Louisiana Healthcare Connections Policies and Procedures Updates
Date: 01/28/25
Louisiana Healthcare Connections is sharing with providers the below policies and procedures that were developed and/or revised; posted for public comment and approved by LDH in accordance with La. R.S. 46:460.54. Non-material revisions do not require LDH approvals.
Please share this notice with other members of your practice and office staff as necessary.
These guidelines will be implemented 30 days from the date of this notice and will be posted on our Clinical & Payment Policies page.
Policy & Procedure # | Policy & Procedure Title | New, material revisions, non-material revisions |
LA.PP.503c | Respiratory Viral Panels | New |
LA.CP.MP.248 | Facility Based Sleep Studies for Obstructive Sleep Apnea | Material |
LA.CP.MP.100 | Allergy Testing and Therapy | Material |
LA.CP.MP.134 | Evoked Potential Testing | Non-Material |
LA.CP.MP.152 | Measurement of serum 1.25 Vit D | Non-Material |
LA.CP.MP.154 | Thyroid Insulin Tests in Ped | Non-Material |
LA.CP.MP.155 | EEG Headache | Non-Material |
LA.CP.MP.156 | Cardiac Biomarker Testing | Non-Material |
LA.CP.MP.157 | Vitamin D Testing Peds | Non-Material |
LA.CP.MP.38c | Ultrasound in Pregnancy | Non-Material |
LA.CP.MP.143 | Wireless Motility Capsule | Material |
LA.CP.MP.22 | Stereotactic Body Radiation Therapy | Material |
LA.CP.MP.144 | Mechanical Stretch Devices for Joint Stiffness and Contracture | Non-Material |
LA.CP.MP.145 | Electric Tumor Treating Fields | Material |
LA.CP.MP.247 | Transplant Service Documentation Requirements | Non-Material |
LA.CP.MP.107c | Durable Medical Equipment and Orthotics and Prosthetics Guidelines | Material |
LA.CP.BH.521c | Multi-Systemic Therapy (MST) | Material |
LA.PHAR.184 | Aflibercept (Eylea) | Material |
LA.PHAR.58 | Denosumab (Xgeva) | Material |
LA.PHAR.322 | Pembrolizumab (Keytruda) | Material |
LA.PHAR.456 | Fam-trastuzumab deruxtecan-nxki (Enhertu) | Material |
LA.PHAR.384 | Lutetium Lu 177 Dotatate (Lutathera) | Material |
LA.PHAR.310 | Daratumumab Daratumumab-Hyaluronidase-fihj (Darzalex, Darzalex, Faspro) | Material |
LA.PHAR.533 | Ciltacabtagene Autoleucel (Carvykti) | Material |
LA.PHAR.338 | Cerliponase alfa (Brineura) | Material |
LA.PHAR.526 | Fibrinogen concentrate (human) (Fibryga, RiaSTAP) | Material |
LA.PHAR.176 | Paclitaxel protein-bound (Abraxane) | Material |
LA.PHAR.612 | Tremelimumab-actl (Imjudo) | Material |
LA.PHAR.461 | Nadofaragene Firadenovec-vncg (Adstiladrin) | Material |
LA.PHAR.536 | Ophthalmic Riboflavin (Photrexa, Photrexa Viscous) | Material |
LA.PHAR.186 | Ranibizumab (Lucentis, Susvimo), Lucentis Biosimilars | Material |
LA.PHAR.588 | Nivolumab and Relatlimab (Opdualag) | Material |
LA.PHAR.544 | Amivantamab-vmjw (Rybrevant) | Material |
LA.PHAR.303 | Brentuximab Vedotin (Adcetris) | Material |
LA.PHAR.608 | Furosemide (Furoscix) | Material |
LA.PHAR.550 | Vutrisiran (Amvuttra) | Material |
LA.PHAR.582 | Lutetium Lu 177 vipivotide tetraxetan (Pluvicto) | Material |
LA.PHAR.482 | Isatuximab-irfc (Sarclisa) | Material |
LA.PHAR.149 | Baclofen (Fleqsuvy, Gablofen, Lioresal, Lyvispah, Ozobax) | Material |
LA.PHAR.439 | Valrubicin (Valstar) | Material |
LA.PHAR.508 | Tafasitamab-cxix (Monjuvi) | Material |
LA.PHAR.139 | Mogamulizumab-kpkc (Poteligeo) | Material |
LA.PHAR.214 | Desmopressin Acetate (DDAVP) | Material |
LA.PHAR.304 | Irinotecan Liposome (Onivyde) | Material |
LA.PHAR.611 | Teclistamab-cqyv (Tecvayli) | Material |
LA.PHAR.535 | Melphalan Flufenamide (Pepaxto) | Material |
LA.PHAR.151 | Levoleucovorin (Fusilev, Khapzory) | Material |
LA.PHAR.05 | Hyaluronate Derivatives | Material |
LA.PHAR.617 | Mirvetuximab soravatansine-gynx (Elahere) | Non-Material |
LA.PHAR.212 | Clinical Policy: Dornase Alfa (Pulmozyme) | Non-Material |
LA.PHAR.306 | Ofatumumab (Arzerra) | Non-Material |
LA.PHAR.425 | Metreleptin (Myalept) | Non-Material |
LA.PHAR.434 | Bremelanotide (Vyleesi) | Non-Material |
LA.PHAR.469 | Belantamab Mafodotin-blmf (Blenrep) | Non-Material |
LA.PHAR.495 | Mitomycin for Pyelocalyceal Solution (Jelmyto) | Non-Material |
LA.PHAR.575 | Tebentafusp-tebn (Kimmtrak) | Non-Material |
LA.PHAR.613 | LFecal Microbiota, Live-jslm (Rebyota) | Non-Material |
LA.PMN.177 | Glycopyrronium (Qbrexza) | Non-Material |
LA.PHAR.691 | Axatilimab-csfr (Niktimvo) | New |
LA.PHAR.693 | Denileukin Diftitox-cxdl (Lymphir) | New |
LA.PHAR.696 | Palopegteriparatide (Yorvipath) | New |