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 February 2026

Updated Medical Policies

Medical Policy: I.91 Cardiac Hemodynamic Monitoring in the Management of Heart Failure (requires preauthorization)

Effective Date: 6/1/2026
Preauthorization Required: Yes

Policy

  1. In the ambulatory care and outpatient setting, cardiac hemodynamic monitoring for the management of heart failure using implantable direct pressure monitoring of the pulmonary artery, thoracic bioimpedance, inert gas rebreathing, and arterial pressure during the Valsalva maneuver is considered investigational.


New Medical Policy

Medical Policy: III.275 Image Guided Minimally Invasive Decompression for Spinal Stenosis (requires preauthorization)
Effective Date: 6/1/2026
Preauthorization Required: Yes

Policy

  1. Image-guided minimally invasive spinal decompression is considered investigational.

Codes: 

62330 - Decompression, percutaneous, with partial removal of the ligamentum flavum, including laminotomy for access, epidurography, and imaging guidance (i.e., CT or fluoroscopy), bilateral; one interspace, lumbar
62331 - Decompression, percutaneous, with partial removal of the ligamentum flavum, including laminotomy for access, epidurography, and imaging guidance (i.e., CT or fluoroscopy), bilateral; additional interspace(s), lumbar 
G0276 - Blinded procedure for lumbar stenosis, percutaneous image-guided lumbar decompression (pild) or placebo-control, performed in an approved coverage with evidence 
development (ced) clinical trial

Medical Policy: Intracameral Implants (requires preauthorization)
Effective Date: 6/1/2026
Preauthorization Required: Yes
  1. One-time intracameral injection (bimatoprost (Durysta)) may be scientifically validated for the reduction of intraocular pressure (IOP) in members with open angle glaucoma or ocular hypertension (OHT) when ALL the following criteria are met:
    1. The patient is 18 years of age and older, AND
    2. The patient has tried and failed or has intolerance to at least one topical ophthalmic prostaglandin (e.g., bimatoprost, lantanoprost, travaprost) AND
    3. The patient has tried and failed or has intolerance or contraindication to at least one topical beta-adrenergic blocker (betaxolol, metipranolol, timolol), AND
    4. The injection or implant will only be administered to the affected eye AND
    5. The affected eye has not received prior treatment with bimatoprost (Durysta) AND
    6. The dose does not exceed 10 mcg bimatoprost per affected eye. 
  2. One-time intracameral implant (travoprost (iDose TR) may be scientifically validated for the reduction of intraocular pressure (IOP) in members with open angle glaucoma or ocular hypertension (OHT) when ALL the following criteria are met: 
    1. The patient is 18 years of age and older AND
    2. The patient has tried and failed or has intolerance to at least one topical ophthalmic prostaglandin (e.g., bimatoprost, lantanoprost, travaprost) AND
    3. The patient has tried and failed or has intolerance or contraindication to at least one topical beta-adrenergic blocker (betaxolol, metipranolol, timolol)
    4. The injection or implant will only be administered to the affected eye AND
    5. The affected eye has not received prior treatment with travoprost (iDose TR)
    6. The dose does not exceed 75 mcg travoprost (iDose TR) per affected eye. 
  3. When the above criteria are not met, services are considered investigational.
  4. All other indications are considered investigational.
Medical Policy: I.218 Remote Electrical Neuromodulation for Migraines (requires preauthorization)
Effective Date: 6/1/2026
Preauthorization Required: Yes

Initiation of Use

  1. Remote electrical neuromodulation (REN [e.g. Nerivio]) for the prevention and management of migraine may be considered medically necessary in individuals when the following criteria are met:
    1. Individual is 18 years of age or older; AND
    2. Headaches meet the International Classification of Headache Disorders (ICHD-3) diagnostic criteria for migraine with or without aura (see Policy Guidelines); AND
    3. The REN device will be used in the following clinical scenario:
      For the prevention and management of migraine in individuals with 6 to 24 headache 
      days (defined as a calendar day with headache regardless of severity or duration) per 28-day period in each of the 3 months preceding use of the REN device); AND
    4. One of the following additional criteria must also be met:
      1. Insufficient response, contraindication, or intolerance to 2 or more guideline-recommended preventive headache medications (e.g., anticonvulsants, antihypertensives, antidepressants, CGRP inhibitors); OR
      2. Pregnancy, breastfeeding, or planning to conceive; OR
      3. At risk for or have a history of medication overuse headache; OR
      4. At risk for drug-drug interactions with medications for comorbid conditions.
  2. Remote electrical neuromodulation for prevention AND MANAGEMENT of migraine outside of the above criteria is considered investigational (see Policy Guidelines Considerations).

Preventive treatment: Continuation of Use

  1. Continued use of the REN device and/or accessories for the prevention and management of migraine is considered medically necessary in individuals when the following criteria are met:
    1. Compliance with ongoing use; AND
    2. Documentation of clinical benefit (see Policy Guidelines).

Policy Guidelines
Remote Electrical Neuromodulation Contraindications
Nerivio is contraindicated in patients with uncontrolled epilepsy and patients with an active implantable medical device, such as a pacemaker, hearing aid implant, or any implanted electronic device. Nerivio has not been evaluated in patients with congestive heart failure, severe cardiac or cerebrovascular disease, pregnancy, or patients under the age of 8 years.

Code: A4540 - Distal transcutaneous electrical nerve stimulator, stimulates peripheral nerves of the upper arm

 
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