Medical Policy Updates

Medical Policy Update August 11, 2020

Medical Guidelines Reason for Update
Autologous Chondrocyte Implantation Reference added. Specialty Matched Consultant Advisory Panel review 6/17/2020.
Brexanolone (Zulresso™) Minor typographical edits made throughout policy for clarity. Reference added. Specialty Matched Consultant Advisory Panel review 6/17/2020.
Buprenorphine Implant for Treatment of Opioid Dependence Minor typographical edits made throughout policy for clarity. Reference added. Specialty Matched Consultant Advisory Panel review 6/17/2020.
Chemoembolization of the Hepatic Artery, Transcatheter Approach When not covered section clarified with bullet 2àe. No change to policy intent.
Esketamine (Spravato™) Nasal Spray Added score descriptions to MADRS scoring description in Policy Guidelines. References added. Specialty Matched Consultant Advisory Panel review 6/17/2020.
Gastric Electrical Stimulation Policy statement revised as follows: "BCBSNC will provide coverage for gastric electrical stimulation when it is determined to be considered medically necessary because the medical criteria and guidelines noted below are met." When Covered section revised as follows: "Gastric Electrical Stimulation (gastric pacemaker) may be considered medically necessary in individuals for the treatment of chronic, intractable nausea and vomiting secondary to gastroparesis of diabetic, idiopathic, or post-surgical etiology." When Not Covered section revised. Policy guidelines revised to support policy statement. References updated. Medical Director review 7/2020.
Genetic Testing for Familial Hypercholesterolemia AHS - M2137 Minor revision to "Last Review" date for clarification.
Measurement of Thomboxane Metabolites for ASA Resistance AHS - G2107 Specialty Matched Consultant Advisory Panel review 7/2020. Medical Director review 7/2020.
Sublocade Specialty Matched Consultant Advisory Panel review 6/17/2020.
Treatment For Opioid Use Disorder in Opioid Treatment Programs (OTPs) Specialty Matched Consultant Advisory Panel review 6/17/2020. Updated When Covered section criteria 1. from "severe" to "moderate or severe". Medical Director review. No change to policy statement.