Medical Policy Updates
View any medical policy or medical necessity criteria changes that will be implemented in the next 60 days or more.
- BCBSWY requires prior authorization for certain health care services, treatments, prescription drugs, and durable medical equipment (DME) before a member can receive them, except in emergency.
- Prior authorization is based on BCBSWY medical policy. Medical policy and criteria changes that will be implemented in the next 60 days are listed below.
- This information is not intended to instruct providers or members on benefit changes or authorization requirements. Members can login to YourWyoBlue.com to search prior authorization requirements for their benefit plan. Providers can learn more about prior authorization requirements here →
- This page is not valid for FEP members.
- This page is only valid for members with BCBSWY membership and not other Blue plans
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Medical Policy Updates
Use the Policy Number, Policy Title, or CPT Codes to find and view the full medical policy.
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| Policy # | Policy Title | Change Type | Summary of Changes | Effective Date | Provider Notification Date |
|---|---|---|---|---|---|
| 08.01.065 | Gene Therapies for Congenital Hemophilia A or B (Hemgenix, Roctavian) | NEW | Implementation of NEW guidelines. | 11/1/25 | 8/20/25 |
| 05.01.049 | Gene Therapies for Metachromatic Leukodystrophy (Lenmeldy) | NEW | Implementation of NEW guidelines. | 11/1/25 | 8/20/25 |
| 12.01.082 | Adstiladrin | NEW | Implementation of NEW guidelines. | 11/1/25 | 8/18/25 |
| 12.01.056 | Yescarta | DELETE | Archiving Policy. | 11/1/25 | 8/18/25 |
| 12.01.022 | Kymriah | DELETE | Archiving Policy. | 11/1/25 | 8/18/25 |
| 08.01.063 | Chimeric Antigen Receptor Therapy for Leukemia and Lymphoma (Breyanzi, Carvykti, Kymriah, Yescarta) | NEW | Implementation of NEW guidelines. | 11/1/25 | 8/18/25 |
| 05.01.028 | Treatment for Spinal Muscluar Atrophy (Zolgensma) | NEW | Implementation of NEW guidelines. | 11/1/25 | 8/18/25 |
| 05.01.042 | Gene Therapies for Thalassemia (Casgevy and Zynteglo) | NEW | Implementation of NEW guidelines. | 11/1/25 | 8/18/25 |
| 05.01.047 | Gene Therapies or Treatments of Wounds in Dystrophic Epidermolysis Bullosa (Vyjuvek) | NEW | Implementation of NEW guidelines. | 11/1/25 | 8/18/25 |
| 12.01.045 | Radicava | UPDATE | Updated policy information, including updated policy position information. | 10/20/25 | 8/18/25 |
| 12.01.003 | Botulinum Toxin - Botox, Daxxify, Dysport, Myobloc, Xeomin | UPDATE | Updated policy information, including updated policy position information. | 10/20/25 | 8/18/25 |
| 12.01.014 | Hereditary Angiodema | UPDATE | Updated policy information, added biosimilar drug. | 10/20/25 | 8/18/25 |
| 08.01.066 | Chimeric Antigen Receptor Therapy for Multiple Myeloma (Abecma, Carvykti) | NEW | Implementation of NEW guidelines. | 10/20/25 | 8/18/25 |
| 2.04.82 | Genetic Testing for Inherited Thrombophilia | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 10/13/25 | 8/11/25 |
| 6.01.55 | Selected Positron Emission Tomography Technologies for Evaluation of Alzheimer Disease | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 10/13/25 | 8/11/25 |
| 7.01.107 | Electrical Bone Growth Stimulation of the Appendicular Skeleton | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 10/13/25 | 8/11/25 |
| 7.01.124 | Treatment of Varicose Veins/Venous Insufficiency | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 10/13/25 | 8/11/25 |
| 7.01.125 | Occipital Nerve Stimulation | UPDATE | Clinical evidence to support the policy position reviewed. There is no change to the policy position statement listed. | 10/13/25 | 8/11/25 |
| 7.01.132 | Transcatheter Aortic-Valve Implantation for Aortic Stenosis | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 10/13/25 | 8/11/25 |
| 7.01.166 | Allograft Injection for Degenerative Disc Disease | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 10/13/25 | 8/11/25 |
| 7.01.44 | Implantable Cardioverter Defibrillators | UPDATE | Clinical evidence to support the policy position reviewed and references added. Minor editorial refinements to policy statements; intent unchanged. | 10/13/25 | 8/11/25 |
| 2.04.075 | Genetic Testing of CADASIL Syndrome | DELETE | Archiving the criteria. | 10/13/25 | 8/11/25 |
| 2.04.107 | Carrier Screening for Genetic Diseases | UPDATE | Adding code 0449U | 10/13/25 | 8/11/25 |
| 7.01.156 | Radiofrequency Volumetric Tissue Reduction for Nasal Obstruction | NEW | Implementation of NEW guidelines. | 10/13/25 | 8/11/25 |
| 7.01.85 | Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 10/13/25 | 8/11/25 |
| 8.01.10 | Charged-Particle (Proton or Helium Ion) Radiotherapy for Neoplastic Conditions | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 10/13/25 | 8/11/25 |
| 8.01.37 | Inhaled Nitric Oxide | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 10/13/25 | 8/11/25 |
| 1.01.010 | Continuous Passive Motion in the Home Setting | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 10/6/25 | 8/6/25 |
| 1.01.30 | Artificial Pancreas Device System | UPDATE | Clinical evidence to support the policy position reviewed. Policy title changed to Automated Insulin Delivery Systems. Policy updated with new evidence following FDA approval of the t:slim X2 insulin pump with Control-IQ+ technology for adults with type 2 diabetes. Medically necessary policy statement with criteria revised in individuals with type 2 diabetes. | 10/6/25 | 8/6/25 |
| 2.02.09 | Closure Devices for Patent Foramen Ovale and Atrial Septal Defects | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 10/6/25 | 8/6/25 |
| 2.02.10 | Biventricular Pacemakers (Cardiac Resynchronization Therapy) for the Treatment of Heart Failure | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 10/6/25 | 8/6/25 |
| 2.02.26 | Percutaneous Left Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 10/6/25 | 8/6/25 |
| 2.02.30 | Transcatheter Mitral Valve Repair or Replacement | UPDATE | Clinical evidence to support the policy position reviewed and references added. Policy statement changed: Transcatheter mitral valve-in-valve replacement (TMViVR) with a device approved by the U.S. FDA is considered medically necessary for individuals when all of the following conditions are present: Failure (stenosed, insufficient, or combined) of a surgical bioprosthetic mitral valve; AND New York Heart Association heart failure class II, III, or IV symptoms; AND Individual is not an operable candidate for open surgery, as documented by at least 2 cardiovascular specialists (including a cardiac surgeon); OR individual is an operable candidate but is considered at an intermediate to prohibitive surgical risk for open surgery, as documented by at least 2 cardiac specialists (including a cardiac surgeon); OR individual is considered at increased surgical risk for open surgery (eg, repeat sternotomy) due to a history of congenital vascular anomalies AND/OR has a complex intrathoracic surgical history, as documented by at least 2 cardiovascular specialists (including a cardiac surgeon) (see Policy Guidelines section).. | 10/6/25 | 8/6/25 |
| 2.02.31 | Myocardial Strain Imaging | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 10/6/25 | 8/6/25 |
| 2.02.33 | Phrenic Nerve Stimulation for Central Sleep Apnea | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 10/6/25 | 8/6/25 |
| 2.04.14 | Evaluation of Biomarkers for Alzheimer Disease | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. Minor revisions to policy guidelines regarding laboratory testing considerations | 10/6/25 | 8/6/25 |
| 2.04.142 | Molecular Testing in the Management of Pulmonary Nodules | UPDATE | Clinical evidence to support the policy position reviewed and references added. Minor editorial refinements to policy statements, intent unchanged. | 10/6/25 | 8/6/25 |
| 2.04.146 | Gene Expression Profiling for Cutaneous Melanoma | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 10/6/25 | 8/6/25 |
| 2.04.80 | Genetic Testing for Hereditary Hemochromatosis | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 10/6/25 | 8/6/25 |
| myprime.com | Atypical Antipsychotics | UPDATE | *Removed step through of generic medications for Caplyta *Updated tiering to non-preferred brand | 10/1/25 | 8/5/25 |
| myprime.com | Bempedoic Acid | UPDATE | *Updated wording of policy criteria. Criteria has been changed from established cardiovasular disease to a high risk of cardiovascular disease. Criteria has been updated that the patient must have one of the following: A. Acute coronary syndrome OR B. History of myocardial infarction OR C. Stable or unstable angina OR D. Coronary or other arterial revascularization OR E. Stroke OR F. Transient ischemic attack OR G. Peripheral arterial disease, including aortic aneurysm, presumed to be of atherosclerotic origin *Updated supplemental information in the policy. | 10/1/25 | 8/5/25 |
| myprime.com | Biologic Immunomodulators OC | UPDATE | *Added a note in the Step Table for Actemra requests for GCA to require a step-through the preferred biosimilar Tyenne. Added due to the recent FDA approval of Rinvoq for GCA and its placement at Step 1a. *Removed requirement confirming the prescriber has documented the patient's baseline pruritus and other symptom severity for AD; no longer needed/applicable due to standardization of clinical benefit requirement for AD *Added requirement to confirm requests for Omvoh 300 mg are being used for a diagnosis of Crohn's disease based on FDA labeled dosing. Requests for ulcerative colitis should utilize the Omvoh 200 mg dose. (Initial and Renewal) *(Renewal): Removed specific efficacy/improvement (clinical benefit) requirements for atopic dermatitis and standardized the clinical benefit requirement; no specific examples/instructions are listed in FDA labeling *Added Avtozma and Omlyclo to "Agents NOT to be used Concomitantly" table | 10/1/25 | 8/5/25 |
| myprime.com | Camzyos | UPDATE | *Changed "AND" to an "OR" between beta blockers and calcium channel blockers in statement 1D of the authorization criteria. *Removed requirement for needing a left ventricular outflow tract (LVOT) peak gradient greater than 50 mmHg at rest/provocation (Valsalva, post-exercise) due to concern for the variable ability for provocation methods to provoke gradients. *Added criteria point to assess for a compendia supported indication to provide a review path downstream and a more appropriate denial reason for Clinical Operations for off-label indications and specified allowed sources of compendia | 10/1/25 | 8/5/25 |
| myprime.com | Cholestasis Pruritis | UPDATE | *Added sertraline as an additional prerequisite *Addition of optional continuation of therapy (COT) *Criteria added with the following: 8. The patient does NOT have any FDA labeled contraindications to the requested agent *Criteria has been added for continuation of therapy - The requested agent is eligible for continuation of therapy AND ONE of the following: All target agents are eligible for continuation of therapy 1. The patient has been treated with the requested agent (starting on samples is not approvable) within the past 90 days OR 2. The prescriber states the patient has been treated with the requested agent (starting on samples is not approvable) within the past 90 days AND is at risk if therapy is changed OR B. BOTH of the following: 1. ONE of the following: A. BOTH of the following: 1. ONE of the following: A. The patient has a diagnosis of Alagille syndrome with pruritus (medical records required) OR | 10/1/25 | 8/5/25 |
