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Medical Policies - CURRENT

Cosmetic Services (Possible)

Diagnostic Testing

Durable Medical Equipment, Prosthetics and Orthotics

Facility Services

Home Infusion Therapy

Home Services - Miscellaneous

Injectables and Infused Drugs

Miscellaneous Services

Obstetrics, Gynecology and Reproductive Medicine

ACA Preventive Services

Radiology

Rehabilitative Therapy

Surgery

Transplants, Solid Organ

Transplants, Stem Cell

ALL MEDICAL POLICIES:

Document Name:Document Number:
3D Reconstructionpel.aa.3DR.501
Afirma Thyroid FNA Analysispel.ph.AFI.500x
Aimovig (erenumab-aooe)pel.ph.AIM.750
Air Ambulance Servicespel.aa.AIR.100
Alimta (Pemetrexed)pel.ph.ALI.500x
Aliqopa (copanlisib)pel.ph.ALQ.700
Allogeneic Hematopoietic Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasmspel.aa.BCBS.8.02.21
Allogeneic Hematopoietic Stem-Cell Transplantation for Genetic Diseases and Acquired Anemiaspel.aa.BCBS.8.02.22
Allogeneic Pancreas Transplantpel.aa.BCBS.7.03.03
Ambulatory Event Monitors and Mobile Cardiac Outpatient Telemetrypel.aa.AMB.601
Amniotic Membrane and Amniotic Fluidpel.aa.AMN.501
Anesthesia Services for Gastrointestinal Endoscopic Procedurespel.aa.ANE.851
Applied Behavior Analysis Therapy for Treatment of Autism Spectrum Disorderpel.aa.APP.700
Aranesp - No precertification required; Guideline onlypel.aa.ARA.700
Arcalyst (rilonacept)pel.ph.ARC.700
Artificial Intervertebral Disc Replacement - Cervical - ARCHIVEDpel.aa.ART.501-Archived
AVASTIN (bevacizumab)pel.aa.AVA.500x
Bariatric Surgerypel.aa.BAR.201
Benlysta (belimumab)pel.ph.BEN.700
Berinert (C1 esterase inhibitor)pel.ph.BER.700
Bio-Engineered Skin and Soft Tissue Substitutespel.aa.TIS.501
Bivigampel.aa.BIV.700
Blepharoplasty and Repair of Blepharoptosispel.ph.BLE.501
Bone (Mineral) Density Studiespel.aa.BON.501
Botoxpel.aa.BTX.700
Botulinum Toxins (BOTOX, DYSPORT, MYOBLOC and XEOMIN)pel.aa.BOT.501
Brachytherapy, Noncoronarypel.ph.BRA.501
Breast Cancer Assays of Genetic Expression in Tumor Tissuepel.aa.ONC.501
Breast Pumpspel.aa.BRE.501
Bronchial Thermoplastypel.aa.BRO.501
Cardiac-Related Procedurespel.aa.CAR.700
Cardiovascular Risk Panelspel.aa.CAR.300
Carimune NFpel.aa.cam.700
Carotid Artery Stentingpel.ph.CAR.601
Catheter Ablation as Treatment for Atrial Fibrillationpel.aa.RAD.251
Cerezyme (imiglucerase)pel.ph.CER.700
Charged-Particle (Proton or Helium Ion) Radiation Therapy for Neoplastic Conditionspel.aa.CHA.701
Chiropractic Servicespel.aa.CHI.501
Cinryze (C1 esterase inhibitor)pel.ph.CIN.700
Circulating Tumor DNA and Circulating Tumor Cells for Cancer Management (Liquid Biopsy)pel.aa.CIR.500
Circulating Tumor DNA Management of Non-Small-Cell Lung Cancer (Liquid Biopsy)pel.aa.CIR.550
Clinical Trials - Routine Costspel.aa.CLI.501
Cognitive Rehabilitation Therapypel.aa.COG.501
Colonoscopypel.aa.COL.301
Colorectal Cancer Screeningpel.aa.COL.401
Complementary and Alternative Medicine (CAM)pel.aa.COM.300
Composite Tissue Allotransplantation of the Hand and Facepel.aa.COM.200
Compression Garments (Gradient) for the Extremitiespel.ph.GRA.500
