411 Form

1

Medical Policy Directory of Documents Policy Number: 411

Q: How do I comment on the documents? A: You can email us at ebr@bcbsma.com.

Q: How do I find out which documents have changed? A: New and updated documents are posted to the system every week. To find out what has changed see the Provider Focus newsletter.

Drugs ∙ Tests - Treatments ∙ Devices and Equipment ∙ Surgeries ∙ Other Information

Drugs
Medical Technology Assessment Investigational (Non-Covered) Services List 400 Carelon (formerly AIM) Oncology Medication Management Program
Carelon (formerly AIM) Quality Care Cancer Program (Medical Oncology) 099 Adoptive Cell Therapies for Melanoma (Amtagvi) 089 Antihyperlipidemics: A Prescription Drug Therapy Guideline 013 ↳Prior Authorization/ Formulary Exception Form 434 Anti-Parkinsonism Drugs 054 Antisense Oligonucleotide Medications 027 Asthma and Chronic Obstructive Pulmonary Disease Medication Management
011 ↳Prior Authorization/ Formulary Exception Form 434 Botulinum Toxin Injections 006 Anti-Migraine Policy 021 Cell and Gene Therapy for Ocular Diseases 911 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 Drug Management and Prior Authorization 251 ↳Prior Authorization/ Formulary Exception Form 434 Drugs for Cystic Fibrosis 408 Drugs for the Treatment of Hereditary Angioedema HAE 058 Drugs that Impact Adrenal Steroid Production 064 Engineered T-Cell Therapy Synovial Sarcoma Policy 213 Entyvio (Vedolizumab) Policy 162 Erythropoietin, Recombinant Human and hypoxia-inducible factor inhibitors 262 Esketamine Nasal Spray (SpravatoTM) and Intravenous Ketamine for Mental Health Conditions 087

2

Fentanyl, oral/transmucosal 113 Heart Failure and Hypertrophic Cardiomyopathy (HCM) Policy 063 Hypoactive Sexual Desire Disorder 131 Injectable Specialty Medication Coverage 071 Gene Therapies for Aromatic L-amino Acid Decarboxylase Deficiency 180 Gene Therapies for Duchenne Muscular Dystrophy 022 Gene Therapy for Dystrophic Epidermolysis Bullosa - Zevaskyn 229 Gene Therapies for Hemophilia B 168 Gene Therapies for Metaloleukodystrophy 106 Gene Therapies for Sickle Cell Disease 050 Gene Therapies for Thalassemia Zynteglo Betibeglogene automeucel 215 GLP-1 and GLP-1 - GIP Agonist Drugs for Anti-Obesity Management and Other Non-Obesity Conditions 572 Glucagon-like Peptide-1 (GLP-1) Receptor Agonists and Related Drugs for the Treatment of Type 2 Diabetes 056 Growth Hormone and Insulin-like Growth Factor 257 ↳Prior Authorization/ Formulary Exception Form 434 Guideline for Oncologic Use for WBC growth factors 105 Hepatitis C Medication Management 344 HETLIOZ (tasimelteon) 697 Home Total Parenteral Nutrition (TPN) 296 ↳Prior Authorization Form 430 ↳Prior Authorization Form 430 Injectable Asthma Medications 017 Immune Modulating Drugs 004 Immunomodulators for Skin Conditions 010 Influenza Drugs: Tamiflu and Relenza 440 Interferons Alpha and Gamma
052 ↳Prior Authorization/ Formulary Exception Form 434 Intravenous Immunogammaglobulin (IVIg) 310 ↳Prior Authorization Form 430 Medical Benefit Prior Authorization Medication List 034 Med UM Pharmacy Prior Authorization 033 Medical and Surgical Management of Obesity including Anorexiants 379 Medications for Sickle Cell and Beta Thalassemia 083 Melanoma Vaccines 453 Methotrexate Step Therapy 840 Monitored Anesthesia Care (MAC) 154 Monoclonal Antibodies for Treatment of Alzheimer's Disease 946 Multiple Sclerosis Prior Auth Policy 839 Mupirocin Step Policy 062 New Drug Approval Program 005 Non-Covered Drug List 433 ↳ Formulary Exception Form 434 Non-GLP-1 Agonists for Anti-obesity Management 110 Non Opioid Medication Pain Management 040 Oncology Drugs 409 Ophthalmic Prostaglandins 346 Opioid and Opioid Combination Medication Management
102 Overactive Bladder Medications 170

