1

Medical Policy Outpatient Prior Authorization Code List for Commercial Plans Managed Care (HMO and POS), PPO, EPO and Indemnity

Policy Number: 072 Related Medical Policies:
Medicare Advantage Management, #132 Medical Technology Assessment Non-Covered Services List, #400 InterQual Musculoskeletal Services Management, #220 InterQual Musculoskeletal Services Management CPT and HCPCS Codes, #221

Table Contents Overview ....................................................................................................................................................... 1 Requesting Prior Authorization Using Authorization Manager ...................................................................... 2 Authorization Manager Resources ................................................................................................................ 2 List of Medical Policies that Require Prior Authorization .............................................................................. 2 Prior authorization is required for the following Gender Affirming Transgender codes for Commercial Managed Care (HMO and POS), Commercial PPO, and Indemnity: ......................................................... 17 Prior authorization is required for the following Assisted Reproductive Services codes for Commercial Managed Care (HMO and POS), Commercial PPO, and Indemnity: ......................................................... 20 Policy History .............................................................................................................................................. 21

Overview The table below represents medical policies with corresponding specific procedure codes. These procedure codes require prior authorization when they are performed in the outpatient setting.

If the procedure codes that are listed in this document are performed in the inpatient setting, precertification/prior authorization is required for all products.

How to use the table • If a policy-specific prior authorization request form is included under the policy title column, please complete the prior authorization request form using authorization manager.
• If there is no policy-specific prior authorization request form, providers should complete either of the following using authorization manager. o Massachusetts Collaborative Prior Authorization Form OR
o Blue Cross Blue Shield of Massachusetts Pre-certification Request Form

2 Click on the title for complete list of drugs that require prior authorization: ▪ Medical Benefit Prior Authorization Medication List, #034 ▪ Medical Utilization Management and Pharmacy Prior Authorization, #033

Click on the link for InterQual spine procedures that require prior authorization: ▪ Change Healthcare InterQual Criteria Subsets and SmartSheets

Requesting Prior Authorization Using Authorization Manager Providers will need to use Authorization Manager to submit initial authorization requests for services. Authorization Manager, available 24/7, is the quickest way to review authorization requirements, request authorizations, submit clinical documentation, check existing case status, and view/print the decision letter. For commercial members, the requests must meet medical policy guidelines.

To ensure the request is processed accurately and quickly: • Enter the facility’s NPI or provider ID for where services are being performed. • Enter the appropriate surgeon’s NPI or provider ID as the servicing provider, not the billing group.

Authorization Manager Resources ▪ Refer to our Authorization Manager page for tips, guides, and video demonstrations.

List of Medical Policies that Require Prior Authorization Policy Number and Title
Products Procedure codes

008 Zolgensma (onasemnogene abeparvovec-xioi) for Spinal Muscular Atrophy

Complete Prior Authorization Request Form for Zolgensma (085) using Authorization Manager

All commercial products C9399, J3490, J3590: Prior authorization is required; in effect.

J3399: Prior authorization is required effective 7.1.2020.

009 Elzonris (tagraxofusp-erzs) for the Treatment of Blastic Plasmacytoid Dendritic Cell Neoplasm

Complete Prior Authorization Request Form for Elzonris (928) using Authorization Manager

All commercial products J9269: Prior authorization is required; in effect.

022 Gene Therapies for Duchenne Muscular Dystrophy.pdf

Complete Prior Authorization Request Form for Elevidys (delandistrogene moxparvovec-rokl) (025) using Authorization Manager

All commercial products No specific J codes. See policy for additional information

028 Omidubicel as Adjunct Treatment for Hematologic Malignancies All commercial products J3402 Prior authorization is required; in effect

3 Complete Prior Authorization Request Form for Omidubicel (067) using Authorization Manager

035 Temporomandibular Joint Disorder

Complete Prior Authorization Request Form using Authorization Manager ▪ Massachusetts Collaborative Prior Authorization Form OR ▪ Blue Cross Blue Shield of Massachusetts Precertification Request Form

Commercial HMO and POS 21010, 21050, 21060, 21240, 21242, 21243, 29800, 29804: Prior authorization is required; in effect.

Commercial PPO/EPO

21010, 21050, 21060, 21240, 21242, 21243, 29800, 29804: Prior authorization is required. Effective 6.1.2022

037 Surgical and Debulking Treatments for Lymphedema.pdf

Complete Prior Authorization Request Form using Authorization Manager ▪ Massachusetts Collaborative Prior Authorization Form OR ▪ Blue Cross Blue Shield of Massachusetts Precertification Request Form

Commercial HMO and POS 15878, 15879, 1019T Prior authorization is required; in effect.

Commercial PPO/EPO 15878, 15879, 1019T Prior authorization is required; in effect.

043 Suction lipectomy for lipedema.pdf Complete Prior Authorization Request Form using Authorization Manager ▪ Massachusetts Collaborative Prior Authorization Form OR ▪ Blue Cross Blue Shield of Massachusetts Precertification Request Form

Commercial HMO and POS 15832, 15833, 15834, 15835, 15836, 15878, 15879 Prior authorization is required. Effective 5.1.2024

Commercial PPO/EPO

15832, 15833, 15834, 15835, 15836, 15878, 15879 Prior authorization is required. Effective 5.1.2024 050 Gene Therapies for Sickle Cell Disease.pdf

Complete Prior Authorization Request Form using Authorization Manager

Gene Therapies for Sickle Cell Disease Prior Authorization Request Form for Casgevy ™ (Exagamglogene autotemcel), (055) All commercial products J3394
Prior authorization is required.
Effective 7.1.2024.

066 Chimeric Antigen Receptor Therapy for Leukemia and Lymphoma.pdf

Complete Prior Authorization Request Form using Authorization Manager All commercial products Q2041, Q2042, Q2053; Q2054:
Prior authorization is required; in effect.

