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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
Preventive Services
Rehabilitative Therapy
Transplants, Solid Organ
Transplants, Stem Cell


Document Name:Document Number:
3D Reconstructionpel.aa.3DR.501
Afirma Thyroid FNA
Alimta (Pemetrexed)
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
Anesthesia Services for Gastrointestinal Endoscopic Procedurespel.aa.ANE.851
Applied Behavior Analysis Therapy for Treatment of Autism Spectrum Disorderpel.aa.APP.700
Arcalyst (rilonacept)
Artificial Intervertebral Disc: Cervical Spinepel.aa.ART.501
Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesionspel.aa.AUT.201
Avastin (Bevacizumab)pel.aa.AVA.500x
Bariatric Surgerypel.aa.BAR.201
Benlysta (belimumab)
Berinert (C1 esterase inhibitor)
Bio-Engineered Skin and Soft Tissue Substitutespel.aa.TIS.501
Blepharoplasty and Repair of
Bone (Mineral) Density Studiespel.aa.BON.501
Botulinum Toxins (BOTOX, DYSPORT, MYOBLOC and XEOMIN)pel.aa.BOT.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 Disease Risk Assessment and Management Using Novel Biomarkerspel.aa.LIP.601
Cardiovascular Risk Panelspel.aa.CAR.300
Carotid Artery
Carrier Testing for Genetic Diseasespel.aa.GEN.801
Catheter Ablation as Treatment for Atrial Fibrillationpel.aa.RAD.251
Cerezyme (imiglucerase)
Charged-Particle (Proton or Helium Ion) Radiation Therapypel.aa.CHA.701
Chiropractic Servicespel.aa.CHI.501
Cinryze (C1 esterase inhibitor)
Clinical Trials - Routine Costspel.aa.CLI.501
Cognitive Rehabilitation Therapypel.aa.COG.501
Colorectal Cancer Screeningpel.aa.COL.401
Compression Garments (Gradient) for the
Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedurepel.aa.COM.301
Computerized Corneal
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)
Cytochrome p450
Dietetic Treatment of Eating Disorderspel.aa.DIE.501
Digital Breast Tomosynthesispel.aa.DIG.501
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)
Eligard (leuprolide acetate)
Enbrel (etanercept)
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)
Erbitux (Cetuximab)pel.aa.ERB.500x
Erectile Dysfunctionpel.aa.MAL.501
Erythropoiesis Stimulating Agents (ESA) - ARCHIVEDpel.aa.ERY.501
Esophageal pH
Expanded Molecular Panel Testing of Cancers to Identify Targeted Therapiespel.aa.MOL.500
Extracorporeal Membrane Oxygenation (ECMO)pel.aa.EXT.501
Eylea (aflibercept)
Firazyr (icatibant)
Flebogamma DIFpel.aa.fle.700
Flolan (epoprostenol)
Folotyn (pralatrexate)
Forteo (Teriparatide)
GamaSTAN S/D (Immune Globulin [Human])
Gammagard Liquidpel.aa.gam.700
Gammagard S/Dpel.aa.gsd.700
Gattex (teduglutide)
Gazyva (obinutuzumab)
Gender Identity Servicespel.aa.GEN.650
Genetic Testing for Developmental Delay/Intellectual Disability, Autism Spectrum Disorder, and Congenital Anomaliespel.aa.GEN.901
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 Mental Health Conditionspel.aa.GEN.501
Genetic Testing for Non-Cancerous Inheritable Diseasespel.aa.GEN.801
Genetic Testing - Oncologypel.aa.GEN.851
Growth Hormone Therapypel.aa.GRO.501
H.P. Acthar Gel (repository corticotropin injection)
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 Chronic Lymphocytic Leukemia and Small Lymphocytic Lymphomapel.aa.BCBS.8.01.151
Hematopoietic Cell Transplantation for Chronic Myelogenous 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 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 Waldenstrom Macroglobulinemiapel.aa.BCBS.8.01.421
Hematopoietic Cell Transplantation in the Treatment of Germ-Cell Tumorspel.aa.BCBS.8.01.351
Hematopoietic Stem-Cell Transplantation for Acute Myeloid Leukemiapel.aa.BCBS.8.01.261
Hematopoietic Stem-Cell Transplantation for Autoimmune Diseasespel.aa.BCBS.8.01.251
Hematopoietic Stem-Cell Transplantation for Miscellaneous Solid Tumors in Adultspel.aa.BCBS.8.01.241
Hematopoietic Stem-Cell Transplantation for Solid Tumors of Childhoodpel.aa.BCBS.8.01.341
Hepatitis C (Direct Acting Antiviral Medications for Treatment of Hepatitis C)pel.aa.DIR.505
High Frequency Chest Wall Oscillation Devicespel.aa.OSC.501
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
