Directory of Documents - Policy 411

Updated: 12/01/2017

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Addyi 131
Massachusetts Standard Form for Medication Prior Authorization Requests 434
Prior Authorization Form Formulary Exception Form 430
Antihyperlipidemics: A Prescription Drug Therapy Guideline 013
Massachusetts Standard Form for Medication Prior Authorization Requests 434
Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer 055
Asthma and Chronic Obstructive Pulmonary Disease Medication Management 011
Massachusetts Standard Form for Medication Prior Authorization Requests 434
Benign Prostatic Hyperplasia - BPH 040
Bisphosphonate, Oral 058
Botulinum Toxin Injection 006
B-Type Natriuretic Peptide, Natrecor (nesiritide) 031
CNS Stimulants and Psychotherapeutic Agents 019
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications 705
Compound Inclusion List for Pharmacy Medical Policy 579, Compounded Medications 704
Compounded Medications 579
Cox II Inhibitor Drugs: 002
Diabetes Step Therapy 041
Dificid fidaxomicin 700
Dopamine Agonists, non-ergot derived 119
Drugs for Cystic Fibrosis 408
Drugs for Weight Loss 572
Drug Management and Prior Authorization 251
Massachusetts Standard Form for Medication Prior Authorization Requests 434
Duchenne muscular dystrophy (DMD) Medications 027
Epoetin Alpha 262
Fentanyl, oral-transmucosal 113
Follitropin Step Therapy 014
Glucagon-like Peptide-1 - GLP-1 - Receptor Agonists 282
Massachusetts Standard Form for Medication Prior Authorization Requests 434
Growth Hormone and Insulin-like Growth Factor 257
Massachusetts Standard Form for Medication Prior Authorization Requests 434
Hepatitis C Medication Management 344
HETLIOZ tasimelteon 697
Home Total Parenteral Nutrition (TPN) 296
Prior Authorization Form 430
Human Anti-hemophilic Factor: Factor VIII for Hemophilia 360
Prior Authorization Form 430
Injectable Asthma Medications 017
Immune Modulating Drugs 004
Immunomodulators Topical 010
Influenza Drugs 440
See Also Immunizations Redirect Document 132
Interferons Alpha and Gamma  052
Massachusetts Standard Form for Medication Prior Authorization Requests 434
Interleukin-2 (IL-2) 103
Intravenous Immunogammaglobulin (IVIg) 310
Prior Authorization Form 430
Medical and Surgical Management of Obesity including Anorexiants 379
Medicare Part D Coverage Determination Request Form 442
Med UM Drug List 034
Med UM and Pharmacy Prior Authorization  033
Melanoma Vaccines 453
Monitored Anesthesia Care - MAC 154
New Drug Approval Program 005
Non-Covered Drug List 433
Massachusetts Standard Form for Medication Prior Authorization Requests 434
Oncology Drugs 409
Ophthalmic Prostaglandins 346
Opioid and Opioid Combination Medication Management 102
Overactive Bladder Medications 170
Paternal or Fetal Immunotherapy for Recurrent Fetal Loss 387
Phosphodiesterase Type-5 Inhibitors for Pulmonary Arterial Hypertension 036
Pregabalin (Lyrica) 057
Proton Pump Inhibitors 030
Quality Care Dosing - QCD - Guidelines 621
Quality Care Dosing - QCD - Guidelines Drug List 727
Radioimmunotherapy in the Treatment of Non-Hodgkin Lymphoma 146
Restasis - Topical Ocular Hydrating Agents 426
RSV Immunoglobulin: Palivizumab (Synagis™) & RSV-IVIg & RespiGam« ) for Respiratory Syncytial Virus 422
Prior Authorization Form 430
Special Foods: Special Infant Formula, Enteral Formula, Ketogenic Diet for Seizures, and Formula Infusion Pumps 304
Spinal Muscular Atrophy (SMA) Medications 044
Sublingual Immunotherapy with Allergen-specific Pollen Extracts (SLIT) 681
Topical Testosterone 345

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Tests
Clinical Recommendation   Billing Guideline   Benefit Information
Medical Technology Assessment Investigational (Non-Covered) Services List 400
Acoustic Cardiography 537
Actigraphy 533
Alpha-Fetoprotein-L3 for Detection of Hepatocellular Cancer 504
Ambulatory Event Monitors and Mobile Outpatient Cardiac Telemetry 347
Analysis of Human DNA in Stool Samples as a Technique for Colorectal Cancer Screening 557
Analysis of MGMT Promoter Methylation in Malignant Gliomas 587
Analysis of Proteomic Patterns for Early Detection of Cancer 536
Anti-CCP Testing for Rheumatoid Arthritis 142
Antigen Leukocyte Antibody Test 673
Automated Ambulatory Blood Pressure Monitoring for the Diagnosis of Hypertension in Patients with Elevated Office Blood Pressure 206
Automated Point of Care Nerve Conduction Tests 222
Autonomic Nervous System Testing 713
BCR-ABL1 Testing in Chronic Myelogenous Leukemia and Acute Lymphoblastic Leukemia 612
Positron Emission Tomography (PET) Brain 903
Bi-Level Positive Airway Pressure - BPAP Devices 527
Biochemical Markers of Alzheimers Disease 581
Bone Turnover Markers for Diagnosis and Management of Osteoporosis and Diseases Associated with High Bone Turnover 549
BRAF Gene Mutation Testing To Select Melanoma Patients for BRAF Inhibitor Targeted Therapy 398
Breast Duct Endoscopy 493
CA-125 503
Cardiac Computed Tomography (CT) for Quantitative Evaluation of Coronary Calcification 832
Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting 287
Cardiokymography 049
Cardiovascular Risk Panels  664
Carrier Screening for Genetic Diseases 666