4 ▪ CAR T-Cell Therapy Services for Treatment of Diffuse Large B-cell Lymphoma (924) ▪ CAR T-Cell Therapy Services for B-cell Acute Lymphoblastic Leukemia (tisagenlecleucel) (925) ▪ CAR T-Cell Therapy Services for Mantle Cell Lymphoma (Brexucabtagene Autoleucel) (940) ▪ CAR T-Cell Therapy Services for Non-Hodgkin Lymphoma (Lisocabtagene Maraleucel) (941) ▪ CAR T-Cell Therapy Services for Follicular Lymphoma (Axicabtagene Ciloleucel) (944) ▪ CAR T-Cell Therapy Services for B-cell Acute Lymphoblastic Leukemia (Brexucabtagene Autoleucel) Prior Authorization Request Form (945)

068 Plastic Surgery

Complete Prior Authorization Request Form using Authorization Manager ▪ Massachusetts Collaborative Prior Authorization Form OR ▪ Blue Cross Blue Shield of Massachusetts Precertification Request Form

Commercial HMO and POS 15780, 15781, 15782, 15783, 30400, 30410, 30420, 30430, 30435, 30450, 15830, 15876, 15877, 15878, 15879: Prior authorization is required; in effect.

Commercial PPO/EPO

15780, 15781, 15782, 15783, 30400, 30410, 30420, 30430, 30435, 30450, 15830, 15876, 15877, 15878, 15879: Prior authorization is required. Effective 6.1.2022

074 Hematopoietic Stem Cell Transplantation for Chronic Lymphocytic Leukemia and Small Lymphocytic Lymphoma

Complete Prior Authorization Request Form using Authorization Manager ▪ Massachusetts Collaborative Prior Authorization Form OR ▪ Blue Cross Blue Shield of Massachusetts Precertification Request Form

All commercial products 38240, S2142, S2150: Prior authorization is required; in effect.

075 Hematopoietic Cell Transplantation for Plasma Cell Dyscracias, Including Multiple Myeloma and POEMS Syndrome

All commercial products 38241, S2150: Prior authorization is required; in effect.

5 Complete Prior Authorization Request Form using Authorization Manager ▪ Massachusetts Collaborative Prior Authorization Form OR ▪ Blue Cross Blue Shield of Massachusetts Precertification Request Form

076 Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia

Complete Prior Authorization Request Form using Authorization Manager ▪ Massachusetts Collaborative Prior Authorization Form OR ▪ Blue Cross Blue Shield of Massachusetts Precertification Request Form

All commercial products 38240, 38241, S2142, S2150: Prior authorization is required; in effect.

077 Scenesse afamelanotide for the treatment of Erythropoietic protoporphyria

Complete Prior Authorization Request Form for Scenesse (160) using Authorization Manager

All commercial products J7352: Prior authorization is required effective 2.1.2021.

086 Assisted Reproductive Services Infertility Services

Complete Prior Authorization Request Form for Assisted Reproductive Technology Services (694) using Authorization Manager

Commercial HMO and POS

Click here for CPT codes Prior authorization is required; in effect.

Prior authorization is not required for Diagnostic Testing.

Prior authorization is required for Infertility Treatment.

Commercial PPO
Indemnity

Click here for CPT codes Prior authorization is required; in effect.

Prior authorization is not required for Diagnostic Testing.

Prior authorization is required for Infertility Treatment.

087 Esketamine Nasal Spray (Spravato) and Intravenous Ketamine for Treatment Resistant Depression
All commercial products G2082, G2083: Prior authorization is required effective 4.1.2020.

6

Complete Prior Authorization Request Form for Esketamine Nasal Spray (Spravato) and Intravenous Ketamine (094) using Authorization Manager

088 Preimplantation Genetic Testing

Complete Prior Authorization Request Form using Authorization Manager ▪ Massachusetts Collaborative Prior Authorization Form OR ▪ Blue Cross Blue Shield of Massachusetts Precertification Request Form

All commercial products

89290, 89291: Prior authorization is required; in effect.

089 Adoptive Cell Therapies for Melanoma

Complete Prior Authorization Request Form using Authorization Manager

Prior Authorization Request Form for Lifileucel (Amtagvi), #096

Commercial Managed Care (HMO and POS) Commercial PPO and Indemnity See policy for coding information. Prior authorization is required.
Effective 8.1.2024.

091 Applied Behavioral Analysis (ABA).pdf

Complete Prior Authorization Request Form using Authorization Manager ▪ Massachusetts Collaborative Prior Authorization Form

Commercial Managed Care (HMO and POS) Commercial PPO and Indemnity

97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0373T, 0362T Prior authorization is required, in effect.

MP 106 Gene Therapies for Metachromatic Leukodystrophy

Complete Prior Authorization Request Form using Authorization Manager ▪ Massachusetts Collaborative Prior Authorization Form OR ▪ Blue Cross Blue Shield of Massachusetts Precertification Request Form

Commercial Managed Care (HMO and POS) Commercial PPO and Indemnity Prior authorization is required. Effective 12.1.2024

121 Closure Devices for Patent Foramen Ovale and Atrial Septal Defects

Complete Prior Authorization Request Form using Authorization Manager All commercial products 93580: Prior authorization is required; in effect.

7 ▪ Massachusetts Collaborative Prior Authorization Form OR ▪ Blue Cross Blue Shield of Massachusetts Precertification Request Form

130 Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome

068 Plastic Surgery prn.pdf Complete Prior Authorization Request Form using Authorization Manager ▪ Massachusetts Collaborative Prior Authorization Form OR ▪ Blue Cross Blue Shield of Massachusetts Precertification Request Form

Commercial HMO and POS

21193, 21194, 21195, 21196, 21198, 21199, 21206, 21685, 42145: Prior authorization is required; in effect.

Commercial PPO/EPO

21193, 21194, 21195, 21196, 21198, 21199, 21206, 21685, 42145: Prior authorization is required. Effective 6.1.2022.

133 Microprocessor Controlled Prostheses for the Lower Limb

Complete Prior Authorization Request Form using Authorization Manager ▪ Massachusetts Collaborative Prior Authorization Form OR ▪ Blue Cross Blue Shield of Massachusetts Precertification Request Form

Commercial HMO and POS)

K1014, L5856, L5857, L5858: Prior authorization is required; in effect.

Commercial PPO/EPO

K1014, L5856, L5857, L5858: Prior authorization is required. Effective 6.1.2022.