Computer-Assisted Navigation for Orthopedic Procedurepel.aa.COM.301
Computerized Corneal Topographypel.ph.COM.801
Continuous Glucose Monitoring Systempel.aa.CON.701
Corneal Collagen Cross-Linkingpel.aa.CRO.300
Cosmetic and Reconstructive Surgery and Servicespel.aa.COS.401
Cuvitru (Immune Globulin Subcutaneous [Human], 20% Liquid)pel.aa.cuv.700
Cyramza (ramucirumab)pel.ph.CYR.700
Cytochrome p450 Genotypingpel.ph.CYT.501
Dietetic Treatment of Eating Disorderspel.aa.DIE.501
Digital Breast Tomosynthesispel.aa.DIG.501
Drug Testing in Pain Management and Substance Abuse Treatmentpel.aa.DRU.500
Dupixent (dupilumab)pel.ph.DUP.700
Durable Medical Equipment, Prosthetics and Orthoticspel.aa.DUR.501
Durable Medical Equipment, Prosthetics and Orthotics - Small Group & Individual Plans, Fed 87 and QUEST Integrationpel.aa.DUR.601
Elelyso (taliglucerase)pel.ph.ELE.700
Eligard (leuprolide acetate)pel.ph.ELI.700
Enbrel (etanercept)pel.ph.ENB.700
Endoscopic Radiofrequency Ablation or Cryoablation for Barrett Esophaguspel.aa.RAD.651
Endovascular Procedures for Intracranial Arterial Disease (Atherosclerosis and Aneurysms)pel.aa.END.100
Entyvio (vedolizumab)pel.ph.ERB.700
Epogen - No precertification required; Guideline onlypel.aa.EPO.700
Erbitux (Cetuximab)pel.aa.ERB.500x
Erectile Dysfunctionpel.aa.MAL.501
Erythropoiesis Stimulating Agents (ESA) - No Precertification Required; Guideline Onlypel.aa.ERY.501
Esophageal pH Monitoringpel.ph.ESO.601
Euflexxapel.aa.EUF.700
Expanded Molecular Panel Testing of Cancers to Identify Targeted Therapiespel.aa.MOL.500
Extracorporeal Membrane Oxygenation (ECMO)pel.aa.EXT.501
Eylea (aflibercept) – no precertification required as of 03/01/2019pel.ph.EYL.700
Firazyr (icatibant)pel.ph.FIR.700
Flebogamma DIFpel.aa.fle.700
Flolan (epoprostenol)pel.ph.FLO.700
Folotyn (pralatrexate)pel.ph.FOL.700
Forteo (Teriparatide)pel.ph.TER.201
Gammagard Liquidpel.aa.gam.700
Gammagard S/Dpel.aa.gsd.700
Gammakedpel.aa.gak.700
Gammaplexpel.aa.gap.700
Gamunex-Cpel.aa.gax.700
Gattex (teduglutide)pel.ph.GAT.700
Gazyva (obinutuzumab)pel.ph.GAZ.700
Gel-Onepel.aa.gel.700
Gender Identity Servicespel.aa.GEN.650
Gene Expression Profiling and Protein Biomarkers for Prostate Cancer Managementpel.aa.GEN.250
Genetic Testing for Developmental Delay/Intellectual Disability, Autism Spectrum Disorder, and Congenital Anomaliespel.aa.GEN.901
Genetic Testing for Diagnosis and Management of Mental Health Conditionspel.aa.GEN.501
Genetic Testing for Hereditary Breast and/or Ovarian Cancerpel.aa.GEN.701
Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromespel.aa.GEN.301
Genetic Testing for Non-Cancerous Inheritable Diseasespel.aa.GEN.801
Genetic Testing of Inherited Cancer Predispositionpel.aa.GEN.851
Global Oncologypel.ph.GLO.700
Gonal-f (follitropin alfa)pel.ph.GON.700
Growth Hormone Therapypel.aa.GRO.501
H.P. Acthar Gel (repository corticotropin injection)pel.ph.HPA.700
Habilitative Servicespel.aa.HAB.501
Heart/Lung Transplantpel.aa.BCBS.7.03.081
Heart Transplantpel.aa.BCBS.7.03.091
Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemiapel.aa.BCBS.8.01.321