Cerebrospinal Fluid and Urinary Biomarkers of Alzheimer Disease 581
Cervicography 630
Chromoendoscopy as an Adjunct to Colonoscopy 904
Chromosomal Microarray Testing for the Evaluation of Early Pregnancy Loss 686
Circulating Tumor DNA and Circulating Tumor Cells for Cancer 797
Computed Tomography (CT) Abdomen 749
Computed Tomography (CT) Abdomen and Pelvis Combination 750
Computed Tomography (CT) Cardiac (Structure) 833
Computed Tomography (CT) Cervical Spine 751
Computed Tomography (CT) Chest 752
Computed Tomography (CT) CT Colonography (Virtual Colonoscopy) 179 
Computed Tomography (CT) Head 753
Computed Tomography (CT) Lower Extremity 754 
Computed Tomography (CT) Lumbar Spine 755
Computed Tomography (CT) Neck for Soft Tissue Evaluation 756 
Computed Tomography (CT) Orbit, Sella Turcica, Posterior Fossa, Temporal Bone, including Mastoids 757
Computed Tomography (CT) Paranasal Sinus & Maxillofacial Area 758
Computed Tomography (CT) Pelvis 791 
Computed Tomography Perfusin Imaging of the Brain 448
Computed Tomography (CT) Thoracic Spine 759
Computed Tomography (CT) Upper Extremity 760 
Computed Tomographic Angiography Coronary Arteries (CCTA) 831
Computer-Aided Evaluation of Malignancy with Magnetic Resonance Imaging of the Breast 578
Computerized 2-lead Resting Electrocardiogram Analysis for the Diagnosis of Coronary Artery Disease 312
Confocal Laser Endomicroscopy 618
Corneal Endothelial Microscopy-Specular Microscopy 050
Corneal Topography, Computer-Assisted Corneal Topography, and Photokeratoscopy 301
CT Angiography (CTA) Abdomen and Pelvis Combination 761
CT Angiography (CTA) Abdominal Aorta and Bilateral Iliofemoral Lower Extremity 762 
CT Angiography (CTA) and MR Angiography (MRA) Abdomen 763 
CT Angiography (CTA) and MR Angiography (MRA) Lower Extremity 764 
CT Angiography (CTA) and MR Angiography (MRA) Pelvis 765 
CT Angiography (CTA) and MR Angiography (MRA) Upper Extremity 766
CT Angiography (CTA) Chest (Non Coronary) 767
CT MR Angiography (CTA MRA) Head Cerebrovascular 768
CT MR Angiography (CTA MRA) Neck 769
Cytochrome p450 Genotyping 256
Detection of Circulating Tumor Cells in the Management of Patients with Cancer 265
Diagnosis and Management of Idiopathic Environmental Intolerance or Clinical Ecology 264
DNA-Based Testing for Adolescent Idiopathic Scoliosis 545
Dopamine Transporter Imaging with Single Photon Emission Computed Tomography - DAT-SPECT 918
Drug Testing in Pain Management and Treatment of Substance Use Disorders 674
Dynamic Posturography To Assess Vestibular Dysfunction 263
Dynamic Spinal Visualization 195
Electrocardiographic Body Surface Mapping 289
Electromagnetic Navigation Bronchoscopy 203
Electromyography and Nerve Conduction Studies 701
Endobrachial Ultrasound for Diagnosis and Staging of Lung Cancer 715
Endovascular Therapies for Extracranial Vertebral Artery Disease 730
Epithelial Cell Cytology in Breast Cancer Risk Assessment and High-Risk Patient Management - Ductal Lavage and Suction Collection Systems 492
Expanded Molecular Panel Testing of Cancers to Identify Targeted Therapies 790 
Fecal Analysis in the Diagnosis of Intestinal Dysbiosis 556
Fecal Calprotectin Testing 329
Fetal MRI 770 
Flow Cytometry for Cell Analysis 341
Functional Magnetic Resonance Imaging (fMRI) Brain 771 
Gene Expression Analysis for Prostate Cancer Management 670
Gene Expression Based Assays for Cancers of Unknown Primary 614
Gene Expression Profiling for Uveal Melanoma 683
Gene Expression Testing in the Evaluation of Patients with Stable Ischemic Heart Disease 349
Gene-Based Tests for Screening, Detection, and Management of Prostate Cancer 333
General Approach to Genetic Testing 735
General Approach to Evaluating the Utility of Genetic Panels 734
Genetic Cancer Susceptibility Panels Using Next Generation Sequencing 574
Genetic Testing for Alpha Thalassemia 520
Genetic Testing for Alpha1- Antitrypsin Deficiency 906
Genetic Testing for Cardiac Ion Channelopathies 082
Genetic Testing for CHARGE Syndrome 540
Genetic Testing for CHEK2 Mutations for Breast Cancer 741
Genetic Testing for Developmental Delay Intellectual Disability, Autism Spectrum Disorder and Congenital Anomalies 228
Genetic Testing for Dilated Cardiomyopathy 601
Genetic Testing for Epilepsy 668
Genetic Testing for Facioscapulohumeral Muscular Dystrophy 535
Genetic Testing for Familial Alzheimers Diseases 580
Genetic Testing for Familial Cutaneous Malignant Melanoma 300
Genetic Testing for Fanconi Anemia 714
Genetic Testing for FLT3 and NPM1 Mutations in Cytogenetically Normal Acute Myeloid Leukemia 693
Genetic Testing for FMR1 mutations - including Fragile X Syndrome 907
Genetic Testing for Germline Mutations of the RET Proto-Oncogene in Medullary Carcinoma of the Thyroid 564
Genetic Testing for Helicobacter Pylori Treatment 288
Genetic Testing for Hereditary Breast and or Ovarian Cancer 245
Genetic Testing for Hereditary Hearing Loss 452
Genetic Testing for Hereditary Hemochromatosis 908
Genetic Testing for Herditary Pancreatitis 516
Genetic Testing for Heterozygous Familial Hypercholesterolemia 796
Genetic Testing for Inherited Thrombophilia 802
Genetic Testing for Lactase Insufficiency 565