142 Air Ambulance Transport

Complete Prior Authorization Request Form using Authorization Manager ▪ Massachusetts Collaborative Prior Authorization Form OR ▪ Blue Cross Blue Shield of Massachusetts Precertification Request Form

Commercial HMO and POS A0430, A0431, S9960, S9961: Prior authorization is required for air ambulance transport; in effect.

Note: As air ambulance transport is normally of an urgent or emergency nature, a retrospective review of documentation will be performed prior to payment authorization.

Commercial PPO and Indemnity Prior authorization is not required.

However, all air ambulance transport claims must be submitted with supporting documentation and reviewed for medical necessity.

Note: As air ambulance transport is normally of an urgent or emergency nature, a retrospective review of documentation will be performed prior to payment authorization.

8 We recommend submitting authorization requests electronically. For more information, please refer to the Utilization Management section of our Blue Cross Blue Book. Claims payment is based on eligibility at the time of service, availability of benefits at the time of claim receipt, and medical necessity. All covered services, even those that don’t require authorization, are subject to the plan’s medical necessity requirements and may be subject to audit or review, including after the service was rendered or after the claim has been paid.

143 Hematopoietic Cell Transplantation for Non-Hodgkin Lymphomas

Complete Prior Authorization Request Form using Authorization Manager ▪ Massachusetts Collaborative Prior Authorization Form OR ▪ Blue Cross Blue Shield of Massachusetts Precertification Request Form

All commercial products 38240, 38241, S2142, S2150: Prior authorization is required; in effect.

146 Ground Ambulance

Complete Prior Authorization Request Form using Authorization Manager ▪ Massachusetts Collaborative Prior Authorization Form OR ▪ Blue Cross Blue Shield of Massachusetts Precertification Request Form

Commercial Managed Care (HMO and POS)

For Managed care members (HMO Blue, Blue Choice, Access Blue) A0426; A0428: Prior authorization is required; in effect. • All non-emergent ambulance transports from a member’s home or residence1 to a contracted facility or provider • Chair car/van

Prior authorization is not required for: • Emergency transports • Non-emergency ambulance transports between facilities when the patient is an inpatient • Involuntary transport to a psychiatric facility 1 A member’s “residence” is defined as the place where he or she makes their home and dwells permanently, or for an extended period of time.

Commercial PPO and Indemnity Prior authorization is not required for: • Any ground ambulance services

9 • Involuntary transport to a psychiatric facility • Air ambulances

Note: all air ambulance claims must be submitted with supporting documentation and will be reviewed for medical necessity.

150 Hematopoietic Cell Transplantation for Acute Myeloid Leukemia

Complete Prior Authorization Request Form using Authorization Manager ▪ Massachusetts Collaborative Prior Authorization Form OR ▪ Blue Cross Blue Shield of Massachusetts Precertification Request Form

All commercial products 38240, 38241, S2142, S2150: Prior authorization is required; in effect.

151 Neuropsychological and Psychological testing

Complete Prior Authorization Request Form using Authorization Manager ▪ Massachusetts Collaborative Prior Authorization Form

Commercial HMO and POS

96130, 96131, 96132, 96133: Prior authorization is required; in effect.

Commercial PPO/EPO Indemnity

Prior authorization is not required.

155 Allogeneic Hematopoietic Cell transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms

Complete Prior Authorization Request Form using Authorization Manager ▪ Massachusetts Collaborative Prior Authorization Form OR ▪ Blue Cross Blue Shield of Massachusetts Precertification Request Form

All commercial products 38240, S2150: Prior authorization is required; in effect.

10 158 Outpatient Pediatric Pain Rehabilitation Centers

Complete Prior Authorization Request Form using Authorization Manager ▪ Massachusetts Collaborative Prior Authorization Form OR ▪ Blue Cross Blue Shield of Massachusetts Precertification Request Form

All commercial products For CPT codes, see policy 158 Prior authorization is required; in effect

159 Gene Therapies for Bladder Cancer

Complete Prior Authorization Request Form for Adstiladrin (nadofaragene firadenovec-vncg) (193) using Authorization Manager

All commercial products For CPT codes, see policy 159. Prior authorization is required.
Effective 6.8.2023.

168 Gene Therapies for Hemophilia A or B

Complete Prior Authorization Request Form for Gene Therapies using Authorization Manager for:
• Hemophilia B Hemgenix® (Etranacogene dezaparvovec) (169)
• Hemophilia A Roctavian® (Valoctocogene roxaparvovec- rvox), (#166)

All commercial products

J1411, J1412: Prior authorization is required. Effective 4.3.2023.

179 Orthognathic Surgery

Complete Prior Authorization Request Form using Authorization Manager ▪ Massachusetts Collaborative Prior Authorization Form OR ▪ Blue Cross Blue Shield of Massachusetts Precertification Request Form

All commercial products 21193, 21194, 21195, 21196,21198 21199, 21206, 21240, 21242, 21243: Prior authorization is required; in effect

181 Hematopoietic Cell Transplantation for Primary Amyloidosis

Complete Prior Authorization Request Form using Authorization Manager ▪ Massachusetts Collaborative Prior Authorization Form OR All commercial products 38241, S2150: Prior authorization is required; in effect.

11 ▪ Blue Cross Blue Shield of Massachusetts Precertification Request Form

189 Gender Affirming Services (Transgender Services)

Complete Prior Authorization Request Form for Gender Affirming Services (901) using Authorization Manager

Complete Prior Authorization Request Form for Electrolysis for Gender Affirming Services (902) using Authorization Manager

Commercial HMO and POS

Click here for CPT codes
Prior authorization is required; in effect.

Commercial PPO
Indemnity Click here for CPT codes
Prior authorization is required; in effect.

190 Allogeneic Hematopoietic Cell Transplantation for Genetic Diseases and Acquired Anemias

Complete Prior Authorization Request Form using Authorization Manager ▪ Massachusetts Collaborative Prior Authorization Form OR ▪ Blue Cross Blue Shield of Massachusetts Precertification Request Form

All commercial products 38240, S2142, S2150: Prior authorization is required; in effect.

