411 Directory Of Documents - Bluecrossma

Biofeedback for the Treatment of HeadacheBiofeedback: Complementary Medicine, Mind-Body, Alternative, Holistic, Naturopathic and OtherTherapiesBronchial ThermoplastyCardiac Rehabilitation in the Outpatient SettingCharged-Particle - Proton or Helium Ion - Radiation TherapyChelation TherapyChimeric Antigen Receptor Therapy for Leukemia and LymphomaChimeric Antigen Receptor Therapy for Multiple MyelomaCochlear ImplantCognitive RehabilitationComplementary Medicine: Mind-Body, Alternative, Holistic, Naturopathic and Other TherapiesCorneal Collagen Cross-linkingCranial Electrotherapy Stimulation and Auricular ElectrostimulationCryoablation for Chronic RhinitisCryoablation of Tumors Located in the Kidney, Lung, Breast, Pancreas, or BoneDeep Brain StimulationDiagnosis and Treatment of Chronic Cerebrospinal Venous Insufficiency in Multiple SclerosisDiagnosis and Treatment of Sacroiliac Joint PainDigital Health Therapies for Attention DeficitDonor Lymphocyte Infusion for Malignancies Treated with an Allogeneic Hematopoietic CellTransplantDry Needling and Trigger Point Injections for Myofascial PainElectrical Bone Growth Stimulation of the Appendicular SkeletonElectrical Stimulation for the Treatment of ArthritisElectrical Stimulation of the Spine as an Adjunct to Spinal Fusion ProceduresElectrostimulation and Electromagnetic Therapy for Treating WoundsElzonris (tagraxofusp-erzs) for the Treatment of Blastic Plasmacytoid Dendritic Cell NeoplasmElzonris Prior Authorization Request Form MP 009End-Diastolic Pneumatic Compression Boot as a Treatment of Peripheral Vascular Disease orLymphedemaEndoscopic Radiofrequency Ablation or Cryoablation for Barrett’s EsophagusEndovascular Procedures for Intracranial Arterial Disease - Atherosclerosis and AneurysmsEnhanced External Counterpulsation (EECP) for Chronic Stable Angina or Congestive HeartFailureEpidural Steroid Injections for Neck and Back PainEvaluation of Biomarkers for Alzheimer DiseaseExtracorporeal PhotopheresisEyelid Thermal Pulsation for the Treatment of Dry Eye SyndromeFocal Treatments for Prostate CancerFunctional Neuromuscular Electrical StimulationGas Permeable Scleral Contact LensGastric Electrical StimulationGenotype-Guided Tamoxifen TreatmentHematopoietic Cell Transplantation for Acute Myeloid LeukemiaHematopoietic Stem Cell Transplantation for Non-Hodgkin LymphomasHippotherapyHyperbaric Oxygen TherapyImplantable Bone-Conduction and Bone-Anchored Hearing AidsInfertility Diagnosis and TreatmentInfluenza Drugs: Tamiflu and Relenza 486137332013716360671501435606534790864406

