Medical Policy Update

Blue Cross and Blue Shield of Nebraska is proud to work with our provider network to serve your patients, our members. We are updating several medical policies. Please review the changes and effective dates outlined here:

MPC August 2023

August 1, 2023

New Medical Policies

Medical Policy I.215 Intense Pulse Light Therapy for the Treatment of Dry Eyes

Effective Date: 12/01/2023
Preauthorization Required: Recommended

Policy statement:

  1. Intensive pulse light therapy (IPL) for the treatment of dry eye disease is investigational.

Revised Medical Policies

Medical Policy V.19 Cardiovascular Risk Panels and Biomarkers 
Effective Date: 12/01/2023
Preauthorization Required: Yes

Policy statement:

  1. Cardiovascular risk panels* and biomarkers (see guidelines below), for the risk assessment and management of cardiovascular disease, including but not limited to, measurement of novel lipid and non-lipid biomarkers (i.e., apolipoprotein B, apolipoprotein AI, apolipoprotein E, low-density lipoprotein subclass, high-density lipoprotein subclass, lipoprotein [a], B-type natriuretic peptide, cystatin C, fibrinogen, leptin) is considered investigational as an adjunct to low-density lipoprotein cholesterol.
  2. Measurement of lipoprotein-associated phospholipase A2 (83698, 0052U) is considered investigational.

Guidelines:

A simple lipid panel (Code 86001) is generally composed of the following lipid measures:

  • Total cholesterol 82465
  • Low-density lipoprotein cholesterol 83721
  • High-density lipoprotein cholesterol 83718
  • Triglycerides 84478

Certain calculated ratios (e.g., total/high-density lipoprotein cholesterol) may also be reported as part of a simple lipid panel.

Other types of lipid testing (i.e., apolipoproteins, lipid particle number or particle size, lipoprotein [a]) are not considered components of a simple lipid profile.

This policy does not address the use of panels of biomarkers in the diagnosis of acute myocardial infarction.

*Some examples (not all inclusive) of commercially available Cardiovascular risk panels are as follows:

  • Advanced Lipid Panel 
  • Algorithmically scored multi-protein biomarker panels
  • Applied Genetics Cardiac Panel
  • Applied Genetics Cardiac Panel
  • Atherotech® Diagnostics Lab CVD Risk Panel and VAP Lipid Panel
  • Berkeley Heart Lab Cardio IQ™
  • Boston Heart Advanced Risk Markers Panel
  • Boston Heart Cholesterol Balance Test
  • Boston Heart HDL Map panel
  • Cleveland HeartLab CVD Inflammatory Profile
  • CV Health Plus Genomics Panel
  • CV Health Plus Panel 
  • CVD Inflammatory Profile 
  • Genetiks Genetics Diagnosis and Research Center Cardiovascular Risk Panel
  • Genova Diagnostic CV Health Plus Genomics™ Panel
  • Health Diagnostics Cardiac Risk Panel
  • Metametrix Cardiovascular Health Profile
  • OmegaCheck Panel
  • Singulex
  • True Health Diagnostics
Medical Policy III.62 Surgeries for obstructive sleep apnea: Uvulopalatopharyngoplasty (UPPP), Palatopharyngoplasty (PPP), Uvulectomy, Tonsillectomy, Adenoidectomy, Nasal Septoplasty, laser-assisted uvulopalatoplasty (LAUP)
Effective Date: 12/01/2023
Preauthorization Required: Yes

Adding policy statement:

  1. Maxillofacial surgery, including mandibular-maxillary advancement (MMA) may be medically necessary for clinically significant documented obstructive sleep apnea and upper airway resistance syndrome when ALL the following criteria are met:
    1. Adults age ≥ 21 years, AND
    2. AHI ≥ 20 with less than 20% central apneas, AND
    3. Trial and failure or intolerance of CPAP, AND
    4. No other surgical options are recommended
Medical Policy Hyperbaric Oxygen Therapy
Effective Date: 8/14/2023
Preauthorization Required: Yes

Added new indications to policy statement:

Systemic hyperbaric oxygen pressurization is scientifically validated treatment of the following conditions:

  • Soft tissue radiation necrosis (e.g. radiation enteritis, cystitis, myelitis, proctitis) and osteoradionecrosis

New Pharmacy Updates

Medical Policy X.TBD: Roctavian
Effective: 9/1/23
Preauthorization Required: Yes

Policy Statement: Roctavian is considered medically necessary for the treatment of adults with severe hemophilia A without antibodies to adeno-associated virus serotype-5 (AAV%).

Medical Policy X.TBD: Vyjuvek
Effective: 9/1/23
Preauthorization Required: Yes

Policy Statement: Vyjuvek is considered medically necessary for the treatment of wounds in patients 6 months and older with dystrophic epidermolysis bullosa (DEB) with mutation in the collagen type VII alpha 

Medical Policy X.TBD: Elevidys
Effective: 9/1/23
Preauthorization Required: Yes

Policy Statement: Elevidys is considered investigational as there is a lack of conclusive evidence confirming clinical efficacy of micro-dystrophin protein.

Medical Policy X.TBD: Leqembi
Effective: 9/1/23
Preauthorization Required: Yes

Policy Statement: Leqembi is considered investigational as the clinical benefit of decreased amyloid beta plaques in the brain has not been established.

Medical Policy X.TBD: Qalsody
Effective: 9/1/23
Preauthorization Required: Yes

Policy Statement: Qalsody is considered investigational as there is a lack of conclusive evidence confirming clinical efficacy of reduction in SOD1 protein synthesis.

Medical Policy X.TBD: Gonadotropin Releasing Hormone Agonist Policy
Effective: TBD
Preauthorization Required: Yes

Policy Statement: Gonadotropin releasing hormone agonist agents will be considered medically necessary for FDA approved indications, indications supported in NCCN Guidelines at rating of 2A or higher, or gender dysphoria in compliance with state regulations. 

Revised Pharmacy Updates

Medical Policy X.174 Ivermectin: Policy will be retired on 9/1/23

Medical Policy X.187 Vyvgart: Addition of Vyvgart Hytrulo

Medical Policy X.I.0 Procedures for Medical Review: Addition of Columvi and Zynyz

Medical Policy X.185 Sodium Glucose Co-Transporter (SGLT2) Products: Addition of Inpefa and Brenzavvy

Medical Policy X.170 Enzyme Replacement Therapy: Addition of Lamzede

Medical Policy X.152: Addition of Zavzpret

Medical Policy X.48: Addition of Lumryz

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