192 Hematopoietic Cell Transplantation for Autoimmune Diseases

Complete Prior Authorization Request Form using Authorization Manager ▪ Massachusetts Collaborative Prior Authorization Form OR ▪ Blue Cross Blue Shield of Massachusetts Precertification Request Form

All commercial products 38241, S2150: Prior authorization is required; in effect.

194 Behavioral Health Continuum of Care.pdf

Complete Prior Authorization Request Form using Authorization Manager ▪ Massachusetts Collaborative Prior Authorization Form OR Blue Cross Blue Shield of Massachusetts Precertification Request Form

All commercial products S0201, H0015, H0035, S9480: Prior authorization is required. Effective 7/1/2025.

12

205 Hematopoietic Cell Transplantation for CNS Embryonal Tumors and Ependymoma

Complete Prior Authorization Request Form using Authorization Manager ▪ Massachusetts Collaborative Prior Authorization Form OR ▪ Blue Cross Blue Shield of Massachusetts Precertification Request Form

All commercial products S2150: Prior authorization is required; in effect.

207 Hematopoietic Cell Transplantation for Hodgkin Lymphoma Complete Prior Authorization Request Form using Authorization Manager ▪ Massachusetts Collaborative Prior Authorization Form OR ▪ Blue Cross Blue Shield of Massachusetts Precertification Request Form

All commercial products 38241, S2142, S2150: Prior authorization is required; in effect.

208 Hematopoietic Cell Transplantation for Solid Tumors of Childhood

Complete Prior Authorization Request Form using Authorization Manager ▪ Massachusetts Collaborative Prior Authorization Form OR ▪ Blue Cross Blue Shield of Massachusetts Precertification Request Form

All commercial products 38241, S2150: Prior authorization is required; in effect.

211 Intraoperative Neurophysiologic Monitoring Sensory-Evoked Potentials, Motor-Evoked Potentials, EEG Monitoring

Complete Prior Authorization Request Form using Authorization Manager ▪ Massachusetts Collaborative Prior Authorization Form OR ▪ Blue Cross Blue Shield of Massachusetts Precertification Request Form

All commercial products 95940, 95941, G0453: Prior authorization is required; in effect.

13 212 Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia

Complete Prior Authorization Request Form using Authorization Manager ▪ Massachusetts Collaborative Prior Authorization Form OR ▪ Blue Cross Blue Shield of Massachusetts Precertification Request Form

All commercial products 38240, S2142, S2150: Prior authorization is required; in effect.

215 Gene Therapies for Thalassemia

Complete Prior Authorization Request Form using Authorization Manager ▪ Gene Therapies for Thalassemia Prior Authorization Request Form for Zynteglo for Betibeglogene (216) ▪ Gene Therapies for Thalassemia Prior Authorization Request Form for Casgevy™ (Exagamglogene autotemcel) for Beta thalassemia,

217

All commercial products Zynteglo J3393
Prior authorization is required.
Effective 7.1.2024.

Casgevy: See policy for coding information. Prior authorization is required.
Effective 8.1.2024.

227 Myoelectric Prosthetic and Orthotic Components for the Upper Limb

Complete Prior Authorization Request Form for Myoelectric Prosthetic and Components for the Upper Limb (973) using Authorization Manager

Commercial HMO and POS

L6026, L6925, L6935, L6945, L6955, L6965, L6975, L7007, L7008, L7009, L7045, L7180, L7181, L7190, L7191: Prior authorization is required; in effect.

Commercial PPO/EPO

L6026, L6925, L6935, L6945, L6955, L6965, L6975, L7007, L7008, L7009, L7045, L7180, L7181, L7190, L7191: Prior authorization is required.
Effective 6.1.2022.

229 Gene Therapy for Treatment of Wounds in Dystrophic Epidermolysis Bullosa – Zevaskyn

Complete Prior Authorization Request Form using Authorization Manager ▪ Gene Therapy for Treatment of Wounds in Dystrophic Epidermolysis Bullosa - Prior Authorization Request Form for Zevaskyn® (prademagene zamikeracel),

230

All commercial products Zevaskyn J3389 Prior authorization is required.

14

238 Treatment of Varicose Veins/Venous Insufficiency

Complete Prior Authorization Request Form for Treatment of Varicose Veins/Venous Insufficiency (129) using Authorization Manager

Commercial HMO and POS 36465, 36466, 36470, 36471, 36475, 36476, 36478, 36479, 36482, 36483,37500, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785, S2202: Prior authorization is required; in effect.

Commercial PPO/EPO

36465, 36466, 36470, 36471, 36475, 36476, 36478, 36479, 36482, 36483,37500, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785, S2202: Prior authorization is required. Effective 6.1.2022.

241 Gene Therapies for Cerebral Adrenoleukodystrophy

Complete Prior Authorization Request Form for Cerebral Adrenoleukodystrophy Skysona® (Elivaldogene autotemcel) (242) using Authorization Manager

All commercial products Skysona J3387
Prior authorization is required.
Effective 2.1.2023.

247 Hematopoietic Cell Transplantation in the Treatment of Germ Cell Tumors

Complete Prior Authorization Request Form using Authorization Manager ▪ Massachusetts Collaborative Prior Authorization Form OR ▪ Blue Cross Blue Shield of Massachusetts Precertification Request Form

All commercial products 38241, S2150: Prior authorization is required; in effect.

284 Bronchial Thermoplasty

Complete Prior Authorization Request Form using Authorization Manager ▪ Massachusetts Collaborative Prior Authorization Form OR ▪ Blue Cross Blue Shield of Massachusetts Precertification Request Form

Commercial HMO and POS

31660, 31661: Prior authorization is required; in effect.

Commercial PPO/EPO

31660, 31661: Prior authorization is required. Effective 6.1.2022.

297 Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric Neurologic Disorders Commercial HMO and POS

90867, 90868, 90869: Prior authorization is required; in effect.

15

Complete Prior Authorization Request Form using Authorization Manager ▪ Massachusetts Collaborative Prior Authorization Form OR ▪ Blue Cross Blue Shield of Massachusetts Precertification Request Form

Commercial PPO/EPO
Indemnity

90867, 90868, 90869: Prior authorization is required. Effective 7.1.2024.