Hematopoietic Cell Transplantation for Acute Myeloid Leukemiapel.aa.BCBS.8.01.261
Hematopoietic Cell Transplantation for Autoimmune Diseasespel.aa.BCBS.8.01.251
Hematopoietic Cell Transplantation for Chronic Lymphocytic Leukemia and Small Lymphocytic Lymphomapel.aa.BCBS.8.01.151
Hematopoietic Cell Transplantation for Chronic Myeloid Leukemiapel.aa.BCBS.8.01.301
Hematopoietic Cell Transplantation for CNS Embryonal Tumors and Ependymomapel.aa.BCBS.8.01.281
Hematopoietic Cell Transplantation for Epithelial Ovarian Cancerpel.aa.BCBS.8.01.231
Hematopoietic Cell Transplantation for Hodgkin Lymphomapel.aa.BCBS.8.01.291
Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors in Adultspel.aa.BCBS.8.01.241
Hematopoietic Cell Transplantation for Non-Hodgkin Lymphomaspel.aa.BCBS.8.01.201
Hematopoietic Cell Transplantation for Plasma Cell Dyscrasias, Including Multiple Myeloma and POEMS Syndromepel.aa.BCBS.8.01.171
Hematopoietic Cell Transplantation for Primary Amyloidosispel.aa.BCBS.8.01.421a
Hematopoietic Cell Transplantation for Solid Tumors of Childhoodpel.aa.BCBS.8.01.341
Hematopoietic Cell Transplantation for Waldenstrom Macroglobulinemiapel.aa.BCBS.8.01.421
Hematopoietic Cell Transplantation in the Treatment of Germ-Cell Tumorspel.aa.BCBS.8.01.351
Hepatitis C (Direct Acting Antiviral Medications for Treatment of Hepatitis C)pel.aa.DIR.505
High Frequency Chest Wall Oscillation Devicespel.aa.OSC.501
Hip, Knee, and Shoulder Surgerypel.aa.HIP.200
Hizentra (Immune Globulin Subcutaneous [Human], 20% Solution)pel.aa.hiz.700
HMSA's Business Association with NIApel.aa.HMS.650
Home Continuous Inotropic Infusion Therapypel.aa.HOM.351
Home Enteral Nutrition Therapypel.aa.HOM.151
Home Health Carepel.aa.HOM.201
Home Infusion Pain Management Therapypel.ph.HOM.301
Home Total Parenteral Nutrition for Adultspel.aa.HOM.901
Humatropepel.aa.HUM.700
Humira (adalimumab)pel.ph.HUM.700
Hyalganpel.aa.hya.700
Hyaluronate Productspel.ph.HYA.700
Hyperbaric Oxygen Pressurization (HBO)pel.ph.HYP.501
Hyqviapel.aa.hyq.700
Ilaris (canakinumab)pel.ph.ILA.700
Immune Globulin Therapypel.aa.INT.701
Implantable Ventricular Assist Devices and Total Artificial Heartspel.aa.VEN.501
Incontinence Suppliespel.aa.INC.505
Insulin Pumps - Externalpel.aa.INS.501
Intensity Modulated Radiation Therapy (IMRT)pel.aa.INT.201
Intravenous (IV) Anti-Infective Therapypel.aa.HOM.501
Intravenous (IV) Hydration Therapy for Adultspel.aa.HOM.551
In Vitro Fertilizationpel.ph.INV.501
Isolated Small Bowel Transplantpel.aa.BCBS.7.03.041
Jetrea (ocriplasmin) – no precertification required as of 03/01/2019pel.ph.JET.700
Kadcyla (ado-trastuzumab emtansine)pel.ph.KAD.700
Kalbitor (ecallantide)pel.ph.KAL.700
Keytruda (pembrolizumab)pel.ph.KEY.700
Knee Orthoses for Osteoarthritispel.aa.KNE.501
Krystexxa (pegloticase)pel.ph.KRY.700
Kymriah (tisagenlecleucel)pel.ph.KYM.700
Kynamro (mipomersen)pel.ph.KYN.700
Kyphoplasty and Vertebroplastypel.aa.KYP.501
Kyprolis (carfilzomib)pel.ph.KYP.700
Laser Therapy for Plaque Psoriasispel.aa.LAS.501
Leadless Cardiac Pacemakerpel.aa.CAR.600
Leuprolidepel.aa.leu.700
Liver Transplantpel.aa.BCBS.7.03.061
Low-Molecular-Weight Heparinpel.ph.LOW.501