3

Pregabalin (Lyrica and Lyrica CR) 057 Proton Pump Inhibitors 030 Quality Care Dosing (QCD) Guidelines 621A Quality Care Dosing Guidelines Drug List 621B Topical Ocular Hydrating Agents 426 Drug Management & Retail Pharmacy Prior Authorization Policy 049 RSV Immunoglobulin: Palivizumab (Synagis™) & RSV-IVIg & RespiGam) for Respiratory Syncytial Virus 422 ↳Prior Authorization Form 430 Soliris Ultomiris Uplizna Policy 093 Special Foods: Special Infant Formula, Enteral Formula, Ketogenic Diet for Seizures, and Formula Infusion Pumps 304 ↳Prior Authorization/ Formulary Exception Form 434 Spinal Muscular Atrophy (SMA) Medications 044 Sublingual Immunotherapy with Allergen-specific Extracts (SLIT) 681 Therapeutic Drug Monitoring for Biologic Agents 917 Topical Testosterone 345

Transthyretin-Mediated Amyloidosis Medications 137 Drugs for Macular Degeneration and Diabetic Eye Disease 092 Tests

Medical Technology Assessment Investigational (Non-Covered) Services List 400 Adjunctive Techniques for Screening and Surveillance and Risk Classification of Barrett Esophagus and Esophageal Dysplasia 841 Carelon (formerly AIM) Advanced Imaging Radiology CPT and HCPCS Codes 900 Analysis of Human DNA in Stool Samples as a Technique for Colorectal Cancer Screening 557 Antigen Leukocyte Antibody Test 673 Automated Ambulatory Blood Pressure Monitoring for the Diagnosis of Hypertension in Patients with Elevated Office Blood Pressure 206 Autonomic Nervous System Testing 713 Axillary Reverse Mapping for Prevention of Breast Cancer-Related Lymphedema 184 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 Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting 287 Chromoendoscopy as an Adjunct to Colonoscopy 904 Computer-Aided Evaluation of Malignancy with Magnetic Resonance Imaging of the Breast 578 Computer-Assisted Navigation Orthopedic Procedure 594 Confocal Laser Endomicroscopy 618 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 and Vertebral Motion Analysis 195 Electromagnetic Navigation Bronchoscopy 203 Electromyography and Nerve Conduction Studies 701 Endobrachial Ultrasound for Diagnosis and Staging of Lung Cancer 715 Epithelial Cell Cytology in Breast Cancer Risk Assessment and High-Risk Patient Management – Ductal Lavage and Suction Collection Systems 492