320 Diagnosis and Treatment of Sacroiliac Joint Pain

Complete Prior Authorization Request Form for Diagnosis and Treatment of Sacroiliac Joint Pain (927) using Authorization Manager

Commercial HMO and POS

27279: Prior authorization is required; in effect. Commercial PPO/EPO 27279: Prior authorization is required. Effective 6.1.2022.

322 Hematopoietic Stem-Cell Transplantation for Waldenstrom Macroglobulinemia

Complete Prior Authorization Request Form using Authorization Manager ▪ Massachusetts Collaborative Prior Authorization Form OR ▪ Blue Cross Blue Shield of Massachusetts Precertification Request Form

All commercial products 38241, S2150: Prior authorization is required; in effect.

365 Manual and Power Operated Wheelchairs

Complete Prior Authorization Request Form using Authorization Manager ▪ Massachusetts Collaborative Prior Authorization Form OR ▪ Blue Cross Blue Shield of Massachusetts Precertification Request Form

Commercial Managed Care (HMO and POS) and Commercial PPO/EPO products Power Operated Wheelchairs: K0813; K0814; K0815; K0816; K0820; K0821; K0822; K0823 K0824; K0825; K0826; K0827; K0828; K0829; K0830; K0831; K0835; K0836; K0837; K0838; K0839; K0840; K0841; K0842; K0843; K0848; K0849; K0850; K0851; K0852; K0853; K0854; K0855; K0856; K0857; K0858; K0859; K0860; K0861; K0862; K0863; K0864; K0890; K0891; K0898: Prior authorization is required. 6.1.2022.

379 Medical and Surgical Management of Obesity including Anorexiants

Complete Prior Authorization Request Form for Surgical Management of Obesity (047) using Authorization Manager Commercial Managed Care (HMO and POS)

43644; 43770, 43775, 43845, 43846, 43848: Prior authorization is required; in effect.

Commercial PPO/EPO

43644; 43770, 43775, 43845, 43846, 43848: Prior authorization is required. Effective 6.1.2022.

16

428 Reconstructive Breast Surgery/Management of Breast Implants

703 Reduction Mammaplasty for Breast-Related Symptoms prn.pdf

Complete Prior Authorization Request Form using Authorization Manager ▪ Massachusetts Collaborative Prior Authorization Form OR ▪ Blue Cross Blue Shield of Massachusetts Precertification Request Form

Commercial HMO and POS 11970, 11971, 19316, 19318, 19325, 19328, 19330, 19340, 19342, 19350, 19355, 19357, 19361, 19364, 19366, 19367, 19368, 19369, 19371, 19380, 19396, S2066, S2067, S2068: Prior authorization is required; in effect.

Prior authorization is not required for breast cancer-related diagnoses.

Commercial PPO/EPO

11970, 11971, 19316, 19318, 19325, 19328, 19330, 19340, 19342, 19350, 19355, 19357, 19361, 19364, 19367, 19368, 19369, 19371, 19380, 19396, S2066, S2067, S2068; L6955, L6965: Prior authorization is required. Effective 6.1.2022.

Prior authorization is not required for breast cancer related diagnoses.

485 Intraosseous Basivertebral Nerve Ablation

Complete Prior Authorization Request Form for Intraosseous Basivertebral Nerve Ablation (486) using Authorization Manager

Commercial HMO and POS 64628 Prior authorization is required.
Effective 2.1.2024

Commercial PPO/EPO 64628 Prior authorization is required.
Effective 2.1.2024

703 Reduction Mammaplasty for Breast-Related Symptoms

Complete Prior Authorization Request Form using Authorization Manager ▪ Massachusetts Collaborative Prior Authorization Form OR ▪ Blue Cross Blue Shield of Massachusetts Precertification Request Form

Commercial HMO and POS

19318: Prior authorization is required; in effect.

Commercial PPO/EPO

19318: Prior authorization is required. Effective 6.1.2022.

740 Blepharoplasty, Blepharoptosis Repair

Complete Prior Authorization Request Form using Authorization Manager ▪ Massachusetts Collaborative Prior Authorization Form OR ▪ Blue Cross Blue Shield of Massachusetts Precertification Request Form

Commercial HMO and POS

15820, 15821, 15822, 15823, 67900, 67901, 67902, 67903, 67904, 67906, 67908: Prior authorization is required; in effect.

Commercial PPO/EPO

15820, 15821, 15822, 15823, 67900, 67901, 67902, 67903, 67904, 67906, 67908: Prior authorization is required. Effective 6.1.2022.

17

911 Cell and Gene Therapy for Ocular Diseases

Complete Prior Authorization Request Form for Cell and Gene Therapy for Ocular Diseases (926) using Authorization Manager

All commercial products J3398; J3403: Prior authorization is required; in effect.

920 Magnetic Esophageal Ring to Treat Gastroesophageal Reflux Disease - GERD

Complete Prior Authorization Request Form for Surgical and Transesophageal Endoscopic Procedures to Treat Gastroesophageal Reflux Disease (956)

Commercial HMO and POS

43210, 43284: Prior authorization is required; in effect.

Commercial PPO/EPO

43210, 43284: Prior authorization is required. Effective 6.1.2022. 942 Chimeric Antigen Receptor Therapy for Multiple Myeloma

Complete Prior Authorization Request Form for CAR T-Cell Therapy Services for Multiple Myeloma (Idecabtagene vicleucel) (943) using Authorization Manager

All commercial products Q2055: Prior authorization is required. Effective 1.1.2022.
Q2056: Prior authorization is required. Effective 10.1.2022. See policy for additional information 946 Monoclonal Antibodies for Treatment of Alzheimer's Disease

Complete Prior Authorization Request Form for Lecanemab (Leqembi®) and
Donanemab (KisunlaTM) for Alzheimer’s Disease (949) using Authorization Manager

All commercial products J0174: Prior authorization is required. Effective 6.1.2024
J0175: Prior authorization is required. Effective 8.1.2024