Genetic Testig for Li-Fraumeni Syndrome 684
Genetic Testing for Limb-Girdle Muscular Dystrophies 738
Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes 226
Genetic Testing for Lipoprotein-a Variants as a Decision Aid for Aspirin Treatment 339
Genetic Testing for Macular Degeneration 665
Genetic Testing for Mental Health Conditions 669
Genetic Testing for Muscular Dystrophies 828
Genetic Testing for Neurofibromatosis 793 
Genetic Testing for Predisposition to Inherited Hypertrophic Cardiomyopathy 909
Genetic Testing for PTEN Hamartoma Tumor Syndrome 615
Genetic Testing for Rett Syndrome 803
Genetic Testing for Statin-Induced Myopathy 575
Genetic Testing for Tamoxifen Treatment 067
Genetic Testing for the Diagnosis of Inherited Perpheral Neuropathies 569
Genetic Testing for Warfarin Dose 214
Genetic Testing of CADASIL Syndrome 357
Genetic Testing of Mitochondrial Disorders 685
Genotyping for 9p21 Single NucleotidePolymorphisms to Predict Risk of Cardiovascular Disease or Aneurysm 340
Handheld Radiofrequency Spectroscopy for Intraoperative Assessment of Surgical Margins during Breast-Conserving Surgery 546
High-Sensitivity C-Reactive Protein 032
Home Prothrombin Time Monitoring For Anticoagulation 429
Home Uterine Activity Monitoring 043
Human Leukocyte Antigen (HLA) Testing for Celiac Disease 567
Homocysteine Testing in the Screening, Diagnosis, and Management of Cardiovascular Disease and Venous Thromboembolic Disease 016
Identification of Microorganisms Using Nucleic Acid Probe 555
Immune Cell Function Assay in Solid Organ Transplantation 182
Immunochemical Fecal Occult Blood Testing 135
In Vivo Analysis of Colorectal Polyps 521
Ingestible pH and Pressure Capsule 045
Intracellular Micronutrient Analysis 073
Intraoperative Neurophysiologic Monitoring (Sensory-Evoked Potentials, Motor-Evoked Potentials, EEG Monitoring) 211
Invasive Prenatal (Fetal) Diagnostic Testing 708
InVitro Chemoresistance and Chemosensitivity Assays 253
KIF6 Genotyping for Predicting Cadiovascular Risk and or Effectiveness of Statin Therapy 129
KIT (c-KIT) Mutation Analysis 829 
KRAS and BRAF Mutation Analysis in Metastatic Colorectal Cancer 104
Laboratory Testing for HIV Tropism 008
Laboratory and Genetic Testing for Use of 5-Fluorouracil in Patients with Cancer 318
Laboratory Tests for Heart Transplant Rejection 530
Leukocyte Histamine Release Test 589
Magnetic Resonance Imaging (MRI) Abdomen - Cholangiopancreatography (MRCP) Abdomen 773
Magnetic Resonance Imaging (MRI) Bone Marrow Blood Supply 798
Magnetic Resonance Imaging (MRI) Breast 774
Magnetic Resonance Imaging (MRI) Cardiac 835
Magnetic Resonance Imaging (MRI) Cervical Spine 775 
Magnetic Resonance Imaging (MRI) Chest 776 
Magnetic Resonance Imaging (MRI) Head Brain 777 
Magnetic Resonance Imaging (MRI) Lumbar Spine 778 
Magnetic Resonance Imaging (MRI) of the Lower Extremity (Joint & Non-Joint) 779
Magnetic Resonance Imaging MRI, MRA, MRV, MRS 106
Magnetic Resonance Imaging (MRI) Orbit, Face & Neck (Soft Tissues) 780 
Magnetic Resonance Imaging (MRI) Pelvis 781 
Magnetic Resonance Imaging (MRI) Temporomandibular Joint (TMJ) 782
Magnetic Resonance Imaging (MRI) Thoracic Spine 783 
Magnetic Resonance Imaging (MRI) Upper Extremity (Any Joint) 784
Magnetic Resonance Imaging (MRI) Upper Extremity (Non-Joint) 785
Magnetic Resonance Spectroscopy (MRS) 488
Magnetic Resonance Imaging Targeted Biopsy of the Prostate 747
Magnetoencephalography and Magnetic Source Imaging 137
Management of Obstructive Sleep Apnea - OSA Oral Appliances 529
Management of Obstructive Sleep Apnea - OSA using Auto-Titrating Positive Airway Pressure - APAP and Continuous Positive Airway Pressure - CPAP Devices 526
Measurement of Lipoprotein-Associated Phospholipase A2 -Lp-PLA2 - in the Assessment of Cardiovascular Risk 558
Measurement of Serum Antibodies to Infliximab and Adalimumab 917
Medicare Part D Coverage Determination Request Form 442
Microarray-Based Gene Expression Profile Testing for Multiple Myeloma Risk Stratification 477
Mineral Density Studies 450
Miscellaneous Genetic and Molecular Diagnostic Tests 712
Moderate Penetrance Variants Associated With Breast Cancer in Individuals at High Breast Cancer Risk 722
Molecular Analysis for Targeted Therapy of Non-Small Cell Lung Cancer 563
Molecular Testing for the Management of Pancreatic Cysts or Barrett Esophagus 566
Molecular Testing in the Management of Pulmonary Nodules 029
MR Angiography (MRA) Chest 786 
MR Angiography (MRA) Spinal Canal 789 
Multianalyte Assays with Algorithmic Analyses for Predicting Risk of Type 2 Diabetes 654
Multigene Expression Assay for Predicting Recurrence in Colon Cancer 239
Multiple Sleep Latency Testing - MSLT and Maintenance of Wakefulness Testing - MWT 534
Multimarker Serum Testing Related to Ovarian Cancer 249
Multitarget PCR Testing for Diagnosis of Bacterial Vaginosis 711
Myocardial Sympathetic Innervation Imaging in Patients with Heart Failure 576
Nerve Fiber Density Measurement 393
Neurofeedback 515
Neuropsychological Testing 039
Non-BRCA Breast Cancer Risk Assessment - e.g., OncoVue 188
Noninvasive Fractional Flow Reserve Using Computed Tomography Angiography 028