| myprime.com | Cibinqo | UPDATE | *Removed requirement confirming the prescriber has documented the patient's baseline pruritus and other symptom severity *Removed specific efficacy/improvement (clinical benefit) requirements for atopic dermatitis and standardized the clinical benefit requirement *Added Avtozma and Omlyclo to "Agents NOT to be used Concomitantly" table | 10/1/25 | 8/5/25 |
| myprime.com | Constipation Agents | UPDATE | *Updated the following with no change to clinical intent - *Addition of indication/preferred table in both modules *Addition of the brand vs generic wording and table to the renewal criteria *Addition of Motegrity and generic to the table | 10/1/25 | 8/5/25 |
| myprime.com | Dry Eye Disease | UPDATE | *Updated aqueous enhancement prerequisite language to state "Tried and had an inadequate response to ONE over-the-counter (OTC) aqueous enhancement" *Updated generic ophthalmic corticosteroid prerequisite language to include "ONE" for additional clarity | 10/1/25 | 8/5/25 |
| myprime.com | Egrifta | UPDATE | *No prior authorization will be required | 10/1/25 | 8/5/25 |
| myprime.com | Elmiron | UPDATE | * Removed "The requested quantity (dose) does not exceed the FDA labeled dose for the requested indication." * The program is moving to a PAQL with the addition of standard Universal QL criteria | 10/1/25 | 8/5/25 |
| myprime.com | Endari | UPDATE | *Removed Oxbryta (voxelotor) from all criteria points assessing combination therapy *Removed from all criteria points assessing combination therapy 'for the requested indication' *Updated language in renewal criteria, including adding step through language | 10/1/25 | 8/5/25 |
| myprime.com | Erythropoietins | UPDATE | *Removed step through preferred agent criteria. | 10/1/25 | 8/5/25 |
| myprime.com | Esketamine | UPDATE | *Addition of "The patient has another FDA labeled indication for the requested agent and route of administration" to renewal | 10/1/25 | 8/5/25 |
| myprime.com | Fabhalta | UPDATE | *Added new requirements for complement 3 glomurulopathy (C3G) | 10/1/25 | 8/5/25 |
| myprime.com | Factor VIII and VWF | UPDATE | *Updated grammar for standarization with no changes to clinical intent. | 10/1/25 | 8/5/25 |
| myprime.com | Filspari | UPDATE | *Changed clinical benefit check to a generalized check | 10/1/25 | 8/5/25 |
| myprime.com | Gattex | UPDATE | *Added requirement of an upper GI endoscopy to be done within 6 months prior to initiating agent | 10/1/25 | 8/5/25 |
| myprime.com | Gonadotropin Hormones | UPDATE | *Addition of letrozole trial as option in FSH module *Addition of letrozole in hCG criteria check confirming FSH, clomiphene, or letrozole will be used prior to requested agent unless risk of OHSS *Removed GPI 30062022052220 from criteria | 10/1/25 | 8/5/25 |
| myprime.com | HCN Channel Blocker | UPDATE | *Updated language with no change to clinical intent | 10/1/25 | 8/5/25 |
| myprime.com | Hepatitis C | UPDATE | *Removed Viekira Pak from program *Removed "Turcotte" from Child-Turcotte-Pugh throughout program *Harvoni module: *Removal of wording "and without cirrhosis, HIV infection, history of liver transplantation and/or are not black or African-American" from the clinical rationale and from the table. *Harvoni module: Updated approval timeframe for treatment naïve genotype 1 to 12 weeks | 10/1/25 | 8/5/25 |
| myprime.com | Interleukin-1 (IL-1) Inhibitor | UPDATE | *Updated recurrent pericarditis NSAID or aspirin prerequisite requirement to only require an intolerance or hypersensitivity to ONE (previously BOTH) *Added "used in the treatment of RP" to capture that the patient had an intolerance (or hypersensitivity) to the prerequisite while used in combination with colchicine. *Added Avtozma and Omlyclo to "Agents NOT to be used Concomitantly" table | 10/1/25 | 8/5/25 |
| myprime.com | Interleukin-4 (IL-4) Inhibitor | UPDATE | *Removed requirement confirming the prescriber has documented the patient's baseline pruritus and other symptom severity for AD *Updated language for clarity with no change in clinical intent *Removed COPD requirement confirming patient has mMRC of 2 or greater OR CAT score of 10 or greater *Added COPD requirement confirming patient has had symptoms of chronic bronchitis for at least 3 months within the past 12 months *Added 'i.e.' description of "Frequent COPD exacerbations" *Added additional wording to fluticasone MDI prerequisite description *Added 8-week duration of therapy to prerequisite requirements *Added additional pathway for PN diagnosis to bypass conventional prerequisites *Removed COPD concurrent therapy pathways for intolerance/hypersensitivity/CI to LAMA+LABA *Updated listing of COPD inhaled maintenance therapy examples to be "i.e." to align with concurrent therapy requirements change *Added additional weight requirements *Removed specific efficacy/improvement (clinical benefit) requirements for atopic dermatitis and standardized the clinical benefit requirement *Added Avtozma and Omlyclo to "Agents NOT to be used Concomitantly" table | 10/1/25 | 8/5/25 |
| myprime.com | Interleukin-13 (IL-13) Antagonist | UPDATE | *Removed requirement confirming the prescriber has documented the patient's baseline pruritus and other symptom severity *Removed specific efficacy/improvement (clinical benefit) requirements for atopic dermatitis and standardized the clinical benefit requirement *Added Avtozma and Omlyclo to "Agents NOT to be used Concomitantly" table *Updated language of Adbry dosing requirements with no change to clinical intent | 10/1/25 | 8/5/25 |
| myprime.com | Interleukin-31 (IL-31) Inhibitor | UPDATE | *Added additional diagnosis to bypass prerequisites so step therapy can be continued *Removed requirement confirming the prescriber has documented the patient's baseline pruritus and other symptom severity for AD *Combined atopic dermatitis requrements to be under one header for Initial and Renewal - no change to clinical intent *Updated language within policy for clarity with no change to clinical intent under section 2B2a *Removed specific efficacy/improvement (clinical benefit) requirements for atopic dermatitis and standardized the clinical benefit requirement *Added Avtozma and Omlyclo to "Agents NOT to be used Concomitantly" table | 10/1/25 | 8/5/25 |
| myprime.com | Isturisa | UPDATE | *Updated name from Cushing's disease to Cushing's syndrome with no change in clinical intent *Removed the word pituitary" from the requirement of inadequate response or not a candidate for pituitary" surgery. *Added "another FDA labeled indication" as an option to initial criteria | 10/1/25 | 8/5/25 |
| myprime.com | Neurotrophic Keratitis | UPDATE | *Increased approval duration from 8 weeks to 16 weeks | 10/1/25 | 8/5/25 |
| myprime.com | Ophthalmic Antihistamine | UPDATE | *Removed Lastacraft from policy | 10/1/25 | 8/5/25 |
| myprime.com | Oral Tetracycline | UPDATE | *All strengths of the following generic (MSC-Y) drugs will now be considered prerequisites in this program and will no longer be listed as targets: Generic doxycycline hyclate (tablet, capsule); Generic doxycycline monohydrate (tablet, suspension); Generic doxycycline delayed-release capsule; Generic minocycline hydrochloride capsule; Generic tetracycline hydrochloride capsule. *Updated the following GPI Target Agent entries to only target MSC-M,N,O based on updates to targets and prerequisites (previously targeted M,N,O,Y): 040000601001, 040000200003, 040000201003, 040000401001, 900600250065, 040000200019, 040000201001. *Updated agent listings and note at bottom of step table *Updated step-through requirements | 10/1/25 | 8/5/25 |
| myprime.com | Otezla | UPDATE | *Added Avtozma and Omlyclo to Agents NOT to be used Concomitantly" table *Updated Psoriasis requirements for age specific patients of less than 6 years of age | 10/1/25 | 8/5/25 |
| myprime.com | PCSK9 | UPDATE | *Updated renewal section for statin prerequisiate criteria for concomitant stain usage | 10/1/25 | 8/5/25 |
| myprime.com | Peginterferon | UPDATE | *Updated criteria to allow a general allowance for oncology and non-oncology indications *Added AHFS, or DrugDex 1 or 2a level of evidence for additional compendia support *Updated another diagnosis within renewal clinical benefit requirement with a diagnosis other than chronic hepatitis B or C " | 10/1/25 | 8/5/25 |
| myprime.com | Phosphate Binder | UPDATE | *Updated preferred indication from Auryxia to Ferric Citrate | 10/1/25 | 8/5/25 |
| myprime.com | Primary Biliary Cholangitis | UPDATE | *Updated "ALL of the following" to "BOTH of the following in the renewal criteria: The patient has a diagnosis of primary biliary cholangitis (PBC) AND "BOTH" of the following: *Added continuation of therapy requirements | 10/1/25 | 8/5/25 |
| myprime.com | PPI | UPDATE | *Removed brand name Aciphex from Sprinkle formulation in table *Updated table with current generics available and formulations *Removed obsolete GPI 49270076106805 | 10/1/25 | 8/5/25 |
| myprime.com | Pyrukynd | UPDATE | *Updated clinical criteria for section 1 from ONE to ALL | 10/1/25 | 8/5/25 |
| myprime.com | Resmetirom | UPDATE | *Updated BMI requirements with no change to clinical intent *Moved the age requirement to apply to both possible FDA indications *Addition of medical records at each point required for documentation to mirror Weight Management program | 10/1/25 | 8/5/25 |
| myprime.com | SA Oncology | UPDATE | *Removed Scemblix and Iclusig from preferred/non-preferred table *Removed limitation of use requirement with no change to clinical intent *Updated agent specific criteria points with no change to clinical intent *Obsolete agents removed: 1) Calquence capsule only (acalabrutinib) GPI: 215321030001, 2) Truseltiq (infigratinib) GPI: 2153223540B2, 3) Turalio (pexidartinib) 200mg capsule GPI: 21533045010120 | 10/1/25 | 8/5/25 |
| myprime.com | Tarpeyo | UPDATE | *Removal of ACEi/ARB concomitant therapy | 10/1/25 | 8/5/25 |
| myprime.com | Topiramate ER | UPDATE | *Removed seizure diagnoses attached to renewal criteria for history of use with an anti-seizure med that is not topiramate | 10/1/25 | 8/5/25 |
| myprime.com | Triptans | UPDATE | *Updated Tosymra GPI dosage form with no clinical changes | 10/1/25 | 8/5/25 |
| myprime.com | Vascepa | UPDATE | *Added definitions of ASCVD to diagnosis of established CVD *Updated definitions and language in statin prerequisites with no changes in clinical intent *Updated language from diabetes and cardiovascular criteria with no changes in clinical intent | 10/1/25 | 8/5/25 |
| myprime.com | Verkazia | UPDATE | *Updated topical ophthalmic corticosteroid prerequisite to include "ONE" and "used in the treatment of VKC" for additional clarity | 10/1/25 | 8/5/25 |
| myprime.com | Verquvo | UPDATE | *Updated language throughout with no changes to clinical intent | 10/1/25 | 8/5/25 |
| myprime.com | Wakix | UPDATE | *Updated language in the diagnosis requirement and clinical criteria with no changes in clinical intent | 10/1/25 | 8/5/25 |
| myprime.com | Weight Management | UPDATE | *Removed type 2 diabetes disallowance for pediatrics patients within the Saxenda requirements in the initial and renewal criteria *Updated language for each agent in the requirements with no changes in clinical intent | 10/1/25 | 8/5/25 |
| myprime.com | Xolremdi | UPDATE | *Updated language with no change in clinical intent | 10/1/25 | 8/5/25 |
