Directory of Documents - Policy 411

Updated: 04/24/2019

 

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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
Anti-Parkinsonism Drugs 054
Massachusetts Standard Form for Medication Prior Authorization Requests 434
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 SP 006
B-Type Natriuretic Peptide, Natrecor (nesiritide) 031
Calcitonin Gene-Related Peptide 021
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:

014

Diabetes Step Therapy 041
Dificid fidaxomicin 700
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
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
Human Anti hemophilic Factor 360
Prior Authorization Form 430
Prior Authorization Form 430
Injectable Asthma Medications 017
Immune Modulating Drugs 004
Immunomodulators for Skin Conditions 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 and Lyrica CR) 057
Proton Pump Inhibitors 030
Quality Care Dosing - QCD - Guidelines 621
Quality Care Dosing - QCD - Guidelines Drug List 727
Restasis - Topical Ocular Hydrating Agents 426
Retail Pharmacy Prior Authorization Policy 049
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 Extracts (SLIT) 681
Topical Testosterone 345
Specialty Pharmacy List 051

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Tests
Clinical Recommendation   Billing Guideline   Benefit Information
Medical Technology Assessment Investigational (Non-Covered) Services List 400
Actigraphy 533
AIM Non-Oncologic Imaging of the Abdomen and Pelvis 961
AIM Non-Oncologic Imaging of the Brain 962
AIM Non-Oncologic Imaging of the Chest 963
AIM Non-Oncologic Imaging of the Extremities 964
AIM Non-Oncologic Imaging of the Head and Neck 965
AIM Non-Oncologic Imaging of the Spine 966
AIM Non-Oncologic Vascular Imaging 967
AIM Oncologic Imaging 960
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 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
Bi-Level Positive Airway Pressure - BPAP Devices 527
Biochemical Markers of Alzheimers Disease 581
Biomarkers for Diagnosis & Cancer Risk Assessment of Prostate Cancer 336
Bone Turnover Markers for Diagnosis and Management of Osteoporosis and Diseases Associated with High Bone Turnover 549
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
Cardiovascular Risk Panels  664
Cerebrospinal Fluid and Urinary Biomarkers of Alzheimer Disease 581
Chromoendoscopy as an Adjunct to Colonoscopy 904
Computed Tomography (CT) Cardiac (Structure) 833
Computed Tomography Perfusin Imaging of the Brain 448
Computer Aided Evaluation as an Adjunct to Magnetic Resonance Imaging of the Breast 578
Confocal Laser Endomicroscopy 618
Corneal Endothelial Microscopy-Specular Microscopy 050
Diagnosis and Management of Idiopathic Environmental Intolerance or Clinical Ecology 264
Dopamine Transporter Imaging with Single Photon Emission Computed Tomography 918
Drug Testing in Pain Management and Substance Use Disorder Treatment 674
Dynamic Posturography To Assess Vestibular Dysfunction 263
Dynamic Spinal Visualization 195
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
Flow Cytometry for Cell Analysis 341
Handheld Radiofrequency Spectroscopy for Intraoperative Assessment of Surgical Margins during Breast-Conserving Surgery 546
High-Sensitivity C-Reactive Protein 032
Home Uterine Activity Monitoring 043
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
InVitro Chemoresistance and Chemosensitivity Assays 253
Laboratory Testing for HIV Tropism 008
Laboratory Tests for Heart and Kidney Transplant Rejection 530
Leukocyte Histamine Release Test 589
Magnetic Resonance Imaging (MRI) Cardiac 835
Magnetic Resonance Imaging MRI, MRA, MRV, MRS 106
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
Mineral Density Studies 450
Molecular Testing in the Management of Pulmonary Nodules 029
Multianalyte Assays with Algorithmic Analyses for Predicting Risk of Type 2 Diabetes 654
Multibiomarker Disease Activity Blood Test for Rheumatoid Arthritis 677
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 and Psychological Testing  151
Non-Invasive Vascular Studies - Duplex Scans 691
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
  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
Patient-Specific Instrumentation (eg, Cutting Guides) for Joint Arthroplasty 706
Polysomnography and Home Sleep Testing 525
Positron Emission Tomography (PET) Myocardial Imaging 837
Preimplantation Genetic Testing 088
Preventive Screening Tests (Not a medical policy document) 413
Proteomic Testing for Systemic 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 Tumor Markers for Breast and Gastrointestinal Malignancies 538
Sexual Dysfunction: Diagnosis and Therapy 078
Signal-Averaged Electrocardiography - SAECG 134
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
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
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
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
Absorbable Nasal Implant for Treatment of Nasal Valve Collapse 186
Accelerated Breast Irradiation and Brachytherapy Boost After Breast-Conserving Surgery for Early Stage Breast Cancer 326
Adoptive Immunotherapy including CAR T-Cell therapy 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
Anesthetics for the Treatment of Chronic Pain and Depression 291
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
AXUMIN (fluciclovine F-18) for Recurrent Prostate Cancer 025
Balloon Dilation of the Eustachian Tube 018
Balloon Sinuplasty for Treatment of Chronic Sinusitis 582
Baroreflex Stimulation Devices 595
