132 Medicare Advantage Management - Blue Cross MA · 2020. 12. 31. · 1 Medical Policy Medicare...

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Medical Policy Medicare Advantage Management

Policy Number: 132 Effective Date: 10/1/2020

Related Policies Outpatient Prior Authorization Code List, #072 Medical Technology Assessment Non-Covered Services List, #400

Table of Contents Medicare Advantage Administrative Guidelines .................................................................................................... 1

National Coverage Determinations (NCD) ............................................................................................................ 1

Local Coverage Determinations (LCD) Massachusetts Jurisdiction ..................................................................... 2

Local Coverage Determinations (LCD) Molecular Diagnostic Tests (MolDX) Program by Palmetto GBA ........... 2

High Technology Radiology and Sleep Disorder for Medicare Advantage Products ............................................ 2

Genetic Testing for Medicare Advantage Products ............................................................................................... 3

Commercial and Medicare Policy Directory and Outpatient Prior Authorization Information for Medicare

Advantage.............................................................................................................................................................. 3

Outpatient Prior Authorization Code List for Commercial, #072: This document represents medical policies with specific procedure codes. These procedure codes require prior authorization for Commercial plans when they are performed in the outpatient setting.

Benefits, Eligibility, and Claims Prior Authorization Questions

Provider Services 1-800-882-2060 (Physicians) 1-800-451-8123 (Hospitals) 1-800-451-8124 (Ancillary Providers)

1-800-222-7620

Medicare Advantage Administrative Guidelines As a third party that administers Medicare Advantage products, Blue Cross Blue Shield of Massachusetts uses guidance from the Centers for Medicare and Medicaid Services (CMS) for coverage determinations. Coverage determinations are based on National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs). In addition, available CMS Medicare-related manuals are used to guide medical policy for Medicare Advantage members.

National Coverage Determinations (NCD) BCBSMA is required to make coverage determinations for services through the CMS National Coverage Determination policies and benefit manuals. When there is no NCD, BCBSMA Commercial medical policies are followed for Medicare Advantage members.

https://www.bluecrossma.org/medical-policies/sites/g/files/csphws2091/files/acquiadam-assets/072%20Outpatient%20Prior%20Authorization%20Code%20List%20prn.pdfhttps://www.bluecrossma.org/medical-policies/sites/g/files/csphws2091/files/acquiadam-assets/400%20Medical%20Technology%20Assessment%20NonCovered%20Services%20prn.pdfhttps://www.bluecrossma.org/medical-policies/sites/g/files/csphws2091/files/acquiadam-assets/072%20Outpatient%20Prior%20Authorization%20Code%20List%20prn.pdf

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To review the specific NCDs, please click “accept” on the CMS licensing agreement at the bottom of the CMS webpage. Click here to see the NCDs alphabetical index

Local Coverage Determinations (LCD) Massachusetts Jurisdiction BCBSMA is required to make coverage determinations for services that each Medicare Administrative Contractor (MAC)* publishes as the Local Coverage Determination. The LCDs utilized for coverage determinations are based on the jurisdiction of the member’s residency (unless otherwise specified by CMS). When there is no LCD or benefit statement that addresses the service/procedure, BCBSMA Commercial medical policies are followed for Medicare Advantage members. To review the specific LCDs, please click “accept” on the CMS licensing agreement at the bottom of the CMS webpage. Click here to see the LCDs alphabetical index *Medicare Administrative Contractors (MACs) are private health care insurers that have been awarded a geographic jurisdiction to process Medicare Part A and Part B medical claims or Durable Medical Equipment claims for Medicare Fee-For-Service beneficiaries.

Local Coverage Determinations (LCD) Molecular Diagnostic Tests (MolDX) Program by Palmetto GBA BCBSMA is required to make coverage determinations for services that each Medicare Administrative Contractor (MAC)* publishes as the Local Coverage Determination. When there is no MolDX LCD on the jurisdiction of the member’s residency, Palmetto GBA MolDX LCDs are followed for Medicare Advantage members. Click here to see Palmetto GBA MolDX LCDs *Medicare Administrative Contractors (MACs) are private health care insurers that have been awarded a geographic jurisdiction to process Medicare Part A and Part B medical claims or Durable Medical Equipment claims for Medicare Fee-For-Service beneficiaries.

High Technology Radiology and Sleep Disorder for Medicare Advantage Products Please use the following steps to determine the appropriate clinical guidance for High Technology Radiology and Sleep Disorder Management medical policies for Medicare Advantage only: 1. Determine if Prior Authorization is required for the member through the AIM Specialty Health website – see

Prior Authorization Information. If prior authorization IS required through AIM Specialty Health: 1. Request prior authorization from AIM Specialty Health at www.aimspecialtyhealth.com or call 1-866-745-

1783. 2. Follow steps outlined by AIM Specialty Health. If prior authorization IS NOT required through AIM Specialty Health: 1. Determine if there is National Coverage Determination (NCD) or Local Coverage Determination (LCD) on

the technology. To view the Centers for Medicare and Medicaid Services website, click CMS.gov. Exception: For Magnetic Resonance Imaging (MRI) Breast (#774), we follow AIM Specialty Health guidelines.

2. When there is no NCD or LCD guidance, go to AIM Specialty Health guidelines for clinical review criteria. 3. If member meets clinical criteria, order test. 4. If member does not meet clinical criteria but requires a clinical exception, follow the Clinical Exception

Process. Prior Authorization Information: Medicare HMO BlueSM and Medicare PPO BlueSM The requirements of BCBSMA Radiology Management Program may require a precertification/prior authorization via AIM Specialty Health. These requirements are member-specific: please verify member eligibility and requirements through Online Services by logging onto Provider Central. Refer to our Authorization Quick Tip for an overview of pre-certification and prior authorization requirements.

https://www.cms.gov/medicare-coverage-database/indexes/ncd-alphabetical-index.aspx?bc=AgAAAAAAAAAA&https://www.cms.gov/medicare-coverage-database/indexes/lcd-list.aspx?Cntrctr=304&ContrVer=1&CntrctrSelected=304*1&s=24&DocType=1&bc=AAgAAAAAAAAAaFinalhttps://www.palmettogba.com/palmetto/MolDX.nsf/docsCat/MolDx%20Website~MolDx~Browse%20By%20Topic~MolDX%20LCDs?open&expand=1&navmenu=Browse%5EBy%5ETopic%7C%7Chttps://www.bluecrossma.com/common/en_US/medical_policies/923%20Medicare%20Advantage%20High%20Technology%20Radiology%20&%20Sleep%20Disorder%20Management%20Redirect%20prn.pdfhttps://www.bluecrossma.com/common/en_US/medical_policies/923%20Medicare%20Advantage%20High%20Technology%20Radiology%20&%20Sleep%20Disorder%20Management%20Redirect%20prn.pdfhttp://www.aimspecialtyhealth.com/https://www.cms.gov/medicare-coverage-database/indexes/national-and-local-indexes.aspxhttps://www.bluecrossma.com/common/en_US/medical_policies/774%20Magnetic%20Resonance%20Imaging%20(MRI)%20Breast%20prn.pdfhttp://www.bluecrossma.com/provider).https://provider.bluecrossma.com/ProviderHome/portal/home/office-resources/plans-and-products/bluecard-and-out-of-area-programs/

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Ordering clinicians should request pre-certification from AIM Specialty Health at www.aimspecialtyhealth.com or call 1-866-745-1783 (when applicable).

Genetic Testing for Medicare Advantage Products Prior authorization through AIM Specialty Health is not required for Medicare Advantage products. Please see the appropriate National Coverage Determination (NCD) or Local Coverage Determination (LCD) through the CMS website for specific genetic testing guidelines.

Commercial and Medicare Policy Directory and Outpatient Prior Authorization Information for Medicare Advanatge Policy # BCBSMA Medical Policy Medicare Advantage

Local Coverage Determination (LCD) National Coverage Determination (NCD) Click here for Palmetto GBA MolDX LCD

MP 003 Transcutaneous Electrical Nerve Stimulation

NCD: Assessing Patient's Suitability for Electrical Nerve Stimulation Therapy (160.7.1) NCD: Transcutaneous Electrical Nerve Stimulation for Acute Post-Operative Pain (10.2) NCD: Supplies Used in the Delivery of Transcutaneous Electrical Nerve Stimulation and Neuromuscular Electrical Stimulation (160.13) Outpatient Prior Authorization Prior authorization is not required

MP 007 Obstetrical Ultrasound & Ultrasound for Family Planning

No LCD or NCD BCBSMA Commercial policy is followed Outpatient Prior Authorization Prior authorization is not required

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

No LCD or NCD BCBSMA Commercial policy is followed Outpatient Prior Authorization C9399, J3490, J3590: Prior authorization is required; in effect J3399: Prior authorization is required effective 7.1.2020 085 Prior Authorization Request Form for Zolgensma

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

No LCD or NCD BCBSMA Commercial policy is followed Outpatient Prior Authorization J9269: Prior authorization is required; in effect 928 Prior Authorization Request Form for Elzonris