4

Fecal Analysis in the Diagnosis of Intestinal Dysbiosis 556 Fecal Calprotectin Testing 329 Flow Cytometry for Cell Analysis 341 Genetic Testing for Familial Cutaneous Malignant Melanoma 300 Handheld Radiofrequency Spectroscopy for Intraoperative Assessment of Surgical Margins during Breast-Conserving Surgery 546 High-Sensitivity C-Reactive Protein 032 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 In Vivo Analysis of Colorectal Polyps 521 Intracellular Micronutrient Analysis 073 Laboratory Tests Post Transplant and for Heart Failure 530 Laboratory Testing Investigational Services 165 Leukocyte Histamine Release Test 589 Maternal Serum Biomarkers for Prediction of Adverse Obstetric Outcomes 163 Measurement of Serum Antibodies to Selected Biologic Agents 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 Analysis for the Evaluation and Monitoring of Patients with Chronic Liver Disease 921 Multibiomarker Disease Activity Blood Test for Rheumatoid Arthritis 677 Multicancer Early Detection Testing 124 Multispectral Digital Skin Lesion Analysis 748 Multitarget Polymerase Chain Reaction Testing for Diagnosis of Bacterial Vaginosis 711 Myocardial Strain Imaging 112 Myocardial Sympathetic Innervation Imaging in Patients with Heart Failure 576 Nerve Fiber Density Measurement 393 Neurofeedback 515 Neuropsychological Testing 039 Non-Invasive Vascular Studies - Duplex Scans 691 Novel Biomarkers in Risk Assessment and Management of Cardiovascular Disease 283 Nutrient - Nutritional Panel Testing 745 Ophthalmologic Techniques That Evaluate the Posterior Segment for Glaucoma 053 Optical Coherence Tomography for Imaging of Coronary Arteries 915 Optical Coherence Tomography of the Anterior Eye Segment 084 Paraspinal Surface Electromyography - SEMG - to Evaluate and Monitor Back Pain 517 Pathogen Panel Testing 045 Preimplantation Genetic Testing 088 Preventive Screening Tests (This is not a medical policy document) 413 Proteomic Testing for Systemic Therapy in Non-Small Cell Lung Cancer
709 Psychological Testing 363 Quantitative Electroencephalography as a Diagnostic Aid for Attention-Deficit Hyperactivity Disorder, Cognitive Impairment, or Autism Spectrum 554 Radiofrequency Ablation of Peripheral Nerves to Treat Pain 794 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

5

Sensory Evoked Potentials. Somatosensory, Visual, and Auditory Evoked Potentials and Intra- operative Neurophysiologic Monitoring 211 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 Signal-Averaged Electrocardiography (SAECG) 134 Systems Pathology in Prostate Cancer 250 Temporomandibular Joint Dysfunction 035 Ultrasonographic Evaluation of Skin Lesions 303 Ultrasonographic Measurement of Carotid Intima-Medial Thickness as an Assessment of Subclinical Atherosclerosis 547 Ultrasound: Breast, Cranial, Duplex, Fetal, Obstetrical, Intravascular, Prostate, Transvaginal, Transrectal and Other Uses 007 Ultrasound for the Evaluation of Paranasal Sinuses 445 Urinary Metabolite Tests for Adherence to Direct-Acting Antiviral 742 Urinary Test for Renal Allograft Rejection 065 Vertebral Fracture Assessment with Densitometry or Biomechanical Computed Tomography 449 Vitamin B12 Testing 061 Vitamin D Assay Testing 746 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

Treatments

Medical Technology Assessment Investigational (Non-Covered) Services List 400 Absorbable Nasal Implant for Treatment of Nasal Valve Collapse 186 Adjunct Medications to Support Hematopoietic Stem Cell Transplantation and Complications 028 Adoptive Immunotherapy 455 Allogeneic Hematopoietic Cell transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms 155 Allograft Injection for Degenerative Disc Disease
838 Amniotic Membrane and Amniotic Fluid 643 Intravenous Anesthetics for the Treatment of Chronic Pain and Depression 291 Applied Behavioral Analysis (ABA) 091 Artificial Intervertebral Disc - Lumbar Spine 592 Assisted Reproductive Technology Services Form for Policy #086 Infertility Diagnosis and Treatment 694 Auditory Brainstem Implant 481 Balloon Dilation of the Eustachian Tube
018 Balloon Sinuplasty for Treatment of Chronic Sinusitis 582 Baroreflex Stimulation Devices 595 Benign Skin Lesions 707 Bioengineered Skin and Soft Tissue Substitutes 663 Biofeedback as a Treatment of Chronic Pain 210 Biofeedback as a Treatment of Fecal Incontinence or Constipation 308