Benign Skin Lesions 707
Bioegineered 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
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 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
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 Neck and 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
Gene Therapy for Inherited Retinal Dystrophy Luxturna 911
Gastric Electrical Stimulation 636
Hematopoietic Cell Transplantation for Acute Myeloid Leukemia 150
Hematopoietic Cell Transplantation for Non-Hodgkin Lymphomas 143
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
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 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
Lipid Apheresis 465
Low-Level Laser Therapy 522
Lysis of Epidural Adhesions 598
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 for Opioid Use Disorder  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
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, Radiofrequency 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 PUVA UV-B and Targeted Phototherapy 059
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 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
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 Focal 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 and Transesophageal Endoscopic Procedures to Treat Gastroesophageal Reflux Disease 920
Surgical Ventricular Restoration 544
Temporomandibular Joint Disorder 035
Outpatient Cardiac Rehabilitation (Not a medical policy document) 060
Therapeutic Radiopharmaceuticals in Oncology 028
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
Transcranial Magnetic Stimulation as a Treatment of Depression 297
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
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
Diaphragmatic Phrenic Nerve and Diaphragm Pacing Systems 593
Electrical Stimulation Devices for Psychiatric and Neurological Conditions 157
Esophageal pH Monitoring 069
Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions 081
Home Cardiorespiratory Monitoring 224
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 and Components for the Upper Limb 227
Orthotics for Progressive Scoliosis 550
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
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
Hyperthermic Intraperitoneal Chemotherapy for Select Intra-Abdominal and Pelvic Malignancies 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
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
Gender Affirming Services (Transgender Services) 189
Heart Transplant 197
Heart/Lung Transplant 269
Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia 076
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 Hodgkin Lymphoma 207
Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors in Adults 191
Hematopoietic Cell Transplantation for Plasma Cell Dyscracias, Including Multiple Myeloma and POEMS Syndrome 075
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 Waldenstrom Macroglobutinemia 322
Hip Resurfacing 046
Image-Guided Minimally Invasive Decompression for Spinal Stenosis 240
Implantable Cardioverter Defibrillator 070
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 Transplant and Combined Liver-Kidney Transplant 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
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
Steroid-Eleuting Sinus Stents 800
Subtalar Arthroereisis 299
Surgery for Groin Pain in Athletes 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 and Non-surgical Treatment of Gynecomastia 661
Surgical and Transesophageal Endoscopic Procedures to Treat Gastroesophageal Reflux Disease 920
Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome 130
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
Treatment of Hyperhidrosis 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
AIM Genetic Testing Management Program CPT and HCPCS Codes 957
AIM High Technology Radiology Management Program CPT and HCPCS Codes 900
Applied Behavioral Analysis Service Request Form 144
AudioHealth Library 506
 Directory of Documents (This Document) 411
E-Blue Review - for Physicians to comment on Medical Policy 500
Fecal Microbiota Transplantation 682
Garments 158
Genetic Testing for Commercial and Medicare Advantage 954
Medical Policy Review Schedule 501
Medical Technology Assessment Guidelines 350
Medicare Advantage High Technology Radiology & Sleep Disorder Management Redirect 923
Preauthorization Request Form for Diagnosis and Treatment of Sacroiliac Joint Pain for MP 320 927
Preauthorization Request Form for Gene Therapy for Inherited Retinal Dystrophy 926
Prior Authorization Request Form for Artificial Intervertebral Disc Cervical Spine MP 585 952
Prior Authorization Request Form for CAR T-Cell Therapy Services for B-cell Acute Lymphoblastic Leukemia (tisagenlecleucel) MP 455 925
Prior Authorization Request Form for CAR T-Cell Therapy Services for Treatment of Diffuse Large B-cell Lymphoma 924
Prior Authorization Request  Form for Gender Affirming Services (Transgender Services) MP 189 901
Prior Authorization Request Form for Electrolysis for Gender Affirming Services MP 189 902
Prior Authorization Request Form for Myoelectric Prosthetic and Components for the Upper Limb MP 227 938
Prior Authorization Request Form for Therapeutic Radiopharmaceuticals in Oncology Lutetium 177 958
Prior Authorization Request Form for Surgical and Transesophageal Endoscopic Procedures to Treat Gastroesophageal Reflux Disease MP 920 956
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.