MP 015 Lung and Lobar Lung Transplant No LCD or NCD BCBSMA Commercial policy is followed Outpatient Prior Authorization This procedure is performed in the inpatient setting

http://www.aimspecialtyhealth.com/https://www.cms.gov/https://www.cms.gov/medicare-coverage-database/indexes/lcd-list.aspx?Cntrctr=304&ContrVer=1&CntrctrSelected=304*1&s=24&DocType=1&bc=AAgAAAAAAAAAaFinalhttps://www.cms.gov/medicare-coverage-database/indexes/ncd-alphabetical-index.aspx?bc=AQAAAAAAAAAA&https://www.palmettogba.com/palmetto/MolDX.nsf/docsCat/MolDx%20Website~MolDx~Browse%20By%20Topic~MolDX%20LCDs?open&expand=1&navmenu=Browse%5EBy%5ETopic%7C%7Chttp://www.bluecrossma.org/medical-policies/sites/g/files/csphws2091/files/acquiadam-assets/928%20Elzonris%20Prior%20Authorization%20Request%20Form%20MP%20009%20prn.pdf

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MP 016 Homocysteine Testing in the Screening, Diagnosis, and Management of Cardiovascular Disease and Venous Thromboembolic Disease

LCD: MolDX: Biomarkers in Cardiovascular Risk Assessment (L36523) Outpatient Prior Authorization Prior authorization is not required

MP 018 Balloon Dilation of the Eustachian Tube

CMS Manual System: Pub 100-04 Medicare Claims Processing Outpatient Prior Authorization Prior authorization is not required

MP 020 Medicare Advantage Part B Step Therapy

Click here for additional coverage information: Medicare Advantage Part B Step Therapy Outpatient Prior Authorization C9257; J0178; J0179; J0881; J0882; J0885; J0887; J0888; J1442; J1447; J1745; J2503; J2505; J2778; J7318; J7320; J7321; J7322; J7323; J7324; J7325; J7326; J7327; J7328; J7329; J7332; J9035; Q4081; Q5103; Q5104; Q5105; Q5106; Q5107; Q5108; Q5110; Q5111; Q5118; Q5120 Prior authorization is required; in effect Q5121; J0897; J9312; J9355; Q5112; Q5113; Q5114; Q5115; Q5116; Q5117; Q5119: Prior authorization for step therapy is required effective 1.1.2021. Massachusetts Standard Form for Medication Prior Authorization Requests (eForm

MP 024 Vestibular Function Testing No LCD or NCD BCBSMA Commercial policy is followed Outpatient Prior Authorization Prior authorization is not required

MP 026 Sphenopalatine Ganglion Block for Headache

No LCD or NCD BCBSMA Commercial policy is followed Outpatient Prior Authorization This is not a covered service

MP 028 Therapeutic Radiopharmaceuticals in Oncology

No LCD or NCD BCBSMA Commercial policy is followed Outpatient Prior Authorization A9513: Prior authorization is required; in effect 958 Prior Authorization Request Form for Therapeutic Radiopharmaceuticals in Oncology Lutetium 177

MP 029 Molecular Testing in the Management of Pulmonary Nodules

LCD: MolDX-CDD: Percepta© Bronchial Genomic Classifier (L36854) LCD: MolDX: Xpresys Lung (L37031) Outpatient Prior Authorization Prior authorization is not required

MP 032 High-Sensitivity C-Reactive Protein No LCD or NCD

https://www.bluecrossma.org/medical-policies/sites/g/files/csphws2091/files/acquiadam-assets/020%20Medicare%20Advantage%20Part%20B%20Step%20Therapy%20prn.pdfhttps://www.bluecrossma.org/medical-policies/sites/g/files/csphws2091/files/acquiadam-assets/020%20Medicare%20Advantage%20Part%20B%20Step%20Therapy%20prn.pdfhttp://www.bluecrossma.com/common/en_US/medical_policies/023%20E%20Form%20medication%20prior%20auth%20instruction%20prn.pdfhttp://www.bluecrossma.com/common/en_US/medical_policies/023%20E%20Form%20medication%20prior%20auth%20instruction%20prn.pdfhttp://www.bluecrossma.org/medical-policies/sites/g/files/csphws2091/files/acquiadam-assets/958%20Prior%20Authorization%20Request%20Form%20for%20Therapeutic%20Radiopharmaceuticals%20in%20Oncology%20Lutetium%20177%20prn.pdfhttp://www.bluecrossma.org/medical-policies/sites/g/files/csphws2091/files/acquiadam-assets/958%20Prior%20Authorization%20Request%20Form%20for%20Therapeutic%20Radiopharmaceuticals%20in%20Oncology%20Lutetium%20177%20prn.pdf

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BCBSMA Commercial policy is followed Outpatient Prior Authorization Prior authorization is not required

MP 035 Temporomandibular Joint Disorder No LCD or NCD BCBSMA Commercial policy is followed Outpatient Prior Authorization 21010, 21050, 21060, 21073, 21116, 21240, 21242, 21243, 29800, 29804: Prior authorization is required Medicare HMO Blue; in effect Prior authorization is not required for Medicare PPO Blue Massachusetts Collaborative Prior Authorization Form OR Blue Cross Blue Shield of Massachusetts Pre-certification Request Form

MP 037 Surgical and Debulking Treatments for Lymphedema


MP038 Leadless Cardiac Pacemakers NCD for Leadless Pacemakers (20.8.4) Outpatient Prior Authorization Prior authorization is not required

MP 042 Wearable Cardioverter Defibrillators

LCD: Automatic External Defibrillators (L33690) Outpatient Prior Authorization Prior authorization is not required

MP 043 Home Uterine Activity Monitoring No LCD or NCD BCBSMA Commercial policy is followed Outpatient Prior Authorization This is not a covered service

MP 046 Hip Resurfacing No LCD or NCD BCBSMA Commercial policy is followed Outpatient Prior Authorization This procedure is performed in the inpatient setting

MP 048 Hyperthermic Intraperitoneal Chemotherapy for Select Intra-Abdominal and Pelvic Malignancies


MP 053 Ophthalmologic Techniques That Evaluate the Posterior Segment for Glaucoma

LCD: Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) (L34380) Outpatient Prior Authorization Prior authorization is not required

MP 059 Phototherapy: PUVA, UV-B and NCD for Treatment of Psoriasis (250.1)

http://www.masscollaborative.org/Standardized_Prior_Authorization_Form.pdf?disclaimer=3rdpartyhttps://provider.bluecrossma.com/ProviderHome/wcm/connect/77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29/MPC_111616-2Z_Pre-cert_Pre-Auth_Request_Form.pdf?MOD=AJPERES&CONVERT_TO=URL&CACHEID=ROOTWORKSPACE-77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29-mpmMcdrhttps://provider.bluecrossma.com/ProviderHome/wcm/connect/77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29/MPC_111616-2Z_Pre-cert_Pre-Auth_Request_Form.pdf?MOD=AJPERES&CONVERT_TO=URL&CACHEID=ROOTWORKSPACE-77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29-mpmMcdr

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Targeted Phototherapy

Outpatient Prior Authorization Prior authorization is not required

MP 065 Retinal Telescreening for Diabetic Retinopathy

LCD: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography) (L33567) Outpatient Prior Authorization Prior authorization is not required

MP 066 Chimeric Antigen Receptor Therapy for Hematologic Malignancies

NCD: Chimeric Antigen Receptor (CAR) T-cell Therapy (110.24) Outpatient Prior Authorization Q2041, Q2042, Q2053: Prior authorization is required; in effect 924 Prior Authorization Request Form for CAR T-Cell Therapy Services for Treatment of Diffuse Large B-cell Lymphoma 925 Prior Authorization Request Form for CAR T-Cell Therapy Services for B-cell Acute Lymphoblastic Leukemia (tisagenlecleucel)

MP 068 Plastic Surgery LCD: Cosmetic and Reconstructive Surgery (L34698) Local Coverage Article: Blepharoplasty Medical Policy Article (A52837) Outpatient Prior Authorization 15780, 15781, 15782, 15783, 30400, 30410, 30420, 30430, 30435, 30450, 15830: Prior authorization is required for Medicare HMO Blue; in effect Prior authorization is not required for Medicare PPO Blue Massachusetts Collaborative Prior Authorization Form OR Blue Cross Blue Shield of Massachusetts Pre-certification Request Form

MP 069 Esophageal pH Monitoring No LCD or NCD BCBSMA Commercial policy is followed Outpatient Prior Authorization Prior authorization is not required

MP 070 Implantable Cardioverter Defibrillator

NCD: Implantable Automatic Defibrillators (20.4) Outpatient Prior Authorization Prior authorization is not required

MP 072

Outpatient Prior Authorization Code List

This document includes all codes that require prior authorization for Commercial plans

MP 073 Intracellular Micronutrient Analysis No LCD or NCD BCBSMA Commercial policy is followed Outpatient Prior Authorization This is not a covered service

MP 074 Hematopoietic Cell Transplantation for Chronic Lymphocytic Leukemia/Small Lymphocytic