6

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, Naturopathic and Other Therapies 178 Bronchial Thermoplasty 284 Cardiac Rehabilitation in the Outpatient Setting 916 Charged-Particle - Proton or Helium Ion - Radiation Therapy 437 Chelation Therapy 122 Engineered T-Cell Therapy for Leukemia and Lymphoma 066 Engineered T-Cell Therapy for Multiple Myeloma 942 Esophagogastroduodenoscopy (EGD) Upper Gastrointestinal Endoscopy 202 Catheter Ablation for Cardiac Arrhythmias 126 Cochlear Implant 478 Cognitive Rehabilitation 439 Complementary Medicine: Mind-Body, Alternative, Holistic, Naturopathic and Other Therapies 178 Corneal Collagen Cross-linking 905 Cranial Electrotherapy Stimulation and Auricular Electrostimulation 362 Cryoablation for Chronic Rhinitis 843 Cryoablation of Tumors Located in the Kidney, Lung, Breast, Pancreas, or Bone 260 Deep Brain Stimulation 473 Diagnosis and Treatment of Chronic Cerebrospinal Venous Insufficiency in Multiple Sclerosis 352 Diagnosis and Treatment of Sacroiliac Joint Pain 320 Digital Health Therapies for Attention Deficit 947 Dry Hydrotherapy for chronic pain conditions 164 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 Electrostimulation and Electromagnetic Therapy for Treating Wounds 655 Elzonris (tagraxofusp-erzs) for the Treatment of Blastic Plasmacytoid Dendritic Cell Neoplasm 009 Elzonris Prior Authorization Request Form MP 009 928 End-Diastolic Pneumatic Compression Boot as a Treatment of Peripheral Vascular Disease or Lymphedema 648 Endoscopic Radiofrequency Ablation or Cryoablation for Barrett’s Esophagus 218 Endovascular Procedures for Intracranial Arterial Disease - Atherosclerosis and Aneurysms 323 Enhanced External Counterpulsation (EECP) for Chronic Stable Angina or Congestive Heart Failure 649 Evaluation of Biomarkers for Alzheimer Disease 581 Extracorporeal Photopheresis 248 Eyelid Thermal Pulsation for the Treatment of Dry Eye Syndrome 613 Focal Treatments for Prostate Cancer 733 Fractional Carbon Dioxide (CO2) Laser Ablation Treatment of Hypertrophic Scars or Keloids for Functional Improvement 039 Functional Neuromuscular Electrical Stimulation 201 Gas Permeable Scleral Contact Lens 371 Gastric Electrical Stimulation 636 Gene Therapies for Bladder Cancer 159 Hematopoietic Cell Transplantation for Acute Myeloid Leukemia 150 Hematopoietic Stem Cell Transplantation for Non-Hodgkin Lymphomas 143 High Intensity Laser Therapy for Chronic Musculoskeletal Pain Conditions and Bell's Palsy 104