Lucentis (ranibizumab) - no precertification required as of 03/01/2019pel.ph.LUC.700
Lung and Lobar Lung Transplantpel.aa.BCBS.7.03.071
Lupaneta Packpel.aa.lut.700
Lupron (Leuprolide Acetate) and Supprelin LA (Histrelin Acetate) Subcutaneous Implantpel.ph.LUP.600x
Lupron Depotpel.aa.LUP.700
Lupron Depot-PEDpel.aa.LDP.700
Luxturna (Voretigene Neparvovec-rzyl)pel.ph.LUX.700
Macugen (pegaptanib) - no precertification required as of 03/01/2019pel.ph.MAC.700
Makena (hydroxyprogesterone caproate injection)pel.ph.MAK.700
Manipulation Treatmentspel.aa.MAN.501
Measurement of Lipoprotein-Associated Phospholipase A2 (Lp-PLA2) in the Assessment of Cardiovascular Riskpel.aa.MEA.501
Medical Foods for Inborn Errors of Metabolismpel.ph.MED.301
Micro-Invasive Glaucoma Surgery (Aqueous Stents)pel.aa.MIC.401
Monoviscpel.aa.mon.700
Multigene Expression Assay for Predicting Recurrence in Colon Cancerpel.aa.MUL.100
Myalept (metreleptin)pel.ph.MYA.700
Mylotarg (gemtuzumab ozogamicin)pel.ph.MYL.700
Myoblocpel.aa.MYO.700
Naturopathic Servicespel.ph.NAT.300
Negative Pressure Wound Therapy (NPWT)pel.aa.NEG.501
Never Events and Hospital-Acquired Conditionspel.aa.NEV.501
Nexavar (Sorafenib)pel.aa.NEX.550x
Noninvasive Prenatal Testing for Fetal Aneuploidies Using Cell-Free Fetal DNApel.aa.SEQ.651
Novel Biomarkers in Risk Assessment and Management of Cardiovascular Diseasepel.aa.LIP.601
Nplate (romiplostim)pel.ph.NPL.700
Observation Servicespel.aa.OBS.501
Occlusion of Uterine Arteries Using Transcatheter Embolizationpel.ph.UTE.501
Occupational Therapypel.aa.OCC.601
Octagampel.aa.oct.700
Off-Label Drug Usepel.aa.OFF.601
Orthodontic Treatment of Orofacial Anomaliespel.aa.ORT.500
Orthoviscpel.aa.ORT.700
Oxygen and Oxygen Equipmentpel.aa.OXY.651
Palynziq (pegvaliase-pqpz)pel.ph.PAL.750
Panniculectomy/Abdominoplastypel.aa.PAN.601
PCSK9 Inhibitors Praluent (Alirocumab) and Repatha (Evolocumab) For the Treatment of Familial Hypercholesterolemiapel.ph.PCS.700
Percutaneous Left Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillationpel.aa.PER.700
Percutaneous Mitral Valve Repairpel.aa.PER.505
Perjeta (pertuzumab)pel.ph.PER.700
Photochemotherapypel.ph.PHO.501
Photodynamic Therapy for the Treatment of Actinic Keratoses and Other Skin Lesionspel.aa.PHO.701
Physical Therapypel.aa.PHY.601
Polysomnography and Home Sleep Apnea Testingpel.aa.POL.501
Positive Airway Pressure and Oral Devices for the Treatment of Obstructive Sleep Apneapel.aa.POS.201
Post-acute, Residential Treatment Facility and Community Care Foster Family Home Carepel.aa.POS.601
Post-acute and Residential Treatment Facility Stayspel.aa.POS.501
Posterior Tibial Nerve Stimulationpel.aa.POS.701
Precertification Requirements - Medicare Advantage Planspel.aa.AKA.501
Preimplantation Genetic Testing Diagnosis (PGD)pel.aa.PRE.901
Prenatal Carrier Screening for Genetic Diseasespel.aa.GEN.801
Preventive Health Guidelines - Menpel.ph.PRE.501
Preventive Health Guidelines - Newborns and Childrenpel.ph.PRE.521
Preventive Health Guidelines - Prenatal Carepel.aa.OBG.501
Preventive Health Guidelines - Womenpel.ph.GUI.401