NCD: Stem Cell Transplantation (110.8.1) Outpatient Prior Authorization

http://www.bluecrossma.org/medical-policies/sites/g/files/csphws2091/files/acquiadam-assets/924%20Prior%20Authorization%20Request%20Form%20for%20CAR%20T-Cell%20Therapy%20Services%20for%20Treatment%20of%20Diffuse%20Large%20B-cell%20Lymphoma%20prn.pdfhttp://www.bluecrossma.org/medical-policies/sites/g/files/csphws2091/files/acquiadam-assets/924%20Prior%20Authorization%20Request%20Form%20for%20CAR%20T-Cell%20Therapy%20Services%20for%20Treatment%20of%20Diffuse%20Large%20B-cell%20Lymphoma%20prn.pdfhttp://www.bluecrossma.org/medical-policies/sites/g/files/csphws2091/files/acquiadam-assets/924%20Prior%20Authorization%20Request%20Form%20for%20CAR%20T-Cell%20Therapy%20Services%20for%20Treatment%20of%20Diffuse%20Large%20B-cell%20Lymphoma%20prn.pdfhttp://www.bluecrossma.org/medical-policies/sites/g/files/csphws2091/files/acquiadam-assets/925%20Prior%20Authorization%20Request%20Form%20for%20CAR%20T-Cell%20Therapy%20Services%20for%20B-cell%20Acute%20Lymphoblastic%20Leukemia%20(tisagenlecleucel)%20MP%20066%20prn.pdfhttp://www.bluecrossma.org/medical-policies/sites/g/files/csphws2091/files/acquiadam-assets/925%20Prior%20Authorization%20Request%20Form%20for%20CAR%20T-Cell%20Therapy%20Services%20for%20B-cell%20Acute%20Lymphoblastic%20Leukemia%20(tisagenlecleucel)%20MP%20066%20prn.pdfhttp://www.bluecrossma.org/medical-policies/sites/g/files/csphws2091/files/acquiadam-assets/925%20Prior%20Authorization%20Request%20Form%20for%20CAR%20T-Cell%20Therapy%20Services%20for%20B-cell%20Acute%20Lymphoblastic%20Leukemia%20(tisagenlecleucel)%20MP%20066%20prn.pdfhttp://www.masscollaborative.org/Standardized_Prior_Authorization_Form.pdf?disclaimer=3rdpartyhttps://provider.bluecrossma.com/ProviderHome/wcm/connect/77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29/MPC_111616-2Z_Pre-cert_Pre-Auth_Request_Form.pdf?MOD=AJPERES&CONVERT_TO=URL&CACHEID=ROOTWORKSPACE-77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29-mpmMcdrhttps://provider.bluecrossma.com/ProviderHome/wcm/connect/77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29/MPC_111616-2Z_Pre-cert_Pre-Auth_Request_Form.pdf?MOD=AJPERES&CONVERT_TO=URL&CACHEID=ROOTWORKSPACE-77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29-mpmMcdr

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Lymphoma

38240, S2142, S2150: Prior authorization is required; in effect Massachusetts Collaborative Prior Authorization Form OR Blue Cross Blue Shield of Massachusetts Pre-certification Request Form

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

NCD: Stem Cell Transplantation Formerly 110.8.1 (110.23) Outpatient Prior Authorization 38241, S2150: Prior authorization is required; in effect Massachusetts Collaborative Prior Authorization Form OR Blue Cross Blue Shield of Massachusetts Pre-certification Request Form

MP 076 Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia

NCD: Stem Cell Transplantation Formerly 110.8.1 (110.23) Outpatient Prior Authorization 38240, 38241, S2142, S2150: Prior authorization is required; in effect Massachusetts Collaborative Prior Authorization Form OR Blue Cross Blue Shield of Massachusetts Pre-certification Request Form

MP 077 Scenesse (afamelanotide) for Treatment of Erythropoietic Protoporphyria (EPP)

No LCD or NCD BCBSMA Commercial policy is followed Outpatient Prior Authorization Prior authorization is required effective 2.1.2021. There are no specfic codes; see policy #077 160 Prior Authorization Request Form for Scenesse (afamelanotide) for Treatment of Erythropoietic Protoporphyria (EPP)

MP 078 Sexual Dysfunction Diagnosis and Therapy


MP 080 Radiofrequency Coblation Tenotomy for Musculoskeletal Conditions


MP 081 Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions


MP 084 Optical Coherence Tomography of the Anterior Eye Segment

LCD: Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) (L34380) Outpatient Prior Authorization This is not a covered service

http://www.masscollaborative.org/Standardized_Prior_Authorization_Form.pdf?disclaimer=3rdpartyhttps://provider.bluecrossma.com/ProviderHome/wcm/connect/77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29/MPC_111616-2Z_Pre-cert_Pre-Auth_Request_Form.pdf?MOD=AJPERES&CONVERT_TO=URL&CACHEID=ROOTWORKSPACE-77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29-mpmMcdrhttps://provider.bluecrossma.com/ProviderHome/wcm/connect/77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29/MPC_111616-2Z_Pre-cert_Pre-Auth_Request_Form.pdf?MOD=AJPERES&CONVERT_TO=URL&CACHEID=ROOTWORKSPACE-77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29-mpmMcdrhttp://www.masscollaborative.org/Standardized_Prior_Authorization_Form.pdf?disclaimer=3rdpartyhttps://provider.bluecrossma.com/ProviderHome/wcm/connect/77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29/MPC_111616-2Z_Pre-cert_Pre-Auth_Request_Form.pdf?MOD=AJPERES&CONVERT_TO=URL&CACHEID=ROOTWORKSPACE-77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29-mpmMcdrhttps://provider.bluecrossma.com/ProviderHome/wcm/connect/77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29/MPC_111616-2Z_Pre-cert_Pre-Auth_Request_Form.pdf?MOD=AJPERES&CONVERT_TO=URL&CACHEID=ROOTWORKSPACE-77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29-mpmMcdrhttp://www.masscollaborative.org/Standardized_Prior_Authorization_Form.pdf?disclaimer=3rdpartyhttps://provider.bluecrossma.com/ProviderHome/wcm/connect/77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29/MPC_111616-2Z_Pre-cert_Pre-Auth_Request_Form.pdf?MOD=AJPERES&CONVERT_TO=URL&CACHEID=ROOTWORKSPACE-77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29-mpmMcdrhttps://provider.bluecrossma.com/ProviderHome/wcm/connect/77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29/MPC_111616-2Z_Pre-cert_Pre-Auth_Request_Form.pdf?MOD=AJPERES&CONVERT_TO=URL&CACHEID=ROOTWORKSPACE-77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29-mpmMcdrhttps://www.bluecrossma.org/medical-policies/sites/g/files/csphws2091/files/acquiadam-assets/160%20Prior%20Authorization%20Request%20Form%20for%20Scenesse%20MP%20077.pdfhttps://www.bluecrossma.org/medical-policies/sites/g/files/csphws2091/files/acquiadam-assets/160%20Prior%20Authorization%20Request%20Form%20for%20Scenesse%20MP%20077.pdfhttps://www.bluecrossma.org/medical-policies/sites/g/files/csphws2091/files/acquiadam-assets/160%20Prior%20Authorization%20Request%20Form%20for%20Scenesse%20MP%20077.pdf

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MP 086 Assisted Reproductive Services No LCD or NCD BCBSMA Commercial policy is followed Outpatient Prior Authorization Prior authorization is not required

MP 087 Esketamine Nasal Spray (Spravato) and Intravenous Ketamine for Treatment-Resistant Depression

No LCD or NCD BCBSMA Commercial policy is followed Outpatient Prior Authorization G2082, G2083: Prior authorization is required effective 4.1.2020 094 Prior Authorization Request Form for Esketamine Nasal Spray (Spravato) and Intravenous Ketamine

MP 088 Preimplantation Genetic Testing No LCD or NCD BCBSMA Commercial policy is followed Outpatient Prior Authorization Prior authorization is not required

MP 090 Intensity-Modulated Radiotherapy of the Prostate


MP 091 Endobronchial Brachytherapy No LCD or NCD BCBSMA Commercial policy is followed Outpatient Prior Authorization Prior authorization is not required

MP 095 Iontophoresis and Phonophoresis as a Transdermal Technique for Drug Delivery


MP 097 Bone Morphogenetic Protein No LCD or NCD BCBSMA Commercial policy is followed Outpatient Prior Authorization 20930: Prior authorization is required for Medicare HMO Blue; in effect Prior authorization is not required for Medicare PPO Blue Massachusetts Collaborative Prior Authorization Form OR Blue Cross Blue Shield of Massachusetts Pre-certification Request Form

MP 098 Endovascular Stent Grafts for Abdominal Aortic Aneurysms

No LCD or NCD BCBSMA Commercial policy is followed Outpatient Prior Authorization This procedure is performed in the inpatient setting

MP 100 Inhaled Nitric Oxide No LCD or NCD BCBSMA Commercial policy is followed

http://www.bluecrossma.org/medical-policies/sites/g/files/csphws2091/files/acquiadam-assets/094%20Prior%20Authorization%20Request%20Form%20for%20Esketamine%20Nasal%20Spray%20and%20Intravenous%20Ketamine%20for%20Treatment%20Resistant%20Depression%20prn.pdfhttp://www.bluecrossma.org/medical-policies/sites/g/files/csphws2091/files/acquiadam-assets/094%20Prior%20Authorization%20Request%20Form%20for%20Esketamine%20Nasal%20Spray%20and%20Intravenous%20Ketamine%20for%20Treatment%20Resistant%20Depression%20prn.pdfhttp://www.masscollaborative.org/Standardized_Prior_Authorization_Form.pdf?disclaimer=3rdpartyhttps://provider.bluecrossma.com/ProviderHome/wcm/connect/77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29/MPC_111616-2Z_Pre-cert_Pre-Auth_Request_Form.pdf?MOD=AJPERES&CONVERT_TO=URL&CACHEID=ROOTWORKSPACE-77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29-mpmMcdrhttps://provider.bluecrossma.com/ProviderHome/wcm/connect/77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29/MPC_111616-2Z_Pre-cert_Pre-Auth_Request_Form.pdf?MOD=AJPERES&CONVERT_TO=URL&CACHEID=ROOTWORKSPACE-77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29-mpmMcdr

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MP 101 Biventricular Pacemakers (Cardiac Resynchronization Therapy) for the Treatment of Heart Failure


MP 107 Continuous or Intermittent Monitoring of Glucose in Interstitial Fluid and Artificial Pancreas Device Systems