| myprime.com | Yorvipath | UPDATE | *Removal of "The patient does NOT have hypoparathyroidism caused by calcium-sensing receptor (CaSR) mutations *Removal of bisphosphonate wording in renewal | 10/1/25 | 8/5/25 |
| myprime.com | GLP-1 Agonists | UPDATE | *Added a requirement disallowing multiple GLP use at the same time and updated language regarding extension requests. No changes to clinical intent. | 10/1/25 | 8/5/25 |
| 11.01.119 | Braces and Supports | DELETE | Archiving the criteria. | 9/29/25 | 7/29/25 |
| 6.01.025 | Minimally Invasive Approaches to Vertebral Fractures and Osteolytic Lesions of the Spine | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 9/29/25 | 7/29/25 |
| 6.01.029 | MRI Detection of Breast Cancer | DELETE | Archiving the criteria. | 9/28/25 | 7/28/25 |
| 12.01.042 | Oncology Immunotherapy | UPDATE | Updated policy information, including updated policy position information. | 9/24/25 | 7/22/25 |
| 7.01.100 | Bone Morphogenetic Protein | UPDATE | Clinical evidence to support the policy position reviewed. There is no change to the policy position statement listed. | 9/22/25 | 7/22/25 |
| 7.01.104 | Subtalar Arthroereisis | UPDATE | Clinical evidence to support the policy position reviewed and refereneces added. There is no change to the policy position statement listed. | 9/22/25 | 7/22/25 |
| 7.01.107 | Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers) | UPDATE | Clinical evidence to support the policy position reviewed and refereneces added. There is no change to the policy position statement listed. | 9/22/25 | 7/22/25 |
| 7.01.108 | Artificial Intervertebral Disc: Cervical Spine | UPDATE | Clinical evidence to support the policy position reviewed. There is no change to the policy position statement listed. | 9/22/25 | 7/22/25 |
| 7.01.113 | Bioengineered Skin and Soft Tissue Substitutes | UPDATE | Clinical evidence to support the policy position reviewed, content on nerve wraps and references added. GraftJacket and AlloMend removed from breast reconstruction policy statement as materials are not evaluated for this indication. All other policy statements unchanged. | 9/22/25 | 7/22/25 |
| 7.01.118 | Surgical Treatment of Femoroacetabular Impingement | UPDATE | Clinical evidence to support the policy position reviewed and refereneces added. Minor editorial revisions to policy guidelines; intent unchanged. Policy statements unchanged. | 9/22/25 | 7/22/25 |
| 7.01.120 | Facet Arthroplasty | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 9/22/25 | 7/22/25 |
| 7.01.126 | Image-Guided Minimally Invasive Decompression for Spinal Stenosis | UPDATE | Clinical evidence to support the policy position reviewed. There is no change to the policy position statement listed. | 9/22/25 | 7/22/25 |
| 7.01.130 | Axial Lumbosacral Interbody Fusion | UPDATE | Clinical evidence to support the policy position reviewed. There is no change to the policy position statement listed. | 9/22/25 | 7/22/25 |
| 7.01.149 | Amniotic Membrane and Amniotic Fluid | UPDATE | Clinical evidence to support the policy position reviewed and refereneces added. NuShield added to existing medically necessary policy statement for the treatment of nonhealing diabetic lower-extremity ulcers based on RCT evidence. Otherwise, policy statements unchanged. | 9/22/25 | 7/22/25 |
| 7.01.015 | Meniscal Allografts and Other Meniscal Implants | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 9/22/25 | 7/22/25 |
| 7.01.025 | Spinal Cord and Dorsal Root Ganglion Stimulation | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 9/22/25 | 7/22/25 |
| 7.01.048 | Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 9/22/25 | 7/22/25 |
| 7.01.058 | Intraoperative Neurophysiologic Monitoring | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 9/22/25 | 7/22/25 |
| 7.01.063 | Deep Brain Stimulation | UPDATE | Clinical evidence to support the policy position reviewed and references added. Evidence review and investigational policy statement added for adaptive deep brain stimulation in Parkinson disease. | 9/22/25 | 7/22/25 |
| 7.01.069 | Sacral Nerve Neuromodulation/Stimulation | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 9/22/25 | 7/22/25 |
| 7.01.078 | Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions | UPDATE | Clinical evidence to support the policy position reviewed and references added. Minor editorial refinements to listed order of policy statements; intent unchanged. | 9/22/25 | 7/22/25 |
| 7.01.080 | Hip Resurfacing | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 9/22/25 | 7/22/25 |
| 7.01.087 | Artificial Intervertebral Disc: Lumbar Spine | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 9/22/25 | 7/22/25 |
| 7.01.093 | Decompression of the Intervertebral Disc Using Laser Energy (Laser Discectomy) or Radiofrequency-Coblation (Nucleoplasty) | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 9/22/25 | 7/22/25 |
| 8.03.009 | Vertebral Axial Decompression | UPDATE | Clinical evidence to support the policy position reviewed. There is no change to the policy position statement listed. | 9/22/25 | 7/22/25 |
| 12.01.079 | Alhemo | NEW | Implementation of NEW guidelines. | 10/1/25 | 7/22/25 |
| 12.01.080 | Sensipar | NEW | Implementation of NEW guidelines. | 10/1/25 | 7/22/25 |
| 12.01.081 | Vanrafia | NEW | Implementation of NEW guidelines. | 10/1/25 | 7/22/25 |
| 12.01.008 | Xgeva - Oncology | UPDATE | Updated policy information, including updated policy position information. | 9/22/25 | 7/21/25 |
| 12.01.009 | Prolia - Osteoporosis | UPDATE | Updated policy information, including updated policy position information. | 9/22/25 | 7/21/25 |
| 12.01.055 | Xolair | UPDATE | Updated policy information, including updated policy position information. | 9/22/25 | 7/21/25 |
| 12.01.039 | Rituxan Oncology - Rituxan Hycela | UPDATE | Updated policy information, including updated policy position information. | 9/22/25 | 7/21/25 |
| 7.01.149 | Amniotic Membrane and Amniotic Fluid | UPDATE | Clinical evidence to support the policy position reviewed and refereneces added. NuShield added to existing medically necessary policy statement for the treatment of nonhealing diabetic lower-extremity ulcers based on RCT evidence. Otherwise, policy statements unchanged. | 9/8/25 | 7/8/25 |
| 1.01.010 | Continuous Passive Motion in the Home Setting | UPDATE | Clinical evidence to support the policy position reviewed and refereneces added. There is no change to the policy position statement listed. | 9/8/25 | 7/8/25 |
| 2.01.100 | Dry Needling of Trigger Points for Myofascial Pain | UPDATE | Clinical evidence to support the policy position reviewed. There is no change to the policy position statement listed. | 9/8/25 | 7/8/25 |
| 2.01.054 | Endovascular Procedures for Intracranial Arterial Disease (Atherosclerosis and Aneurysms) | UPDATE | Clinical evidence to support the policy position reviewed and refereneces added. There is no change to the policy position statement listed. | 9/8/25 | 7/8/25 |
| 2.01.083 | Interventions for Progressive Scoliosis | UPDATE | Clinical evidence to support the policy position reviewed and refereneces added. There is no change to the policy position statement listed. | 9/8/25 | 7/8/25 |
| 2.01.098 | Orthopedic Applications of Platelet-Rich Plasma | UPDATE | Clinical evidence to support the policy position reviewed and refereneces added. There is no change to the policy position statement listed. | 9/8/25 | 7/8/25 |
| 2.04.0111 | Gene Expression Profiling, Protein Biomarkers, and Multimodal Artificial Intelligence for Prostate Cancer Management | UPDATE | Clinical evidence to support the policy position reviewed and refereneces added. Title changed with the addition of 3 new indications for the ArteraAI Prostate Test with accompanying evidence. Added NCCN definitions for test in prostate cancer to the rationale section. Multimodal artificial intelligence (MMAI) testing is considered investigational. | 9/8/25 | 7/8/25 |
| 2.04.0157 | Somatic Biomarker Testing for Immune Checkpoint Inhibitor Therapy (BRAF, MSI/MMR, PD-L1, TMB) | UPDATE | Clinical evidence to support the policy position reviewed. Policy extensively pruned: Extensive evidence review is not included for somatic tests of individual genes (not gene panels) associated with FDA-approved therapies with National Comprehensive Cancer Network (NCCN) recommendations of 2A or higher. Policy statement revised to medically necessary for tumor mutational burden testing to select individuals for immune checkpoint inhibitor therapy. | 9/8/25 | 7/8/25 |
| 2.04.054 | Molecular Genomic Profiling for Cancers of Unknown Primary | UPDATE | Clinical evidence to support the policy position reviewed and refereneces added. Title was changed to molecular genomic profiling, and definitions were included for gene expression and comprehensive genomic profiling. Comprehensive genomic profiling added to investigational policy statement. | 9/8/25 | 7/8/25 |
| 2.04.087 | Genetic Testing for Hereditary Hearing Loss | UPDATE | Clinical evidence to support the policy position reviewed and refereneces added. There is no change to the policy position statement listed. | 9/8/25 | 7/8/25 |
| 12.01.020 | Briumvi, Lemtrada, Ocrevus, Tysabri | UPDATE | Updated policy information, including updated policy position information. | 9/8/25 | 7/8/25 |
| 3.01.003 | Quantitative Electroencephalography as a Diagnostic Aid for Attention-Deficit/Hyperactivity Disorder | DELETE | Archiving the criteria | 8/18/25 | 6/19/25 |
| 12.01.004 | Brineura | UPDATE | Updated policy information, including updated policy position information | 8/18/25 | 6/19/25 |
| 12.01.016 | IVIG | UPDATE | Updated policy information, including updated policy position information | 8/18/25 | 6/19/25 |
| 12.01.019 | Injectable Asthma Agents | UPDATE | Updated policy information, including updated policy position information | 8/18/25 | 6/19/25 |
| 12.01.021 | Krystexxa | UPDATE | Updated policy information, including updated policy position information | 8/18/25 | 6/19/25 |
| 12.01.022 | Kymriah | UPDATE | Updated policy information, including updated policy position information | 8/18/25 | 6/19/25 |
| 12.01.023 | Lysosomal Storage Disorders | UPDATE | Updated policy information, including updated policy position information | 8/18/25 | 6/19/25 |
| 12.01.031 | Bevacizumab | UPDATE | Updated policy information, including updated policy position information | 8/18/25 | 6/19/25 |
| 12.01.17 | Health Care Provider Administered (HCPA) Biologic Immunomodulator - Actemra® (tocilizumab), Avsola™ (infliximab-axxq), Cimzia® certolizumab pegol), Entyvio (vedolizumab), Ilumya™ (tildrakizumab-asmn), Inflectra® (infliximab-dyyb), Orencia® (abatacept), Remicade®, Infliximab, Renflexis (infliximab-abda), Simponi ARIA® (golimumab), Stelara® (ustekinumab) , Taltz® (ixekizumab) | DELETE | Archiving the criteria as policy 12.01.018 will replace this policy | 8/18/25 | 6/19/25 |
| 12.01.068 | Gene Therapies for Sickle Duchenne Muscular Dystrophy – Elevidys | DELETE | Archiving Policy | 8/25/25 | 6/24/25 |
| 12.01.017 | Health Care Provider Administered (HCPA) Biologic Immunomodulator - Actemra® (tocilizumab), Avsola™ (infliximab-axxq), Cimzia® certolizumab pegol), Entyvio (vedolizumab), Ilumya™ (tildrakizumab-asmn), Inflectra® (infliximab-dyyb), Orencia® (abatacept), Remicade®, Infliximab, Renflexis (infliximab-abda), Simponi ARIA® (golimumab), Stelara® (ustekinumab) , Taltz® (ixekizumab) | DELETE | Archiving the criteria. | 8/25/25 | 6/13/25 |