7

Hippotherapy 560 Hyperbaric Oxygen Therapy 653 Implantable Bone-Conduction and Bone-Anchored Hearing Aids 479 Infertility Diagnosis and Treatment 086 Influenza Drugs: Tamiflu and Relenza 440 Inhaled Nitric Oxide as a Treatment of Hypoxic Respiratory Failure in Neonates 100 Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence 471 Injections for osteoarthritis 427 Insulin Potentiation Therapy 532 Interferential Stimulation for Treatment of Pain 509 Interventions for Progressive Scoliosis 550 Intraocular Radiation Therapy for Age-Related Macular Degeneration 610 Intraosseous Basivertebral Nerve Ablation 485 Intravenous Antibiotic Therapy and Associated Diagnostic Testing for Lyme Disease 171 Intravitreal and Punctum Corticosteroid Implants 272 Irreversible Electroporation of Tumors Located in the Liver, Pancreas, Kidney, or Lung 188 Laparoscopic and Transcervical 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 Liposuction for Lipedema and Lymphedema 043 Low-Dose Radiotherapy for Non-Oncologic Indications 177 Low-Level Laser Therapy 522 Manipulation under Anesthesia 483 Measurement of Exhaled Nitric Oxide and Exhaled Breath Condensate in the Diagnosis and Management of Respiratory Disorders 524 Medical and Surgical Management of Obesity including Anorexiants 379 Medicare Advantage Management 132 Melanoma Vaccines 453 Methadone Treatment and Intensive Detoxification or Ultra-Rapid Detoxification for Opiate Addiction 274 Microwave Tumor Ablation 912 Monitored Anesthesia Care - (MAC)
154 MRI-Guided Focused Ultrasound - MRgFUS 243 Multimarker Serum Testing Related to Ovarian Cancer 249 Negative Pressure Wound Therapy in the Outpatient Setting 543 Neural Therapy 914 Noncontact Ultrasound Treatment for Wounds 657 Occipital Nerve Stimulation 237 Oncologic Applications of Photodynamic Therapy, Including Barrett’s 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 Cognitive Rehabilitation 660 Outpatient Psychotherapy 423 Outpatient Pulmonary Rehabilitation 136 Ovarian and Internal Iliac Vein Embolization as a Treatment of Pelvic Congestion Syndrome 266 Patient-Specific Instrumentation (eg, Cutting Guides) for Joint Arthroplasty 706 Pelvic Floor Stimulation as a Treatment of Urinary Incontinence and Fecal Incontinence 470 Percutaneous Electrical Nerve Stimulation and Percutaneous Neuromodulation Therapy 172

8

Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, and Biacuplasty 482 Percutaneous Revascularization Procedures for Lower Extremity Peripheral Arterial Disease 161 Photocoagulation of Macular Drusen 607 Photodynamic Therapy for Choroidal Neovascularization 599 Phototherapy PUVA UV-B and Targeted Phototherapy 059 Phrenic Nerve Stimulation for Central Sleep Apnea 955 Plasma Exchange 466 Plugs for Fistula Repair 528 Peripheral Nerve Injury Repair Using Synthetic Conduits or Processed Nerve Allografts 214 Preauthorization Request Form for 379 Surgical Management of Obesity Policy 047 Prolotherapy, Joint Sclerotherapy and Ligamentous Injections with Sclerosing Agents 183 Prostatic Urethral Lift 744 Quantitative Sensory Testing 258 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 Coblation Tenotomy for Musculoskeletal Conditions 080 Remote Electrical Neuromodulation for Migraines 145 Renal Denervation for Uncontrolled Hypertension 919 Repetitive Transcranial Magnetic Stimulation (rTMS) 297 Responsive Neurostimulation for the Treatment of Refractory Focal Epilepsy 716 Routine Foot Care and Debridement of Toenails 385 Sacral Nerve Neuromodulation/Stimulation 153 Scenesse afamelanotide for the treatment of Erythropoietic protoporphyria 077 Semi-Implantable and Fully Implantable Middle Ear Hearing Aid 480 Sensory Integration Therapy 659 Sphenopalatine Ganglion Block for Headache 026 Stem-cell Therapy for Peripheral Arterial Disease 348 Suprachoroidal Delivery of Pharmacologic Agents 609 Surgical and Transesophageal Endoscopic Procedures to Treat Gastroesophageal Reflux Disease 920 Surgical Ventricular Restoration 544 Suture Button Suspensionplasty Fixation System for Thumb Carpometacarpal Osteoarthritis 031 Temporomandibular Joint Dysfunction 035 Tibial Nerve Stimulation 583 Threshold Electrical Stimulation as a Treatment of Motor Disorders 321 Tonic Motor Activation for Restless Legs Syndrome 224 Transcatheter Arterial Chemoembolization - TACE - to Treat Primary or Metastatic Liver Malignancies 634 Transpupillary Thermotherapy for Treatment of Choroidal Neovascularization 600 Transtympanic Micropressure Applications as a Treatment of Meniere’s Disease 508 Transvaginal and Transurethral Radiofrequency Tissue Remodeling for Urinary Stress Incontinence 523 Treatment of Congenital Athymia 108 Treatment of Tinnitus 267 Treatment of Varicose Veins and Venous Insufficiency 238 Trigger Point and Tender Point Injections 604 Tumor Treatment Field Therapy 111 Vagus Nerve Stimulation 474 Vertebral Axial Decompression 603