LCD: Glucose Monitors (L33822) Outpatient Prior Authorization A9277, K0553, S1036: Prior authorization is required for Medicare HMO Blue; in effect Prior authorization is not required for Medicare PPO Blue 845 Prior Authorization Request Form

MP 110 Meniscal Allografts and Other Meniscal Implants

NCD: Collagen Meniscus Implant (150.12) Outpatient Prior Authorization Prior authorization is not required

MP 111 Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions

No LCD or NCD BCBSMA Commercial policy is followed Outpatient Prior Authorization 27415, 27416, 28446, 29866, 29867: Prior authorization is required; in effect Massachusetts Collaborative Prior Authorization Form OR Blue Cross Blue Shield of Massachusetts Pre-certification Request Form

MP 112 Myocardial Strain Imaging LCD: Category III CPT® Codes (L33392) Outpatient Prior Authorization This is not a covered service

MP 120 Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Conditions

LCD: High Frequency Chest Wall Oscillation Devices (L33785) LCD: Intrapulmonary Percussive Ventilation System (L33786) Outpatient Prior Authorization Prior authorization is not required Intrapulmonary Percussive Ventilation (IPV) System is not a covered device

MP 121 Closure Devices for Patent Foramen Ovale and Atrial Septal Defects

No LCD or NCD BCBSMA Commercial policy is followed Outpatient Prior Authorization 93580: Prior authorization is required; in effect Massachusetts Collaborative Prior Authorization Form OR Blue Cross Blue Shield of Massachusetts Pre-certification Request Form

MP 122 Chelation Therapy No LCD or NCD

https://www.bluecrossma.org/medical-policies/sites/g/files/csphws2091/files/acquiadam-assets/845%20Prior%20Authorization%20Request%20Form%20for%20Continuous%20or%20Intermittent%20Monitoring%20of%20Glucose%20in%20Interstitial%20Fluid%20and%20Artificial%20Pancreas%20Device%20Systems%20prn.pdfhttp://www.masscollaborative.org/Standardized_Prior_Authorization_Form.pdf?disclaimer=3rdpartyhttps://provider.bluecrossma.com/ProviderHome/wcm/connect/77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29/MPC_111616-2Z_Pre-cert_Pre-Auth_Request_Form.pdf?MOD=AJPERES&CONVERT_TO=URL&CACHEID=ROOTWORKSPACE-77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29-mpmMcdrhttps://provider.bluecrossma.com/ProviderHome/wcm/connect/77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29/MPC_111616-2Z_Pre-cert_Pre-Auth_Request_Form.pdf?MOD=AJPERES&CONVERT_TO=URL&CACHEID=ROOTWORKSPACE-77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29-mpmMcdrhttp://www.masscollaborative.org/Standardized_Prior_Authorization_Form.pdf?disclaimer=3rdpartyhttps://provider.bluecrossma.com/ProviderHome/wcm/connect/77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29/MPC_111616-2Z_Pre-cert_Pre-Auth_Request_Form.pdf?MOD=AJPERES&CONVERT_TO=URL&CACHEID=ROOTWORKSPACE-77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29-mpmMcdrhttps://provider.bluecrossma.com/ProviderHome/wcm/connect/77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29/MPC_111616-2Z_Pre-cert_Pre-Auth_Request_Form.pdf?MOD=AJPERES&CONVERT_TO=URL&CACHEID=ROOTWORKSPACE-77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29-mpmMcdr

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MP 124 Isolated Limb Perfusion/Infusion for Malignant Melanoma


MP 125

Medicare Advantage Part B Medical Utilization Management

Click here for additional coverage information: Medicare Advantage Part B Medical Utilization Management Medical necessity criteria will follow CMS NCD/LCD/Article guidance. In the absence of CMS guidance, criteria will follow the medically accepted indication that is supported by the Food and Drug Administration (FDA) labeling of the drug and/or medical references approved by Medicare. Outpatient Prior Authorization J0585;J0586; J0587; J0588; J2357; J2182; J0517; J2786; J2350; J0897: Prior authorization is required. Effective 1.1.2021 Massachusetts Standard Form for Medication Prior Authorization Requests (eForm)

MP 130 Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome

LCD: Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea (L38387) Outpatient Prior Authorization 21193, 21194, 21195, 21196, 21198, 21199, 21206, 21685, 42145: Prior authorization is required for Medicare HMO Blue; in effect Prior authorization is not required for Medicare PPO Blue Massachusetts Collaborative Prior Authorization Form OR Blue Cross Blue Shield of Massachusetts Pre-certification Request Form

MP 133 Microprocessor-Controlled Prostheses for the Lower Limb

LCD: Lower Limb Prostheses (L33787) Outpatient Prior Authorization Prior authorization is not required

MP 134 Signal-Averaged Electrocardiography (SAECG)

LCD: Signal Averaged Electrocardiography (Sa-Ecg) (L7171) Outpatient Prior Authorization Prior authorization is not required

MP 136 Outpatient Pulmonary Rehabilitation

NCD: Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) (20.35) Outpatient Prior Authorization Prior authorization is not required

MP 138 Serological Diagnosis of Celiac No LCD or NCD

https://www.bluecrossma.org/medical-policies/sites/g/files/csphws2091/files/acquiadam-assets/125%20Medicare%20Advanatge%20Part%20B%20Utilization%20Management.pdfhttps://www.bluecrossma.org/medical-policies/sites/g/files/csphws2091/files/acquiadam-assets/125%20Medicare%20Advanatge%20Part%20B%20Utilization%20Management.pdfhttp://www.bluecrossma.com/common/en_US/medical_policies/023%20E%20Form%20medication%20prior%20auth%20instruction%20prn.pdfhttp://www.bluecrossma.com/common/en_US/medical_policies/023%20E%20Form%20medication%20prior%20auth%20instruction%20prn.pdfhttp://www.masscollaborative.org/Standardized_Prior_Authorization_Form.pdf?disclaimer=3rdpartyhttps://provider.bluecrossma.com/ProviderHome/wcm/connect/77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29/MPC_111616-2Z_Pre-cert_Pre-Auth_Request_Form.pdf?MOD=AJPERES&CONVERT_TO=URL&CACHEID=ROOTWORKSPACE-77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29-mpmMcdrhttps://provider.bluecrossma.com/ProviderHome/wcm/connect/77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29/MPC_111616-2Z_Pre-cert_Pre-Auth_Request_Form.pdf?MOD=AJPERES&CONVERT_TO=URL&CACHEID=ROOTWORKSPACE-77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29-mpmMcdr

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Disease BCBSMA Commercial policy is followed Outpatient Prior Authorization Prior authorization is not required

MP 139 Diagnostic Laboratory Services NCD: Blood Counts (190.15) NCD: Thyroid Testing (190.22) NCD: Urine Culture, Bacterial (190.12) NCD: Prothrombin Time (PT) (190.17) NCD: Serum Iron Studies (190.18) NCD: Hepatitis Panel/Acute Hepatitis Panel (190.33) Outpatient Prior Authorization Prior authorization is not required

MP 140 Facet Joint Denervation LCD: Facet Joint Interventions for Pain Management (L35936) Outpatient Prior Authorization Prior authorization is not required

MP 141 Catheter Ablation as Treatment for Atrial Fibrillation


MP 142 Air Ambulance Transport

CMS Medicare Benefit Policy Manual, Chapter 10-Ambulance Services, section 10.4 Air Ambulance Services Outpatient Prior Authorization for Medicare HMO Blue Prior authorization is required for air ambulance transport 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. Outpatient Prior Authorization for Medicare PPO Blue 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. 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

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c10.pdfhttps://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c10.pdf

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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. Massachusetts Collaborative Prior Authorization Form OR Blue Cross Blue Shield of Massachusetts Pre-certification Request Form

MP 143 Hematopoietic Cell Transplantation for Non-Hodgkin Lymphomas

No LCD or NCD BCBSMA Commercial policy is followed Outpatient Prior Authorization 38240, 38241, S2142, S2150: Prior authorization is required; in effect Massachusetts Collaborative Prior Authorization Form OR Blue Cross Blue Shield of Massachusetts Pre-certification Request Form

MP 146 Ground Ambulance

CMS Medicare Benefit Policy Manual, Chapter 10-Ambulance Services Outpatient Prior Authorization for Medicare HMO Blue Prior authorization is required.

