Medical Policy Update

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

MPC August 2026

Revised Medical Policies

Medical Policy: I.200 Amniotic Membrane and Amniotic Fluid

Effective Date: 8/1/2026
Preauthorization Required: Yes

**** This policy is now going to require Prior Authorization

Diabetic Foot Ulcers

Initial Treatment

  1. The initial 1-4 applications with treatment using human amniotic membrane for the following indications may be considered medically necessary when the following criteria are met:
    1. Diagnosis of chronic non-infected diabetic foot ulcers AND
    2. Assessment of Type 1 or Type 2 diabetes and management history to include comorbidities, current glucose levels/A1C, diet and nutritional status, skin assessment, use of appropriate footwear and/or use of mechanically supportive devices designed to reduce or eliminate pressure on wound sites AND
    3. Documented comprehensive assessment, diagnostic tests and treatment plan AND
    4. Standard treatment/conservative measures were provided for a minimum of 4 weeks with documented compliance AND 
    5. Standard of treatment therapy failed to achieve at least 50% ulcer area reduction AND
    6. Documentation of patient compliance with treatment plan AND
    7. One of the following products is utilized:
      • Grafix
      • Affinity
      • NuShield
      • Epicord
      • Amnioband
      • Epifix
  2. The use of human amniotic membranes is considered not medically necessary when the above criteria are not met.

Ongoing Treatment

  1. Additional 5-8 applications with treatment using human amniotic membrane for the following indications may be considered medically necessary when the following criteria are met:
    • Application is within 16 weeks of the first application AND
    • Measurable decreased size or depth of the ulcer OR
    • Evidence of tissue granulation, epithelialization or progress towards closure AND
    •  One of the following products is utilized:
      • Grafix
      • Affinity
      • NuShield
      • Epicord
      • Amnioband
      • Epifix
  2. The use of human amniotic membranes is considered not medically necessary when the above criteria are not met.
Venous Leg Ulcers

Initial Treatment

  1. The initial 1-4 applications with treatment using human amniotic membrane for the following indications may be considered medically necessary when the following criteria are met:
    1. Diagnosis of Chronic non-infected venous leg ulcers AND
    2. Adequate control of systemic disease and any exacerbating or comorbid factors AND
    3. Documented comprehensive assessment, diagnostic tests and treatment plan AND
    4. Use of firm strength compression garment (greater than 20mmHG) or multi-layered compression dressings AND
    5. Standard treatment/conservative measures were provided for a minimum of 4 weeks with documented compliance AND
    6. Ulcers persist AND
    7. Documentation of patient compliance with treatment plan
    8. One of the following products is utilized:
      • Grafix
      • Affinity
      • NuShield
      • Epicord
      • Amnioband
      • Epifix
  2. The use of human amniotic membranes is considered not medically necessary when the above criteria are not met.

Ongoing Treatment

  1.  Additional 5-8 applications with treatment using human amniotic membrane for the following indications may be considered medically necessary when the following criteria are met:
    1. Application is within 16 weeks of the first application AND
    2. Measurable decreased size or depth of the ulcer OR
    3. Evidence of tissue granulation, epithelialization or progress towards closure AND
    4. One of the following products is utilized:
      • Grafix
      • Affinity
      • NuShield
      • Epicord
      • Amnioband
      • Epifix     
  2. The use of human amniotic membranes is considered not medically necessary when the above criteria are not met.
Other Indicators
  1. The applications with treatment using human amniotic membrane for the following indications may be considered medically necessary when the following criteria are met:
    1. Neurotrophic keratitis with ocular surface damage and inflammation that does not respond to conservative therapy OR
    2. Corneal ulcers and melts that do not respond to initial medical therapy. when there is insufficient healthy tissue to create a conjunctival autograft. OR
    3. Pterygium repair when there is insufficient healthy tissue to create a conjunctival autograft OR
    4. Stevens-Johnson syndrome of the eye OR
    5. Persistent epithelial defects of the eye and ulceration that do not respond to conservative therapy AND
    6. One of the following products is utilized:
      • Grafix
      • Affinity
      • NuShield
      • Epicord
      • Amnioband
      • Epifix
  2. The use of human amniotic membranes is considered not medically necessary when the above criteria are not met.
  3. The use of human amniotic fluid injection is not medically necessary for all indications.
Medical Policy: I.202 Bioengineered Skin and Soft Tissue Substitutes