Inhaled Nitric Oxide as a Treatment of Hypoxic Respiratory Failure in NeonatesInjectable Bulking Agents for the Treatment of Urinary and Fecal IncontinenceInjections for osteoarthritisInsulin Potentiation TherapyInterferential Stimulation for Treatment of PainInterventions for Progressive ScoliosisIntraocular Radiation Therapy for Age-Related Macular DegenerationIntravenous Antibiotic Therapy and Associated Diagnostic Testing for Lyme DiseaseIntravitreal and Punctum Corticosteroid ImplantsIontophoresis and Phonophoresis as a Transdermal Technique for Drug DeliveryIsolated Limb Perfusion or Infusion for Malignant MelanomaLaparoscopic and Transcervical Techniques for the Myolysis of Uterine FibroidsLaser Treatment of OnychomycosisLeft-Atrial Appendage Closure Devices for Stroke Prevention in Atrial FibrillationLight Therapy for PsoriasisLipid ApheresisLow-Level Laser TherapyManipulation under AnesthesiaMeasurement of Exhaled Nitric Oxide and Exhaled Breath Condensate in the Diagnosis andManagement of Respiratory DisordersMedical and Surgical Management of Obesity including AnorexiantsMedicare Advantage ManagementMelanoma VaccinesMethadone Treatment and Intensive Detoxification or Ultra-Rapid Detoxification for OpiateAddictionMicrowave Tumor AblationMonitored Anesthesia Care - (MAC)MRI-Guided Focused Ultrasound - MRgFUSMultimarker Serum Testing Related to Ovarian CancerNavigated Transcranial Magnetic StimulationNegative Pressure Wound Therapy in the Outpatient SettingNeural TherapyNoncontact Ultrasound Treatment for WoundsOccipital Nerve StimulationOncologic Applications of Photodynamic Therapy, Including Barrett’s EsophagusOrthopedic Applications of Platelet-Rich PlasmaOrthopedic Applications of Stem Cell TherapyOrthoptic Training for the Treatment of Vision or Learning DisabilitiesOutpatient Cognitive RehabilitationOutpatient PsychotherapyOutpatient Pulmonary RehabilitationOvarian and Internal Iliac Vein Embolization as a Treatment of Pelvic Congestion SyndromePatient-Specific Instrumentation (eg, Cutting Guides) for Joint ArthroplastyPelvic Floor Stimulation as a Treatment of Urinary Incontinence and Fecal IncontinencePercutaneous Balloon Kyphoplasty and Mechanical Vertebral AugmentationPercutaneous Electrical Nerve Stimulation – PENS - and Percutaneous Neuromodulation Therapy- PNTPercutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, andBiacuplastyPercutaneous Vertebroplasty and 46572374547372546116604231362667064704851724824847

Photocoagulation of Macular DrusenPhotodynamic Therapy for Choroidal NeovascularizationPhototherapy PUVA UV-B and Targeted PhototherapyPhrenic Nerve Stimulation for Central Sleep ApneaPlasma ExchangePlugs for Fistula RepairPercutaneous Tibial Nerve StimulationPreauthorization Request Form for 379 Surgical Management of Obesity PolicyProgenitor Cell Therapy for the Treatment of Damaged Myocardium Due to IschemiaProlotherapy, Joint Sclerotherapy and Ligamentous Injections with Sclerosing AgentsProstatic Urethral LiftQuantitative Sensory TestingRadioembolization for Primary and Metastatic Tumors of the LiverRadiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver TumorsRadiofrequency Ablation of Primary or Metastatic Liver TumorsRadiofrequency Ablation of the Renal Sympathetic Nerves as a Treatment for ResistantHypertensionRadiofrequency Coblation Tenotomy for Musculoskeletal ConditionsRemote Electrical Neuromodulation for MigrainesRepetitive Transcranial Magnetic Stimulation (rTMS)Repository Corticotropin Injection (H.P Acthar Gel)Responsive Neurostimulation for the Treatment of Refractory Focal EpilepsyRoutine Foot Care and Debridement of ToenailsSacral Nerve Neuromodulation/StimulationScenesse afamelanotide for the treatment of Erythropoietic protoporphyriaSemi-Implantable and Fully Implantable Middle Ear Hearing AidSensory Integration TherapySexual Dysfunction: Diagnosis and TherapySphenopalatine Ganglion Block for HeadacheSpinal Cord and Dorsal Root Ganglion StimulationStem-cell Therapy for Peripheral Arterial DiseaseSuprachoroidal Delivery of Pharmacologic AgentsSurgical and Transesophageal Endoscopic Procedures to Treat Gastroesophageal RefluxDiseaseSurgical Ventricular RestorationTemporomandibular Joint DysfunctionTherapeutic Radiopharmaceuticals in OncologyThermal Capsulorrhaphy as a Treatment of Joint InstabilityThreshold Electrical Stimulation as a Treatment of Motor DisordersTranscatheter Arterial Chemoembolization - TACE - to Treat Primary or Metastatic LiverMalignanciesTransmyocardial RevascularizationTranspupillary Thermotherapy for Treatment of Choroidal NeovascularizationTranstympanic Micropressure Applications as a Treatment of Meniere’s DiseaseTransvaginal and Transurethral Radiofrequency Tissue Remodeling for Urinary StressIncontinenceTreatment of TinnitusTreatment of Varicose Veins and Venous InsufficiencyTrigger Point and Tender Point InjectionsVagus Nerve StimulationVertebral Axial 46038