• 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. Outpatient Prior Authorization for Medicare PPO Blue Prior authorization is not required for: • Any ground ambulance services • 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. Massachusetts Collaborative Prior Authorization Form OR Blue Cross Blue Shield of Massachusetts Pre-certification Request Form

MP 147 ZulressoTM (Brexanolone) for the Treatment of Post-Partum Depression

No LCD or NCD BCBSMA Commercial policy is followed Outpatient Prior Authorization Prior authorization is required; see policy and form for

http://www.masscollaborative.org/Standardized_Prior_Authorization_Form.pdf?disclaimer=3rdpartyhttps://provider.bluecrossma.com/ProviderHome/wcm/connect/77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29/MPC_111616-2Z_Pre-cert_Pre-Auth_Request_Form.pdf?MOD=AJPERES&CONVERT_TO=URL&CACHEID=ROOTWORKSPACE-77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29-mpmMcdrhttps://provider.bluecrossma.com/ProviderHome/wcm/connect/77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29/MPC_111616-2Z_Pre-cert_Pre-Auth_Request_Form.pdf?MOD=AJPERES&CONVERT_TO=URL&CACHEID=ROOTWORKSPACE-77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29-mpmMcdrhttp://www.masscollaborative.org/Standardized_Prior_Authorization_Form.pdf?disclaimer=3rdpartyhttps://provider.bluecrossma.com/ProviderHome/wcm/connect/77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29/MPC_111616-2Z_Pre-cert_Pre-Auth_Request_Form.pdf?MOD=AJPERES&CONVERT_TO=URL&CACHEID=ROOTWORKSPACE-77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29-mpmMcdrhttps://provider.bluecrossma.com/ProviderHome/wcm/connect/77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29/MPC_111616-2Z_Pre-cert_Pre-Auth_Request_Form.pdf?MOD=AJPERES&CONVERT_TO=URL&CACHEID=ROOTWORKSPACE-77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29-mpmMcdrhttps://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c10.pdfhttps://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c10.pdfhttp://www.masscollaborative.org/Standardized_Prior_Authorization_Form.pdf?disclaimer=3rdpartyhttps://provider.bluecrossma.com/ProviderHome/wcm/connect/77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29/MPC_111616-2Z_Pre-cert_Pre-Auth_Request_Form.pdf?MOD=AJPERES&CONVERT_TO=URL&CACHEID=ROOTWORKSPACE-77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29-mpmMcdrhttps://provider.bluecrossma.com/ProviderHome/wcm/connect/77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29/MPC_111616-2Z_Pre-cert_Pre-Auth_Request_Form.pdf?MOD=AJPERES&CONVERT_TO=URL&CACHEID=ROOTWORKSPACE-77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29-mpmMcdr

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CPT codes 148 Prior Authorization Request Form for Zulresso (Brexanalone) for the Treatment of Postpartum Depression prn.pdf

MP 149 Whole Gland Cryoablation of the Prostate

NCD: Cryosurgery of Prostate (230.9) Outpatient Prior Authorization Prior authorization is not required

MP 150 Hematopoietic Cell Transplantation for Acute Myeloid Leukemia

No LCD or NCD BCBSMA Commercial policy is followed Outpatient Prior Authorization 38240, 38241, S2142, S2150: Prior authorization is required; in effect Massachusetts Collaborative Prior Authorization Form OR Blue Cross Blue Shield of Massachusetts Pre-certification Request Form

MP 151 Neuropsychological and Psychological Testing

LCD: Psychological and Neuropsychological Testing (L34646) LCD: Psychiatry and Psychology Services (L33632) Outpatient Prior Authorization Prior authorization is not required

MP 152 Biofeedback as a Treatment of Headache


MP 153 Sacral Nerve Neuromodulation/Stimulation

NCD: Sacral Nerve Stimulation for Urinary Incontinence (230.18) Outpatient Prior Authorization Prior authorization is not required

MP 154 Monitored Anesthesia Care (MAC) No LCD or NCD BCBSMA Commercial policy is followed Outpatient Prior Authorization Prior authorization is not required

MP 155 Allogeneic Hematopoietic Cell transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms

NCD: Stem Cell Transplantation Formerly 110.8.1 (110.23) Outpatient Prior Authorization 38240, S2150: Prior authorization is required; in effect Massachusetts Collaborative Prior Authorization Form OR Blue Cross Blue Shield of Massachusetts Pre-certification Request Form

MP 156 Shoulder Resurfacing No LCD or NCD BCBSMA Commercial policy is followed Outpatient Prior Authorization This is not a covered service

https://www.bluecrossma.org/medical-policies/sites/g/files/csphws2091/files/acquiadam-assets/148%20Prior%20Authorization%20Request%20%20Form%20for%20Zulresso%20%28Brexanalone%29%20for%20the%20Treatment%20of%20Postpartum%20Depression%20prn.pdfhttps://www.bluecrossma.org/medical-policies/sites/g/files/csphws2091/files/acquiadam-assets/148%20Prior%20Authorization%20Request%20%20Form%20for%20Zulresso%20%28Brexanalone%29%20for%20the%20Treatment%20of%20Postpartum%20Depression%20prn.pdfhttps://www.bluecrossma.org/medical-policies/sites/g/files/csphws2091/files/acquiadam-assets/148%20Prior%20Authorization%20Request%20%20Form%20for%20Zulresso%20%28Brexanalone%29%20for%20the%20Treatment%20of%20Postpartum%20Depression%20prn.pdfhttp://www.masscollaborative.org/Standardized_Prior_Authorization_Form.pdf?disclaimer=3rdpartyhttps://provider.bluecrossma.com/ProviderHome/wcm/connect/77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29/MPC_111616-2Z_Pre-cert_Pre-Auth_Request_Form.pdf?MOD=AJPERES&CONVERT_TO=URL&CACHEID=ROOTWORKSPACE-77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29-mpmMcdrhttps://provider.bluecrossma.com/ProviderHome/wcm/connect/77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29/MPC_111616-2Z_Pre-cert_Pre-Auth_Request_Form.pdf?MOD=AJPERES&CONVERT_TO=URL&CACHEID=ROOTWORKSPACE-77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29-mpmMcdrhttp://www.masscollaborative.org/Standardized_Prior_Authorization_Form.pdf?disclaimer=3rdpartyhttps://provider.bluecrossma.com/ProviderHome/wcm/connect/77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29/MPC_111616-2Z_Pre-cert_Pre-Auth_Request_Form.pdf?MOD=AJPERES&CONVERT_TO=URL&CACHEID=ROOTWORKSPACE-77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29-mpmMcdrhttps://provider.bluecrossma.com/ProviderHome/wcm/connect/77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29/MPC_111616-2Z_Pre-cert_Pre-Auth_Request_Form.pdf?MOD=AJPERES&CONVERT_TO=URL&CACHEID=ROOTWORKSPACE-77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29-mpmMcdr

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MP 157 Electrical Stimulation Devices for Psychiatric and Neurological Conditions


MP 158

Outpatient Pediatric Pain Rehabilitation Centers

No LCD or NCD BCBSMA Commercial policy is followed Outpatient Prior Authorization Prior authorization is required Massachusetts Collaborative Prior Authorization Form OR Blue Cross Blue Shield of Massachusetts Pre-certification Request Form

MP 163 Intensity-Modulated Radiotherapy (IMRT) of the Breast and Lung


MP 164 Intensity-Modulated Radiation Therapy (IMRT) Cancer of the Head and Neck or Thyroid


MP 165 Intensity-Modulated Radiation Therapy (IMRT) Abdomen and Pelvis


MP 167 Tumor Markers for Diagnosis and Management of Cancer


MP 171 Intravenous Antibiotic Therapy and Associated Diagnostic Testing for Lyme Disease


MP 172 Percutaneous Electrical Nerve Stimulation and Percutaneous Neuromodulation Therapy

NCD): Assessing Patient's Suitability for Electrical Nerve Stimulation Therapy (160.7.1) Outpatient Prior Authorization Prior authorization is not required

MP 173 Biofeedback as a Treatment of Urinary Incontinence in Adults

NCD: Biofeedback Therapy for the Treatment of Urinary Incontinence (30.1.1) Outpatient Prior Authorization Prior authorization is not required


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MP 174 Facet Arthroplasty No LCD or NCD BCBSMA Commercial policy is followed Outpatient Prior Authorization This is not a covered service

MP 175 Brachytherapy for Clinically Localized Prostate Cancer Using Permanently Implanted Seeds


MP 178 Complementary Medicine No LCD or NCD BCBSMA Commercial policy is followed Outpatient Prior Authorization This is not a covered service

MP 180 Endothelial Keratoplasty No LCD or NCD BCBSMA Commercial policy is followed Outpatient Prior Authorization Prior authorization is not required

MP 181 Hematopoietic Cell Transplantation for Primary Amyloidosis

No LCD or NCD BCBSMA Commercial policy is followed Outpatient Prior Authorization 38241, S2150: Prior authorization is required; in effect Massachusetts Collaborative Prior Authorization Form OR Blue Cross Blue Shield of Massachusetts Pre-certification Request Form

MP 182 Immune Cell Function Assay No LCD or NCD BCBSMA Commercial policy is followed Outpatient Prior Authorization This is not a covered service

MP 183 Prolotherapy NCD: Prolotherapy, Joint Sclerotherapy, and Ligamentous Injections with Sclerosing Agents (150.7) Outpatient Prior Authorization This is not a covered service

MP 185 Wireless Capsule Endoscopy to Diagnose Disorders of the Small Bowel, Esophagus, and Colon


MP 186 Absorbable Nasal Implant for Treatment of Nasal Valve Collapse



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MP 187 Biofeedback for Miscellaneous Indications

NCD: Biofeedback Therapy (30.1) Outpatient Prior Authorization Prior authorization is not required

MP 189 Gender Affirming Services (Transgender Services)

No LCD or NCD BCBSMA Commercial policy is followed Outpatient Prior Authorization Click here for CPT codes Prior authorization is required for Medicare HMO Blue; in effect Prior authorization is not required for Medicare PPO Blue Prior authorization is required for Medicare HMO Blue for speech therapy and/or voice training services only 901 Prior Authorization Request Form for Gender Affirming Services (Transgender Services) OR 902 Prior Authorization Request Form for Electrolysis for Gender Affirming Services

MP 190 Allogeneic Hematopoietic Cell Transplantation for Genetic Diseases and Acquired Anemias

NCD: Stem Cell Transplantation Formerly 110.8.1 (110.23) Outpatient Prior Authorization 38240, S2142, S2150: Prior authorization is required; in effect Massachusetts Collaborative Prior Authorization Form OR Blue Cross Blue Shield of Massachusetts Pre-certification Request Form

MP 191 Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors in Adults


MP 192 Hematopoietic Cell Transplantation for Autoimmune Diseases

No LCD or NCD BCBSMA Commercial policy is followed Outpatient Prior Authorization 38241, S2150: Prior authorization is required; in effect