| 12.01.018 | Infusible Biologic Immunomodulator - Actemra®, Avsola®, Cimzia® , Cosentyx®, Entyvio®, Ilumya®, Inflectra®, Omvoh®, Orencia®, Remicade®, Infliximab, Renflexis®, Simponi ARIA®, Skyrizi®, Stelara®, Taltz®, Tofidence™, Tremfya®, Tyenne® | UPDATE | Updated policy information, including updated policy position information. | 7/1/25 | 5/1/25 |
| 7.01.014 | Open and Thoracoscopic Approaches to Treat Atrial Fibrillation and Atrial Flutter (Maze and Related Procedures) | UPDATE | Clinical evidence to support the policy position reviewed and refereneces added. There is no change to the policy position statement listed. | 7/28/25 | 5/26/25 |
| 8.03.001 | Functional Neuromuscular Electrical Stimulation | UPDATE | Clinical evidence to support the policy position reviewed and refereneces added. There is no change to the policy position statement listed. | 7/28/25 | 5/26/25 |
| 8.03.013 | Sensory Integration Therapy and Auditory Integration Therapy | UPDATE | Clinical evidence to support the policy position reviewed and refereneces added. There is no change to the policy position statement listed. | 7/28/25 | 5/26/25 |
| 9.03.001 | Keratoprosthesis | UPDATE | Clinical evidence to support the policy position reviewed and refereneces added. There is no change to the policy position statement listed. | 7/28/25 | 5/26/25 |
| 9.03.008 | Photodynamic Therapy for Choroidal Neovascularization | UPDATE | Clinical evidence to support the policy position reviewed and refereneces added. There is no change to the policy position statement listed. | 7/28/25 | 5/26/25 |
| 9.03.023 | Intravitreal and Punctum Corticosteroid Implants | UPDATE | Clinical evidence to support the policy position reviewed and refereneces added. There is no change to the policy position statement listed. | 7/28/25 | 5/26/25 |
| 12.01.070 | Uplizna | UPDATE | Adding HCPCS code J1823 | 7/28/25 | 5/26/25 |
| 12.01.011 | Exondys | DELETE | Archiving the criteria. | 7/28/25 | 5/26/25 |
| 12.01.015 | H.P. Acthar Gel | DELETE | Archiving the criteria. | 7/28/25 | 5/26/25 |
| 5.01.017 | Repository Corticotropin Injection | NEW | Implementation of NEW guidelines. | 7/28/25 | 5/26/25 |
| 5.01.027 | Treatment for Duchenne Muscular Dystrophy | UPDATE | Clinical evidence to support the policy position reviewed. There is no change to the policy position statement listed. | 7/28/25 | 5/26/25 |
| 12.01.024 | Makena | DELETE | Archiving the criteria. | 7/14/25 | 5/15/25 |
| 2.01.038 | Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease | UPDATE | Clinical evidence to support the policy position reviewed and references added. One policy statement changed to include an additional device; "Transoral incisionless fundoplication (eg, EsophyX ,MUSE, GERDX) is considered investigational as a treatment of gastroesophageal reflux disease." Overall intent unchanged. Coding addition of K44.9 for hiatal hernia. | 7/7/25 | 5/1/25 |
| 2.01.089 | Laser Treatment of Onychomycosis | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 7/7/25 | 5/1/25 |
| 2.04.007 | Urinary Biomarkers for Cancer Screening, Diagnosis, and Surveillance | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 7/7/25 | 5/1/25 |
| 2.04.128 | Genetic Testing for Fanconi Anemia | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 7/7/25 | 5/1/25 |
| 2.04.135 | Testing Serum Vitamin D Levels | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 7/7/25 | 5/1/25 |
| 2.04.136 | Nutrient/Nutritional Panel Testing | UPDATE | Clinical evidence to support the policy position reviewed. There is no change to the policy position statement listed. | 7/7/25 | 5/1/25 |
| 2.04.147 | Next-Generation Sequencing for the Assessment of Measurable Residual Disease | UPDATE | Clinical evidence to support the policy position reviewed. There is no change to the policy position statement listed. | 7/7/25 | 5/1/25 |
| 2.04.151 | Germline and Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment in Breast Cancer (BRCA1, BRCA2, PIK3CA, Ki-67, RET, BRAF, ESR1, NTRK) | UPDATE | Clinical evidence to support the policy position reviewed and references added. itle changed to include NTRK. Medically necessary policy statement added for NTRK gene fusion testing for individuals with recurrent unresectable (local or regional) or stage IV breast cancer to select individuals for treatment with FDA-approved therapies. Investigational policy statement added for NTRK gene fusion testing in all other situations. All other policy statements unchanged. | 7/7/25 | 5/1/25 |
| 2.04.023 | Homocysteine Testing in the Screening, Diagnosis, and Management of Cardiovascular Disease and Venous Thromboembolic Disorders | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 7/7/25 | 5/1/25 |
| 2.04.056 | Immune Cell Function Assay | UPDATE | Clinical evidence to support the policy position reviewed. There is no change to the policy position statement listed. | 7/7/25 | 5/1/25 |
| 2.04.058 | Nerve Fiber Density Measurement | UPDATE | Clinical evidence to support the policy position reviewed. There is no change to the policy position statement listed. | 7/7/25 | 5/1/25 |
| 2.04.062 | Multimarker Serum Testing Related to Ovarian Cancer | UPDATE | Clinical evidence to support the policy position reviewed. OvaWatch does not have its own 510K # or FDA approval paperwork yet, but FDA 510(k) submission is planned and in process according to Aspira. Recommend adding when it is cleared. Policy statement unchanged. | 7/7/25 | 5/1/25 |
| 2.04.065 | Biomarker Testing in Risk Assessment and Management of Cardiovascular Disease | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 7/7/25 | 5/1/25 |
| 2.04.066 | Serum Biomarker Human Epididymis Protein 4 | UPDATE | Clinical evidence to support the policy position reviewed. There is no change to the policy position statement listed. | 7/7/25 | 5/1/25 |
| 6.01.033 | Wireless Capsule Endoscopy for Gastrointestinal Disorders | UPDATE | Clinical evidence to support the policy position reviewed. There is no change to the policy position statement listed. | 7/7/25 | 5/1/25 |
| 6.01.049 | Computed Tomography Perfusion Imaging of the Brain | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 7/7/25 | 5/1/25 |
| 6.01.062 | Oncologic Applications of Positron Emission Tomography Scanning (Breast and Gynecologic) | UPDATE | Clinical evidence to support the policy position reviewed and references added. New PICO on the use of adjunctive 18F-FES-PET in individuals with recurrent or metastatic breast cancer and in need of estrogen receptor status information to make decisions about endocrine therapy added with an investigational policy statement. All other policy statements unchanged. | 7/7/25 | 5/1/25 |
| 7.01.165 | Radiofrequency Coblation Tenotomy for Musculoskeletal Conditions | UPDATE | Clinical evidence to support the policy position reviewed. There is no change to the policy position statement listed. | 7/7/25 | 5/1/25 |
| 7.01.047 | Bariatric Surgery | UPDATE | Clinical evidence to support the policy position reviewed, revisions have been made to the Rationale section and references added. A new PICO, as well as indications and evidence review for esophagogastroduodenoscopy in the context of bariatric surgery, have been added based on Topic Selection of July 2024 following the introduction of a new CPT Code. An investigational statement concerning the routine use of esophagogastroduodenoscopy during bariatric surgery has also been added. Added the obesity BMI threshold for the Asian population in the Policy Guidelines section. | 7/7/25 | 5/1/25 |
| 8.01.016 | Chemical Peels | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 7/7/25 | 5/1/25 |
| 2.01.57 | Electrostimulation and Electromagnetic Therapy for Treating Wounds | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 7/7/25 | 5/1/25 |
| 2.01.68 | Laboratory Tests Post Transplant and for Heart Failure | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 7/7/25 | 5/1/25 |
| 2.04.43 | Genetic Testing for Cardiac Ion Channelopathies | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 7/7/25 | 5/1/25 |
| 2.04.79 | Genetic Testing for Alpha-1 Antitrypsin Deficiency | UPDATE | Clinical evidence to support the policy position reviewed. There is no change to the policy position statement listed. | 7/7/25 | 5/1/25 |
| 2.04.83 | Genetic Testing for FMR1 Variants (Including Fragile X Syndrome) | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 7/7/25 | 5/1/25 |
| 2.04.89 | Genetic Testing for FMR1 Variants (Including Fragile X Syndrome) | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 7/7/25 | 5/1/25 |
| 6.01.10 | Stereotactic Radiosurgery and Stereotactic Body Radiotherapy | UPDATE | Clinical evidence to support the policy position reviewed and references added. New indication added for small cell lung cancer with an investigational policy statement. All other policy statements unchanged. | 7/7/25 | 5/1/25 |
| 7.01.153 | Stereotactic Radiosurgery and Stereotactic Body Radiotherapy | UPDATE | Clinical evidence to support the policy position reviewed. There is no change to the policy position statement listed. | 7/7/25 | 5/1/25 |
| 6.01.023 | Diagnosis and Treatment of Sacroiliac Joint Pain | UPDATE | Coding update: added C1737 | 6/30/25 | 4/25/25 |
| 6.01.061 | Oncologic Applications of Positron Emission Tomography Scanning (Gastrointestinal and Pancreatic) | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 6/30/25 | 4/25/25 |
| 6.01.063 | Oncologic Applications of Positron Emission Tomography Scanning (Bone and Sarcoma) | UPDATE | Clinical evidence to support the policy position reviewed. Minor editorial refinements to policy statements; intent unchanged. | 6/30/25 | 4/25/25 |
| 6.01.064 | Oncologic Applications of Positron Emission Tomography Scanning (Hematologic) | UPDATE | Clinical evidence to support the policy position reviewed. Policy statements unchanged. Policy guidelines updated to acknowledge situations when there are contraindications to contrast agents, making initial CT scans unattainable. | 6/30/25 | 4/25/25 |
| 6.01.065 | Oncologic Applications of Positron Emission Tomography Scanning (Lung) | UPDATE | Clinical evidence to support the policy position reviewed and references added. Minor editorial refinements made to policy statements; intent unchanged. Policy guidelines updated to acknowledge situations when there are contraindications to contrast agents making initial CT scans unattainable. | 6/30/25 | 4/25/25 |
| 6.01.066 | Oncologic Applications of Positron Emission Tomography Scanning (Thyroid, Neuroendocrine, Head and Neck) | UPDATE | Clinical evidence to support the policy position reviewed and references added. Minor editorial refinements made to policy statements; intent unchanged. Policy guidelines updated to acknowledge situations when there are contraindications to contrast agents making initial CT scans unattainable. | 6/30/25 | 4/25/25 |
| 6.01.067 | Oncologic Applications of Positron Emission Tomography Scanning (Brain, Melanoma, Unknown Primary) | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 6/30/25 | 4/25/25 |
| 7.01.112 | Transanal Endoscopic Microsurgery | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 6/30/25 | 4/25/25 |
| 7.01.159 | Sphenopalatine Ganglion Block for Headache | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 6/30/25 | 4/25/25 |
| 9.03.021 | Aqueous Shunts and Stents for Glaucoma | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 6/30/25 | 4/25/25 |
| 2.01.071 | Nonpharmacologic Treatment of Rosacea | DELETE | Archiving the criteria. | 6/30/25 | 4/25/25 |