Prior authorization is required for the following Gender Affirming Transgender codes for Commercial Managed Care (HMO and POS), Commercial PPO, and Indemnity:
Male to Female Surgery 17380 Electrolysis epilation, each 30 minutes 19325 Mammaplasty, augmentation; with prosthetic implant 19350 Nipple/areola reconstruction 19357 Breast reconstruction, immediate or delayed, with tissue expander, including subsequent expansion 19380 Breast reconstruction, immediate or delayed, with tissue expander, including subsequent expansion 53410 Urethroplasty, 1-stage reconstruction of male anterior urethra 53420 Urethroplasty, 2-stage reconstruction or repair of prostatic or membranous urethra; first stage

18 53425 Urethroplasty, 2-stage reconstruction or repair of prostatic or membranous urethra; second stage 54120 Amputation of penis; partial
54125 Amputation of penis; complete 54300 Plastic operation of penis for straightening of chordee (eg, hypospadias), with or without mobilization of urethra 55970 Intersex surgery; male to female 56800 Plastic repair of introitus 56805 Clitoroplasty for intersex state 57291 Construction of artificial vagina; without graft
57292 Construction of artificial vagina; with graft Facial Feminization/ Masculinization 21137 Reduction forehead; contouring only 21138 Reduction forehead; contouring and application of prosthetic material or bone graft (includes obtaining autograft) 21139 Reduction forehead; contouring and setback of anterior frontal sinus wall 21208 Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant) 21209 Osteoplasty, facial bones; reduction Brow Lift 67900 Repair of brow ptosis (supraciliary, mid-forehead or coronal approach) Blepharoplasty 15820 Blepharoplasty, lower eyelid 15821 Blepharoplasty, lower eyelid; with extensive herniated fat pad 15822 Blepharoplasty, upper eyelid 15823 Blepharoplasty, upper eyelid; with excessive skin weighting down lid Rhinoplasty 30400 Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip 30410 Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip 30420 Rhinoplasty, primary; including major septal repair Cheek Augmentation 21270 Malar augmentation, prosthetic material 21208 Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant) 21209 Osteoplasty, facial bones; reduction Jaw Reconstruction 21125 Augmentation, mandibular body or angle; prosthetic material 21127 Augmentation, mandibular body or angle; with bone graft, onlay or interpositional (includes obtaining autograft) 21208 Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant) 21209 Osteoplasty, facial bones; reduction Chin Reconstruction 21120 Genioplasty; augmentation (autograft, allograft, prosthetic material) 21121 Genioplasty; sliding osteotomy, single piece 21122 Genioplasty; sliding osteotomies, 2 or more osteotomies (eg, wedge excision or bone wedge reversal for asymmetrical chin) 21123 Genioplasty; sliding, augmentation with interpositional bone grafts (includes obtaining autografts) 21208 Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant) 21209 Osteoplasty, facial bones; reduction Face Lift: These codes are covered when required as part of medically necessary facial feminization procedure 15824 Rhytidectomy; forehead 15825 Rhytidectomy; neck with platysmal tightening (platysmal flap, P-flap) 15826 Rhytidectomy; glabellar frown lines

19 15828 Rhytidectomy; cheek, chin, and neck Liposuction: These codes are covered when required as part of medically necessary facial feminization procedure 15876 Suction assisted lipectomy; head and neck 15877 Suction assisted lipectomy; trunk 15878 Suction assisted lipectomy; upper extremity 15879 Suction assisted lipectomy; lower extremity Trachea Shave/Thyroid Cartilage Reduction 31599 Unlisted procedure, larynx Chest and Genital Surgery for Feminization Surgery 17380 Electrolysis epilation, each 30 minutes 19325 Mammaplasty, augmentation; with prosthetic implant 19350 Nipple/areola reconstruction 19357 Breast reconstruction, immediate or delayed, with tissue expander, including subsequent expansion 19380 Breast reconstruction, immediate or delayed, with tissue expander, including subsequent expansion 53410 Urethroplasty, 1-stage reconstruction of male anterior urethra 53420 Urethroplasty, 2-stage reconstruction or repair of prostatic or membranous urethra; first stage 53425 Urethroplasty, 2-stage reconstruction or repair of prostatic or membranous urethra; second stage 54120 Amputation of penis; partial
54125 Amputation of penis; complete 54300 Plastic operation of penis for straightening of chordee (eg, hypospadias), with or without mobilization of urethra 54125 Amputation of penis; complete 54300 Plastic operation of penis for straightening of chordee (eg, hypospadias), with or without mobilization of urethra 55970 Intersex surgery; male to female 56800 Plastic repair of introitus 56805 Clitoroplasty for intersex state 57291 Construction of artificial vagina; without graft
57292 Construction of artificial vagina; with graft 57335 Vaginoplasty for intersex state Chest and Genital Surgery for Masculinization Surgery 19303 Mastectomy, simple, complete 19316 Mastopexy 19350 Nipple/areola reconstruction 53430 Urethroplasty, reconstruction of female urethra 54660 Insertion testicular prosthesis 55175 Scrotoplasty; simple
55180 Scrotoplasty; complex 55980 Intersex surgery; female to male 56620 Vulvectomy; simple 56625 Vulvectomy; complete 56800 Plastic repair of introitus 56805 Clitoroplasty for intersex state 56810 Perineoplasty, repair of perineum, nonobstetrical 57110 Vaginectomy; complete removal of vaginal wall 57111 Vaginectomy; with removal of paravaginal tissue (radical vaginectomy)

20 Prior authorization is required for the following Assisted Reproductive Services codes for Commercial Managed Care (HMO and POS), Commercial PPO, and Indemnity: Professional Providers 54900 Epididymovasostomy, anastomosis of epididymis to vas deferens; unilateral 54901 Epididymovasostomy, anastomosis of epididymis to vas deferens; bilateral S4026 Procurement of donor sperm from sperm bank Type of service 5, and 1 unit of service, for procurement of donor sperm from a sperm bank, for each vial procured (1 unit = 1vial)