Effective Date: 8/1/2026
Preauthorization Required: Yes

**** This policy is now going to require Prior Authorization

  1. The initial 1-4 applications with treatment using bioengineered skin substitutes for the following indications may be considered medically necessary when the following criteria are met:
    1. Diagnosis of chronic non-infected diabetic foot ulcers AND
    2. Assessment of Type 1 or Type 2 diabetes and management history to include comorbidities, current glucose levels/A1C, diet and nutritional status, skin assessment, use of appropriate footwear and/or use of mechanically supportive devices designed to reduce or eliminate pressure on wound sites AND
    3. Documented comprehensive assessment, diagnostic tests and treatment plan AND
    4. Standard treatment/conservative measures were provided for a minimum of 4 weeks with documented compliance AND
    5. Standard of treatment therapy failed to achieve at least 50% ulcer area reduction AND
    6. Documentation of patient compliance with treatment plan AND
    7. One of the following products is utilized:
      • Alloderm 
      • Integra Omnigraft Dermal 
      • Dermal Regeneration Matrix
      • Flex HD or Allopatch HD 
      • Apligraf 
      • Dermagraft 
      • Integra Flowable Matrix
      • mVASC
      • Theraskin
  2. The use of bioengineered skin substitutes is considered not medically necessary when the above criteria are not met.

Ongoing Treatment 

  1. Additional 5-8 applications with treatment using bioengineered skin substitutes for the following indications may be considered medically necessary when the following criteria are met:
    1. Application is within 16 weeks of the first application AND
    2. Measurable decreased size or depth of the ulcer OR
    3. Evidence of tissue granulation, epithelialization or progress towards closure
    4. One of the following products is utilized:
      • Alloderm
      • Integra Omnigraft Dermal
      • Dermal Regeneration Matrix
      • Flex HD or Allopatch HD
      • Apligraf
      • Dermagraft
      • Integra Flowable Matrix
      • mVASC
      • Theraskin
  2. The use of bioengineered skin substitutes is considered not medically necessary when the above criteria are not met.
Venous Leg Ulcers

Initial Treatment

  1. The initial 1-4 applications with treatment using bioengineered skin substitutes for the following indications may be considered medically necessary when the following criteria are met:
    1. Diagnosis of Chronic non-infected venous leg ulcers AND
    2. Adequate control of systemic disease and any exacerbating or comorbid factors AND
    3. Documented comprehensive assessment, diagnostic tests and treatment plan AND
    4. Use of firm strength compression garment (greater than 20mmHG) or multi-layered compression dressings AND
    5. Standard treatment/conservative measures were provided for a minimum of 4 weeks with documented compliance AND
    6. Ulcers persist AND
    7. Documentation of patient compliance with treatment plan
    8. One of the following products is utilized:
      • Apligraf
      • Oasis Wound Matrix
  2. The use of bioengineered skin substitutes is considered not medically necessary when the above criteria are not met.

Ongoing Treatment

  1. Additional 5-8 applications with treatment using bioengineered skin substitutes for the following indications may be considered medically necessary when the following criteria are met:
    1. Application is within 16 weeks of the first application  AND
    2. Measurable decreased size or depth of the ulcer OR
    3. Evidence of tissue granulation, epithelialization or progress towards closure
    4. One of the following products is utilized:
      • Apligraf
      • Oasis Wound Matrix 
  2. The use of bioengineered skin substitutes is considered not medically necessary when the above criteria are not met.

Other indications

  1. The use of bioengineered skin substitutes for breast reconstruction may be considered medically necessary when the following criteria are met:
    1. There is insufficient tissue expander or implant coverage by the pectoralis major muscle and additional coverage is required, AND
    2. There is viable but compromised or thin postmastectomy skin flaps that are at risk of dehiscence or necrosis, OR
    3. The inframammary fold and lateral mammary folds have been undermined during mastectomy and reestablishment of these landmarks is needed. AND
    4. One of the following products is utilized:
      • Allowmax
      • Dermacell 
      • DermaMatrix
      • FlexHD
      • FlexHD Pilable
      • Alloderm  
        OR
    5. Dystrophic epidermolysis bullosa AND
      1. The following product is utilized:
        • OrCel 
    6. Second- or third-degree burns AND
      1. One of the following products is utilized:
        • Epicel  (when the burns comprise a total body surface area of greater than 30%)
        • Integra Dermal Regeneration Template
  2. The use of any other product is considered not medically necessary
  3. The use of bioengineered skin and soft tissue substitutes is not medically necessary for all other indications

 

Medical Policy: III.189 Treatment of Sacroiliac Joint Pain

Effective Date: 8/1/2026
Preauthorization Required: Yes

Will utilize Interqual criteria

 

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