9

Vision Services 675 Zolgensma (onasemnogene abeparvovec-xioi) for Spinal Muscular Atrophy 008 Devices & Equipment

Medical Technology Assessment Investigational (Non-Covered) Services List 400 Ambulatory Electrocardiograph (AECG) Monitoring 119 Automated Ambulatory Blood Pressure Monitoring for the Diagnosis of Hypertension in Patients with Elevated Office Blood Pressure 206 Balloon Spacers for Treatment of Irreparable Rotator Cuffs of the Shoulder 176 Bioimpedance Devices for the Detection of Lymphedema 261 Biventricular Pacemakers – Cardiac Resynchronization Therapy for the Treatment of Heart Failure 101 Continuous or Intermittent Monitoring of Glucose in Interstitial Fluid and Automated Insulin Delivery Systems 107 Continuous Passive Motion in the Home Setting 407 Cooling Devices Used in the Outpatient Setting 510 Diaphragm Pacing Stimulation 593 Digital Health Technologies Diagnostic Applications 175 Digital Health Technologies Therapeutic Applications 090 Durable Medical Equipment DME 842 Dynamic Low-Load Prolonged Duration Stretch Devices 405 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 Implantable Peripheral Nerve Stimulation for Chronic Pain Conditions 103 Insulin Delivery Devices: Pumps, Pens, and Jet Injectors
332 Laser Interstitial Thermal Therapy for Neurological Conditions 948 Leadless Cardiac Pacemakers 038 Manual and Power Operated Wheelchairs 365 Microprocessor Controlled Prostheses for the Lower Limb 133 Myoelectric Prosthetic and Components for the Upper Limb 227 Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Disorders 120 Ostomy Supplies 369 Patient-Actuated End Range Motion Stretching Devices 721 Percutaneous Electrical Nerve Field Stimulation for Functional Abdominal Pain Disorders 922 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 Single Chamber and Dual Chamber Permanent Cardiac Pacemakers 118 Stationary Ultrasonic Diathermy Devices 199 Transcatheter Tricuspid Valve Repair or Replacement 036 Transcutaneous Electrical Nerve Stimulation 003 Transesophageal Echocardiography (TEE) 114 Transthoracic Echocardiography (TTE) 115 Total Artificial Hearts and Implantable Ventricular Assist Devices 280 Ultrasound Accelerated Fracture Healing Device 497 Urological Supplies 370 Wearable Cardioverter Defibrillators 042

10

Surgeries

Medical Technology Assessment Investigational (Non-Covered) Services List 400 Allogeneic Hematopoietic Cell Transplantation for Genetic Diseases and Acquired Anemias
190 Allogeneic Pancreas Transplant 328 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 Discectomy 231 Axial Lumbosacral Interbody Fusion 404 Bone Morphogenetic Protein 097 Carotid Stent Placement 219 Cardiac Catheterization and Coronary Angiography 116 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 Continuous Passive Motion (CPM) in the Home Setting 407 Cryosurgical Ablation of Primary or Metastatic Liver Tumors 633 Decompression of the Intervertebral Disc Using Laser Energy - Laser Discectomy - or Radiofrequency Coblation - Nucleoplasty 271 Endobronchial Valves 313 Endometrial Ablation 331 Endovascular Grafts for Abdominal Aortic Aneurysms 098 Endovascular Stent Grafts for Disorders of the Thoracic Aorta 233 Extracorporeal Membrane Oxygenation 726 Facet Arthroplasty 174 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 Chronic Myelogenous Leukemia 212 Hematopoietic Cell Transplantation for CNS Embryonal Tumors and Ependymoma 205 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 Hyperthermic Intraperitoneal Chemotherapy for Select Intra-Abdominal and Pelvic Malignancies 048 Image-Guided Minimally Invasive Decompression for Spinal Stenosis 240 Implantable Cardioverter Defibrillator 070 Interspinous and Interlaminar Stabilization - Distraction Devices - Spacers 584 Interspinous Fixation – Fusion Devices 436 Islet Transplantation 324 Isolated Small Bowel Transplant 631