Non-Invasive Vascular Studies - Duplex Scans 691
Noninvasive Prenatal Testing for Trisomy 21 Using Cell-Free Fetal DNA 628
Noninvasive Techniques for the Evaluation and Monitoring of Patients with Chronic Liver Disease 921
Novel Biomarkers in Risk Assessment and Management of Cardiovascular Disease 283
Nuclear Cardiology Cardiac Blood Pool Imaging 830
Nuclear Cardiology Infarct Imaging 834
Nuclear Cardiology Myocardial Perfusion Imaging 836
Nutrient - Nutritional Panel Testing 745
Ophthalmologic Techniques That Evaluate the Posterior Segment for Glaucoma 053
Optical Coherence Tomography of the Anterior Eye Segment 084
Optical Coherence Tomograpy for Imaging of Coronary Arteries 915
Optical Diagnostic Devices for Evaluating Skin Lesions Suspected of Malignancy 519
Paraspinal Surface Electromyography - SEMG - to Evaluate and Monitor Back Pain 517
Partial Left Ventriculectomy 438
Patient Specific Cutting Guides for Knee Arthroplasty 706
PET Scanning in Oncology REDIRECT to 229 335
Pharmacogenomic and Metabolite Markers for Patients Treated with Thiopurines 096
Pharmacogenetic Testing for Pain Management 724
Polysomnography and Home Sleep Testing 525
Positron Emission Tomography (PET) Myocardial Imaging 837 
Positron Emission Tomography, Other PET Applications, Including Oncologic Tumor Imaging 229 
Preimplantation Genetic Testing 088
Preventive Screening Tests (Not a medical policy document) 413
Proteogenomic Testing for Patients With Cancer (GPS CancerTM Test) 838
Proteomic Testing for Targeted Therapy in Non-Small Cell Lung Cancer 709
Psychological Testing 363
Quantitative Assay for Measurement of HER2 Total Protein Expression and HER2 Dimers 397
Quantitative Electroencephalography as a Diagnostic Aid for Attention-Deficit Hyperactivity Disorder 554
Radiofrequency Ablation of Peripheral Nerves to Treat Pain 794 
Radioimmunoscintigraphy Imaging and Monoclonal Antibody Imaging Using In-111 Satumomab Pendetide - OncoScint - or Tc-99m Arcitumomab - IMMU-4, CEA-Scan 638
Radioimmunoscintigraphy Imaging and Monoclonal Antibody Imaging Using Technetium-99m Nofetumomab Merpentan - Verluma 640
Radioimmunoscintigraphy Imaging and Monoclonal Antibody Imaging with Indium-111 Capromab Pendetide for Prostate Cancer 639
REDIRECT to MP 790 637
Retinal Telescreening for Diabetic Retinopathy 065
Rhinomanometry and Acoustic or Optical Rhinometry 586
Saturation Biopsy for Diagnosis and Staging of Prostate Cancer 307
Scintimammography, Breast-Specific Gamma Imaging, and Molecular Breast Imaging 494
Serological Diagnosis of Celiac Disease 138
Serum Antibodies for the Diagnosis of Inflammatory Bowel Disease 551
Serum Biomarker Human Epididymis Protein 4 - HE4 290
Serum Biomarker Panel Testing for Systemic Lupus Erythematosus and Other Connective Tissue Diseases 702
Serum Biomarker Tests for Multiple Sclerosis 676
Serum Holotranscobalamin as a Marker of Vitamin B12 - Cobalamin - Status 561
Serum Tumor Markers for Breast and Gastrointestinal Malignancies 538
Sexual Dysfunction: Diagnosis and Therapy 078
Signal-Averaged Electrocardiography - SAECG 134
ST2 Assay for Chronic Heart Failure 723
Systems Pathology in Prostate Cancer 250
T-Wave Alternans 539
Testing Serum Vitamin D Levels 746
Thermography 342
Tilt Table Testing for Syncope 359
See also Clinical Practice Guideline on TMJ 608
Transrectal Ultrasound of the Prostate 680
Transrectal Ultrasound for Staging Rectal Cancer 679
Tyrosine Kinase Mutations in Myeloproliferative Neoplasms 079
Ultrasonographic Evaluation of Skin Lesions 303
Ultrasonographic Measurement of Carotid Intima-Medial Thickness as an Assessment of Subclinical Atherosclerosis 547
Obstetrical Ultrasound and Ultrasound for Family Planning 007
Ultrasound for the Evaluation of Paranasal Sinuses 445
Urinary Metabolite Tests for Adherence to Direct-Acting Antiviral 742
Urinary Tumor Markers for Bladder Cancer 502
Use of Common Genetic Variants (Single Nucleotide Variants) to Predict Risk of Nonfamilial Breast Cancer 252
Vectra DA Blood Test for Rheumatoid Arthritis 677
Vertebral Fracture Assessment with Densitometry 449
Vestibular Function Testing 024
Virtual Colonoscopy - Computed Tomography Colonography 179
Whole-Body Computed Tomography Scan as a Screening Test 447
Whole Body Dual X-Ray Absorptiometry to Determine Body Composition 577
Whole Exome Sequencing 457
Wireless Capsule Endoscopy as a Diagnostic Technique in Disorders of the Small Bowel, Esophagus, and Colon 185
Wireless Pressure Sensors in Endovascular Aneurysm Repair 306

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Treatments
Clinical Recommendation   Billing Guideline   Benefit Information
Medical Technology Assessment Investigational (Non-Covered) Services List 400
Ablation Procedures for Peripheral Neuromas 719
Accelerated Breast Irradiation and Brachytherapy Boost After Breast-Conserving Surgery for Early Stage Breast Cancer 326
Acute and Maintenance Tocolysis 518
Adoptive Immunotherapy 455
Alcohol Injections for Treatment of Peripheral Neuromas 642
Allogeneic Hematopoietic Cell transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms 155