Home INR Monitoringpel.aa.HOM.601
Home Phototherapy for Neonatal Jaundicepel.aa.HOM.700
Home Total Parenteral Nutrition for Adultspel.aa.HOM.901
Humira (adalimumab)
Hyperbaric Oxygen Pressurization (HBO)
Ilaris (canakinumab)
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
Islet Transplantationpel.aa.ISL.100
Isolated Small Bowel Transplantpel.aa.BCBS.7.03.041
Jetrea (ocriplasmin)
Kadcyla (ado-trastuzumab emtansine)
Kalbitor (ecallantide)
Keytruda (pembrolizumab)
Knee Orthoses for Osteoarthritispel.aa.KNE.501
Krystexxa (pegloticase)
Kynamro (mipomersen)
Kyphoplasty and Vertebroplastypel.aa.KYP.501
Kyprolis (carfilzomib)
Laser Therapy for Plaque Psoriasispel.aa.LAS.501
Liver Transplantpel.aa.BCBS.7.03.061
Lucentis (ranibizumab)
Lung and Lobar Lung Transplantpel.aa.BCBS.7.03.071
Lupaneta Packpel.aa.lut.700
Lupron (Leuprolide Acetate) and Supprelin LA (Histrelin Acetate) Subcutaneous
Lupron Depotpel.aa.LUP.700
Lupron Depot-PEDpel.aa.LDP.700
Macugen (pegaptanib)
Makena (hydroxyprogesterone caproate injection)
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
Multigene Expression Assay for Predicting Recurrence in Colon Cancerpel.aa.MUL.100
Myalept (metreleptin)
Negative Pressure Wound Therapy (NPWT)pel.aa.NEG.501
Nerve Fiber Density Testingpel.aa.NER.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
Nplate (romiplostim)
Observation Servicespel.aa.OBS.501
Occlusion of Uterine Arteries Using Transcatheter
Occupational Therapypel.aa.OCC.601
Off-Label Drug Usepel.aa.OFF.601
Orthodontic Treatment of Orofacial Anomaliespel.aa.ORT.500
Oxygen and Oxygen Equipmentpel.aa.OXY.651
PCSK9 Inhibitors Praluent (Alirocumab) and Repatha (Evolocumab) For the Treatment of Familial
Percutaneous Left Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillationpel.aa.PER.700
Percutaneous Mitral Valve Repairpel.aa.PER.505
Perjeta (pertuzumab)
Photodynamic Therapy for the Treatment of Actinic Keratoses and Other Skin Lesionspel.aa.PHO.701
Physical Therapypel.aa.PHY.601
Polysomnography and Sleep Studiespel.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
Preventive Health Guidelines -
Preventive Health Guidelines - Newborns and
Preventive Health Guidelines - Prenatal Carepel.aa.OBG.501
Preventive Health Guidelines -
Probuphine (buprenorphine implant)
Prolia (denosumab)
Prophylactic Mastectomypel.aa.PRO.4451
Provenge (sipuleucel-T)
Pulmonary Arterial Hypertension Oral Agentspel.aa.PAH.500x
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 Intra-Fraction Motion Management During Radiotherapypel.aa.REA.100
Reduction Mammaplasty for Breast-Related
Remicade (Infliximab)pel.aa.REM.400x
Remodulin (treprostinil)
Repetitive Transcranial Magnetic Stimulation for Treatment Refractory Depressionpel.aa.REP.101
Revlimid (Lenalidomide)
Rituxan (rituximab)
Ruconest (recombinant C1 esterase inhibitor)
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
Signifor (pasireotide)
Small Bowel/Liver and Multivisceral Transplantpel.aa.BCBS.7.03.051
Soliris (eculizumab)
Somatuline Depot (lanreotide)
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 Lumbar Spine Surgerypel.aa.SPI.601
Stelara (ustekinumab)
Stereotactic Radiosurgery and Stereotactic Body Radiation Therapypel.aa.STE.601
Subcutaneous Implantable Cardioverter Defibrillator (ICD) Systempel.aa.SUB.505
Supportive Carepel.aa.SUP.600
Supprelin LA (histrelin acetate)
Surgical Treatment of Femoroacetabular
Sutent (Sunitinib)
Sylvant (siltuximab)
Synagis (Palivizumab)pel.aa.SYN.500x
Synribo (omacetaxine mepesuccinate)
Telehealth Servicespel.aa.TEL.501
Tilt Table Testingpel.aa.TIL.501
Torisel (temsirolimus)
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
Transcutaneous Electrical Nerve Stimulation (TENS)pel.aa.TRA.501
Treatment of
Treatment of Varicose
Vectibix (Panitumumab)pel.aa.VEC.500x
Velcade (Bortezomib)
Vimizim (elosulfase alfa)
VPRIV (velaglucerase)
Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorderspel.aa.WHO.300
Xgeva (denosumab)
Xolair (Omalizumab)
Xyrem (sodium oxybate)
Yervoy (ipilimumab)
Zaltrap (ziv-aflibercept)
Zevalin (Ibritumomab tiuxetan)

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