Premera Blue Cross Medical Policy Updates – December 2022

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December 2022 Premera Blue Cross Medical Policy Updates:

• Ablation of Peripheral Nerves to Treat Pain
• Amniotic Membrane and Amniotic Fluid
• Ampyra® (Dalfampridine)
• Amyloid Antibodies for the Treatment of Alzheimer’s Disease
• Antidepressants: Pharmacy Medical Necessity Criteria for Brands
• Balloon Dilation of the Eustachian Tube
• Bariatric Surgery
• Bioengineered Skin and Soft Tissue Substitutes
• Bone Mineral Density Studies
• Children’s Therapeutic Positioning Equipment
• Chimeric Antigen Receptor Therapy for Leukemia and Lymphoma
• Composite Tissue Allotransplantation of the Hand and Face
• Computerized Diagnostic Imaging for Complex Maxillofacial Procedures
• Cranial Electrotherapy Stimulation and Auricular Electrostimulation
• Cutaneous T-Cell Lymphomas (CTCL): Systemic Therapies
• Dental Restorations
• Drugs for Rare Diseases
• Drugs for Weight Management
• Dupixent® (dupilumab)
• Egrifta SV® (tesamorelin)
• Electrical Stimulation Devices
• Erythropoiesis-Stimulating Agents
• Focal Treatments for Prostate Cancer
• Gender Transition/Affirmation Surgery and Related Services
• Heart/Lung Transplant
• Hematopoietic Cell Transplantation for Waldenström Macroglobulinemia
• Hemlibra® (emicizumab-kxwh)
• Hepatitis C Antiviral Therapy
• Hereditary Angioedema
• Hysterectomy for Non-Malignant Conditions
• IL-5 Inhibitors
• Imlygic® talimogene laherparepvec
• Immune Checkpoint Inhibitors
• Immune Globulin Therapy
• Immune Prophylaxis for Respiratory Syncytial Virus
• Increlex® (mecasermin); Recombinant Human Insulin-Like Growth Factor-1
• Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers)
• Intraoperative Neurophysiologic Monitoring
• Isolated Small Bowel Transplant
• Kidney Transplant
• Lumbar Spinal Fusion in Adults
• Medical Necessity Criteria for Compounded Medications
• Medical Necessity Criteria for Medication Safety: Controlled Substances Utilization Service Program
• Medical Necessity Criteria for Pharmacy Edits
• Migraine and Cluster Headache Medications
• Miscellaneous Oncology Drugs
• Monoclonal Antibodies for the Treatment of Lymphoma
• mTOR Kinase Inhibitors
• Non-covered Services and Procedures
• Nulojix® (belatacept) for Adults
• Orthodontic Services for Treatment of Congenital Craniofacial Anomalies
• Orthognathic Surgery
• Periodontics
• Pharmacologic Treatment of Chronic Non-Infectious Liver Diseases
• Pharmacologic Treatment of Cystinosis
• Pharmacologic Treatment of Gout
• Pharmacologic Treatment of Phenylketonuria
• Pharmacologic Treatment of Urea Cycle Disorders
• Pharmacotherapy of Arthropathies
• Pharmacotherapy of Inflammatory Bowel Disorder
• Pharmacotherapy of Perinatal/Infantile and Juvenile-Onset Hypophosphatasia (HPP)
• Pharmacotherapy of Thrombocytopenia
• Pharmacotherapy of Type I and Type II Diabetes Mellitus
• Phosphate Binders
• Physical Medicine and Rehabilitation – Physical Therapy and Medical Massage Therapy
• Prostate Cancer Targeted Therapies
• Psychiatric Evaluations in Inpatient and Residential Behavioral Health Treatment
• Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors
• Radioimmunotherapy in the Treatment of Non-Hodgkin Lymphoma
• Repository Corticotropin Injection
• Selective Estrogen Receptor Modulators and Down Regulators
• Site of Service: Infusion Drugs and Biologic Agents
• Site of Service: Select Surgical Procedures
• Spravato® (esketamine) Nasal Spray
• Sublingual Immunotherapy as a Technique of Allergen-Specific Therapy
• Surgical Treatments for Lymphedema and Lipedema
• Temporomandibular Joint Disorder
• Therapeutic Radiopharmaceuticals in Oncology
• Topical Drugs for Actinic Keratosis and Other Dermatologic Conditions
• Total Artificial Hearts and Implantable Ventricular Assist Devices
• Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders
• Use of Granulocyte Colony-Stimulating Factors (G-CSF)
• Use of Vascular Endothelial Growth Factor Receptor (VEGF) Inhibitors and Other Angiogenesis Inhibitors in Oncology Treatment
• Vascular Endothelial Growth Factor (VEGF) Receptor Inhibitors for Ocular Disorders
• Venclexta® venetoclax BCL-2 Inhibitor
• Wilderness Therapy/Outdoor Behavioral Healthcare Residential Wilderness Programs

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Health economic and reimbursement information provided by Policy Alerts is gathered from third-party sources and is subject to change without notice as a result of complex and frequently changing laws, regulations, rules and policies. All product and company names are trademarks™ or registered® trademarks of their respective holders. Use of them does not imply any affiliation with or endorsement by them. This information is presented for illustrative purposes only and does not constitute reimbursement or legal advice.