11

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 Open and Thoracoscopic Approaches to Treat Atrial Fibrillation - Maze and Related Procedures 356 Orthognathic Surgery 179 Percutaneous Coronary Intervention 117 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 Radiofrequency Volumetric Tissue Reduction for Nasal Obstruction 140 Reconstructive Breast Surgery-Management of Breast Implants 428 Reduction Mammaplasty for Breast-Related Symptoms 703 Shoulder Resurfacing 156 Small Bowel, Liver, and Multivisceral Transplant 632 Stereotactic Radiosurgery and Stereotactic Body Radiotherapy 277 Steroid-Eleuting Sinus Stents 800 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 and Non-Surgical Treatment of Gynecomastia 661 Surgical Treatments for Lymphedema 037 Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome 130 Transcutaneous Electrical Nerve Stimulation 003 Transanal Endoscopic Microsurgery 200 Transcatheter Aortic-Valve Implantation for Aortic Stenosis 392 Transcatheter Mitral Valve Repair 692 Transcatheter Pulmonary Valve Implantation 403 Gender Affirming Services (Transgender Services) 189 Treatment of Hyperhidrosis excluding Botulinum Toxin 406 Uterus Transplantation for Absolute Uterine Factor Infertility 060 Vertical Expandable Prosthetic Titanium Rib 305 Viscocanalostomy and Canaloplasty 372 Other

Behavioral Health Continuum of Care 194 Carelon (formerly AIM) Advanced Imaging of the Heart CPT and HCPCS Codes 971 Carelon (formerly AIM) Advanced Imaging of the Heart 972 Carelon (formerly AIM) Advanced Imaging Radiology 968 Carelon (formerly AIM) Abdomen and Pelvic Imaging CPT and Diagnoses Codes 930 Carelon (formerly AIM) Brain Imaging CPT and Diagnoses Codes 931 Carelon (formerly AIM) Chest Imaging CPT and Diagnoses Codes 932 Carelon (formerly AIM) Extremity Imaging CPT and Diagnoses Codes 933 Carelon (formerly AIM) Genetic Testing Management Program CPT and HCPCS Codes 957 Carelon (formerly AIM) Head and Neck Imaging CPT and Diagnoses Codes 934 Carelon (formerly AIM) Oncologic Imaging CPT, HCPCS and Diagnoses Codes 929 Carelon (formerly AIM) Spine Imaging CPT and Diagnoses Codes 935