55870 Electroejaculation S4028 Microsurgical epididymal sperm aspiration (MESA) Type of service 2 Note: MESA is payable only for congenital absence or congenital obstruction of the vas deferens. 58974 Embryo transfer, intrauterine 58976 Gamete, zygote, or embryo intrafallopian transfer, any method 89255 Preparation of embryo for transfer (any method) 89257 Sperm identification from aspiration (other than seminal fluid) 89258 Cryopreservation; embryo(s) 89259 Cryopreservation; sperm 89260 Sperm isolation; simple prep (eg. per col gradient, albumin gradient) for insemination or diagnosis with semen analysis
89261 Sperm isolation; complex prep (eg, per col gradient, albumin gradient) for insemination or diagnosis with semen analysis
89264 Sperm identification from testis tissue, fresh or cryopreserved 89268 Insemination of eggs 89272 Extended culture of egg(s)/embryo(s), 4-7 days 89280 Assisted egg fertilization, microtechnique; less than or equal to 10 egg 89281 Assisted egg fertilization, microtechnique; greater than 10 eggs 89321 Semen analysis, presence and/or motility of sperm 89335 Cryopreservation, reproductive tissue, testicular (Covered effective 11/1/2009) 89337 Cryopreservation, mature egg(s) 89342 Storage, (per year); embryo(s) 89343 Storage, (per year); sperm/semen 89346 Storage, (per year); egg 89352 Thawing for cryopreserved; embryo(s) 89353 Thawing of cryopreserved; sperm/semen, each aliquot 89356 Thawing of cryopreserved; egg(s), each aliquot
The following codes are considered non-covered for all Commercial Plans as they do not meet our Medical Technology Assessment Guidelines and if billed will reject leaving no patient balance 89344 Storage, (per year); reproductive tissue, testicular/ovarian (except for authorized TESE) 89354 Thawing of cryopreserved; reproductive tissue, testicular/ovarian (except for authorized TESE)
Reproductive Specialist Providers 58970 Follicle puncture for egg retrieval, any method S4011 In vitro fertilization, including but not limited to identification and incubation of mature eggs, fertilization with sperm, incubation of embryo(s), and subsequent visualization, determination of development Type of service 2
89250 Culture of egg(s)/embryo(s), less than 4 days; Note: This procedure may be billed once per cycle. 89253 Assisted embryo hatching, microtechniques (any method)

21 89254 Egg identification from follicular fluid Note: This procedure may be billed once per cycle. Contracted Sperm Banks S4030 Sperm procurement & cryopreservation services; initial visit Type of service L
Note: This procedure is limited to one visit per lifetime. S4031 Sperm procurement & cryopreservation services; subsequent visits Type of service L
89259 Annual sperm storage due to other medical treatment rendering a member infertile Type of service L Note: This procedure may be billed once per year. The procedure may be covered for members in active infertility treatment, post microsurgical epididymal sperm aspiration (MESA), performed for congenital absence of the vas deferens.

Policy History 3/2026 Title change for 911: from Gene Therapy for Inherited Retinal Dystrophy Cell to Gene Therapy for Ocular Diseases. Also added HCPCS code: J3403. Effective 3/15/26. 11/2025 MP 147 ZulressoTM (Brexanolone) for the Treatment of Post-Partum Depression retired.
Prior authorization requirement removed. Effective 11/1/2025. MP 028 Adjunct Medications to Support Hematopoietic Stem Cell Transplantation and its Complications prior authorization in effect for J3402. 9/2025 MP 428 Reconstructive Breast Surgery/Management of Breast Implants. Prior authorization is not required for breast cancer-related diagnoses. Effective 9/1/2025. 8/2025 MP 086 Assisted Reproductive Services Infertility Services. Removed 58825 from Prior authorization.
8/2025 MP 194 Behavioral Health Continuum of Care added. Prior authorization is required for S0201, H0015, H0035, S9480. Effective 7/1/2025. 5/2025 MP 485 Intraosseous Basivertebral Nerve Ablation clarified. CPT 64629 removed. Prior authorization is no longer required for 64629. Effective 5/1/2025.
4/2025 MP 035 Temporomandibular Joint Disorder clarified. CPT codes 21073 and 21116 removed. Prior authorization is no longer required for codes 21073 and 21116. Effective 4/1/2025.
MP 238 Treatment of Varicose Veins/Venous Insufficiency clarified to add Prior Authorization Request Form (#129). 3/2025 MP 110 Meniscal Allografts and Other Meniscal Implants removed. PA is required through InterQual. Effective 3/1/2025. MP 111 Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions. PA is required through InterQual. Effective 3/1/2025. MP 428 Reconstructive Breast Surgery/Management of Breast Implants clarified to add S2068.
MP 037 Surgical and Debulking Treatments for Lymphedema added. Prior authorization is required for codes 15878, 15879. Effective date in effect. 2/2025 Code 59866 Multifetal pregnancy reduction removed. Effective 2/1/2025. 12/2024 MP 106 Gene Therapies for Metachromatic Leukodystrophy added. Prior authorization is required for Lenmeldy. Effective 12/1/2024. 11/2024 MP 543 Negative Pressure Wound Therapy in the Outpatient Setting. Prior authorization requirements removed. Effective 11/1/2024. 10/2024 MP 107 Continuous or Intermittent Monitoring of Glucose in Interstitial Fluid and Artificial Pancreas Device Systems. Prior authorization requirements removed. Effective 10/1/2024. 8/2024 MP 089 Adoptive Cell Therapies for Melanoma. Prior authorization is required for Amtagvi. Effective 8/1/2024. MP 215 Gene Therapies for Thalassemia. Prior authorization is required for Casgevy.
Effective 8/1/2024. MP 946 Monoclonal Antibodies for Treatment of Alzheimer's Disease. Prior authorization is required for Kisunla. Effective 8/1/2024.

22 7/2024 MP 050 Gene Therapies for Sickle Cell Disease. Prior authorization is required for code J3394. Effective 7/1/2024.
MP 215 Gene Therapies for Thalassemia. Prior authorization is required for code J3393. Effective 7/1/2024. MP 297 Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric Neurologic Disorders.: Prior authorization is required for codes 90867, 90868, 90869 for commercial PPO products. Effective 7.1.2024.
6/2024 MP 946 Monoclonal Antibodies for Treatment of Alzheimer's Disease. Prior authorization is required for code J0174. Effective 6/1/2024. 5/2024 MP 043 Suction Lipectomy for Lipedema added. Prior authorization is required for codes 15832, 15833, 15834, 15835, 15836, 15878, 15879. Effective 5/1/2024. 4/2024 MP 097 Bone Morphogenetic Protein. Prior authorization requirements removed. CPT 20930 does not require prior authorization. Effective 4/1/2024.