| 2.03.005 | Uses of Monoclonal Antibodies for the Treatment of Non-Hodgkin Lymphoma | DELETE | Archiving the criteria. | 6/23/25 | 4/22/25 |
| 15.01.003 | Drug Testing in Pain Management and Substance Use Disorder Treatment | UPDATE | Clinical evidence to support the policy position reviewed. There is no change to the policy position statement listed. | 6/23/25 | 4/22/25 |
| 7.01.123 | Plugs for Anal Fistula Repair | DELETE | Archiving the criteria. | 6/23/25 | 4/22/25 |
| 7.01.137 | Magnetic Esophageal Sphincter Augmentation to Treat Gastroesophageal Reflux Disease | DELETE | Archiving the criteria. | 6/23/25 | 4/22/25 |
| 5.01.009 | Advanced Therapies for Pharmacologic Treatment of Pulmonary Hypertension | NEW | Implementation of NEW guidelines. | 6/23/25 | 4/22/25 |
| 5.01.005 | Calcium Sensing Receptor Agonists - Parsabiv | NEW | Implementation of NEW guidelines. | 6/23/25 | 4/22/25 |
| 2.04.125 | Proteomic Testing for Targeted Therapy in Non-Small-Cell Lung Cancer | UPDATE | Clinical evidence to support the policy position reviewed. There is no change to the policy position statement listed. | 6/23/25 | 4/22/25 |
| 2.04.019 | Pharmacogenomic and Metabolite Markers for Patients Treated With Thiopurines | UPDATE | Clinical evidence to support the policy position reviewed. There is no change to the policy position statement listed. | 6/23/25 | 4/22/25 |
| 2.04.033 | Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 6/23/25 | 4/22/25 |
| 2.04.036 | Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer | UPDATE | Clinical evidence to support the policy position reviewed and references added. New indications and evidence reviews added for the BluePrint and Male Breast Cancer. There is no change to the policy position statement listed. | 6/23/25 | 4/22/25 |
| 2.04.041 | Noninvasive Techniques for the Evaluation and Monitoring of Patients With Chronic Liver Disease | NEW | Implementation of NEW guidelines. | 6/23/25 | 4/22/25 |
| 2.04.045 | Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment in Non-Small-Cell Lung Cancer (EGFR, ALK, BRAF, ROS1, RET, MET, KRAS) | UPDATE | Coding Change only: 81191-81194 added for NTRK | 6/23/25 | 4/22/25 |
| 2.04.084 | Measurement of Serum Antibodies to Selected Biologic Agents | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 6/23/25 | 4/22/25 |
| 2.04.095 | Human Leukocyte Antigen Testing for Celiac Disease | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 6/23/25 | 4/22/25 |
| 2.04.096 | Genetic Testing for Statin-Induced Myopathy | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 6/23/25 | 4/22/25 |
| 8.01.058 | Cranial Electrotherapy Stimulation and Auricular Electrostimulation | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 6/16/25 | 4/9/25 |
| 2.01.050 | Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 6/16/25 | 4/9/25 |
| 2.01.093 | Antigen Leukocyte Antibody Test | UPDATE | Clinical evidence to support the policy position reviewed. There is no change to the policy position statement listed. | 6/16/25 | 4/9/25 |
| 2.04.155 | Comprehensive Genomic Profiling for Selecting Targeted Cancer Therapies | UPDATE | Clinical evidence to support the policy position reviewed. There is no change to the policy position statement listed. | 6/16/25 | 4/9/25 |
| 2.04.139 | Genetic Testing for Heterozygous Familial Hypercholesterolemia | UPDATE | Clinical evidence to support the policy position reviewed. There is no change to the policy position statement listed. | 6/16/25 | 4/9/25 |
| 2.04.013 | Genetic Testing for Alzheimers Disease | UPDATE | Coding correction - removed 0016M due to out-of-scope. | 6/16/25 | 4/9/25 |
| 2.04.014 | Evaluation of Biomarkers for Alzheimer Disease | UPDATE | Clinical evidence to support the policy position reviewed and references added. Clinical input added. Policy statements changed to medically necessary specifically for indication related to use of CSF biomarkers to select individuals for treatment with FDA-approved amyloid targeting therapies. Other policy statements remain investigational. | 6/16/25 | 4/9/25 |
| 2.04.159 | Laboratory Testing Investigational Services | UPDATE | Coding update only: 0365U revised 1/1/25; 0380U deleted | 6/16/25 | 4/9/25 |
| 2.04.052 | Molecular Testing for the Management of Pancreatic Cysts and Solid Pancreaticobiliary Lesions | UPDATE | Clinical evidence to support the policy position reviewed. he indication and investigational policy statement for topographic genotyping (e.g. BarreGen molecular testing) has been migrated to policy 7.01.167 - Adjunctive Techniques for Screening, Surveillance, and Risk Classification of Barrett Esophagus and Esophageal Dysplasia. Policy statement otherwise unchanged. | 6/16/25 | 4/9/25 |
| 2.04.059 | Genetic Testing for Developmental Delay/Intellectual Disability, Autism Spectrum Disorder, and Congenital Anomalies | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 6/16/25 | 4/9/25 |
| 2.04.063 | Use of Common Genetic Variants (Single Nucleotide Variants) to Predict Risk of Nonfamilial Breast Cancer | UPDATE | Clinical evidence to support the policy position reviewed. There is no change to the policy position statement listed. | 6/16/25 | 4/9/25 |
| 2.04.085 | BCR-ABL1 Testing in Chronic Myelogenous Leukemia and Acute Lymphoblastic Leukemia | UPDATE | Clinical evidence to support the policy position reviewed. There is no change to the policy position statement listed. | 6/16/25 | 4/9/25 |
| 2.04.093 | Genetic Cancer Susceptibility Panels Using Next Generation Sequencing | UPDATE | Coding updated: 81435 and 81437 revised; 81433, 81436, 81438 deleted | 6/16/25 | 4/9/25 |
| 2.04.097 | Microarray-Based Gene Expression Profile Testing for Multiple Myeloma Risk Stratification | UPDATE | Clinical evidence to support the policy position reviewed. There is no change to the policy position statement listed. | 6/16/25 | 4/9/25 |
| 15.01.002 | Applied Behavioiral Analysis Policy | UPDATE | Clinical evidence to support the policy position reviewed. There is no change to the policy position statement listed. | 6/16/25 | 4/9/25 |
| 2.04.159 | Laboratory Testing Investigational Services | UPDATE | Update to coding only: 0365U revised 1/1/25 and 0380U deleted. | 6/9/25 | 4/3/25 |
| 6.01.043 | Contrast-Enhanced Computed Tomographic Angiography for Coronary Artery Evaluation | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 6/9/25 | 4/3/25 |
| 6.01.046 | Dynamic Spinal Visualization and Vertebral Motion Analysis | UPDATE | Clinical evidence to support the policy position reviewed and references added. Titile updated to include Vertebral Motion Analysis and an investigational policy position statement added. | 6/9/25 | 4/3/25 |
| 7.01.158 | Balloon Dilation of the Eustachian Tube | NEW | Implementation of NEW guidelines. | 6/9/25 | 4/3/25 |
| 7.01.075 | Cryosurgical Ablation of Primary or Metastatic Liver Tumors | UPDATE | Clinical evidence to support the policy position reviewed, guidelines updated and references added. There is no change to the policy position statement listed. | 6/9/25 | 4/3/25 |
| 6.01.051 | Interim Positron Emission Tomography Scanning in Oncology to Detect Early Response | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 6/9/25 | 4/3/25 |
| 6.01.056 | Myocardial Sympathetic Innervation Imaging in Individuals With Heart Failure | DELETE | Archiving the criteria. | 6/9/25 | 4/3/25 |
| 7.01.009 | Risk-Reducing Mastectomy | DELETE | Archiving the criteria. | 6/9/25 | 4/3/25 |
| 7.01.141 | Lumbar Spinal Fusion | DELETE | Archiving the criteria. | 6/9/25 | 4/3/25 |
| 7.01.152 | Magnetic Resonance Imaging-Targeted Biopsy of the Prostate | DELETE | Archiving the criteria. | 6/9/25 | 4/3/25 |
| 7.01.095 | Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors | UPDATE | Coding updated: Added 60660 and 60661 | 6/9/25 | 4/3/25 |
| 7.03.012 | Islet Transplantation for Chronic Pancreatitis and Donislecel-jujn for Type 1 Diabetes | NEW | Implementation of NEW guidelines. | 6/9/25 | 4/3/25 |
| 8.01.061 | Focal Treatments for Prostate Cancer | UPDATE | Clinical evidence to support the policy position reviewed and references added. New indication added for irreversible electroporation. Policy statements unchanged. There is no change to the policy position statement listed. | 6/9/25 | 4/3/25 |
| 2.01.027 | Biofeedback as a Treatment of urinary incontinence in Adults | DELETE | Archiving the criteria. | 6/9/25 | 4/3/25 |
| 2.04.137 | Genetic Testing for Neurofibromatosis | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 6/2/25 | 3/27/25 |
| 2.04.15 | Bone Turnover Markers for Diagnosis and Management of Osteoporosis and Diseases Associated With High Bone Turnover | UPDATE | Clinical evidence to support the policy position reviewed. There is no change to the policy position statement listed. | 6/2/25 | 3/27/25 |
| 2.04.43 | Genetic Testing for Cardiac Ion Channelopathies | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 6/2/25 | 3/27/25 |
| 2.04.79 | Genetic Testing for Alpha-1 Antitrypsin Deficiency | UPDATE | Clinical evidence to support the policy position reviewed. There is no change to the policy position statement listed. | 6/2/25 | 3/27/25 |
| 2.04.83 | Genetic Testing for FMR1 Variants (Including Fragile X Syndrome) | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 6/2/25 | 3/27/25 |
| 2.04.89 | Genetic Testing for the Diagnosis of Inherited Peripheral Neuropathies | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 6/2/25 | 3/27/25 |
| 6.01.10 | Stereotactic Radiosurgery and Stereotactic Body Radiotherapy | UPDATE | Clinical evidence to support the policy position reviewed and references added. A new indication added for small cell lung cancer with an investigational policy statement. | 6/2/25 | 3/27/25 |
| 7.01.153 | Adipose-Derived Stem Cells in Autologous Fat Grafting to the Breast | NEW | Implementation of NEW guidelines. | 6/2/25 | 3/27/25 |
| 2.01.004 | Hyperbaric Oxygen Therapy | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 6/2/25 | 3/27/25 |
| 2.04.008 | Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes | UPDATE | Coding updated: 81436 deleted 12/31/24; 81435 revised 1/1/25 | 6/2/25 | 3/27/25 |
| 2.04.107 | Carrier Screening for Genetic Diseases | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 6/2/25 | 3/27/25 |
| 2.04.111 | Gene Expression Profiling and Protein Biomarkers for Prostate Cancer Management | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 6/2/25 | 3/27/25 |
| 2.04.117 | Genetic Testing for Mitochondrial Disorders | UPDATE | Clinical evidence to support the policy position reviewed. There is no change to the policy position statement listed. | 6/2/25 | 3/27/25 |
| 2.04.153 | Tumor-Informed Circulating Tumor DNA Testing for Cancer Management | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 6/2/25 | 3/27/25 |
| 5.01.044 | Treatment of Congenital Athymia | NEW | Implementation of NEW guidelines. | 6/2/25 | 3/27/25 |
| 6.01.003 | Computed Tomography to Detect Coronary Artery Calcification | UPDATE | Clinical evidence to support the policy position reviewed. There is no change to the policy position statement listed. | 6/2/25 | 3/27/25 |
| 6.01.018 | Scintimammography and Gamma Imaging of the Breast and Axilla | DELETE | Archiving the criteria. | 6/2/25 | 3/27/25 |
| 6.01.026 | Oncologic Applications of Positron Emission Tomography Scanning (Genitourinary) | UPDATE | Clinical evidence to support the policy position reviewed, references added and guidelines updaeted. Medically necessary policy statements on prostate cancer modified to include new agent (flotufolastat-F18). | 6/2/25 | 3/27/25 |