Vision ServicesZolgensma (onasemnogene abeparvovec-xioi) for Spinal Muscular AtrophyZulressoTM (Brexanolone) for the Treatment of Post-Partum Depression675008147Devices & EquipmentMedical Technology Assessment Investigational (Non-Covered) Services ListAutomated Ambulatory Blood Pressure Monitoring for the Diagnosis of Hypertension in Patientswith Elevated Office Blood PressureBioimpedance Devices for the Detection of LymphedemaBiventricular Pacemakers – Cardiac Resynchronization Therapy for the Treatment of Heart FailureContinuous or Intermittent Monitoring of Glucose in Interstitial Fluid and Artificial Pancreas DeviceSystemsContinuous Passive Motion in the Home SettingCooling Devices Used in the Outpatient SettingDiaphragm Pacing StimulationDurable Medical Equipment DMEElectrical Stimulation Devices for Psychiatric and Neurological ConditionsEsophageal pH MonitoringExtracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal ConditionsHome Cardiorespiratory MonitoringHome Uterine Activity MonitoringInsulin Delivery Devices: Pumps, Pens, and Jet InjectorsLaser Interstitial Thermal Therapy for Neurological ConditionsLeadless Cardiac PacemakersManual and Power Operated WheelchairsMicroprocessor Controlled Prostheses for the Lower LimbMyoelectric Prosthetic and Components for the Upper LimbOscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory DisordersOstomy SuppliesPatient-Actuated End Range Motion Stretching DevicesPercutaneous Electrical Nerve Field Stimulation for Functional Abdominal Pain DisordersPneumatic Compression Pumps for Treatment of Lymphedema and Venous UlcersPostsurgical Outpatient Use of Limb Compression Devices for Venous ThromboembolismProphylaxisPowered Exoskeleton for Ambulation in Patients with Lower Limb DisabilitiesRetinal ProsthesisSexual Dysfunction: Diagnosis and TherapyTranscutaneous Electrical Nerve StimulationTotal Artificial Hearts and Implantable Ventricular Assist DevicesUltrasound Accelerated Fracture Healing DeviceUrological SuppliesWearable Cardioverter 8003280497370042SurgeriesMedical Technology Assessment Investigational (Non-Covered) Services ListAdrenal-to-Brain TransplantationAllogeneic Hematopoietic Cell Transplantation for Genetic Diseases and Acquired AnemiasAllogeneic Pancreas TransplantAqueous Shunts and Stents for Glaucoma4006271903282239