MP 028 Omidubicel as Adjunct Treatment for Hematologic Malignancies. Policy revised to include medically necessary and investigational indications. Prior authorization is required.
Effective 4/1/2024. 3/2024 MP 374 Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions retired. The policy will no longer be available on the Blue Cross website. To submit authorization requests through InterQual, use Authorization Manager. Effective 3/1/2024.
MP 050 Gene Therapies for Sickle Cell Disease added. Effective 1/1/2024. MP 055 Gene Therapies for Sickle Cell Disease Prior Authorization Request Form for Casgevy ™ (Exagamglogene autotemcel) added. Effective 1/1/2024. MP 168 Gene Therapies for Hemophilia A or B. Added HCPCS code J1412 2/2024 MP 485 Intraosseous Basivertebral Nerve Ablation added. Effective 2.1.2024. 12/2023 Policy revised to remove orchiectomy and hysterectomy procedure codes from MP 189. Prior authorization is not required for orchiectomy and hysterectomy codes. Effective 12/1/2023. 11/2023 Policy clarified to include prior authorization request form for Gene Therapies for Hemophilia A Roctavian MP 166. 9/2023 Policy clarified to include prior authorization requests for services listed in MP 072 are to be submitted using Authorization Manager.
9/2023 MP 022 Gene Therapies for Duchenne Muscular Dystrophy added. Effective 8/9/2023.
7/2023 MP 028 Therapeutic Radiopharmaceuticals removed. Policy 028 was retired in October

2022. 7/2023 MP 159 Gene Therapies for Bladder Cancer added. Effective 6/8/2023. Prior authorization is no longer required for 58321, 58322, 58323; 74740. These codes were removed from MP #072. 6/7/2023
      5/2023 MP 320 Diagnosis and Treatment of Sacroiliac Joint Pain reinstated and added.
      4/2023 MP 168 Gene Therapies for Hemophilia B added. Prior authorization is required for code J1411. Effective 4/3/2023. 4/2023 Musculoskeletal medical policies retired effective April 1, 2023. These policies will no longer be available on the Blue Cross website. To submit authorization requests through InterQual use Authorization Manager. MP 585 Artificial Intervertebral Disc - Cervical Spine

      MP 320 Diagnosis and Treatment of Sacroiliac Joint Pain

      MP 690 Epidural Steroid Injections

      MP 485 Percutaneous Balloon Kyphoplasty, Radiofrequency Kyphoplasty and Mechanical Vertebral Augmentation
      MP 484 Percutaneous Vertebroplasty and Sacroplasty

      MP 472 Spinal Cord and Dorsal Root Ganglion Stimulation

      3/2023 Policy #179 Orthognathic Surgery added. 2/2023 MP 241 Gene Therapies for Cerebral Adrenoleukodystrophy added. Effective 2/1/2023. 1/2023 MP#107- removed K0553 as it was deleted and replaced with A4239. Effective 1/1/2023. 12/2022 MP#107- removed S1036. Prior authorization is no longer required for this code.

23 10/2022 Policy clarified. Hyperlink to InterQual spine procedures that require prior authorization added. Code Q2056 added under #942 Chimeric Antigen Receptor Therapy for Multiple Myeloma. 6/2022 Policy #653 removed. Prior authorization is no longer required for MP 653 HBO Therapy.
Effective 6/1/2022.
6/2022 Policy updated to include prior authorization requirements for Commercial PPO. Effective 6/1/2022.
4/2022 Policy #465 was removed. Prior authorization is no longer required for #465 Lipid Apheresis.
3/2022 Policy #091 Applied Behavioral Analysis (ABA) added.
10/2021 HCPCS code C9081 & Q2054 added. 6/2021 Prior authorization is required for #942 Chimeric Antigen Receptor Therapy for Multiple Myeloma. Effective 6/4/2021. 5/2021 Prior authorization requirements clarified: L6955; L6965; 43847 in effect. C1062 added effective 1/1/2021.
4/2021 Prior authorization is clarified: #142 Air Ambulance Transport; #146 Ground Ambulance;

158 Outpatient Pediatric Pain Rehabilitation Centers. Clarified coding information.

3/2021 Policy #285 Placental or Umbilical Cord Blood as a Source of Stem Cells retired; outpatient prior authorization requirements removed. Effective 3/1/2021.
2/2021 Prior authorization is required for #077 Scenesse (afamelanotide) for Treatment of Erythropoietic Protoporphyria. Effective 2/1/2021. 1/2021 Prior authorization information for Medicare Advantage transferred into Policy # 132, Medicare Advantage Management. Links to the following pharmacy policies were added:
▪ Medical Benefit Prior Authorization Medication List 034 ▪ Medical Utilization Management and Pharmacy Prior Authorization Policy 033. 11/2021 HCPCS code G0277 added. Prior authorization is required. Policy #653 Hyperbaric Oxygen Therapy. Effective 11/1/2020. 10/2020 Prior authorization for policy #088 Preimplantation Genetic Testing is not required for Medicare Advantage. Effective 10/23/2020. 7/2020 HCPCS code J3399 added. Effective 7/1/2020. 5/2020 HCPCS code J2001 removed. The code is not specific to policy #087 Esketamine Nasal Spray (Spravato) and Intravenous Ketamine for Treatment Resistant Depression. This code does not require prior authorization. Effective 5/1/2020.
4/2020 The following codes were added: G2082, G2083, J2001. Policy #087 Esketamine Nasal Spray (Spravato) and Intravenous Ketamine for Treatment-Resistant Depression. Effective 4/1/2020. 4/2020 The following codes were removed: 38205; 38206; 38230; 38232; S2140. Effective 4/1/2020.
2/2020 New document #072 issued. Effective 2/1/2020.