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 May 2023
May 1, 2023
New Medical Policies
Medical Policy: Virtual Reality Behavior Therapy
Effective: 08/01/2023
Preauthorization Required: Yes
Preauthorization Required: Yes
Policy Statement:
- The use of virtual reality assisted therapy systems (e.g., Ease VR, SootheVR, and RelieVR) for screening, diagnosis and/or treatment is considered investigational for all indications because there are no net health benefits.
Revised Medical Policies
Medical Policy: I.105 Electrical Stimulation
Effective: 08/01/2023
Preauthorization Required: Yes
Policy Statement:
- Disposable neuromuscular electrical stimulator (NMES) (e.g., Geko) is considered investigational.
- Transcutaneous Afferent Pattern Stimulation (TAPS) is considered Investigational for all indications including essential hand tremors.
Medical Policy: IV.83 Oncologic Applications of PET Scan
Effective: 05/17/2023
Preauthorization Required: Yes
Policy Statement:
Prostate Cancer
Prostate Cancer
- PET scanning with 11C-choline or with fluciclovine F18 (Axumin) may be medically necessary in the:
- evaluation of response to primary treatment for prostate cancer, OR
- evaluation of suspected recurrence when the PSA level is elevated or increasing.
- Prostate-specific membrane antigen (PSMA) PET scan may be considered medically necessary for initial staging and restaging of prostate cancer for suspected metastatic or recurrence of prostate cancer.
- PET scanning is considered investigational for all other indications.
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