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Premera Blue Cross Medical Policy Updates – May 2018
Click here to view the Premera Blue Cross Medical Policy Updates »
May 2018 Medical Policy Updates:
- 1.01.05 Ultrasound Accelerated Fracture Healing Device
- 1.01.10 Continuous Passive Motion in the Home Setting
- 1.01.11 Adjustable Cranial Orthoses for Positional Plagiocephaly and Craniosynostoses
- 1.01.18 Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers
- 1.01.26 Cooling Devices Used in the Outpatient Setting
- 1.01.507 Electrical Stimulation Devices
- 1.01.525 Postsurgical Outpatient Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis
- 1.03.04 Powered Exoskeleton for Ambulation in Patients With Lower-Limb Disabilities
- 1.04.502 Myoelectric Prosthetic and Orthotic Components for the Upper Limb
- 10.01.503 General Anesthesia and Facility Services Related to Dental Treatment
- 10.01.518 Clinical Trials
- 10.01.525 Right-to-Try Laws and Coverage of Services
- 12.04.103 Genetic Testing for Macular Degeneration
- 12.04.114 Genetic Testing for Dilated Cardiomyopathy
- 12.04.120 Gene Expression Profiling for Uveal Melanoma
- 12.04.129 Genetic Testing for Marfan Syndrome, Thoracic Aortic Aneurysms and Dissections, and Related Disorders
- 12.04.28 Genetic Testing for Predisposition to Inherited Hypertrophic Cardiomyopathy
- 12.04.36 Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis In Patients With Breast Cancer
- 12.04.44 Genetic Testing for Familial Cutaneous Malignant Melanoma
- 12.04.510 Molecular Markers in Fine Needle Aspirates of the Thyroid
- 12.04.514 Genetic Testing for Epilepsy
- 12.04.519 Genetic Testing for Alpha Thalassemia
- 12.04.54 Gene Expression-Based Assays for Cancers of Unknown Primary
- 12.04.72 Gene Expression Testing to Predict Coronary Artery Disease
- 12.04.74 DNA-Based Testing for Adolescent Idiopathic Scoliosis
- 12.04.88 Genetic Testing for PTEN Hamartoma Tumor Syndrome
- 12.04.99 Genetic Testing for Hereditary Pancreatitis
- 2.01.21 Temporomandibular Joint Disorder
- 2.01.38 Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease
- 2.04.68 Laboratory and Genetic Testing for Use of 5-Fluorouracil in Patients With Cancer
- 2.04.73 Intracellular Micronutrient Analysis
- 5.01.518 Bcr-Abl Kinase Inhibitors
- 5.01.534 Multiple Receptor Tyrosine Kinase Inhibitors
- 5.01.547 Medical Necessity Criteria and Dispensing Quantity Limits for Exchange Formulary Benefits
- 5.01.550 Pharmacotherapy of Arthropathies
- 5.01.558 Proprotein Convertase Subtilisin Kexin Type 9 (PCSK9) Inhibitors
- 5.01.563 Pharmacotherapy of Inflammatory Bowel Disorder
- 5.01.572 Coverage Criteria of Excluded Drugs for Essentials Formulary
- 5.01.573 Pharmacotherapy of Perinatal/Infantile and Juvenile Onset Hypophosphatasia (HPP)
- 5.01.574 Pharmacotherapy of Spinal Muscular Atrophy (SMA)
- 5.01.583 Criteria for Safe Management of Opioid Therapy
- 5.01.605 Medical Necessity Criteria for Pharmacy Edits
- 5.01.605 (effective Aug. 3, 2018) Medical Necessity Criteria for Pharmacy Edits
- 7.01.05 Cochlear Implant
- 7.01.113 Bioengineered Skin and Soft Tissue Substitutes
- 7.01.142 Surgery for Athletic Pubalgia
- 7.01.149 Amniotic Membrane and Amniotic Fluid Injections
- 7.01.150 Vagal Nerve Blocking Therapy for Treatment of Obesity
- 7.01.158 Balloon Dilation of the Eustachian Tube
- 7.01.20 Vagus Nerve Stimulation
- 7.01.503 Reduction Mammoplasty for Breast-Related Symptoms
- 7.01.503 (effective June 1, 2018) Reduction Mammaplasty for Breast-Related Symptoms
- 7.01.516 Bariatric Surgery
- 7.01.521 Mastectomy for Gynecomastia
- 7.01.522 Gastric Electrical Stimulation
- 7.01.547 Implantable Bone Conduction and Bone-Anchored Hearing Aids
- 7.01.559 Sinus Surgery
- 7.01.559 (effective June 1, 2018) Sinus Surgery
- 7.01.83 (effective Aug. 3, 2018) Auditory Brainstem Implant
- 7.01.84 Semi-Implantable and Fully Implantable Middle Ear Hearing Aids
- 8.01.21 Allogeneic Hematopoietic Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms
- 8.01.22 Allogeneic Hematopoietic Cell Transplantation for Genetic Diseases and Acquired Anemias
- 8.01.23 Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer
- 8.01.24 Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors in Adults
- 8.01.25 Hematopoietic Cell Transplantation for Autoimmune Diseases
- 8.01.26 Hematopoietic Cell Transplantation for Acute Myeloid Leukemia
- 8.01.28 Hematopoietic Cell Transplantation for Central Nervous System Embryonal Tumors and Ependymoma
- 8.01.503 Immune Globulin Therapy
- 8.01.52 Orthopedic Applications of Cell Therapy (Including Allograft and Bone Substitute Products Used with Autologous Bone Marrow)
- 8.01.520 Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia
- 8.01.529 Hematopoietic Cell Transplantation for Non-Hodgkin Lymphomas
- 8.01.535 Chelation Therapy
- 8.01.55 Stem Cell Therapy for Peripheral Arterial Disease
- 8.03.01 Functional Neuromuscular Electrical Stimulation
- 8.03.05 Outpatient Pulmonary Rehabilitation
- 8.03.08 Cardiac Rehabilitation in the Outpatient Setting
- 8.03.504 Cognitive (Neurologic) Rehabilitation in the Outpatient Setting
- 9.02.500 Orthodontic Services for Treatment of Congenital Craniofacial Anomalies
- 9.02.502 Periodontics
- 9.02.503 Computerized Diagnostic Imaging for Complex Maxillofacial Procedures
- 9.02.506 Dental Restorations
- 9.03.01 Keratoprosthesis
- 9.03.03 Orthoptic Training for the Treatment of Vision or Learning Disabilities
- 9.03.29 Eyelid Thermal Pulsation for the Treatment of Dry Eye Syndrome
Click here to view the Premera Blue Cross Medical Policy Updates »
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