Pompe Disease Drug-Specific Eligibility & Continuation Criteria — Mar 2026

Effective 03/01/2026 Blue Cross Blue Shield of Louisiana consolidated and clarified agent-specific initial and continuation criteria for enzyme replacement and adjunctive therapies for Pompe disease (Policy #00771). The update lists distinct eligibility, baseline testing (percent predicted FVC and 6MWT), age/weight limits, and objective response thresholds for alglucosidase alfa (Lumizyme), avalglucosidase alfa-ngpt (Nexviazyme), cipaglucosidase alfa-atga (Pombiliti), and miglustat (Opfolda), and prohibits certain concurrent combinations. Continuation requires documented stabilization or improvement versus pretreatment baselines with numeric ambulation/FVC/ventilation limits; several criteria are explicitly labeled as Company requirements and will be denied if unmet. Diagnostic confirmation by GAA enzyme assay or genetic testing and trial context for infantile-onset disease are reiterated to support coverage decisions.

Intracoronary Drug Delivery Balloon Policy (7.01.97) Open for Review — Feedback by Mar 5, 2026

Premera-Blue Cross has listed policy 7.01.97, “Intracoronary Drug Delivery Balloon Procedures,” among multiple policies open for stakeholder feedback with a submission deadline of March 5, 2026. The notice is an index entry only and contains no coverage criteria, coding guidance, prior authorization rules, or clinical details for intracoronary drug delivery balloons. This listing reflects inclusion in a broader review cycle alongside many other medical and surgical policies, not a specific substantive policy change. No contact, submission instructions, effective date, or indication of whether this is a new, revised, or reissued policy are provided in the excerpt.

Combined Procedure Allowance: Consolidated Perioperative CV Risk Criteria (Mar 2026)

Premera-bluecross’s March 2026 revision consolidates explicit perioperative risk criteria that can justify combining procedures for patients with obstructive sleep apnea (OSA) when medically necessary. Cardiovascular risk examples now called out include NYHA III–IV heart failure, recent MI or stroke (<3 months), uncontrolled or resistant hypertension, recent coronary interventions (e.g., DES <1 year, angioplasty <90 days), symptomatic arrhythmias despite treatment, and significant valvular disease. These cardiovascular items are grouped with anesthesia, liver (e.g., MELD >8), and pulmonary (e.g., COPD FEV1 <50%, poorly controlled asthma) risks to guide operative planning. The policy reiterates definitions of clinically significant OSA (adult AHI/RDI ≥15 or ≥5 with symptoms; pediatric thresholds lower) and reaffirms CPAP as first‑line therapy and rationale for hypoglossal nerve stimulation.

MDC 05 Update: Clarified MCT/ILR and CardioMEMS Criteria; Added References

Effective 03/01/2026, Baylor Scott & White Health Plan updated MDC 05 (Cardiology & Vascular) to add references and document ongoing annual review with next review due 02/26/2027. The policy clarifies coverage criteria: external loop recorders and MCT (e.g., Ziopatch®, CardioNet MCOT) are medically necessary for specified arrhythmia evaluations after nondiagnostic Holter or when symptoms are infrequent, and MCT is required to document absence of atrial fibrillation before stopping anticoagulation. Implantable loop recorders are covered when noninvasive monitoring (MCT or two 30‑day ELRs) fails and a dysrhythmia is suspected; CardioMEMS™ PAP monitoring is covered for select NYHA class III patients meeting strict clinical and anatomical criteria. Multiple consumer ECG products, alternative implantable HF monitors, pulse tachometers, and several named devices are designated investigational or not covered. The policy cites systematic reviews, trials, guideline statements, and HTAs to support coverage distinctions between CardioMEMS and other telemonitoring or consumer devices.

Clarified Endovascular Criteria for Claudication, CLTI — Effective Mar 1, 2026

Effective March 1, 2026 UnitedHealthcare clarifies coverage for endovascular revascularization of lower-extremity ischemia: procedures are covered for lifestyle‑limiting Claudication only when documented impaired ADLs/work, failure of ≥12 weeks supervised or structured exercise plus guideline‑directed medical therapy and smoking cessation, and objective hemodynamic/imaging evidence (ABI ≤0.90 and ≥50% stenosis on duplex or confirmatory CTA/MRA/angiography). Retreatment for in‑stent restenosis is covered when recurrent symptoms and imaging-confirmed ≥50% stenosis are present. Endovascular treatment for CLTI remains covered as limb‑threatening care. The policy lists several unproven/not‑medically‑necessary indications (eg, non‑limb‑threatening infrapopliteal interventions, asymptomatic disease, procedures solely to prevent progression, iliac atherectomy, treatment of nonviable limbs, and endovenous femoropopliteal bypass with stent graft) and cites current guideline and trial evidence supporting these distinctions.

