Preview questionnaires and medical necessity criteria Form

Preview questionnaires and medical necessity criteria For Medicare Plus BlueSM, BCN commercial and BCN AdvantageSM Revised April 2026

1

For commercial members, Blue Cross Blue Shield of Michigan and Blue Care Network use the pertinent medical necessity criteria to make determinations on prior authorization requests for the services listed below.
For Medicare Advantage (Medicare Plus Blue and BCN Advantage) members, we make medical necessity decisions based on national coverage determinations, local coverage determinations, and other applicable coverage criteria in Medicare statutes and regulations to determine if an item or service is reasonable, necessary and coverable under Medicare. If such criteria are not fully established and as permitted by Medicare statutes and regulations, we may create internal coverage criteria. Blue Cross licenses InterQual® to assist in creating internal coverage criteria. If InterQual criteria are unavailable, we’ll use our own medical policies, which have been developed in accordance with Medicare statutes and regulations and approved by the Blue Cross Utilization Management Committee. To view medical necessity criteria: • InterQual criteria for various services: Sign up or log in to One Healthcare ID view InterQual procedure criteria. • National Coverage Determinations and Local Coverage Determinations: See the Medicare Coverage Database* for the most current NCDs and LCDs. • Medical policies: Open our Medical Policy Router Search page on bcbsm.com. Enter a procedure code in the Policy/Topic Keyword field to search for the pertinent policy. Preview questionnaires show the questions you’ll need to answer within the questionnaire that opens in the e-referral system so you can prepare your answers ahead of time. For some services, more than one preview questionnaire is listed in the following table because either: • A different questionnaire opens in the e-referral system based on the line of business.
• A trigger questionnaire opens in the e-referral system, after which an additional questionnaire opens. Instead of completing a questionnaire, some services listed below require you to complete a series of InterQual Connect guideline questions in the e-referral system. For more information, refer to the document Submitting prior authorization requests with InterQual® Connect guidelines: Best practices for providers. In the following table, the Criteria source column specifies the criteria we use to make determinations on prior authorization requests for specific services.

Preview questionnaires and medical necessity criteria For Medicare Plus BlueSM, BCN commercial and BCN AdvantageSM Revised April 2026

2

Service Requires prior authorization for Related documents Criteria source Medicare Plus Blue BCN commercial BCN Advantage Balloon ostial dilation ✓ ✓ ✓ Preview questionnaire Balloon Dilation for Treatment of Chronic Sinusitis medical policy Breast elastography

✓ ✓ Preview questionnaire Breast Elastography – Ultrasound or Magnetic Resonance Breast implant management

✓

Preview questionnaire Reconstructive Breast Surgery/Management of Breast Implants medical policy Breast reconstruction

✓

Preview questionnaire Reconstructive Breast Surgery/Management of Breast Implants medical policy Breast reduction

✓

Preview questionnaire Breast Reduction for Breast- Related Symptoms medical policy

✓ Preview questionnaire Local Coverage Determination for Cosmetic and Reconstructive Surgery (L39051) Cosmetic or reconstructive surgery

✓

Preview questionnaire Cosmetic and reconstructive surgery medical policy Dental general anesthesia or dental services, trigger

✓

Preview questionnaire Not applicable

Preview questionnaires and medical necessity criteria For Medicare Plus BlueSM, BCN commercial and BCN AdvantageSM Revised April 2026

3

Service Requires prior authorization for Related documents Criteria source Medicare Plus Blue BCN commercial BCN Advantage Dental general anesthesia

✓

Preview questionnaire Dental General Anesthesia medical policy Dental services

✓

Preview questionnaire • Immediate Repair of Trauma to Natural Teeth medical policy • Dental General Anesthesia medical policy • Oral Surgery medical policy Endoscopic bypass

✓ ✓ Preview questionnaire Gastric Bypass Surgery for Gastroparesis Enteral nutrition

✓

Preview questionnaire Enteral Nutrition medical policy Enteral nutrition – specialized formula

✓ Preview questionnaire Enteral Nutrition CGS Administrators (L38955) Enteral nutrition – standardized formula

✓ Preview questionnaire Enteral Nutrition CGS Administrators (L38955) Gastric pacing / stimulation ✓ ✓ ✓ Preview questionnaire Gastric Electrical Stimulation medical policy Hammertoe correction surgery ✓ ✓ ✓ Preview questionnaire InterQual Procedures Adult Criteria, Arthrodesis or Arthroplasty, Interphalangeal Joint, Second-Fifth Toes

Preview questionnaires and medical necessity criteria For Medicare Plus BlueSM, BCN commercial and BCN AdvantageSM Revised April 2026

4

Service Requires prior authorization for Related documents Criteria source Medicare Plus Blue BCN commercial BCN Advantage Non-Coronary Vascular Stents (previously known as Endovascular intervention, peripheral artery) ✓

✓ None — complete the InterQual Connect guideline questions in the e-referral system. Local Coverage Determination for Non-Coronary Vascular Stents (L35998) Not otherwise classified codes

✓ ✓ Preview questionnaire Applicable Medicare guidelines or medical policies Oral surgery

✓

Preview questionnaire Oral Surgery medical policy Orthognathic surgery

✓

Preview questionnaire Orthognathic Surgery medical policy Panniculectomy (previously known as abdominoplasty)

✓

Preview questionnaire Panniculectomy medical policy

✓ Preview questionnaire Local Coverage Determination for Cosmetic and Reconstructive Surgery (L39051) Prostatic urethral lift

✓ ✓ Preview questionnaire Prostatic Urethral Lift Procedure for the Treatment of BPH medical policy

Preview questionnaires and medical necessity criteria For Medicare Plus BlueSM, BCN commercial and BCN AdvantageSM Revised April 2026

5

Service Requires prior authorization for Related documents Criteria source Medicare Plus Blue BCN commercial BCN Advantage Rhinoplasty

✓

Preview questionnaire Cosmetic and Reconstructive Surgery medical policy ✓

✓ Preview questionnaire Local Coverage Determination for Cosmetic and Reconstructive Surgery (L39051) Sacral nerve neuromodulation / stimulation for fecal incontinence

✓

Preview questionnaire • Sacral Nerve Neuromodulation/Stimulation medical policy • National Coverage Determination for Sacral Nerve Stimulation for Urinary Incontinence (230.18) Sacral nerve neuromodulation / stimulation for urinary incontinence

✓

Preview questionnaire • Sacral Nerve Neuromodulation/Stimulation medical policy • National Coverage Determination for Sacral Nerve Stimulation for Urinary Incontinence (230.18)

✓ Preview questionnaire

Preview questionnaires and medical necessity criteria For Medicare Plus BlueSM, BCN commercial and BCN AdvantageSM Revised April 2026

6

Service Requires prior authorization for Related documents Criteria source Medicare Plus Blue BCN commercial BCN Advantage Septoplasty ✓ ✓ ✓ Preview questionnaire • InterQual Procedures Adult Criteria, Septoplasty • Local Coverage Determination for Cosmetic and Reconstructive Surgery (L39051) Temporomandibular joint surgery

✓

Preview questionnaire Temporomandibular Joint Disorder medical policy Varicose vein treatment

✓

None — complete the InterQual Connect guideline questions in the e-referral system.
Treatment of Varicose Veins/Venous Insufficiency medical policy ✓

✓ Local Coverage Determination for Treatment of Varicose Veins of the Lower Extremities (L34536) Visual training, orthoptic and pleoptic

✓ ✓ Preview questionnaire • Orthoptic Training/Vision Therapy for the Treatment of Vision or Learning Disabilities medical policy • Member certificate or benefit document