Autografts and Allografts in the Treatment of Focal Articular Cartilage LesionsAutologous Chondrocyte Implantation for Focal Articular Cartilage LesionsAutomated Percutaneous and Percutaneous DiscectomyAxial Lumbosacral Interbody FusionBone Morphogenetic ProteinCarotid Stent PlacementCatheter Ablation as Treatment for Atrial FibrillationClosure Devices for Patent Foramen Ovale and Artial Septal DefectsComposite Tissue Allotransplantation of the Hand and FaceContinuous Passive Motion (CPM) in the Home SettingWhole Gland Cryoablation of the ProstateCryosurgical Ablation of Primary or Metastatic Liver TumorsDecompression of the Intervertebral Disc Using Laser Energy - Laser Discectomy - orRadiofrequency Coblation - NucleoplastyEmbryonic Mesencephalic Transplantation for the Treatment of Parkinson’s DiseaseEndobronchial ValvesEndometrial AblationEndothelial KeratoplastyEndovascular Grafts for Abdominal Aortic AneurysmsEndovascular Stent Grafts for Disorders of the Thoracic AortaExtracorporeal Membrane OxygenationFacet ArthroplastyFacet Joint DenervationHeart TransplantHeart/Lung TransplantHematopoietic Cell Transplantation for Acute Lymphoblastic LeukemiaHematopoietic Cell Transplantation for Autoimmune DiseasesHematopoietic Cell Transplantation for Chronic Lymphocytic Leukemia and Small LymphocyticLymphomaHematopoietic Cell Transplantation for Chronic Myelogenous LeukemiaHematopoietic Cell Transplantation for CNS Embryonal Tumors and EpendymomaHematopoietic Cell Transplantation for Epithelial Ovarian CancerHematopoietic Cell Transplantation for Hodgkin LymphomaHematopoietic Cell Transplantation for Miscellaneous Solid Tumors in AdultsHematopoietic Cell Transplantation for Plasma Cell Dyscracias, Including Multiple Myeloma andPOEMS SyndromeHematopoietic Cell Transplantation for Primary AmyloidosisHematopoietic Cell Transplantation for Solid Tumors of ChildhoodHematopoietic Cell Transplantation in the Treatment of Germ-Cell TumorsHematopoietic Stem-Cell Transplantation for Waldenstrom MacroglobutinemiaHip ResurfacingHyperthermic Intraperitoneal Chemotherapy for Select Intra-Abdominal and Pelvic MalignanciesImage-Guided Minimally Invasive Decompression for Spinal StenosisImplantable Cardioverter DefibrillatorInterspinous and Interlaminar Stabilization - Distraction Devices - SpacersInterspinous Fixation – Fusion DevicesIslet TransplantationIsolated Small Bowel TransplantKidney TransplantLiver Transplant and Combined Liver-Kidney 810

Lung and Lobar Lung TransplantLung Volume Reduction Surgery for Severe EmphysemaMedical and Surgical Management of Obesity including AnorexiantsMeniscal Allografts and Other Meniscal ImplantsMinimally Invasive Coronary Artery Bypass Graft SurgeryNerve Graft in Association with Radical ProstatectomyOpen and Thoracoscopic Approaches to Treat Atrial Fibrillation - Maze and Related ProceduresPenile Revascularization: Surgery for Vasculogenic (See Sexual Dysfunction Diagnosis &Therapy under Treatments)Peroral Endoscopic Myotomy for Treatment of Esophageal AchalasiaPlastic Surgery: Reconstructive, Restorative, and Cosmetic ServicesPreauthorization Request Form for 379 Surgical Management of Obesity PolicyReconstructive Breast Surgery-Management of Breast ImplantsReduction Mammaplasty for Breast-Related SymptomsSexual Dysfunction: Diagnosis and TherapyShoulder ResurfacingSmall Bowel, Liver, and Multivisceral TransplantStereotactic Radiofrequency Pallidotomy for the Treatment of Parkinsons DiseaseStereotactic Radiosurgery and Stereotactic Body RadiotherapySteroid-Eleuting Sinus StentsSubtalar ArthroereisisSurgery for Athletic PubalgiaSurgical and Debulking Treatments for LymphedemaSurgical Deactivation of Headache Trigger SitesSurgical Interruption of Pelvic Nerve Pathways for Primary and Secondary DysmenorrheaSurgical and Non-Surgical Treatment of GynecomastiaSurgical Treatment of Snoring and Obstructive Sleep Apnea SyndromeTranscutaneous Electrical Nerve StimulationTotal Ankle ReplacementTransanal Endoscopic MicrosurgeryTranscatheter Aortic-Valve Implantation for Aortic StenosisTranscatheter Mitral Valve RepairTranscatheter Pulmonary Valve ImplantationGender Affirming Services (Transgender Services)Treatment of Hyperhidrosis excluding Botulinum ToxinVertical Expandable Prosthetic Titanium RibViscocanalostomy and 92692403189406305372OtherAdvanced Imaging of the Heart CPT and HCPCS CodesAdvanced Imaging of the HeartAdvanced Imaging RadiologyAIM Abdomen and Pelvic Imaging CPT and Diagnoses CodesAIM Brain Imaging CPT and Diagnoses CodesAIM Chest Imaging CPT and Diagnoses CodesAIM Extremity Imaging CPT and Diagnoses CodesAIM Genetic Testing Management Program CPT and HCPCS CodesAIM Head and Neck Imaging CPT and Diagnoses CodesAIM Oncologic Imaging CPT, HCPCS and Diagnoses CodesAIM Spine Imaging CPT and Diagnoses Codes97197296893093193293395793492993511