| 6.01.032 | Virtual Colonoscopy/Computed Tomography Colonography | DELETE | Archiving the criteria. | 6/2/25 | 3/27/25 |
| 6.01.040 | Whole Body Dual X-Ray Absorptiometry to Determine Body Composition | DELETE | Archiving the criteria. | 6/2/25 | 3/27/25 |
| 6.01.047 | Functional Magnetic Resonance Imaging of the Brain (Title change Functional Magnetic Resonance Imaging of the Brain for Presurgical Mapping or Seizure Focus Location) | DELETE | Archiving the criteria. | 6/2/25 | 3/27/25 |
| 1.01.018 | Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers | UPDATE | Clinical evidence to support the policy position reviewed and references added. The second PICO (pneumatic compression pumps for lymphedema unresponsive to conservative therapy) has been refined to more accurately frame the intervention under review. There is no change to the policy position statement listed. | 5/26/25 | 3/20/25 |
| 2.01.82 | Bioimpedance Devices for Detection and Management of Lymphedema | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 5/26/25 | 3/20/25 |
| 2.04.124 | Genetic Testing for FLT3, NPM1, and CEBPA Variants in Cytogenetically Normal Acute Myeloid Leukemia | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 5/26/25 | 3/20/25 |
| 2.04.131 | Pharmacogenetic Testing for Pain Management | UPDATE | Clinical evidence to support the policy position reviewed and references added. New indication added for individuals with need for pharmacologic management of acute pain who receive pharmacogenetic testing to assess risk of developing opioid use disorder, with an investigational policy statement. Other policy statement unchanged. | 5/26/25 | 3/20/25 |
| 17.01.001 | Applied Behavioral Analysis (FEP Only) | DELETE | Criteria is located in policy 15.01.002 | 5/26/25 | 3/20/25 |
| 2.01.077 | Automated Point-of-Care Nerve Conduction Tests | DELETE | Achiving the criteria. | 5/12/25 | 3/12/25 |
| 8.01.15 | Hematopoietic Cell Transplantation for Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 5/12/25 | 3/12/25 |
| 8.01.17 | Hematopoietic Cell Transplantation for Plasma Cell Dyscrasias, Including Multiple Myeloma and POEMS Syndrome | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 5/12/25 | 3/12/25 |
| 8.01.20 | Hematopoietic Cell Transplantation for Non-Hodgkin Lymphomas | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 5/12/25 | 3/12/25 |
| 8.01.21 | Allogeneic Hematopoietic Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 5/12/25 | 3/12/25 |
| 8.01.22 | Allogeneic Hematopoietic Cell Transplantation for Genetic Diseases and Acquired Anemias | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 5/12/25 | 3/12/25 |
| 8.01.23 | Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 5/12/25 | 3/12/25 |
| 8.01.24 | Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors in Adults | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 5/12/25 | 3/12/25 |
| 8.01.25 | Hematopoietic Cell Transplantation for Autoimmune Diseases | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 5/12/25 | 3/12/25 |
| 8.01.26 | Hematopoietic Cell Transplantation for Acute Myeloid Leukemia | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 5/12/25 | 3/12/25 |
| 8.01.28 | Hematopoietic Cell Transplantation for Central Nervous System Embryonal Tumors and Ependymoma | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 5/12/25 | 3/12/25 |
| 8.01.29 | Hematopoietic Cell Transplantation for Hodgkin Lymphoma | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 5/12/25 | 3/12/25 |
| 8.01.30 | Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 5/12/25 | 3/12/25 |
| 8.01.32 | Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 5/12/25 | 3/12/25 |
| 8.01.33 | High-Dose Rate Temporary Prostate Brachytherapy | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 5/12/25 | 3/12/25 |
| 8.01.34 | Hematopoietic Cell Transplantation for Solid Tumors of Childhood | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 5/12/25 | 3/12/25 |
| 8.01.35 | Hematopoietic Cell Transplantation in the Treatment of Germ Cell Tumors | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 5/12/25 | 3/12/25 |
| 8.01.42 | Hematopoietic Cell Transplantation for Primary Amyloidosis | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 5/12/25 | 3/12/25 |
| 8.01.52 | Orthopedic Applications of Stem Cell Therapy (Including Allografts and Bone Substitutes Used With Autologous Bone Marrow) | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 5/12/25 | 3/12/25 |
| 8.01.55 | Stem Cell Therapy for Peripheral Arterial Disease | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 5/12/25 | 3/12/25 |
| 5.01.030 | Treatment of Hereditary Transthyretin-Mediated Amyloidosis in Adult Patients - Onpattro, Amvuttra | NEW | Implementation of NEW guidelines. | 5/15/25 | 2/28/25 |
| 12.01.074 | Hympavzi Prior Authorization with Quantity Limit | NEW | Implementation of NEW guidelines | 5/1/25 | 2/28/25 |
| 12.01.073 | Yorvipath Prior Authorization with Quantity Limit | NEW | Implementation of NEW guidelines | 5/1/25 | 2/28/25 |
| 12.01.072 | Niemann-Pick Disease Type C Agents Prior Authorization with Quantity Limit | NEW | Implementation of NEW guidelines | 5/1/25 | 2/28/25 |
| 2.02.001 | Catheter Ablation for Cardiac Arrhythmias | DELETE | Archiving the criteria. | 5/1/25 | 2/27/25 |
| 2.01.079 | Noncontact Ultrasound Treatment for Wounds | DELETE | Archiving the criteria. | 4/28/25 | 2/27/25 |
| 11.01.154 | Chronic Wound Management | DELETE | Archiving the criteria. | 4/28/25 | 2/27/25 |
| 2.04.141 | Circulating Tumor DNA and Circulating Tumor Cells for Cancer Management (Liquid Biopsy) | NEW | Implementation of NEW guidelines. | 4/28/25 | 2/27/25 |
| 2.04.127 | Multitarget Polymerase Chain Reaction Testing for Diagnosis of Bacterial Vaginosis | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 4/28/25 | 2/27/25 |
| 2.02.033 | Phrenic Nerve Stimulation for Central Sleep Apnea | NEW | Implementation of NEW guidelines. | 4/28/25 | 2/27/25 |
| 5.01.048 | Gene Therapies for Sickle Cell Disease - Casgevy, Lyfgenia | NEW | Implementation of NEW guidelines. | 4/28/25 | 2/27/25 |
| 12.01.068 | Gene Therapies for Sickle Duchenne Muscular Dystrophy – Elevidys | NEW | Implementation of NEW guidelines. | 4/28/25 | 2/27/25 |
| 5.01.048 | Gene Therapies for Sickle Cell Disease - Casgevy, Lyfgenia | NEW | Implementation of NEW guidelines. | 4/8/25 | 2/7/25 |
| 12.01.018 | Infusible Biologic Immunomodulators - Actemra, Avsola, Cimzia, Cosentyx, Entyvio, Ilumya, Inflectra, Omvoh, Orencia, Remicade, Infliximab, Renflexis, Simponi Aria, Skyrizi, Stelara, Taltz, Tofidence, Tremfya, Tyenne | UPDATE | Clinical evidence to support the policy position reviewed and references added. The following medications were removed: Amjevita® (adalimumabatto), Cyltezo®/Adal imumabadbm, Enbrel® (etanercept), Hadlima™ (adalimumabbwwd), Hulio®, Adalimumabfkjp, Humira® (adalimumab), Hyrimoz®/Ad alimumabadaz, Idacio® (adalimumabaacf), Kevzara® (sarilumab), Kineret® (anakinra), Litfulo™ (ritlecitinib), Olumiant® (baricitinib),Rinvoq™ (upadacitinib extended release), Siliq™ (brodalumab), Sotyktu™ (deucravacitin ib), Xeljanz® (tofacitinib), Xeljanz XR® (tofacitinib extended release) Yuflyma® (adalimumabaaty), Yusimry™ (adalimumabaqvh)The following medications were added with specific criteria for approval updated: Avsola, Ilumya, Inflectra, Omvoh, Remicade, Renflexis, Tofidence, Tremfya, Tyenne. | 4/8/25 | 2/7/25 |
| 15.01.004 | Basivertebral Nerve Ablation | NEW | Implementation of NEW guidelines. | 4/8/25 | 2/7/25 |
| 7.03.011 | Total Artificial Hearts and Implantable Ventricular Assist Devices | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 4/8/25 | 2/7/25 |
| 7.03.013 | Composite Tissue Allotransplantation of the Hand and Face | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 4/8/25 | 2/7/25 |
| 8.01.068 | Omidubicel as Adjunct Treatment for Hematologic Malignancies | UPDATE | Clinical evidence to support the policy position reviewed and references added. Policy statements changed to: Omidubicel is considered medically necessary in individuals 12 years or older with hematologic malignancies planning myeloablative allogenic umbilical cord transplantation to reduce the time to neutrophil recovery and the incidence of infection. Investigational statement added for all other uses. | 4/8/25 | 2/7/25 |
| 4.02.005 | Preimplantation Genetic Testing | NEW | Implementation of NEW guidelines. | 4/8/25 | 2/7/25 |
| 2.04.141 | Circulating Tumor DNA and Circulating Tumor Cells for Cancer Management (Liquid Biopsy) | NEW | Implementation of NEW guidelines. | 4/8/25 | 2/7/25 |
| 2.04.149 | Molecular Testing for Germline Variants Associated with Ovarian Cancer (BRIP1, RAD51C, RAD51D, NBN) | NEW | Implementation of NEW guidelines. | 4/8/25 | 2/7/25 |
| 2.04.154 | Germline Genetic Testing for Hereditary Diffuse Gastric Cancer (CDH1, CTNNA1) | NEW | Implementation of NEW guidelines. | 4/8/25 | 2/7/25 |
| 4.01.018 | Ovarian and Internal Iliac Vein Endovascular Occlusion as a Treatment of Pelvic Congestion Syndrome | NEW | Implementation of NEW guidelines. | 4/8/25 | 2/7/25 |
| 8.01.008 | Intraoperative Radiotherapy | DELETE | Archiving the criteria. | 4/8/25 | 2/7/25 |
| 12.01.016 | Immune Globulins | UPDATE | Biosimilar products of Alyglo, Asceniv, Cutaquig, Panzyga and Xembify were added to the policy. Effective 2/18/2025, some members may be required to utilize preferred products. The preferred products for Immune Globulins IV are Octagam, Gamunex-C/Gammaked, Gammagard, and Privigen. | 2/18/25 | 12/20/24 |
| 7.01.164 | Hydrogel Spacer use During Radiotherapy for Prostate Cancer | UPDATE | Clinical evidence to support the policy position was updated, new products added to Regulatory Status and references added. There is no change to the policy position statement listed. | 2/18/25 | 12/20/24 |
| 8.01.006 | Oncologic Applications of Photodynamic Therapy, Including Barrett Esophagus | UPDATE | Clinical evidence to support the policy position was reviewed. There is no change to the policy position statement listed. | 2/18/25 | 12/20/24 |
| 8.01.013 | Accelerated Breast Irradiation and Brachytherapy Boost After Breast-Conserving Surgery for Early-Stage Breast Cancer | UPDATE | Clinical evidence to support the policy position was updated and references added. There is no change to the policy position statement listed. | 2/18/25 | 12/20/24 |
| 8.01.014 | Brachytherapy for Clinically Localized Prostate Cancer Using Permanently Implanted Seeds | UPDATE | Clinical evidence to support the policy position reviewed and references added. There is no change to the policy position statement listed. | 2/18/25 | 12/20/24 |
| 12.01.051 | Injectable and Implantable Testosterone - Aveed, Delatestryl, Depo-Testosterone | DELETE | Archiving this criteria - see policy 5.01.023 | 2/18/25 | 12/20/24 |
| 12.01.031 | Bevacizumab | UPDATE | Biosimilar products of Alymsys, Vegzelma, and Zirabev were added to the policy. Effective 2/1/2025, some members may be required to utilize preferred products. The preferred products for Bevacuzmab are Zirabev or Mvasi. | 2/1/25 | 12/1/24 |
| 12.01.052 | Viscosupplements Medical Drug Criteria | UPDATE | Biosimilar products of Triluron, TriVisc, Sodium Hyaluronate were added to the policy. Effective 2/1/2025, some members may be required to utilize preferred products. The preferred products for Viscosupplements are Gel-one or Durolane. | 2/1/25 | 12/1/24 |