Ambulance: Advanced Life-Support, Basic Life-Support, Transport to Psychiatric Facility, Air Transport, Two-Tiered Ambulance 273
Amniotic Membrane and Amniotic Fluid 643
Anesthesia (Not a medical policy document) 148
Artificial Intervertebral Disc- Cervical Spine 585
Artificial Intervertebral Disc- Lumbar Spine 592
Assisted Reproductive Services Infertility Services 086
Assisted Reproductive Technology Services Form for Policy #086 Infertility Diagnosis and Treatment 694
Auditory Brainstem Implant 481
Autologous Hematopoietic Stem Cell Transplantation for Malignant Astrocytomas and Glioma 159
Balloon Sinuplasty for Treatment of Chronic Sinusitis 582
Baroreflex Stimulation Devices 595
Benign Skin Lesions 707
Bio-Engineered Skin and Soft Tissue Substitutes 663
Biofeedback as a Treatment of Chronic Pain 210
Biofeedback as a Treatment of Fecal Incontinence or Constipation 308
Biofeedback as a Treatment of Urinary Incontinence 173
Biofeedback for Miscellaneous Indications 187
Biofeedback for the Treatment of Headache 152
Biofeedback: Complementary Medicine, Mind-Body, Alternative, Holistic, Naaturopathic, & Other Therapies 178
Brachytherapy for Clinically Localized Prostate Cancer Using Permanently Implanted Seeds 175
Bronchial Thermoplasty 284
Cardiac Rehabilitation in the Outpatient Setting 916
Carotid, Vertebral and Intracranial Artery Stent Placement with or without Angioplasty 219
Catheter Ablation for Cardiac Arrhythmias 123
Cellular Immunotherapy for Prostate Cancer 268
Charged-Particle - Proton or Helium Ion - Radiation Therapy  437
Chelation Therapy 122
Chemical Peels 732
Cochlear Implant 478
Complementary Medicine: Mind-Body Medicine, Alternative Medicine, Holistic, Naturopathic, and Other Therapies 178
Corneal Collagen Cross-linking 905
Cranial Electrotherapy Stimulation - CES and Auricular Electrostimulation 362
Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate, or Dermatologic Tumors 260
Deep Brain Stimulation 473
Dermatologic Applications of Photodynamic Therapy 463
Diagnosis and Treatment of Chronic Cerebrospinal Venous Insufficiency in Multiple Sclerosis 352
Diagnosis and Treatment of Sacroiliac Joint Pain 320
Donor Lymphocyte Infusion for Malignancies Treated with an Allogeneic Hematopoietic Cell Transplant 338
Dry Needling and Trigger Point Injections for Myofascial Pain 792
Electrical Bone Growth Stimulation of the Appendicular Skeleton 499
Electrical Stimulation for the Treatment of Arthritis 302
Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures 498
Electronic Brachytherapy for Nonmelanoma Skin Cancer 739
Electrostimulation and Electromagnetic Therapy for Treating Wounds 655
End-Diastolic Pneumatic Compression Boot as a Treatment of Peripheral Vascular Disease or Lymphedema 648
Endobronchial Brachytherapy 091
Endometrial Ablation 331
Endoscopic Radiofrequency Ablation or Cryoablation for Barretts Esophagus 218
Endoscopic retrograde cholangiopancreatography - ECRP - with Laser or Electrohydraulic Lithotripsy 209
Endovascular Procedures for Intracranial Arteria Disease - Atherosclerosis and Aneurysms 323
Enhanced External Counterpulsation - EECP - for Chronic Stable Angina or Cogestive Heart Failure 649
Epidural Injections for Back Pain 690
Extracorporeal Photopheresis 248
Eyelid Thermal Pulsation for the Treatment of Dry Eye Syndrome 613
Focal Treatments for Prostate Cancer 733
Functional Neuromuscular Electrical Stimulation 201
Gas Permeable Scleral Contact Lens 371
Genetic Testing for Marfan Syndrome - Thoracic Aortic Aneurysms and Dissections 729
Gastric Electrical Stimulation 636
Hematopoietic Cell Transplantation for Non-Hodgkin Lymphomas 143
Hematopoietic Stem Cell Transplantation for Acute Myeloid Leukemia 150
High-Dose Rate Temporary Prostate Brachytherapy 353
Hippotherapy 560
Hyperbaric Oxygen Therapy 653
Immunizations (Not a medical policy document) 132
Implantable Bone-Conduction and Bone-Anchored Hearing Aids 479
Implantable Minature Telescope - IMT 464
Influenza Drugs: Tamiflu® and Relenza® 440
See also Immunizations (Not a medical policy document)

132

Inhaled Nitric Oxide as a Treatment of Hypoxic Respiratory Failure 100
Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence 471
Injections for Osteoarthritis 427
Insulin Potentiation Therapy 532
Intensity-Modulated Radiation Therapy - IMRT - Abdomen and Pelvis 165
Intensity-Modulated Radiation Therapy - IMRT - Cancer of the Head and Neck or Thyroid 164
Intensity Modulated Radiation Therapy - IMRT - Central Nervous System Tumors 910
Intensity-Modulated Radiation Therapy - IMRT - of the Breast and Lung 163
Intensity Modulated Radiation Therapy - IMRT - of the Prostate 090
Interferential Stimulation for Treatment of Pain 509
Interventions for Progressive Scoliosis 550
Intracavitary Balloon Catheter Brain Brachytherapy for Malignant Gliomas or Metastasis to the Brain 602
Intraocular Radiation Therapy for Age-Related Macular Degeneration 610
Intraoperative Radiation Therapy, Selective Internal Radiation Therapy (also see 277 for stereotactic radiosurgery) 278
Intravascular Brachytherapy for Preventing and Managing Restenosis after Percutaneous Transluminal Angioplasty - PTA 650
Intravenous Anesthetics for the Treatment of Chronic Pain 291