12

Carelon (formerly AIM) Vascular Imaging CPT and Diagnoses Codes 936 Air Ambulance Transport 142 AudioHealth Library 506 Diagnostic Laboratory Services 139 Directory of Documents (this document) 411 E-Blue Review - for Physicians to comment on Medical Policy 500 Engineered T-Cell Therapy for Multiple Myeloma Prior Authorization Request Form 943 Fecal Microbiota Transplantation 682 Carelon (formerly AIM) Genetic Testing Management Program
954 Ground Ambulance 146 Musculoskeletal Services Management 220 Musculoskeletal Services Management CPT and HCPCS Codes 221 Medical Policy Review Schedule 501 Medical Technology Assessment Guidelines 350 Medical Technology Assessment Investigational (Non-Covered) Services List 400 Carelon (formerly AIM) Medicare Advantage Radiology and & Sleep Disorder Management 923
Medicare Advantage Part B Step Therapy 020 Medicare Advantage Part B Utilization Management 125 Outpatient Pediatric Pain Rehabilitation Centers 158 Outpatient Prior Authorization Code List 072 Prior Authorization Request Form for Adoptive Cell Therapies for Melanoma MP 089 096 Prior Authorization Request Form for Adstiladrin (nadofaragene firadenovec-vncg) 193 Prior Authorization Request Form for CAR T-Cell Therapy Services for Treatment of Diffuse Large B-cell Lymphoma MP 066 924
Prior Authorization Request Form for CAR T-Cell Therapy Services for B-cell Acute Lymphoblastic Leukemia (tisagenlecleucel) MP 066
925 Prior Authorization Request Form for CAR T-Cell Therapy Services for B-cell Acute Lymphoblastic Leukemia (Brexucabtagene Autoleucel) MP 066 945 Prior Authorization Request Form for CAR T-Cell Therapy Services for Treatment of Diffuse Large B-cell Lymphoma (Tisagenlecleucel) MP 066 844 944 Prior Authorization Request Form for CAR T-Cell Therapy Services for Follicular Lymphoma (Axicabtagene Ciloleucel) 944 Prior Authorization Request Form for CAR T-Cell Therapy Services for Treatment of Follicular Lymphoma (tisagenlecleucel) MP 066 846 Prior Authorization Request Form for CAR T-Cell Therapy Services for Mantle Cell Lymphoma (Brexucabtagene Autoleucel) MP 066 940 Prior Authorization Request Form for CAR T-Cell Therapy Services for Non-Hodgkin Lymphoma (Lisocabtagene Maraleucel) 941 Prior Authorization Request Form for Diagnosis and Treatment of Sacroiliac Joint Pain MP 320 927 Prior Authorization Request Form for Duchenne Muscular Dystrophy MP 022 025 Prior Authorization Request Form for Gender Affirming Services (Transgender Services) MP 189 901 Prior Authorization Request Form for Gene Therapies for Aromatic L-amino Acid Decarboxylase Deficiency 209 Prior Authorization Request Form for Gene Therapies DEB - Zevaskyn 230 Prior Authorization Request Form for Gene Therapies for Thalassemia Zynteglo Betibeglogene automeucel MP 215 216 Prior Authorization Request Form for Gene Therapies for Thalassemia Casgevy Autotemcel
MP 215 217 Prior Authorization Request Form for Electrolysis for Gender Affirming Services MP 189 902 Prior Authorization Request Form for Esketamine Nasal Spray and Intravenous Ketamine for Treatment Resistant Depression 094

13

Prior Authorization Request Form for Gene Therapies for Hemophilia B 169 Prior Authorization Request Form for Gene Therapies for Hemophilia A Roctavian (Valoctocogene roxaparvovec-rvox) 166 Prior Authorization Request Form for Cell and Gene Therapies for Ocular Diseases MP 911 926 Prior Authorization Request Form for Gene Therapies for Metachromatic Leukodystrophy 109 Prior Authorization Request Form for Gene Therapies for Sickle Cell Disease 055 Prior Authorization Request Form for Intraosseus Basivertebral Nerve Ablation Intracept System 486 Prior Authorization Request for MP 028 Adjunct Meds to Support Hematopoietic Stem Cell Transplantation and Complications 067 Prior Authorization Request Form for Lyfgenia 079 Prior Authorization Request Form for Myoelectric Prosthetic and Components for the Upper Limb MP 227 973 Prior Authorization Request Form for Scenesse MP 077 160 Prior Authorization Request Form for Synovial Sarcoma 222 Prior Authorization Request Form for Treatment of Varicose Veins Venous Insufficiency 129 Prior Authorization Request Form for Zolgensma (onasemnogene abeparvovec-xioi) for Spinal Muscular Atrophy MP 008 085 Carelon (formerly AIM) Quality Care Cancer Program (Radiation Oncology) 937 Carelon (formerly AIM) Quality Care Cancer Program (Radiation Oncology) CPT and HCPCS Codes 938 Carelon (formerly AIM) Sleep Disorder Management 969 Carelon (formerly AIM) Sleep Disorder Management CPT and HCPCS Codes 970

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.

©2026 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.