Privigenpel.aa.pri.700
Probuphine (buprenorphine implant)pel.ph.PRB.700
Procrit - No precertification required; Guideline onlypel.aa.PRO.700
Prolia (denosumab)pel.ph.PRO.700
Provenge (sipuleucel-T)pel.ph.PRV.700
Pulmonary Rehabilitationpel.aa.PUL.501
Pulse Oximeter for Childrenpel.aa.HOM.801
Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumorspel.aa.RAD.652
Radiology Guidelines for Advanced Imaging Studiespel.aa.IMA.501
Readmissions and Transferspel.aa.REA.401
Real-Time Intrafraction Motion Management During Radiotherapypel.aa.REA.100
Reduction Mammaplasty for Breast-Related Symptomspel.ph.RED.501
Remicade (Infliximab)pel.aa.REM.400x
Remodulin (treprostinil)pel.ph.REM.700
Risk-Reducing Mastectomypel.aa.PRO.4451
Rituxan (rituximab)pel.ph.RIT.700
Ruconest (recombinant C1 esterase inhibitor)pel.ph.RUC.700
Sensory Integration Therapy and Auditory Integration Therapypel.aa.SEN.101
Sepsis and Septic Shockpel.aa.SEP.500
Services from the Radiology Section of CPT Billed with Other Servicespel.ph.SER.450
Signifor (pasireotide)pel.ph.SIG.700
Small Bowel/Liver and Multivisceral Transplantpel.aa.BCBS.7.03.051
Soliris (eculizumab)pel.ph.SOL.700
Somatuline Depot (lanreotide)pel.ph.SOM.700
Specialty Drugs Requiring Precertificationpel.aa.FDA.501
Speech Therapy Services/Rehabilitationpel.aa.SPE.601a
Spinal Cord Stimulationpel.aa.SPI.501
Spinal Interventional Pain Management and Spine Surgerypel.aa.SPI.601
Spinraza (nusinersen)pel.ph.SPI.700
Stelara (ustekinumab)pel.ph.STE.700
Stereotactic Radiosurgery and Stereotactic Body Radiation Therapypel.aa.STE.601
Subcutaneous Implantable Cardioverter Defibrillator (ICD) Systempel.aa.SUB.505
Supartzpel.aa.sup.700
Supportive Carepel.aa.SUP.600
Supprelin LA (histrelin acetate)pel.ph.SUP.700
Surgical Treatment of Femoroacetabular Impingementpel.ph.SUR.801
Sylvant (siltuximab)pel.ph.SYL.700
Synagis (Palivizumab)pel.aa.SYN.500x
Synribo (omacetaxine mepesuccinate)pel.ph.SYN.700
Synviscpel.aa.syn.700
Telehealth Servicespel.aa.TEL.501
Tilt Table Testingpel.aa.TIL.501
Torisel (temsirolimus)pel.ph.TOR.700
Transcatheter Aortic-Valve Implantation for Aortic Stenosispel.aa.TRA.601
Transcatheter Closure of Patent Foramen Ovale for Stroke Preventionpel.aa.TRA.500
Transcatheter Pulmonary Valve Implantationpel.aa.TRA.701
Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorderspel.aa.REP.101
Transcutaneous Electrical Nerve Stimulation (TENS)pel.aa.TRA.501
Treatment of Hyperhidrosispel.ph.THO.501
Treatment of Varicose Veinspel.ph.TRE.501
Vagus Nerve Stimulationpel.aa.VAG.100
Vectibix (Panitumumab)pel.aa.VEC.500x
Velcade (Bortezomib)pel.ph.VEL.500x
Vimizim (elosulfase alfa)pel.ph.VIM.700
Virtual Colonoscopypel.ph.VIR.500
VPRIV (velaglucerase)pel.ph.VPR.700
Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorderspel.aa.WHO.300
Xgeva (denosumab)pel.ph.XGE.700
Xolair (Omalizumab)pel.ph.XOL.500x
Xyrem (sodium oxybate)pel.ph.XYR.700
Yervoy (ipilimumab)pel.ph.YER.700
Yescarta (Axicabtagene Ciloleucel)pel.aa.YES.201
Zaltrap (ziv-aflibercept)pel.ph.ZAL.700
Zevalin (Ibritumomab tiuxetan)pel.ph.ZEV.500x
 

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