Intravenous Antibiotic Therapy and Associated Diagnostic Testing for Lyme Disease 171
Intravitreal Angiogenesis Inhibitors for Choroidal Vascular Conditions 343
Intravitreal Angiogenesis Inhibitors for Retinal Vascular Conditions 401
Intravitreal Corticosteroid Implants 272
Iontophoresis and Phonophoresis as a Transdermal Technique for Drug Delivery 095
Isolated Limb Perfusion or Infusion for Malignant Melanoma 124
Laparoscopic and Percutaneous Techniques for the Myolysis of Uterine Fibroids 244
Laser Treatment of Onychomycosis 562
Left-Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation 334
Light Therapy for Psoriasis 698
Lipid Apheresis 465
Low-Level Laser Therapy 522
Lysis of Epidural Adhesions 598
Magnetic Esophageal Sphincter Augmentation to Treat Gastroesophageal Reflux Disease 920
Manipulation under Anesthesia 483
Measurement of Exhaled Nitric Oxide and Exhaled Breath Condensate in the Diagnosis and Management of Respiratory Disorders 524
Mechanical Embolectomy for Treatment of Acute Stroke 184
Medical and Surgical Management of Obesity including Anorexiants 379
Melanoma Vaccines 453
Methadone Treatment and Intensive Detoxification or Ultra-Rapid Detoxification for Opiate Addiction 274
Microwave Tumor Ablation 912
Monitored Anesthesia Care (MAC) during Gastrointestinal Endoscopy 154
MRI-Guided Focused Ultrasound - MRgFUS 243
Navigated Transcranial Magnetic Stimulation 596
Negative Pressure Wound Therapy in the Outpatient Setting 543
Neural Therapy 914
Noncontact Ultrasound Treatment for Wounds 657
Noncontact Radiant Heat Bandage for the Treatment of Wounds 656
Noninvasive Fetal RHD Genotyping Using Cell-Free Fetal DNA 667
Occipital Nerve Stimulation 237
Occlusion of Uterine Arteries Using Transcatheter Embolization 242
Oncologic Applications of Photodynamic Therapy, Including Barretts Esophagus 454
Orthopedic Applications of Platelet-Rich Plasma 737
Orthopedic Applications of Stem Cell Therapy 254
Orthoptic Training for the Treatment of Vision or Learning Disabilities 611
Outpatient Cardiac Rehabilitation 060
Outpatient Cognitive Rehabilitation 660
Outpatient Electroconvulsive Therapy 319
Outpatient Psychotherapy 423
Outpatient Pulmonary Rehabilitation 136
Ovarian and Internal Iliac Vein Embolization as a Treatment of Pelvic Congestion Syndrome 266
Paternal or Fetal Immunotherapy for Recurrent Fetal Loss 387
Patient-Specific Cutting Guides for Knee Arthroplasty 706
Pelvic Floor Stimulation as a Treatment of Urinary Incontinence and Fecal Incontinence 470
Percutaneous Balloon Kyphoplasty and Mechanical Vertebral Augmentation 485
Percutaneous Electrical Nerve Stimulation - PENS - and Percutaneous Neuromodulation Therapy - PNT 172
Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, and Biacuplasty 482
Percutaneous Transluminal Angioplasty (PTA) for non-cardiac vessels 077
Percutaneous Vertebroplasty and Sacroplasty 484
Peripheral Subcutaneous Field Stimulation 513
PET Scanning in Oncology REDIRECT to 229 335
Photocoagulaton of Macular Drusen 607
Photodynamic Therapy for Choroidal Neovascularization 599
Phototherapeutic Kertectomy 597
Phototherapy 059
Phototherapy Light for the Treatment of Seasonal Affective - SAD - and Other Depressive Disorders 037
Placental or Umbilical Cord Blood as a Source of Stem Cells 285
Plasma Exchange 466
Plugs for Fistula Repair 528
Percutaneous Tibial Nerve Stimulation for Voiding Dysfunction 583
Preauthorization Request Form for 379 Surgical Management of Obesity Policy 047
Progenitor Cell Therapy for the Treatment of Damaged Myocardium Due to Ischemia 652
Prolotherapy, Joint Sclerotherapy and Ligamentous Injections with Sclerosing Agents 183
Prostatic Urethral Lift 744
Quantitative Sensory Testing 258
Radioactive Seed Localization of Nonpalpable Breast Lesions 469
Radioembolization for Primary and Metastatic Tumors of the Liver 292
Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors 259
Radiofrequency Ablation of Primary or Metastatic Liver Tumors 286
Radiofrequency Ablation of the Renal Sympathetic Nerves as a Treatment for Resistant Hypertension 919
Repetitive Transcranial Magnetic Stimulation - rTMS 297
Request for Clinical Exception to BCBSMA Charged Particle - Proton Beam - Policy and Notification 678
Request for Clinical Exception to BCBSMA Intensity Modulated Radiation Therapy (IMRT) Policy and Notification 325
Responsive Neurostimulation for the Treatment of Refractory Partial Epilepsy 716
Routine Foot Care and Debridement of Toenails 385
Sacral Nerve Neuromodulation and Stimulation 153
Semi-Implantable and Fully Implantable Middle Ear Hearing Aid 480
Sensory Integration Therapy 659
Sexual Dysfunction: Diagnosis and Therapy 078
Skin Contact Monochromatic Infrared Energy as a Technique to Treat Cutaneous Ulcers, Diabetic Neuropathy, and Miscellaneous Musculoskeletal Conditions 507
Sphenopalatine Ganglion Block for Headache 026
Spinal Cord and Dorsal Root Ganglion Stimulation 472
Stem-cell Therapy for Peripheral Arterial Disease 348
Stereotactic Radiosurgery and Stereotactic Body Radiotherapy 277
Suprachoroidal Delivery of Pharmacologic Agents 609
Surgical Ventricular Restoration 544
Temporomandibular Joint Dysfunction 035