AIM Vascular Imaging CPT and Diagnoses CodesAir Ambulance TransportAudioHealth LibraryDiagnostic Laboratory ServicesDirectory of Documents (this document)E-Blue Review - for Physicians to comment on Medical PolicyFecal Microbiota TransplantationGenetic Testing for Commercial and Medicare AdvantageGround AmbulanceMedical Policy Review ScheduleMedical Technology Assessment GuidelinesMedical Technology Assessment Investigational (Non-Covered) Services ListMedicare Advantage High Technology Radiology & Sleep Disorder ManagementMedicare Advantage Part B Step TherapyMedicare Advantage Part B Utilization ManagementOutpatient Pediatric Pain Rehabilitation CentersOutpatient Prior Authorization Code ListPrior Authorization Request Form for Artificial Intervertebral Disc Cervical Spine MP 585Prior Authorization Request Form for CAR T-Cell Therapy Services for Treatment of Diffuse LargeB-cell Lymphoma MP 066Prior Authorization Request Form for CAR T-Cell Therapy Services for B-cell Acute LymphoblasticLeukemia (tisagenlecleucel) MP 066Prior Authorization Request Form for CAR T-Cell Therapy Services for B-cell Acute LymphoblasticLeukemia (Brexucabtagene Autoleucel) MP 066944 Prior Authorization Request Form for CAR T-Cell Therapy Services for Follicular Lymphoma(Axicabtagene Ciloleucel)Prior Authorization Request Form for CAR T-Cell Therapy Services for Mantle Cell Lymphoma(Brexucabtagene Autoleucel) MP 066Prior Authorization Request Form for CAR T-Cell Therapy Services for Non-Hodgkin Lymphoma(Lisocabtagene Maraleucel)Prior Authorization Request Form for Gender Affirming Services (Transgender Services) MP 189Prior Authorization Request Form for Electrolysis for Gender Affirming Services MP 189Prior Authorization Request Form for Esketamine Nasal Spray and Intravenous Ketamine forTreatment Resistant DepressionPreauthorization Request Form for Gene Therapy for Inherited Retinal Dystrophy for MP 911Prior Authorization Request Form for Myoelectric Prosthetic and Components for the Upper LimbMP 227Prior Authorization Request Form for Scenesse MP 077Prior Authorization Request Form for Therapeutic Radiopharmaceuticals in Oncology Lutetium177Prior Authorization Request Form for Zolgensma (onasemnogene abeparvovec-xioi) for SpinalMuscular Atrophy MP 008Prior Authorization Request Form for Zulresso (Brexanalone) for the Treatment of PostpartumDepressionQuality Care Cancer Program (Radiation Oncology)Quality Care Cancer Program (Radiation Oncology) CPT and HCPCS CodesSleep Disorder ManagementSleep Disorder Management CPT and HCPCS 514893793896997012

This document is designed for informational purposes only and is not an authorization, or an explanationof benefits, or a contract. Receipt of benefits is subject to satisfaction of all terms and conditions of thecoverage. Medical technology is constantly changing, and we reserve the right to review and update ourpolicies periodically. 2022 Blue Cross and Blue Shield of Massachusetts, Inc. All rights reserved. Blue Cross and BlueShield of Massac

Homocysteine Testing in the Screening, Diagnosis, and Management of Cardiovascular Disease and Venous Thromboembolic Disease 016 Identification of Microorganisms Using Nucleic Acid Probe 555 . End-Diastolic Pneumatic Compression Boot as a Treatment of Peripheral Vascular Disease or Lymphedema 648