| 12.01.017 | Health Care Provider Administered (HCPA) Biologic Immunomodulator | UPDATE | Added preferred products language. Effective 2/1/2025, some members may be required to utilize preferred products. The preferred products for biologic immunomodulators are Inflectra or Avsola. | 2/1/25 | 12/1/24 |
| 12.01.006 | Colony Stimulating Factors - Neupogen, Neulasta, Leukine, Granix, Zarxio | UPDATE | Biosimilar products of Fylnetra, Rolvedon, Stimufend were added to the policy. Effective 2/1/2025, some members may be required to utilize preferred products. The preferred products for colony stimulating factors are Neulasta or Udenica. | 2/1/25 | 12/1/24 |
| 12.01.016 | Immune Globulins | UPDATE | Biosimilar products of Alyglo, Asceniv, Cutaquig, Panzyga and Xembify were added to the policy. Effective 2/1/2025, some members may be required to utilize preferred products. The preferred products for Immune Globulins IV are Octagam, Gamunex-C/Gammaked, Gammagard, and Privigen. | 2/1/25 | 12/1/24 |
| 2.04.150 | Serologic Genetic and Molecular Screening for Colorectal Cancer | NEW | Implementation of NEW guidelines. | 1/27/25 | 11/27/24 |
| 1.01.029 | Tumor Treating Fields Therapy | UPDATE | Clinical evidence to support the policy position reviewed. There are minor editorial changes to the policy position statement listed. | 1/27/25 | 11/27/24 |
| 1.01.030 | Artificial Pancreas Device Systems | UPDATE | Clinical evidence to support the policy position reviewed. There is no change to the policy position statement listed. | 1/27/25 | 11/27/24 |
| 2.01.073 | Actigraphy | UPDATE | Clinical evidence to support the policy position reviewed. There is no change to the policy position statement listed. | 1/27/25 | 11/27/24 |
| 2.02.030 | Transcatheter Mitral Valve Repair or Replacement | UPDATE | Policy titled changed to include "replacement", new indication for transseptal valve-in-valve replacement and references added. Policy statement added: Transcatheter mitral valve-in-valve replacement (TMViVR) with a transcatheter heart valve system approved for use for repair of a degenerated bioprosthetic valve (valve-in-valve) is considered medically necessary for individuals when all of the following conditions are present: Failure (stenosed, insufficient, or combined) of a surgical bioprosthetic mitral valve; AND New York Heart Association heart failure class II, III, or IV symptoms; AND Individual is not an operable candidate for open surgery, as documented by at least 2 cardiovascular specialists (including a cardiac surgeon); OR individual is an operable candidate but is considered at increased surgical risk for open surgery, as documented by at least 2 cardiac specialists (including a cardiac surgeon); OR individual is considered at increased surgical risk for open surgery (eg, repeat sternotomy) due to a history of congenital vascular anomalies AND/OR has a complex intrathoracic surgical history, as documented by at least 2 cardiovascular specialists (including a cardiac surgeon). | 1/27/25 | 11/27/24 |
| 2.03.007 | Hyperthermic Intraperitoneal Chemotherapy for Select Intra-Abdominal and Pelvic Malignancies | UPDATE | Clinical evidence to support the policy position was updated and references added. There is no change to the policy position statement listed. | 1/27/25 | 11/27/24 |
| 2.04.053 | Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment in Metastatic Colorectal Cancer (KRAS, NRAS, BRAF, and HER2) | UPDATE | Clinical evidence to support the policy position reviewed, new indications and medically necessary policy position statement for NTRK gene fusion testing to select targeted treatment added. | 1/27/25 | 11/27/24 |
| 2.04.101 | Genetic Testing for Li-Fraumeni Syndrome | UPDATE | Clinical evidence to support the policy position reviewed. There is no change to the policy position statement listed. | 1/27/25 | 11/27/24 |
| 2.04.110 | Genetic Testing for Diagnosis and Management of Mental Health Conditions | UPDATE | Clinical evidence to support the policy position was updated and references added. There is no change to the policy position statement listed. | 1/27/25 | 11/27/24 |
| 2.04.121 | Miscellaneous Genetic and Molecular Diagnostic Tests | UPDATE | Clinical evidence to support the policy position reviewed. There is no change to the policy position statement listed. | 1/27/25 | 11/27/24 |
| 2.04.080 | Genetic Testing for Hereditary Hemochromatosis | UPDATE | Minimal clinical evidence reviewed. There is no change to the policy position statement listed. | 1/27/25 | 11/27/24 |
| 02.02.016 | Ultrasonographic Measurement of Carotid Intimal-Medial Thickness as an Assessment of Subclinical Atherosclerosis | DELETE | Archiving the criteria. | 12/9/24 | 10/7/24 |
| 07.01.128 | Bronchial Valves | UPDATE | Clinical evidence to support the policy position was updated, references added and outdated clinical input was removed. There is no change to the policy position statement listed. | 12/9/24 | 10/7/24 |
| 07.01.071 | Lung Volume Reduction Surgery for Severe Emphysema | UPDATE | Clinical evidence to support the policy position reviewed. There is no change to the policy position statement listed. | 12/9/24 | 10/7/24 |
| 08.01.046 | Intensity Modulated Radiotherapy of the Breast and Lung | DELETE | Archiving the criteria. | 12/9/24 | 10/7/24 |
| 08.01.047 | Intensity Modulated Radiotherapy of the Prostate | DELETE | Archiving the criteria. | 12/9/24 | 10/7/24 |
| 08.01.048 | Intensity Modulated Radiotherapy: Cancer of the Head and Neck or Thyroid | DELETE | Archiving the criteria. | 12/9/24 | 10/7/24 |
| 08.01.049 | Intensity Modulated Radiotherapy of the Abdomen and Pelvis | DELETE | Archiving the criteria. | 12/9/24 | 10/7/24 |
| 08.01.059 | Intensity Modulated Radiotherapy of the Central Nervous System | DELETE | Archiving the criteria. | 12/9/24 | 10/7/24 |
| 02.01.073 | Actigraphy | UPDATE | Clinical evidence to support the policy position was updated. There is no change to the policy position statement listed. | 12/9/24 | 10/7/24 |
| 02.04.080 | Genetic Testing for Hereditary Hemochromatosis | UPDATE | Clinical evidence to support the policy position was updated and references added. There is no change to the policy position statement listed. | 12/9/24 | 10/7/24 |
| 07.01.147 | Minimally Invasive Ablation Procedures for Morton and Other Peripheral Neuromas | UPDATE | Title changed to "Minimally Invasive Ablation Procedures for Morton and Other Peripheral Neuromas". Clinical evidence to support the policy position was updated and references added. Codes 64632, 0441T added to authorization requirement. Intralesional alcohol ablation added to investigational policy statement. | 12/9/24 | 10/7/24 |
| 08.01.019 | Treatment of Hyperhidrosis | UPDATE | Clinical evidence to support the policy position was updated and references were added. There is no change to the policy position statement listed. | 12/9/24 | 10/7/24 |
| 07.01.047 | Bariatric Surgery | UPDATE | Clerical error omited codes 43771-43773 - these codes were added to the policy. | 12/9/24 | 10/7/24 |
| 01.01.023 | Transtympanic Micropressure Applications as a Treatment of Meniere's Disease | DELETE | Archiving the criteria. | 12/9/24 | 10/7/24 |
| 02.02.018 | Progenitor Cell Therapy for the Treatment of Damaged Myocardium Due to Ischemia | DELETE | Archiving the criteria. | 12/9/24 | 10/7/24 |
| 02.02.006 | Enhanced External Counterpulsation | DELETE | Archiving the criteria. | 12/9/24 | 10/7/24 |
| 02.04.037 | Detection of Circulating Tumor Cells in the Management of Patients With Cancer | DELETE | Archiving the criteria. | 12/9/24 | 10/7/24 |
| 02.04.081 | Genetic Testing for Rett Syndrome | DELETE | Archiving the criteria. | 12/9/24 | 10/7/24 |
| 02.04.067 | KIF6 Genotyping for Predicting Cardiovascular Risk and/or Effectiveness of Statin Therapy | DELETE | Archiving the criteria. | 12/9/24 | 10/7/24 |
| 02.04.076 | Quantitative Assay for Measurement of HER2 Total Protein Expression and HER2 Dimers | DELETE | Archiving the criteria. | 12/9/24 | 10/7/24 |
| 02.04.059 | Genetic Testing for Developmental Delay/Intellectual Disability, Autism Spectrum Disorder, and Congenital Anomalies | UPDATE | Clinical evidence to support the policy position was updated, code 0243U was added and code 0318U was removed. There is no change to the policy position statement listed. | 12/9/24 | 10/7/24 |
| 02.01.001 | Diagnosis and Management of Idiopathic Environmental Intolerance (ie, Multiple Chemical Sensitivities) | DELETE | Archiving the criteria. | 12/9/24 | 10/7/24 |
| 07.01.018 | Automated Percutaneous and Percutaneous Endoscopic Discectomy | NEW | Implementation of NEW guidelines. | 12/9/24 | 10/7/24 |
| 08.01.022 | Allogeneic Hematopoietic Cell Transplantation for Genetic Diseases and Acquired Anemias | DELETE | Archiving the criteria. | 12/9/24 | 10/7/24 |
| 11.01.147 | Hematopoetic Stem Cell Transplantation for Breast Cancer | DELETE | Archiving the criteria. | 12/9/24 | 10/7/24 |
| 11.01.102 | Laminectomy | DELETE | Archiving the criteria and creating new policy guidelines under policy 07.01.145. | 12/9/24 | 10/7/24 |
| 07.01.145 | Laminectomy | NEW | Implementation of NEW guidelines. | 12/9/24 | 10/7/24 |
| 11.01.117 | Hugh Resolution Anoscopy | DELETE | Archiving the criteria. | 12/9/24 | 10/7/24 |
| 11.01.084 | Percutaneous Discectomy | DELETE | Archiving the criteria. | 12/9/24 | 10/7/24 |
| 02.02.018 | Progenitor Cell Therapy for the Treatment of Damaged Myocardium Due to Ischemia | DELETE | Archiving the criteria. | 12/9/24 | 10/7/24 |
| 12.01.060 | Amtagvi® (lifileucel) (Intravenous) | NEW | Implementation of NEW guidelines. | 12/9/24 | 10/7/24 |
| 06.01.050 | Magnetic Resonance Imaging to Monitor the Integrity of Silicone Gel-Filled Breast Implants | DELETE | Archiving the criteria. | 12/9/24 | 10/7/24 |
| 02.04.094 | Genetic Testing for Lactase Insufficiency | DELETE | Archiving the criteria. | 12/9/24 | 10/7/24 |
| 06.01.052 | Positron Emission Mammography | DELETE | Archiving the criteria. | 12/9/24 | 10/7/24 |
| 02.04.130 | Molecular Testing for Chronic Heart Failure and Heart Transplant | DELETE | Archiving the criteria. | 12/9/24 | 10/7/24 |
| 02.01.068 | Laboratory Tests Post Transplant and for Heart Failure | UPDATE | Clinical evidence to support the policy position was updated and code 0085T was removed. New investigational policy statements regarding dd-cfDNA testing in lung and heart transplantation were added. Investigational policy statement for GEP testing (ie, AlloMap) in heart transplantation was updated to include use alone or in combination with dd-cfDNA testing (ie, HeartCare). | 12/9/24 | 10/7/24 |
| 07.01.041 | Implantable Infusion Pump for Pain and Spasticity | DELETE | Archiving the criteria. | 12/9/24 | 10/7/24 |
| 06.01.037 | Radioimmunoscintigraphy (Monoclonal Antibody Imaging) With Indium 111 Capromab Pendetide for Prostate Cancer | DELETE | Archiving the criteria. | 12/9/24 | 10/7/24 |
| 01.01.024 | Interferential Current Stimulation | UPDATE | Clinical evidence to support the policy position was updated. There is no change to the policy position statement listed. | 12/9/24 | 10/7/24 |
| 02.01.039 | Quantitative Sensory Testing | UPDATE | Clinical evidence to support the policy position was updated. There is no change to the policy position statement listed. | 12/9/24 | 10/7/24 |
| 02.01.056 | Low Level Laser Therapy | UPDATE | Clinical evidence to support the policy position was updated and code 97037 was added. There is no change to the policy position statement listed. | 12/9/24 | 10/7/24 |