Outpatient Cardiac Rehabilitation (Not a medical policy document) 060
Therapies Physical, Occupational and Speech 215
Thermal Capsulorrhaphy as a Treatment of Joint Instability 591
Threshold Electrical Stimulation as a Treatment of Motor Disorders 321
See also Clinical Practice Guideline on TMJ 608
Transanal Radiofrequency Treatment of Fecal Incontinence 309
Transcatheter Arterial Chemoembolization - TACE - to Treat Primary or Metastatic Liver Malignancies 634
Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease 635
Transmyocardial Revascularization 651
Transpupillary Thermotherapy for Treatment of Choroidal Neovascularization 600
Transtympanic Micropressure Applications as a Treatment of Menieres Disease 508
Transvaginal and Transurethral Radiofrequency Tissue Remodeling for Urinary Stress Incontinence 523
Treatment of Tinnitus 267
Treatment of Varicose Veins and Venous Insufficiency 238
Tumor Markers for Diagnosis and Management of Cancer 167
Tumor-Treatment Fields Therapy for Glioblastoma 514
Ultrafiltration in Decompensated Heart Failure 542
Vagus Nerve Blocking Therapy for Treatment of Obesity 644
Vagus Nerve Stimulation 474
Vertebral Axial Decompression 603
Vision Services 675

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Devices & Equipment
Clinical Recommendation   Billing Guideline   Benefit Information
Medical Technology Assessment Investigational (Non-Covered) Services List 400
Ambulance: Advanced Life-Support, Basic Life-Support, Transport to Psychiatric Facility, Air Transport, Two-Tiered Ambulance (Not a medical policy document) 273
Artificial Pancreas Device Systems 720
Automated Ambulatory Blood Pressure Monitoring for the Diagnosis of Hypertension in Patients with Elevated Office Blood Pressure 206
Bioimpedance Devices for the Detection of Lymphedema 261
Biventricular Pacemakers - Cardiac Resynchronization Therapy for the Treatment of Heart Failure 101
Computer-Assisted Navigation Orthopedic Procedure 594
Continuous or Intermittent Monitoring of Glucose in Interstitial Fluid 107
Continuous Passive Motion in the Home Setting 407
Cooling Devices Used in the Outpatient Setting 510
Diabetic Supplies: Glucometers and Supplies 202
Diaphragm Pacing Stimulation 593
Esophageal pH Monitoring 069
Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions 081
Home Cardiorespiratory Monitoring 224
Home Prothrombin Time Monitoring 429
Home Uterine Activity Monitoring 043
Insulin Delivery Devices: Pumps, Pens, and Jet Injectors 332
Microprocessor Controlled Prostheses for the Lower Limb 133
Multispectral Digital Skin Lesion Analysis 748
Myoelectric Prosthetic Components for the Upper Limb 227
Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Disorders 120
Patient-Actuated End Range Motion Stretching Devices 721
Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers 354
Postsurgical Outpatient Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis 541
Powered Exoskeleton for Ambulation in Patients with Lower Limb Disabilities 718
Retinal Prosthesis 606
Sexual Dysfunction: Diagnosis and Therapy 078
Total Artificial Hearts and Implantable Ventricular Assist Devices 280
Transcutaneous Electrical Nerve Stimulation 003
Ultrasound Accelerated Fracture Healing Device 497
Wearable Cardioverter Defibrillators 042
Wheelchairs (Not a medical policy document) 276

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Surgeries
Clinical RecommendationBilling GuidelineBenefit Information
Medical Technology Assessment Investigational (Non-Covered) Services List 400
Adrenal-to-Brain Transplantation 627
Allogeneic Hematopoietic Cell Transplantation for Genetic Diseases and Acquired Anemias 190
Allogeneic Pancreas Transplant 328
Ambulatory Surgical Procedures (Not a medical policy document) 389
Aqueous Shunts and Stents for Glaucoma 223
Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions 111
Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions 374
Automated Percutaneous and Percutaneous Endoscopic Discectomy 231
Axial Lumbosacral Interbody Fusion 404
Blepharoplasty, Blepharoptosis repair, and Brow ptosis repair 740
Bone Morphogenetic Protein 097
Bronchial Valves 313
Catheter Ablation as Treatment for Atrial Fibrillation 141
Catheter Ablation of Arrhythmogenic Foci 123
Closure Devices for Patent Foramen Ovale and Artial Septal Defects 121
Composite Tissue Allotransplantation of the Hand and Face 662
Cryoablation of the Prostate 149
Cryosurgical Ablation of Primary or Metastatic Liver Tumors 633
Cytoreductive and Hyperthermic Intraperitoneal Chemotherapy 048
Decompression of the Intervertebral Disc Using Laser Energy - Laser Discectomy - or Radiofrequency Coblation - Nucleoplasty 271
Embryonic Mesencephalic Transplantation for the Treatment of Parkinsons Disease 625
Endometrial Ablation 331
Endothelial Keratoplasty 180
Endovascular Grafts for Abdominal Aortic Aneurysms 098
Endovascular Stent Grafts for Disorders of the Thoracic Aorta 233
Extracorporeal Membrane Oxygenation 726
Facet Arthroplasty 174
Facet Joint Denervation 140
Heart Transplant 197
Heart/Lung Transplant 269
Hematopoietic Cell Transplantation for Autoimmune Diseases 192
