BCBS Horizon Medical Policy Updates – September 2018

September 2018 Medical Policy Updates:

• Ablation Procedures for Peripheral Neuromas
• Actigraphy
• Agalsidase Beta (Fabrazyme)
• Alcohol Injections for Treatment of Peripheral Neuromas
• Ambulatory Event Monitors and Mobile Cardiac Outpatient Telemetry
• Arthroscopy for Treatment of Knee Derangement
• Automated Point-of-Care Nerve Conduction Tests
• Autonomic Nervous System Testing
• Belimumab (Benlysta)
• Bronchial Thermoplasty
• Bronchial Valves
• Chemonucleolysis
• Colon Hydrotherapy
• Cosmetic Procedures
• Cupping Therapy
• Drug Therapy for Hereditary Angioedema [Cinryze Berinert Haegarda (Human C1 Inhibitor) Kalbitor (Ecallantide) Firazyr (Icatibant) Ruconest (C1 Esterase Inhibitor [Recombinant])]
• Eculizumab (Soliris)
• Electromagnetic Navigation Bronchoscopy
• Electronic Salivary Reflex Stimulator
• Epidural Spinal Endoscopy
• Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions
• Fluency Enhancing Devices for Stuttering
• Gait Trainers and Standing Frames
• Gaucher Disease Therapy
• Gender Reassignment Surgery
• Genetic Cancer Susceptibility Panels Using Next Generation Sequencing
• Heart Rate Variability Measurement
• Hematopoietic Cell Transplantation for Acute Myeloid Leukemia
• Home Traction Devices for the Treatment of Spinal Disorders and Pain
• Hyperbaric Oxygen Therapy
• Immune Globulin Subcutaneous (Vivaglobin Hizentra Gammagard Liquid Gamunex-C or Gammaked HyQvia and Cuvitru for Subcutaneous Administration)
• In Vitro Chemosensitivity and Chemoresistance Assays
• Interferential Current Stimulation
• Intermittent Pneumatic or Mechanical Compression Devices for Peripheral Artery Disease
• Intravenous Immunoglobulin (IVIG) Therapy
• Laronidase (Aldurazyme) Galsulfase (Naglazyme) and Idursulfase (Elaprase) elosulfase alfa (Vimizim) and vestronidase alfa (Mepsevii)
• Low-Level Laser Therapy
• Magnetic Resonance-Guided Focused Ultrasound
• Melphalan (Alkeran and Evomela)
• Navigated Transcranial Magnetic Stimulation
• Neurofeedback
• Paraspinal Surface Electromyography (SEMG) to Evaluate and Monitor Back Pain
• Periureteral Bulking Agents as a Treatment of Vesicoureteral Reflux (VUR)
• Polysomnography for NonRespiratory Sleep Disorders
• Pompe Disease Treatment with Myozyme (Alglucosidase alfa) and Lumizyme (Alglucosidase alfa)
• Quantitative Sensory Testing
• Removal of Benign Skin Lesions
• Rhinoplasty
• Salivary Hormone Testing for Menopause
• Seat Lift Mechanisms
• Site of Service for Administration for Infusion and Injectable Prescription Medications
• Thoracic-Lumbo-Sacral Orthosis with Pneumatics
• Treatment of Tinnitus

Added 9/18/2018;

• Ablation Procedures for Peripheral Neuromas
• Alcohol Injections for Treatment of Peripheral Neuromas
• Angiogenic Inhibitors for the Treatment of Ophthalmic Macular Conditions
• Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions
• Automated Point-of-Care Nerve Conduction Tests
• Autonomic Nervous System Testing
• BRAF Gene Mutation Testing To Select Melanoma or Glioma Patients for Targeted Therapy
• Bronchial Thermoplasty
• Bronchial Valves
• Compression Stockings
• Continuous or Intermittent Monitoring of Glucose in the Interstitial Fluid
• Cranial Electrotherapy Stimulation and Auricular Electrostimulation
• Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver Prostate or Dermatologic Tumors
• Cytochrome P450 Genotype-Guided Treatment Strategy
• Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome
• Electromagnetic Navigation Bronchoscopy
• Electromyography and Nerve Conduction Studies
• Electronic Brachytherapy for Nonmelanoma Skin Cancer
• Electrotherapies in Pain Management
• Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions
• Fecal Calprotectin Testing
• Gender Reassignment Surgery
• Gene Expression Profiling for Uveal Melanoma
• Genetic Testing for Diagnosis and Management of Mental Health Conditions
• Genetic Testing for Mitochondrial Disorders
• Genotype-Guided Warfarin Dosing
• Home Cardiorespiratory Monitoring
• Interferential Current Stimulation
• Interspinous and Interlaminar Stabilization or Distraction Devices (Spacers)
• JAK2 MPL and CALR Testing for Myeloproliferative Neoplasms
• Low-Level Laser Therapy
• Lumbar Spinal Fusion
• Lung Volume Reduction Surgery for Severe Emphysema
• Molecular Markers in Fine Needle Aspirates of the Thyroid
• Myoelectric Prosthetic and Orthotic Components for the Upper Limb
• Noninvasive Prenatal Screening for Fetal Aneuploidies and Microdeletions Using Cell-Free Fetal DNA
• Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Disorders
• Polysomnography for NonRespiratory Sleep Disorders
• Prostatic Urethral Lift
• Proton Beam Therapy
• Quantitative Sensory Testing
• Radioembolization for Primary and Metastatic Tumors of the Liver
• Refractive Keratoplasty Procedures
• Serum Biomarker Panel Testing for Systemic Lupus Erythematosus and Other Connective Tissue Diseases
• Sodium Hyaluronate Injections
• Transcatheter Arterial Chemoembolization To Treat Primary or Metastatic Liver Malignancies
• Treatment of Varicose Veins or Venous Insufficiency
• Tumor-Treatment Fields Therapy

Added 9/27/2018;

• Abdominoplasty
• Allergen Immunotherapy
• Antineoplaston Therapy
• Cryosurgical Ablation of Primary or Metastatic Liver Tumors
• Donor Lymphocyte Infusion for Malignancies Treated with an Allogeneic Hematopoietic Stem-Cell Transplant
• Endobronchial Brachytherapy
• Genetic Testing for Li-Fraumeni Syndrome
• Home Uterine Activity Monitoring (HUAM)
• Insulin Infusion Pumps
• Intracavitary Balloon Catheter Brain Brachytherapy for Malignant Gliomas or Metastasis to the Brain
• Ipilimumab (Yervoy)
• KRAS NRAS and BRAF Variant Analysis in Metastatic Colorectal Cancer
• Mechanical Stretching Devices for Limited Jaw Mobility
• Miscellaneous Genetic and Molecular Diagnostic Tests
• Moderate Penetrance Variants Associated with Breast Cancer in Individuals at High Breast Cancer Risk
• Optical Coherence Tomography for Imaging of Coronary Arteries
• Physician Standby Service
• Plasma Exchange
• Prophylactic Oophorectomy
• Radiofrequency Ablation of Primary or Metastatic Liver Tumors
• Septoplasty
• Surgical Interruption of Pelvic Nerve Pathways for Primary and Secondary Dysmenorrhea
• Threshold Electrical Stimulation as a Treatment of Motor Disorders