MP 193 Total Ankle Replacement No LCD or NCD BCBSMA Commercial policy is followed Outpatient Prior Authorization Prior authorization is not required

MP 195 Dynamic Spinal Visualization and Vertebral Motion Analysis


MP 196 Kidney Transplant No LCD or NCD BCBSMA Commercial policy is followed Outpatient Prior Authorization This procedure is performed in the inpatient setting

http://www.bluecrossma.org/medical-policies/sites/g/files/csphws2091/files/acquiadam-assets/901%20Prior%20Authorization%20Request%20%20Form%20for%20Gender%20Affirming%20Services%20(Transgender%20Services)%20MP%20189%20prn.pdfhttp://www.bluecrossma.org/medical-policies/sites/g/files/csphws2091/files/acquiadam-assets/901%20Prior%20Authorization%20Request%20%20Form%20for%20Gender%20Affirming%20Services%20(Transgender%20Services)%20MP%20189%20prn.pdfhttp://www.bluecrossma.org/medical-policies/sites/g/files/csphws2091/files/acquiadam-assets/902%20Prior%20Authorization%20Request%20Form%20for%20Electrolysis%20for%20Gender%20Affirming%20Services%20MP%20189%20prn.pdfhttp://www.bluecrossma.org/medical-policies/sites/g/files/csphws2091/files/acquiadam-assets/902%20Prior%20Authorization%20Request%20Form%20for%20Electrolysis%20for%20Gender%20Affirming%20Services%20MP%20189%20prn.pdfhttp://www.masscollaborative.org/Standardized_Prior_Authorization_Form.pdf?disclaimer=3rdpartyhttps://provider.bluecrossma.com/ProviderHome/wcm/connect/77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29/MPC_111616-2Z_Pre-cert_Pre-Auth_Request_Form.pdf?MOD=AJPERES&CONVERT_TO=URL&CACHEID=ROOTWORKSPACE-77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29-mpmMcdrhttps://provider.bluecrossma.com/ProviderHome/wcm/connect/77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29/MPC_111616-2Z_Pre-cert_Pre-Auth_Request_Form.pdf?MOD=AJPERES&CONVERT_TO=URL&CACHEID=ROOTWORKSPACE-77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29-mpmMcdr

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MP 197 Heart Transplant No LCD or NCD BCBSMA Commercial policy is followed Outpatient Prior Authorization This procedure is performed in the inpatient setting

MP 198 Liver Transplant and Combined Liver-Kidney Transplant

NCD: Adult Liver Transplantation (260.1) Outpatient Prior Authorization This procedure is performed in the inpatient setting

MP 200 Transanal Endoscopic Microsurgery

LCD: Category III CPT® Codes (L33392) (A56195) Outpatient Prior Authorization Prior authorization is not required

MP 201 Functional Neuromuscular Electrical Stimulation

NCD: Neuromuscular Electrical Stimulation (NMES) (160.12) Outpatient Prior Authorization Prior authorization is not required

MP 203 Electromagnetic Navigation Bronchoscopy


MP 204 Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer


MP 205 Hematopoietic Cell Transplantation for CNS Embryonal Tumors and Ependymoma

No LCD or NCD BCBSMA Commercial policy is followed Outpatient Prior Authorization S2150: Prior authorization is required; in effect Massachusetts Collaborative Prior Authorization Form OR Blue Cross Blue Shield of Massachusetts Pre-certification Request Form

MP 206 Automated Ambulatory Blood Pressure Monitoring for the Diagnosis of Hypertension in Patients with Elevated Office Blood Pressure

NCD: Ambulatory Blood Pressure Monitoring (20.19) Outpatient Prior Authorization Prior authorization is not required

MP 207 Hematopoietic Cell Transplantation for Hodgkin Lymphoma

NCD: Stem Cell Transplantation (110.8.1) Outpatient Prior Authorization 38241, S2142, S2150: Prior authorization is required; in effect Massachusetts Collaborative Prior Authorization Form OR Blue Cross Blue Shield of Massachusetts Pre-certification Request Form

http://www.masscollaborative.org/Standardized_Prior_Authorization_Form.pdf?disclaimer=3rdpartyhttps://provider.bluecrossma.com/ProviderHome/wcm/connect/77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29/MPC_111616-2Z_Pre-cert_Pre-Auth_Request_Form.pdf?MOD=AJPERES&CONVERT_TO=URL&CACHEID=ROOTWORKSPACE-77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29-mpmMcdrhttps://provider.bluecrossma.com/ProviderHome/wcm/connect/77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29/MPC_111616-2Z_Pre-cert_Pre-Auth_Request_Form.pdf?MOD=AJPERES&CONVERT_TO=URL&CACHEID=ROOTWORKSPACE-77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29-mpmMcdrhttp://www.masscollaborative.org/Standardized_Prior_Authorization_Form.pdf?disclaimer=3rdpartyhttps://provider.bluecrossma.com/ProviderHome/wcm/connect/77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29/MPC_111616-2Z_Pre-cert_Pre-Auth_Request_Form.pdf?MOD=AJPERES&CONVERT_TO=URL&CACHEID=ROOTWORKSPACE-77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29-mpmMcdrhttps://provider.bluecrossma.com/ProviderHome/wcm/connect/77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29/MPC_111616-2Z_Pre-cert_Pre-Auth_Request_Form.pdf?MOD=AJPERES&CONVERT_TO=URL&CACHEID=ROOTWORKSPACE-77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29-mpmMcdr

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MP 208 Hematopoietic Cell Transplantation for Solid Tumors of Childhood

NCD: Stem Cell Transplantation (110.8.1) Outpatient Prior Authorization 38241, S2150: Prior authorization is required; in effect Massachusetts Collaborative Prior Authorization Form OR Blue Cross Blue Shield of Massachusetts Pre-certification Request Form

MP 209 Endoscopic Retrograde Cholangiopancreatography (ECRP) with Laser or Electrohydraulic Lithotripsy


MP 210 Biofeedback as a Treatment of Chronic Pain


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

LCD: Visual Electrophysiology Testing (L36831) LCD: Intraoperative Neurophysiological Testing (L34623) No LCD or NCD BCBSMA Commercial policy is followed ▪ Somatosensory Evoked Potential Testing ▪ Motor Evoked Potential Testing Outpatient Prior Authorization 95940, 95941, G0453: Prior authorization is required; in effect Massachusetts Collaborative Prior Authorization Form OR Blue Cross Blue Shield of Massachusetts Pre-certification Request Form

MP 212 Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia

No LCD or NCD BCBSMA Commercial policy is followed Outpatient Prior Authorization 38240, S2142, S2150: Prior authorization is required; in effect Massachusetts Collaborative Prior Authorization Form OR Blue Cross Blue Shield of Massachusetts Pre-certification Request Form

MP 218 Endoscopic Radiofrequency Ablation or Cryoablation for Barrett Esophagus


MP 219 Carotid Stent Placement

NCD: Percutaneous Transluminal Angioplasty (PTA) (20.7) Outpatient Prior Authorization Prior authorization is not required

MP 223 Aqueous Shunts and Stents for Glaucoma

LCD: Micro-Invasive Glaucoma Surgery (MIGS) (L37244)

http://www.masscollaborative.org/Standardized_Prior_Authorization_Form.pdf?disclaimer=3rdpartyhttps://provider.bluecrossma.com/ProviderHome/wcm/connect/77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29/MPC_111616-2Z_Pre-cert_Pre-Auth_Request_Form.pdf?MOD=AJPERES&CONVERT_TO=URL&CACHEID=ROOTWORKSPACE-77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29-mpmMcdrhttps://provider.bluecrossma.com/ProviderHome/wcm/connect/77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29/MPC_111616-2Z_Pre-cert_Pre-Auth_Request_Form.pdf?MOD=AJPERES&CONVERT_TO=URL&CACHEID=ROOTWORKSPACE-77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29-mpmMcdrhttp://www.masscollaborative.org/Standardized_Prior_Authorization_Form.pdf?disclaimer=3rdpartyhttps://provider.bluecrossma.com/ProviderHome/wcm/connect/77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29/MPC_111616-2Z_Pre-cert_Pre-Auth_Request_Form.pdf?MOD=AJPERES&CONVERT_TO=URL&CACHEID=ROOTWORKSPACE-77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29-mpmMcdrhttps://provider.bluecrossma.com/ProviderHome/wcm/connect/77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29/MPC_111616-2Z_Pre-cert_Pre-Auth_Request_Form.pdf?MOD=AJPERES&CONVERT_TO=URL&CACHEID=ROOTWORKSPACE-77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29-mpmMcdrhttp://www.masscollaborative.org/Standardized_Prior_Authorization_Form.pdf?disclaimer=3rdpartyhttps://provider.bluecrossma.com/ProviderHome/wcm/connect/77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29/MPC_111616-2Z_Pre-cert_Pre-Auth_Request_Form.pdf?MOD=AJPERES&CONVERT_TO=URL&CACHEID=ROOTWORKSPACE-77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29-mpmMcdrhttps://provider.bluecrossma.com/ProviderHome/wcm/connect/77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29/MPC_111616-2Z_Pre-cert_Pre-Auth_Request_Form.pdf?MOD=AJPERES&CONVERT_TO=URL&CACHEID=ROOTWORKSPACE-77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29-mpmMcdr

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MP 224 Home Cardiorespiratory Monitoring No LCD or NCD BCBSMA Commercial policy is followed Outpatient Prior Authorization Prior authorization is not required