Hematopoietic Cell Transplantation for Chronic Lymphocytic Leukemia and Small Lymphocytic Lymphoma 074
Hematopoietic Cell Transplantation for CNS Embryonal Tumors and Ependymoma 205
Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia 212
Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer 204
Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors in Adults 191
Hematopoietic Cell Transplantation for Primary Amyloidosis 181
Hematopoietic Cell Transplantation for Solid Tumors of Childhood 208
Hematopoietic Cell Transplantation in the Treatment of Germ-Cell Tumors 247
Hematopoietic Stem Cell Transplantation for Acute Lymphoblastic Leukemia 076
Hematopoietic Cell Transplantation for Hodgkin Lymphoma 207
Hematopoietic Stem Cell Transplantation for Plasma Cell Dyscracias, Including Multiple Myeloma and POEMS Syndrome 075
Hematopoietic Stem-Cell Transplantation for Waldenstrom Macroglobutinemia 322
Hip Resurfacing 046
Image-Guided Minimally Invasive Decompression for Spinal Stenosis 240
Implantable Cardioverter Defibrillator 070
Implantable Sinus Stents for Postoperative Use Following Endoscopic Sinus Surgery and Recurrent Sinus Disease 800
Implantation of Intrastromal Corneal Ring Segments 235
Interspinous Fixation - Fusion Devices 436
Interspinous and Interlaminar Stabilization Distraction Devices - Spacers 584
Islet Transplantation 324
Isolated Small Bowel Transplant 631
Keratoprosthesis 221
Kidney Transplant 196
Liver Transplantation 198
Lung and Lobar Lung Transplant 015
Lung Volume Reduction Surgery for Severe Emphysema 364
Medical and Surgical Management of Obesity including Anorexiants 379
Meniscal Allografts and Other Meniscal Implants 110
Minimally Invasive Coronary Artery Bypass Graft Surgery 553
Nerve Graft in Association with Radical Prostatectomy 590
Obstetrical Services: Global OB Allowance (Not a medical policy document) 255
Open and Thoracoscopic Approaches to Treat Atrial Fibrillation - Maze and Related Procedures 356
Partial Left Ventriculectomy: The Batista Procedure 438
Penile Revascularization: Surgery for Vasculogenic (See Sexual Dysfunction Diagnosis & Therapy under Treatments) 078
Peroral Endoscopic Myotomy for Treatment of Esophageal Achalasia 451
Plastic Surgery: Reconstructive, Restorative, and Cosmetic Services 068
Preauthorization Request Form for 379 Surgical Management of Obesity Policy 047
Reconstructive Breast Surgery-Management of Breast Implants 428
Reduction Mammaplasty for Breast-Related Symptoms 703
Reverse Shoulder Arthroplasty 161
Sexual Dysfunction: Diagnosis and Therapy 078
Shoulder Resurfacing 156
Small Bowel, Liver, and Multivisceral Transplant 632
Stereotactic Radiofrequency Pallidotomy for the Treatment of Parkinsons Disease 626
Stereotactic Radiosurgery and Stereotactic Body Radiotherapy 277
Subtalar Arthroereisis 299
Surgery for Athletic Pubalgia 695
Surgical Deactivation of Headache Trigger Sites 801
Surgical Interruption of Pelvic Nerve Pathways for Primary and Secondary Dysmenorrhea 570
Surgical Treatment of Femoroacetabular Impingement 145
Surgical Treatment of Gynecomastia 661
Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome 130
Thoracoscopic Laser Ablation of Emphysematous Pulmonary Bullae 275
Total Ankle Replacement 193
Transanal Endoscopic Microsurgery 200
Transcatheter Aortic-Valve Implantation for Aortic Stenosis 392
Transcatheter Mitral Valve Repair 692
Transcatheter Pulmonary Valve Implantation 403
Transgender Services 189
Treatment of Hyperhidrosis excluding Botulinum Toxin 406
Vertical Expandable Prosthetic Titanium Rib 305
Viscocanalostomy and Canaloplasty 372

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Clinical Practice Guidelines
TMJ Disorders Clinical Practice Guideline 608
See also Medical Policy On TMJ Treatments 035

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Other Information
Applied Behavioral Analysis Service Request Form 144
AudioHealth Library 506
Back School 743
 Directory of Documents (This Document) 411
E-Blue Review - for Physicians to comment on Medical Policy 500
Fecal Microbiota Transplantation 682
Garments 158
Medical Policy Review Schedule 501
Medical Technology Assessment Guidelines 350
Prior Authorization Requirements, Limitations, and Medical Necessity Review 998
Prior Authorization Instruction Manual 023
Request for Clinical Exception to BCBSMA Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy - SBRT - Policy 922

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New Category
Clinical Recommendation   Billing Guideline   Benefit Information
Medical Technology Assessment Investigational (Non-Covered) Services List 400

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This document is designed for informational purposes only and is not an authorization, or an explanation of benefits, or a contract. Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage. Medical technology is constantly changing, and we reserve the right to review and update our policies periodically.

¨2006 Blue Cross and Blue Shield of Massachusetts, Inc.  All rights reserved.  Blue Cross and Blue Shield of Massachusetts, Inc. is an Independent Licensee of the Blue Cross and Blue Shield Association.