Premera Blue Cross Medical Policy Updates – January 2023

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January 2023 Premera Blue Cross Medical Policy Updates:

• Absorbable Nasal Implant for Treatment of Nasal Valve Collapse
• Adjunctive Techniques for Screening and Surveillance of Barrett Esophagus and Esophageal Dysplasia
• Adoptive Immunotherapy
• Allogeneic Hematopoietic Cell Transplantation for Genetic Diseases and Acquired Anemias
• Alpha-1 Proteinase Inhibitors
• Amniotic Membrane and Amniotic Fluid
• Antibody-Drug Conjugates
• Applied Behavior Analysis ABA
• Artificial Intervertebral Disc: Lumbar Spine
• Bariatric Surgery
• BCR-ABL Kinase Inhibitors
• Bioengineered Skin and Soft Tissue Substitutes
• BRAF and MEK Inhibitors
• Bruton’s Kinase Inhibitors
• C3 and C5 Complement Inhibitors
• CGRP Inhibitors for Migraine Prophylaxis
• Coronary Angiography for Known or Suspected Coronary Artery Disease in Adults
• Coverage Criteria of Excluded Drugs for Essentials Formulary
• Cranial Electrotherapy Stimulation and Auricular Electrostimulation
• Diagnosis and Treatment of Sacroiliac Joint Pain
• Dopamine Transporter Imaging with Single-Photon Emission Computed Tomography
• Durable Medical Equipment Repair/Replacement
• Dynamic Spinal Visualization and Vertebral Motion Analysis
• Epidermal Growth Factor Receptor (EGFR) Inhibitors
• Erythroid Maturation Agents
• Extracorporeal Photopheresis
• Focal Treatments for Prostate Cancer
• Folate Antimetabolites
• Gender Transition/Affirmation Surgery and Related Services
• Gender Transition/Affirmation Surgery and Related Services
• Growth Hormone Therapy
• HMO Medical Policy Search | Provider | Premera Blue Cross
• Hysterectomy for Non-Malignant Conditions
• Hysterectomy for Non-Malignant Conditions
• Immune Checkpoint Inhibitors
• Implantable Bone-Conduction and Bone-Anchored Hearing Aids
• Intravitreal and Suprachoroidal Corticosteroids
• Medical Necessity Criteria for Pharmacy Edits
• Microwave Tumor Ablation
• Migraine and Cluster Headache Medications
• Miscellaneous Oncology Drugs
• Miscellaneous Oncology Drugs
• Non-covered Experimental/Investigational Services
• Off-Label Use of Drugs and Biologic Agents
• Oral Iron Chelating Agents
• Orthoptic Training, Vision Therapy, Visual Perceptual Training, Vision Restoration Therapy, and Neurovisual Rehabilitation
• Percutaneous Balloon Kyphoplasty, Radiofrequency Kyphoplasty, and Mechanical Vertebral Augmentation
• Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, Biacuplasty,and Intraosseous Basivertebral Nerve Ablation
• Percutaneous Vertebroplasty and Sacroplasty
• Pharmacologic Treatment in Assisted Reproduction
• Pharmacologic Treatment of Osteoporosis
• Pharmacologic Treatment of Sleep Disorders
• Pharmacologic Treatment of Transthyretin-Mediated Amyloidosis
• Pharmacotherapy of Arthropathies
• Pharmacotherapy of Inflammatory Bowel Disorder
• Plasma-based Proteomic Screening in the Management of Pulmonary Nodules
• Prescription Digital Therapeutics
• Prescription Digital Therapeutics for Substance Use Disorder
• Preventive Care
• Protein Biomarkers for Diagnosis and Risk Assessment of Prostate Cancer
• Rhinoplasty
• Spinal Cord and Dorsal Root Ganglion Stimulation
• Upper Gastrointestinal (UGI) Endoscopy for Adults
• Use of Granulocyte Colony-Stimulating Factors (G-CSF)
• Use of Vascular Endothelial Growth Factor Receptor (VEGF) Inhibitors and Other Angiogenesis Inhibitors in Oncology Treatment
• Wearable Cardioverter-Defibrillators as a Bridge to Implantable Cardioverter-Defibrillator Placement
• Whole Body Dual X-Ray Absorptiometry to Determine Body Composition
• Xolair® omalizumab

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