MP 227 Myoelectric Prosthetic and Orthotic Components for the Upper Limb


MP 231 Automated Percutaneous and Percutaneous Discectomy


MP 233 Endovascular Stent Grafts for Disorders of the Thoracic Aorta


MP 237 Occipital Nerve Stimulation No LCD or NCD BCBSMA Commercial policy is followed Outpatient Prior Authorization This is not a covered service

MP 238 Treatment of Varicose Veins/Venous Insufficiency

LCD: Varicose Veins of the Lower Extremity, Treatment of (L33575) Outpatient Prior Authorization 36465, 36466, 36470, 36471, 36475, 36476, 36478, 36479, 36482, 36843, 37500, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785, S2202: Prior authorization is required for Medicare HMO Blue; in effect Prior authorization is not required for Medicare PPO Blue Massachusetts Collaborative Prior Authorization Form OR Blue Cross Blue Shield of Massachusetts Pre-certification Request Form

MP 240 Image-Guided Minimally Invasive Decompression for Spinal Stenosis

NCD: Percutaneous image-guided lumbar decompression for lumbar spinal stenosis (150.13) Outpatient Prior Authorization Prior authorization is not required

MP 243 Magnetic Resonance‒Guided Focused Ultrasound

LCD: Magnetic Resonance Image Guided High Intensity Focused Ultrasound (MRgFUS) for Essential Tremor (L37421) Outpatient Prior Authorization


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Prior authorization is not required

MP 244 Laparoscopic and Transcervical Techniques for the Myolysis of Uterine Fibroids


MP 247 Hematopoietic Cell Transplantation in the Treatment of Germ Cell Tumors


MP 248 Extracorporeal Photopheresis

NCD: Extracorporeal Photopheresis (110.4) Outpatient Prior Authorization Prior authorization is not required

MP 249 Multimarker Serum Testing Related to Ovarian Cancer

LCD: Non-covered Services (L33629) Outpatient Prior Authorization This is not a covered service

MP 250 Systems Pathology in Prostate Cancer


MP 253 InVitro Chemoresistance and Chemosensitivity Assays


MP 254 Orthopedic Applications of Stem Cell Therapy (Including Allograft and Bone Substitute Products Used With Autologous Bone Marrow)


MP 258 Quantitative Sensory Testing NCD: Sensory Nerve Conduction Threshold Tests (sNCTs) (160.23) Outpatient Prior Authorization This is not a covered service

MP 259 Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors


MP 260 Cryosurgical Ablation of No LCD or NCD


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Miscellaneous Solid Tumors Other Than Liver, Prostate, or Dermatologic Tumors


MP 261 Bioimpedance Devices for the Detection of Lymphedema


MP 263 Dynamic Posturography No LCD or NCD BCBSMA Commercial policy is followed Outpatient Prior Authorization This is not a covered service

MP 264 Diagnosis and Management of Idiopathic Environmental Intolerance or Clinical Ecology


MP 266 Ovarian and Internal Iliac Vein Endovascular Occlusion as a Treatment of Pelvic Congestion Syndrome


MP 267 Treatment of Tinnitus No LCD or NCD BCBSMA Commercial policy is followed Outpatient Prior Authorization Prior authorization is not required

MP 268 Cellular Immunotherapy for Prostate Cancer

NCD: Autologous Cellular Immunotherapy Treatment (110.22) Outpatient Prior Authorization Prior authorization is not required

MP 269 Heart/Lung Transplant No LCD or NCD BCBSMA Commercial policy is followed Outpatient Prior Authorization This procedure is performed in the inpatient setting

MP 271 Decompression of the Intervertebral Disc Using Laser Energy (Laser Discectomy) or Radiofrequency Coblation (Nucleoplasty)

NCD: Thermal Intradiscal Procedures (TIPs) (150.11) Outpatient Prior Authorization This is not a covered service

MP 272 Intravitreal and Punctum Corticosteroid Implants


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MP 274 Methadone Treatment for Opioid Use Disorder

MLN Matters Number: SE1604 Medicare Coverage of Substance Abuse Services Medicare Prescription Drug Benefit Manual Chapter 6 – Part D Drugs and Formulary Requirements Outpatient Prior Authorization Prior authorization is not required

MP 277 Stereotactic Radiosurgery and Stereotactic Body Radiotherapy

LCD: Stereotactic Radiation Therapy: Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT) (L35076) Outpatient Prior Authorization Prior authorization is not required

MP 278 Intraoperative Radiotherapy No LCD or NCD BCBSMA Commercial policy is followed Outpatient Prior Authorization Prior authorization is not required

MP 280 Total Artificial Hearts and Implantable Ventricular Assist Devices

NCD: Artificial Hearts and Related Devices (20.9) Outpatient Prior Authorization This procedure is performed in the inpatient setting

MP 283 Novel Biomarkers in Risk Assessment and Management of Cardiovascular Disease

NCD: Lipid Testing (190.23) LCD: B-type Natriuretic Peptide (BNP) Testing (L33573) LCD: MolDX: Biomarkers in Cardiovascular Risk Assessment (L36523) Outpatient Prior Authorization Prior authorization is not required

MP 284 Bronchial Thermoplasty No LCD or NCD BCBSMA Commercial policy is followed Outpatient Prior Authorization Prior authorization is not required

MP 287 Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting

NCD: Cardiac Output Monitoring by Thoracic Electrical Bioimpedance (TEB) (20.16) Outpatient Prior Authorization Prior authorization is not required

MP 290 Serum Biomarker Human Epididymis Protein 4 - HE4


MP 291 Intravenous Anesthetics for the Treatment of Chronic Pain


https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1604.pdfhttps://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1604.pdf

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MP 292 Radioembolization for Primary and Metastatic Tumors of the Liver


MP 297 Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders

LCD: Transcranial Magnetic Stimulation (L33398) Outpatient Prior Authorization 90867, 90868, 90869: Prior authorization is required for Medicare HMO Blue; in effect 90867, 90868, 90869: Prior authorization is required for Medicare PPO Blue; in effect Massachusetts Collaborative Prior Authorization Form OR Blue Cross Blue Shield of Massachusetts Pre-certification Request Form

MP 299 Subtalar Arthroereisis No LCD or NCD BCBSMA Commercial policy is followed Outpatient Prior Authorization This is not a covered service

MP 302 Electrical Stimulation for the Treatment of Arthritis


MP 303 Ultrasonographic Evaluation of Skin Lesions


MP 305 Vertical Expandable Prosthetic Titanium Rib


MP 306 Wireless Pressure Sensors in Endovascular Aneurysm Repair


MP 307 Saturation Biopsy for Diagnosis, Staging and Management of Prostate Cancer


MP 308 Biofeedback as a Treatment of Fecal Incontinence or Constipation



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MP 313 Bronchial Valves No LCD or NCD BCBSMA Commercial policy is followed Outpatient Prior Authorization This is not a covered service Prior authorization is not required

MP 320 Diagnosis and Treatment of Sacroiliac Joint Pain

LCD: Pain Management (L33622) LCD: Minimally invasive Surgical (MIS) Fusion of the Sacroiliac (SI) Joint (L36406) Outpatient Prior Authorization Prior authorization is not required

MP 321 Threshold Electrical Stimulation as a Treatment of Motor Disorders

NCD: Treatment of Motor Function Disorders with Electric Nerve Stimulation (160.2) Outpatient Prior Authorization This is not a covered service

MP 322 Hematopoietic Stem-Cell Transplantation for Waldenstrom Macroglobulinemia


MP 323

Endovascular Procedures for Intracranial Arterial Disease (Atherosclerosis and Aneurysms)

NCD: Percutaneous Transluminal Angioplasty (PTA) (20.7) Outpatient Prior Authorization Prior authorization is not required

MP 324 Islet Transplantation NCD: Islet Cell Transplantation in the Context of a Clinical Trial (260.3.1) Outpatient Prior Authorization This procedure is performed in the inpatient setting

MP 326 Accelerated Breast Irradiation and Brachytherapy Boost after Breast-Conserving Surgery for Early Stage Breast Cancer


MP 328 Allogeneic Pancreas Transplant NCD: Pancreas Transplants (260.3) Outpatient Prior Authorization This procedure is performed in the inpatient setting

MP 329 Fecal Calprotectin Testing No LCD or NCD BCBSMA Commercial policy is followed Outpatient Prior Authorization Prior authorization is not required

MP 332 Insulin Delivery Devices NCD: Infusion Pumps (280.14)


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MP 334 Percutaneous Left Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation

NCD: Percutaneous Left Atrial Appendage Closure (LAAC) (20.34) Outpatient Prior Authorization Prior authorization is not required

MP 336 Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer

LCD: MolDX-CDD: ConfirmMDx Epigenetic Molecular Assay (L35632) LCD: Biomarker Testing (Prior to Initial Biopsy) for Prostate Cancer Diagnosis (L37733) Local Coverage Article: MolDX: Progensa® PCA3 Assay Coverage Update (A53107) Outpatient Prior Authorization Prior authorization is not required

MP 341 Flow Cytometry for Cell Analysis No LCD or NCD BCBSMA Commercial policy is followed Outpatient Prior Authorization Prior authorization is not required

MP 342 Thermography NCD: Thermography (220.11) Outpatient Prior Authorization This is not a covered service

MP 347 Ambulatory Event Monitors and Mobile Cardiac Outpatient Telemetry

NCD: Electrocardiographic Services (20.15) Outpatient Prior Authorization Prior authorization is not required

MP 348 Stem Cell Therapy for Peripheral Arterial Disease


MP 352 Diagnosis and Treatment of Chronic Cerebrospinal Venous Insufficiency in Multiple Sclerosis


