Medical Policy Updates

Home ❯ Providers ❯ Medical Policies and Coverage ❯ Back to Medical Policy Updates ❯ Blue Cross and Blue Shield of North Carolina Medical Policy Update January 26, 2021

Medical Policy Update for January 26, 2021

Medical Guidelines Reason for Update
Allergy Immunotherapy (Desensitization) Added language for clarification to the Billing/Coding section as follows: "Accumulation of service is based on rolling calendar year."
Belimumab (Benlysta) Under "When Covered" section, added coverage for FDA approved indication for adult patients with active lupus nephritis who are receiving standard therapy, when specific criteria are met for new indication. Reference added. Medical Director review 1/2021.
Botulinum Toxin Injection Updated indication for Xeomin for chronic sialorrhea to patients ≥2 years of age to be consistent with FDA labeling. Added the following to "When Covered" for sialorrhea: "associated with a neurological disorder (e.g., amyotrophic lateral sclerosis, atypical parkinsonian disorders, cerebral palsy, Parkinson disease, stroke, traumatic brain injury)." Reference added.
Margetuximab-cmkb (Margenza™) New policy developed. Margenza is considered medically necessary for the treatment of adult patients with metastatic HER2-positive breast cancer when specific medical criteria and guidelines are met. Added HCPCS codes C9399, J3490, J3590, J9999, S0353, S0354 to Billing/Coding section. References added. Medical Director review 1/2021.
Naxitamab-gqgk (Danyelza®) New policy developed. Danyelza is considered medically necessary for the treatment of adult and pediatric patients (≥ 1 year of age) with neuroblastoma when specific medical criteria and guidelines are met. Added HCPCS codes C9399, J3490, J3590, J9999, S0353, S0354 to Billing/Coding section. References added. Medical Director review 1/2021.
Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders When covered section updated to clarify age requirement as "18 years or older" based on current FDA approval and criteria added for repeat rTMS. Medical Director review. References added.
Xolair® (Omalizumab) Under "When Covered" section, added coverage for FDA approved indication as add-on maintenance treatment for nasal polyps in adults with inadequate response to nasal corticosteroids, when specific criteria are met for new indication. Reference added. Medical Director review 1/2021.