheumatoid Arthritis
- Myocardial Sympathetic Innervation Imaging for Individuals with Heart Failure
- Nadofaragene firadenovec-vncg (Adstiladrin®)
- Natalizumab
- Navigated Transcranial Magnetic Stimulation
- Naxitamab-gqgk (Danyelza®)
- Necitumumab
- Nedosiran (Rivfloza™)
- Negative Pressure Wound Therapy in the Outpatient Setting
- Nelarabine
- Nerve Graft with Radical Prostatectomy
- Neuromuscular Electrical Stimulation
- Nivolumab
- Nivolumab/Relatlimab-rmbw (Opdualag™)
- Nogapendekin Alfa-Inbakicept-pmln (Anktiva®)
- Nonfamilial Genetic Testing for Breast Cancer Risk Assessment
- Noninvasive Imaging Techniques for Evaluation and Monitoring of Chronic Liver Diseases
- Non-invasive Positive Pressure Ventilators (In-Home Use)
- Non-invasive Prenatal Testing Using Cell-free Fetal DNA (cffDNA)
- Nonoperative Diagnostic Spinal Ultrasound (Echography/Sonogram)
- Novel Biomarkers for the Diagnosis and Management of Prostate Cancer
- Nusinersen
- Nutritional Treatment of Inborn Errors of Metabolism
- Obinutuzumab
- Ocrelizumab
- Olipudase Alfa (Xenpozyme™)
- Omacetaxine Mepesuccinate
- Omalizumab
- OnabotulinumtoxinA (Botox®)
- Onasemnogene Abeparvovec-xioi
- Ophthalmologic Techniques for the Evaluation of Glaucoma
- Orthognathic Surgery
- Orthopedic Applications of Stem Cell Therapy
- Orthoptic Training for the Treatment of Vision or Learning Disabilities
- Oscillating Devices for the Treatment of Respiratory Conditions
- Otoplasty and External Ear Reconstruction
- Ovarian Cancer Tumor Markers
- Paclitaxel (Protein-Bound)
- Palatal Implants for the Treatment of Obstructive Sleep Apnea or Snoring
- Palivizumab
- Pancreas/Pancreas-Kidney/Pancreatic Islet Cell Transplantation
- Panitumumab
- Pasireotide (Signifor® LAR)
- Patisiran
- Pegaspargase
- Pegcetacoplan (Syfovre™)
- Pegfilgrastim
- Pegloticase
- Pegunigalsidase Alfa-iwxj (Elfabrio®)
- Pelvic Floor Stimulation
- Pembrolizumab
- Pemetrexed
- Percutaneous Electrical Nerve Stimulation (PENS) and Percutaneous Neuromodulation Therapy
- Percutaneous Sacroplasty
- Percutaneous Vertebroplasty, Kyphoplasty and Sacroplasty
- Peripheral Subcutaneous Field Stimulation for the Treatment of Pain
- Pertuzumab
- Pertuzumab Trastuzumab and Hyaluronidase-zzxf
- Pharmacogenetic Testing for Pain Management
- Photodynamic Therapy (PDT) for the Treatment of Cancer, including Barrett’s Esophagus
- Piezoelectric Sensor Analysis and Oscillating Force Delivered Vertebral Adjustment in the Evaluation and Treatment of the Spinal Column
- Plasma Exchange
- Platelet Rich Plasma as a Treatment for Wound Healing or Other Conditions
- Pneumatic Compression Pumps
- Polatuzumab Vedotin-piiq
- Positron Emission Tomography (PET) for Cardiac Applications
- Powered Exoskeleton for Ambulation in Individuals with Lower-Limb Disabilities
- Pozelimab-bbfg (Veopoz®)
- Pralatrexate
- Prolotherapy for Musculoskeletal Disorders
- Prostate Specific Antigen (PSA)
- Proteomic Testing for Targeted Therapy in Non-Small Cell Lung Cancer
- Proteomics-based Testing for the Evaluation of Ovarian (Adnexal) Masses
- Proton Beam Therapy
- Pulmonary Arterial Hypertension Agents
- Quantitative Sensory Testing
- Radioembolization for Primary Tumors of the Liver and Metastatic Tumors to the Liver
- Radiofrequency Energy Transanal Treatment of Fecal Incontinence
- Radiofrequency Tissue Volume Reduction (RFTVR) for the Treatment of Upper Airway Obstruction
- Radiotherapy for Prostate Cancer
- Ramucirumab
- Ranibizumab
- Ravulizumab-cwvz
- Reduction Mammaplasty (Non-Cancerous)