MP 353 High-Dose Rate Temporary Prostate Brachytherapy


MP 354 Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers

NCD: Pneumatic Compression Devices (280.6) Outpatient Prior Authorization Prior authorization is not required

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MP 356 Open and Thoracoscopic Approaches to Treat Atrial Fibrillation and Atrial Flutter (Maze and Related Procedures)


MP 362 Cranial Electrotherapy Stimulation and Auricular Electrostimulation


MP 364 Lung Volume Reduction Surgery for Severe Emphysema

NCD: Lung Volume Reduction Surgery (Reduction Pneumoplasty) (100-3/240.1) Outpatient Prior Authorization This procedure is performed in the inpatient setting

MP 371 Gas Permeable Scleral Contact Lens


MP 372 Viscocanalostomy and Canaloplasty


MP 374 Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions

No LCD or NCD BCBSMA Commercial policy is followed Outpatient Prior Authorization 27412: Prior authorization is required; in effect Massachusetts Collaborative Prior Authorization Form OR Blue Cross Blue Shield of Massachusetts Pre-certification Request Form

MP 379 Medical and Surgical Management of Obesity including Anorexiants

NCD: Intensive Behavioral Therapy for Obesity (210.12) NCD: Bariatric Surgery for the Treatment of Morbid Obesity (100.1) Outpatient Prior Authorization 43644; 43770, 43775, 43845, 43846;43847: Prior authorization is required for Medicare HMO Blue; in effect Prior authorization is not required for Medicare PPO Blue 047 Preauthorization Request Form for 379 Surgical Management of Obesity

MP 385 Routine Foot Care and Debridement of Nails

LCD: Routine Foot Care and Debridement of Nails (L33636) Outpatient Prior Authorization Prior authorization is not required

MP 392 Transcatheter Aortic Valve NCD: Transcatheter Aortic Valve Replacement (TAVR)

http://www.masscollaborative.org/Standardized_Prior_Authorization_Form.pdf?disclaimer=3rdpartyhttps://provider.bluecrossma.com/ProviderHome/wcm/connect/77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29/MPC_111616-2Z_Pre-cert_Pre-Auth_Request_Form.pdf?MOD=AJPERES&CONVERT_TO=URL&CACHEID=ROOTWORKSPACE-77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29-mpmMcdrhttps://provider.bluecrossma.com/ProviderHome/wcm/connect/77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29/MPC_111616-2Z_Pre-cert_Pre-Auth_Request_Form.pdf?MOD=AJPERES&CONVERT_TO=URL&CACHEID=ROOTWORKSPACE-77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29-mpmMcdrhttp://www.bluecrossma.org/medical-policies/sites/g/files/csphws2091/files/acquiadam-assets/047%20Preauthorization%20Request%20Form%20for%20379%20Surgical%20Management%20of%20Obesity%20Policy%20prn.pdfhttp://www.bluecrossma.org/medical-policies/sites/g/files/csphws2091/files/acquiadam-assets/047%20Preauthorization%20Request%20Form%20for%20379%20Surgical%20Management%20of%20Obesity%20Policy%20prn.pdf

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Implantation for Aortic Stenosis (20.32) Outpatient Prior Authorization This procedure is performed in the inpatient setting

MP 393 Nerve Fiber Density Measurement No LCD or NCD BCBSMA Commercial policy is followed Outpatient Prior Authorization Prior authorization is not required

MP 403 Transcatheter Pulmonary Valve Implantation


MP 404 Axial Lumbosacral Interbody Fusion


MP 406 Treatment of Hyperhidrosis No LCD or NCD BCBSMA Commercial policy is followed Outpatient Prior Authorization Prior authorization is not required

MP 407 Continuous Passive Motion in the Home Setting

NCD: Durable Medical Equipment Reference List (280.1) Outpatient Prior Authorization Prior authorization is not required

MP 423 Outpatient Psychotherapy LCD: Psychiatry and Psychology Services (L33632) Outpatient Prior Authorization Prior authorization is not required

MP 428 Reconstructive Breast Surgery/Management of Breast Implants

No LCD or NCD BCBSMA Commercial policy is followed Outpatient Prior Authorization 11970, 11971, 19316, 19318, 19324, 19325, 19328, 19330, 19340, 19342, 19350, 19355, 19357, 19361, 19364, 19366, 19367, 19368, 19369, 19371, 19380, 19396, S2066, S2067: Prior authorization is required Medicare HMO Blue; in effect Prior authorization is not required for Medicare PPO Blue Massachusetts Collaborative Prior Authorization Form OR Blue Cross Blue Shield of Massachusetts Pre-certification Request Form

MP 436 Interspinous Fixation - Fusion Devices



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MP 437 Charged-Particle (Proton or Helium Ion) Radiotherapy for Neoplastic Conditions

LCD: Proton Beam Therapy (L35075) Outpatient Prior Authorization Prior authorization is not required

MP 445 Ultrasound for the Evaluation of Paranasal Sinuses


MP 447 Whole-Body Computed Tomography Scan as a Screening Test

NCD: Computed Tomography (220.1) Outpatient Prior Authorization Prior authorization is not required

MP 449 Vertebral Fracture Assessment with Densitometry


MP 450 Bone Mineral Density Studies LCD: Category III CPT® Codes (L33392) (A56195) Medicare Benefit Policy Manual - Pub 100-02 Medicare Benefit Policy Outpatient Prior Authorization Prior authorization is not required

MP 451 Peroral Endoscopic Myotomy for Treatment of Esophageal Achalasia


MP 453 Melanoma Vaccines No LCD or NCD BCBSMA Commercial policy is followed Outpatient Prior Authorization This is not a covered service

MP 454 Oncologic Applications of Photodynamic Therapy, Including Barrett Esophagus


MP 455 Adoptive Immunotherapy No LCD or NCD BCBSMA Commercial policy is followed Outpatient Prior Authorization This is not a covered service

MP 461 Laser Treatment of Active Acne No LCD or NCD BCBSMA Commercial policy is followed

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Outpatient Prior Authorization This is not a covered service

MP 462 Nonpharmacologic Treatment of Rosacea


MP 463 Dermatologic Applications of Photodynamic Therapy

NCD: Treatment of Actinic Keratosis (250.4) Outpatient Prior Authorization Prior authorization is not required

MP 465 Lipid Apheresis No LCD or NCD BCBSMA Commercial policy is followed Outpatient Prior Authorization 36516, S2120: Prior authorization is required for Medicare HMO Blue; in effect Prior authorization is not required for Medicare PPO Blue Massachusetts Collaborative Prior Authorization Form OR Blue Cross Blue Shield of Massachusetts Pre-certification Request Form

MP 466 Plasma Exchange NCD: Apheresis (Therapeutic Pheresis) (110.14) Outpatient Prior Authorization Prior authorization is not required

MP 470 Pelvic Floor Stimulation as a Treatment of Urinary Incontinence and Fecal Incontinence

NCD: Non-Implantable Pelvic Floor Electrical Stimulator (230.8) Outpatient Prior Authorization Prior authorization is not required

MP 471 Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence

NCD: Incontinence Control Devices (230.10) Outpatient Prior Authorization Prior authorization is not required

MP 472 Spinal Cord and Dorsal Root Ganglion Stimulation

NCD: Electrical Nerve Stimulators (160.7) Outpatient Prior Authorization 63655; 63685: Prior authorization is required for Medicare HMO Blue; in effect Prior authorization is not required for Medicare PPO Blue Massachusetts Collaborative Prior Authorization Form OR Blue Cross Blue Shield of Massachusetts Pre-certification Request Form

MP 473 Deep Brain Stimulation NCD: Deep Brain Stimulation for Essential Tremor and Parkinson Disease (160.24) Outpatient Prior Authorization This procedure is performed in the inpatient setting

MP 474 Vagus Nerve Stimulation NCD: Vagus Nerve Stimulation (VNS) (160.18)

http://www.masscollaborative.org/Standardized_Prior_Authorization_Form.pdf?disclaimer=3rdpartyhttps://provider.bluecrossma.com/ProviderHome/wcm/connect/77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29/MPC_111616-2Z_Pre-cert_Pre-Auth_Request_Form.pdf?MOD=AJPERES&CONVERT_TO=URL&CACHEID=ROOTWORKSPACE-77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29-mpmMcdrhttps://provider.bluecrossma.com/ProviderHome/wcm/connect/77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29/MPC_111616-2Z_Pre-cert_Pre-Auth_Request_Form.pdf?MOD=AJPERES&CONVERT_TO=URL&CACHEID=ROOTWORKSPACE-77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29-mpmMcdrhttp://www.masscollaborative.org/Standardized_Prior_Authorization_Form.pdf?disclaimer=3rdpartyhttps://provider.bluecrossma.com/ProviderHome/wcm/connect/77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29/MPC_111616-2Z_Pre-cert_Pre-Auth_Request_Form.pdf?MOD=AJPERES&CONVERT_TO=URL&CACHEID=ROOTWORKSPACE-77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29-mpmMcdrhttps://provider.bluecrossma.com/ProviderHome/wcm/connect/77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29/MPC_111616-2Z_Pre-cert_Pre-Auth_Request_Form.pdf?MOD=AJPERES&CONVERT_TO=URL&CACHEID=ROOTWORKSPACE-77c7dfbe-1502-4ddf-a5e9-1f3f5af26a29-mpmMcdr

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MP 478 Cochlear Implant NCD: C

132 Medicare Advantage Management - Blue Cross MA · 2020. 12. 31. · 1 Medical Policy Medicare...

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