| 02.01.061 | Measurement of Exhaled Nitric Oxide and Exhaled Breath Condensate in the Diagnosis and Management of Respiratory Disorders | UPDATE | Clinical evidence to support the policy position was updated & references added. There is no change to the policy position statement listed. | 12/9/24 | 10/7/24 |
| 02.01.096 | Autonomic Nervous System Testing | UPDATE | Clinical evidence to support the policy position was updates & references added. There is no change to the policy position statement listed. | 12/9/24 | 10/7/24 |
| 05.01.043 | Therapeutic Radiopharmaceuticals for Prostate Cancer | NEW | Implementation of NEW guidelines. | 12/9/24 | 10/7/24 |
| 01.01.023 | Transtympanic Micropressure Applications as a Treatment of Meniere's Disease | DELETE | Archiving the criteria. | 12/9/24 | 10/7/24 |
| 02.01.058 | Transanal Radiofrequency Treatment of Fecal Incontinence | DELETE | Archiving the criteria. | 12/9/24 | 10/7/24 |
| 02.02.006 | Enhanced External Counterpulsation | DELETE | Archiving the criteria. | 12/9/24 | 10/7/24 |
| 02.04.113 | Analysis of MGMT Promoter Methylation in Malignant Gliomas | DELETE | Archiving the criteria. | 12/9/24 | 10/7/24 |
| 07.01.079 | Whole Gland Cryoablation of Prostate Cancer | DELETE | Archiving the criteria. | 12/9/24 | 10/7/24 |
| 07.01.081 | Nerve Graft with Radical Prostatectomy | DELETE | Archiving the criteria. | 12/9/24 | 10/7/24 |
| 07.01.124 | Treatment of Varicose Veins/Venous Insufficiency | UPDATE | Clinical evidence to support the policy position was updates & references added. Minor editorial refinements to policy statement; intent unchanged. | 12/9/24 | 10/7/24 |
| 07.01.164 | Hydrogel Spacer use During Radiotherapy for Prostate Cancer | NEW | Implementation of NEW guidelines. | 12/9/24 | 10/7/24 |
| 11.01.153 | Treatment of Prostate | DELETE | Archiving the criteria. | 12/9/24 | 10/7/24 |
| 06.01.023 | Diagnosis and Treatment of Sacroiliac Joint Pain | UPDATE | Clinical evidence to support the policy position was updated, references added, Codes 0775T and 0809T were deleted effective 12/31/2023 and code 27278 was added effective 01/01/2024. Minor editorial refinements to policy statement; intent unchanged. | 12/9/24 | 10/7/24 |
| 01.01.002 | Automated Ambulatory Blood Pressure Monitoring for Diagnosis of Hypertension in Patients with Elevated Office Blood Pressure | DELETE | Archiving the criteria. | 12/9/24 | 10/7/24 |
| 02.02.024 | Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting | UPDATE | Clinical evidence to support the policy position was updated, references added and code 81418 added. There is no change to the policy position statement listed. | 12/9/24 | 10/7/24 |
| 02.04.010 | Identification of Microorganisms Using Nucleic Acid Probes | UPDATE | Clinical evidence to support the policy position was updated, references added and codes 87154, 0301U, 0302U, 87468, 87469, 87484, 0097U, 0151U were removed. Mycoplasma genitalium added to list of medically necessary NAATs. | 12/9/24 | 10/7/24 |
| 02.04.038 | Cytochrome P450 Genotype-Guided Treatment Strategy | UPDATE | Clinical evidence to support the policy position was updated. There is no change to the policy position statement listed. | 12/9/24 | 10/7/24 |
| 02.04.048 | Genotype-Guided Warfarin Dosing | UPDATE | Clinical evidence to support the policy position was updated. Minor editorial refinements to policy statement; intent unchanged. | 12/9/24 | 10/7/24 |
| 02.04.104 | Genetic Testing for α-Thalassemia | UPDATE | Clinical evidence to support the policy position was updated and references added. Corrected third policy statement, intent unchanged: Preconception (carrier) testing for α-thalassemia in prospective parents may be considered medically necessary when both parents have evidence of possible α-thalassemia (including α-thalassemia minor, hemoglobin H disease [α-thalassemia intermedia], or α-thalassemia minima [silent carrier] based on biochemical testing | 12/9/24 | 10/7/24 |
| 02.04.119 | Multibiomarker Disease Activity Blood Test for Rheumatoid Arthritis | UPDATE | Clinical evidence to support the policy position was updated and code 83529 was added. There is no change to the policy position statement listed. | 12/9/24 | 10/7/24 |
| 02.04.123 | Serum Biomarker Panel Testing for Systemic Lupus Erythematosus and Other Connective Tissue Diseases | UPDATE | Clinical evidence to support the policy position was updated, references added and code 0312U was added. There is no change to the policy position statement listed. | 12/9/24 | 10/7/24 |
| 02.04.140 | Genetic Testing for a-Thalassemia | UPDATE | Clinical evidence to support the policy position was updates. Minor editorial refinements to policy statement; intent unchanged. | 12/9/24 | 10/7/24 |
| 07.01.122 | Electromagnetic Navigational Bronchoscopy | UPDATE | Clinical evidence to support the policy position was updated and codes C7509, C7510, C7511 were added. There is no change to the policy position statement listed. | 12/9/24 | 10/7/24 |
| 07.01.018 | Automated Percutaneous and Percutaneous Endoscopic Discectomy | UPDATE | Clinical evidence to support the policy position was updated and references added. Minor editorial refinements to policy statement; intent unchanged. | 12/9/24 | 10/7/24 |
| 07.01.131 | Transcatheter Pulmonary Valve Implantation | UPDATE | Clinical evidence to support the policy position was updated. Minor editorial refinements to policy statement; intent unchanged. | 12/9/24 | 10/7/24 |
| 12.01.067 | Leqembi (Lecanemab) | NEW | Implementation of NEW guidelines. | 11/7/24 | 1/6/25 |
| 12.01.060 | Amtagvi (lifileucel)(Intravenous) | NEW | Implementation of New guidelines regarding new to market pharmaceutical Amtagvi. | 10/8/24 | 8/9/24 |
| 15.01.001 | Wearable Cardioverter Defibrillators | NEW | Implementation of NEW guidelines. | 9/30/24 | 7/30/24 |
| 02.01.058 | Transanal Radiofrequency Treatment of Fecal Incontinence | DELETE | Archiving the criteria. | 9/30/24 | 7/30/24 |
| 11.01.014 | Intraperitoneal Chemotherapy | DELETE | Archiving the criteria. | 9/30/24 | 7/30/24 |
| 11.01.017 | Long QT Syndrome Testing | DELETE | Archiving the criteria. | 9/30/24 | 7/30/24 |
| 11.01.044 | Implantable Hormone Replacement Pellets | DELETE | Archiving the criteria. | 9/30/24 | 7/30/24 |
| 11.01.065 | Photodynamic Therapy (PDT) with Porifmer Sodium | DELETE | Archiving the criteria. | 9/30/24 | 7/30/24 |
| 11.01.082 | Implantable Automatic Cardioverter-Defibrillator | DELETE | Archiving the criteria. | 9/30/24 | 7/30/24 |
| 11.01.088 | Transcutaneous Magnetic Stimulation (TMS) | DELETE | Archiving the criteria. | 9/30/24 | 7/30/24 |
| 11.01.099 | Islet Cell Transplantation | DELETE | Archiving the criteria. | 9/30/24 | 7/30/24 |
| 11.01.102 | Laminectomy | DELETE | Archiving the criteria. | 9/30/24 | 7/30/24 |
| 11.01.121 | Single Photon Emission Computed Tomography (SPECT) | DELETE | Archiving the criteria. | 9/30/24 | 7/30/24 |
| 8.03.010 | Cognitive Rehabilitation | NEW | Cognitive Rehabilitation will now be managed through prior authorization. | 9/22/24 | 7/22/24 |
| 06.01.055 | Selected Positron Emission Tomography Technologies for Evaluation of Alzheimer Disease | UPDATE | Policy Title Changed; Clinical criteria updated to discuss requirements to ensure appropriate use for Alzheimer's Disease as well as FDG-PET criteria. | 9/22/24 | 7/22/24 |
| 11.01.117 | High Resolution Anoscopy | DELETE | No authorization will be required. | 9/22/24 | 7/22/24 |
| 6.01.026 | Oncologic Applications of Positron Emission Tomography Scanning (Geniourinary) | UPDATE | Policy Title Changed; Clinical criteria updated for geniourinary oncolgic conditions and removal of all other oncologic indications. Other indications are listed in other policies. | 9/22/24 | 7/22/24 |
| 15.01.002 | Applied Behavioral Analysis | NEW | Implementation of public facing guidelines for Applied Behavioral Analysis. BCBSWY has historically held prior authorization requirements for these services. | 9/22/24 | 7/22/24 |
| 06.01.067 | Oncologic Applications of Positron Emission Tomography Scanning (Brain, Melanoma, Unknown Primary) | NEW | Implementation of NEW guidelines. | 9/22/24 | 7/22/24 |
| 06.01.066 | Oncologic Applications of Positron Emission Tomography Scanning (Thyroid, Neuroendocrine, Head and Neck) | NEW | Implementation of NEW guidelines. | 9/22/24 | 7/22/24 |
| 06.01.064 | Oncologic Applications of Positron Emission Tomography Scanning (Hematologic) | NEW | Implementation of NEW guidelines. | 9/22/24 | 7/22/24 |
| 06.01.063 | Oncologic Applications of Positron Emission Tomography Scanning (Bone and Sarcoma) | NEW | Implementation of NEW guidelines. | 9/22/24 | 7/22/24 |
| 06.01.062 | Oncologic Applications of Positron Emission Tomography Scanning (Breast and Gynecologic) | NEW | Implementation of NEW guidelines. | 9/22/24 | 7/22/24 |
| 06.01.061 | Oncologic Applications of Positron Emission Tomography Scanning (Gastrointestinal and Pancreatic) | NEW | Implementation of NEW guidelines. | 9/22/24 | 7/22/24 |
| 06.01.051 | Interim Positron Emission Tomography Scanning in Oncology to Detect Early Response During Treatment | NEW | Implementation of NEW guidelines. | 9/22/24 | 7/22/24 |
| 07.01.044 | Implantable Cardioverter Defibrillators | NEW | Implementation of NEW guidelines. | 9/22/24 | 7/22/24 |
| 06.01.065 | Oncologic Applications of Positron Emission Tomography Scanning (Lung) | NEW | Implementation of NEW guidelines. | 9/22/24 | 7/22/24 |
| 06.01.006 | Miscellaneous (Noncardiac, Nononcologic) Applications of Fluorine 18 Fluorodeoxyglucose Positron Emission Tomography | NEW | Implementation of NEW guidelines. | 9/22/24 | 7/22/24 |
| 15.01.001 | Wearable Cardioverter Defibrillators | NEW | Implementation of NEW guidelines. | 9/22/24 | 7/22/24 |
| 02.02.015 | Wearable Cardioverter Defibrillators | DELETE | Archiving the criteria and replacing with NEW policy 15.01.001 | 9/22/24 | 7/22/24 |
| 06.01.020 | Cardiac Applications of Positron Emission Tomography Scanning | NEW | Implementation of NEW guidelines. | 9/22/24 | 7/22/24 |
| 12.01.020 | Briumvi, Lemtrada, Ocrevus, Tysabri | NEW | Implementation of public facing guidelines for Briumvi, Lemtrada, Ocrevus, and Tysabri. BCBSWY has historically held prior authorization requirements for these medications but the criteria was furnished by our Pharmacy Benefit Manager and was cumbersome for providers to access. This is a posting of the criteria set. Please note that authorizations are subject to a one year authorization period while units approved will be subject to standard dosing and quantity level limits. | 9/15/24 | 7/15/24 |
| 12.01.059 | Verkazia | NEW | Implementation of NEW guidelines regarding the use of Verkazia. This has historically held prior authorization requirements but was included with other pharmaceuticals for criteria [Ophthalmic Immunomodulators]. This new criteria allows for medication specific guidelines to ensure clear presentation of requirements. | 9/15/24 | 7/15/24 |
| 12.01.057 | Filsuvez | NEW | Implementation of NEW guidelines regarding the use of Verkazia. This is a new to market product. | 9/15/24 | 7/15/24 |
| 12.01.058 | Vyepti | NEW | Implementation of public facing guidelines for Vyepti. BCBSWY has historically held prior authorization requirements for this medication but the criteria was furnished by our Pharmacy Benefit Manager and was cumbersome for providers to access. This is a posting of the criteria set. | 9/15/24 | 7/15/24 |