- Remdesivir (Veklury®) as an Outpatient Treatment of COVID-19
- Reslizumab
- Responsive Neurostimulation for the Treatment of Refractory Focal Epilepsy
- Retifanlimab-dlwr (Zynyz™)
- Retinal Telescreening for Diabetic Retinopathy
- Rhinomanometry and Acoustic Rhinometry
- Rhinoplasty
- RimabotulinumtoxinB
- Risankizumab-rzaa (Skyrizi®)
- Rituximab and Hyaluronidase Human Injection
- Rituximab Products (Rituxan®, Rituximab-abbs [Truxima®],Rituximab-arrx [Riabni™] and Rituximab-pvvr [Ruxience®]) (Non-Oncology Indications)
- Rituximab Products (Rituxan®, Rituximab-abbs [Truxima®],Rituximab-arrx [Riabni™] and Rituximab-pvvr [Ruxience®]) (Oncology Indications)
- Romidepsin
- Romiplostim
- Romosozumab-aqqg
- Rozanolixizumab‐noli (Rystiggo®)
- Sacituzumab Govitecan-hziy
- Sargramostim
- Saturation Biopsy for Diagnosis and Staging of Prostate Cancer
- Sebelipase Alfa
- Secukinumab (Cosentyx®)
- Sensory and Auditory Integration Therapies
- Serum Biomarker Panel Testing for Systemic Lupus Erythematosus
- Signal Averaged Electrocardiography (SAECG)
- Siltuximab
- Sipuleucel-T
- Sirolimus albumin-bound (Fyarro™)
- Sodium Thiosulfate (Pedmark®)
- Sotatercept-csrk (WinrevairI™)
- Spesolimab (Spevigo®)
- Spinal Cord Stimulation / Peripheral Subcutaneous Field Stimulation for the Treatment of Pain
- Spinal Unloading Devices for the Treatment of Low Back Pain
- Stem Cell Therapy for Peripheral Artery Disease
- Subcutaneous Immune Globulins
- Subtalar Arthroereisis
- Surgical Deactivation of Headache Trigger Sites
- Surgical Treatment of Femoroacetabular Impingement
- Sutimlimab-jome (Enjaymo™)
- Tafasitamab-cxix
- Tagraxofusp-erzs
- Taliglucerase Alfa
- Talimogene Laherparepvec
- Talquetamab-tgvs (Talvey™)
- Tarlatamab-dlle (Imdelltra™)
- Tebentafusp-tebn (Kimmtrak®)
- Teclistamab-cqyv (Tecvayli™)
- Temozolomide for Injection
- Temsirolimus
- Teprotumumab-trbw
- Testosterone Pellets for Subcutaneous Implantation
- Tezepelumab-ekko (Tezspire™)
- Thermography
- Thyrotropin Alfa
- Tildrakizumab-asmn
- Tisagenlecleucel
- Tisotumab Vedotin-tftv (Tivdak™)
- Tocilizumab (Intravenous)
- Tofersen (Qalsody™)
- Toripalimab-tpzi (Loqtorzi)
- Total Ankle Replacement
- Total Artificial Heart (TAH)
- Trabectedin
- Transcatheter Hepatic Arterial Chemoembolization
- Transcranial Magnetic Stimulation (TMS)
- Transcutaneous Electrical Nerve Stimulation (TENS)
- Transpupillary Thermotherapy (TTT)
- Trastuzumab
- Trastuzumab and Hyaluronidase-oysk
- Travoprost Intracameral Implant (iDose TR®)
- Treatment for Lyme Disease
- Treatment of Tinnitus
- Treatments for Athletic Groin Pain
- Tremelimumab-actl (Imjudo®)
- Triamcinolone Acetonide Injectable Suspension (Xipere®)
- Trigger Point Injections
- Trilaciclib Cosela
- Triptorelin (Triptodur®)
- Triptorelin Pamoate
- Ublituximab-xiiy (Briumvi™)
- Ultrasonographic Measurements of Carotid Intima-Medial Thickness (CIMT) as an Assessment of Subclinical Atherosclerosis
- Upper Limb Myoelectric Orthosis
- Urinary Metabolite Tests for Adherence to Direct-Acting Antiviral Medications for Hepatitis C
- Ustekinumab
- Valoctocogene Roxaparvovec‐rvox (Roctavian®)
- Vedolizumab
- Velaglucerase Alfa
- Velmanase Alfa-tycv (Lamzede®)
- Vertebral Fracture Assessment with Densitometry
- Verteporfin
- Vestronidase alfa-vjbk
- Viltolarsen
- Voretigene Neparvovec-rzyl
- Vutrisiran (Amvuttra™)
- Wearable Cardioverter Defibrillator
- Whole Body Dual X-Ray Absorptiometry (DEXA) to Determine Body Composition
- Ziv-Aflibercept
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