UHC NJ: Ovarian/Internal Iliac Vein Embolization for PCS—Not Medically Necessary (Mar 2026)

UnitedHealthcare NJ (effective March 1, 2026) now classifies embolization of the ovarian or internal iliac veins for Pelvic Congestion Syndrome as unproven and not medically necessary due to insufficient evidence of efficacy. The policy cites mostly low-quality, heterogeneous studies and systematic reviews through 2025 that report symptom improvement but are limited by retrospective designs, small cohorts, inconsistent outcome measures, variable follow-up, and heterogeneous techniques. Recent single-center data suggesting symptom benefit are tempered by concerns about potential harm to ovarian reserve (decreased AMH) and variable recurrence and complication rates. The insurer cites conflicting guideline guidance and calls for randomized, multicenter, longer-term studies before changing coverage.

Premera: Rezdiffra (resmetirom) Added for MASH; Dosing, Specialist Prescriber, and PBC Criteria

Premera‑Blue Cross updated MDC 05 to incorporate FDA approval of Rezdiffra (resmetirom) for MASH (approved March 14, 2024) and limits dosing to 100 mg daily. Rezdiffra must be prescribed by or in consultation with an endocrinologist, gastroenterologist, or hepatologist; non‑formulary exception approvals may be granted up to 12 months for initial authorization. The policy designates Iqirvo (elafibranor), Livdelzi (seladelpar), and Rezdiffra as investigational when used outside the policy’s specified indications and ties coverage to FDA dosing/labeling. It also aligns PBC coverage with cardiometabolic management: age ≥30, exclude Wilson disease and cirrhosis (F4), require A1c <9% if type 2 diabetes, BMI ≥30 requires documented diet and activity, and concurrent treatment of CVD, diabetes, dyslipidemia, and hypertension is expected.

Cigna (6/15/26): Atrial Overdrive Pacing Not Supported for OSA

Effective June 15, 2026, Cigna policy concludes there is insufficient evidence to support atrial overdrive pacing as a treatment for obstructive sleep apnea (OSA). The update distinguishes that while some cardiac pacing modalities, notably cardiac resynchronization therapy, have reduced apneic events in central sleep apnea, atrial overdrive pacing has not demonstrated consistent efficacy for OSA in systematic reviews and randomized trials. The policy cites Anastasopoulos et al. (2016), Weng et al. (2009), and ACCF/AHA/HRS guidance (Epstein et al., 2013) to justify the determination. A health equity note reiterates OSA disparities—particularly greater severity and underdiagnosis in Black men—while not linking these directly to pacing therapy.

CAR T‑Cell Cardiac Eligibility & Cardiotoxicity Findings — Mar 2026

UnitedHealthcare’s March 2026 CAR T‑cell guideline update emphasizes cardiac eligibility criteria and observed cardiotoxicity in clinical trials and real‑world cohorts. Trials used varying LVEF exclusion thresholds (Yescarta <50%, Kymriah <45%, Breyanzi cohorts with <40–50% exclusions), underscoring heterogeneity in cardiac selection. A retrospective cohort (Alvi et al., 2019) found 12% cardiac event rate, troponin elevations common, and all events occurred with grade ≥2 CRS; each 12‑hour delay to tocilizumab was linked to a 1.7‑fold higher cardiovascular risk. The guideline notes evidence gaps around routine troponin monitoring and whether earlier CRS intervention reduces cardiac events.

Cigna 4/15/2026: Multiple Cardiac Category III CPT Codes Marked Experimental

Effective 4/15/2026, Cigna updated Medical Coverage Policy 0558 (MDC 05: Cardiology & Vascular) to designate a broad set of Category III CPT codes as Experimental/Investigational/Unproven, including cardiovascular-specific codes such as 0439T (myocardial contrast perfusion echocardiography) and 0525T (intracardiac ischemia monitoring system insertion/replacement). The revision lists multiple transcatheter and intracardiac procedures (for example, 0338T/0339T renal denervation, 0644T intracardiac mass debulking, 0659T intracoronary supersaturated oxygen) with procedural descriptions highlighting imaging and device components. Related Coverage Resources were updated to cross-reference other Cigna and eviCore policies (ambulatory external/implantable ECG monitoring, adult/pediatric cardiac imaging, transcatheter heart valve procedures), and the policy notes that some Category III codes are treated as medically necessary in other Cigna or eviCore resources. Providers should review the effective-dated list before billing or requesting authorization for these Category III services given the experimental/unproven designation.