Medical Policy Directory of Documents Policy Number: 411

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Drugs ∙ Treatments ∙ Devices and Equipment ∙ Surgeries ∙ Other

Drugs Medical Technology Assessment Investigational (Non-Covered) Services List 400 Ampyra™ (dalfampridine) 246 Antihyperlipidemics: A Prescription Drug Therapy Guideline 013 ↳Prior Authorization/ Formulary Exception Form 434 Anti-Parkinsonism Drugs 054 Antisense Oligonucleotide Medications 027 Asthma and Chronic Obstructive Pulmonary Disease Medication Management 011 ↳Prior Authorization/ Formulary Exception Form 434 Benign Prostatic Hyperplasia (BPH) 040 Bisphosphonate, Oral 058 Botulinum Toxin Injections 006 B-Type Natriuretic Peptide 031 Anti-Migraine Policy 021 CNS Stimulants and Psychotherapeutic Agents 019 Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications 705 Compound Inclusion List for Pharmacy Medical Policy 579, Compounded Medications 704 Compounded Medications 579 Cox II Inhibitor Drugs 002 Diabetes Step Therapy 041 Dificid (fidaxomicin) 700 Drug Management and Prior Authorization 251 ↳Prior Authorization/ Formulary Exception Form 434 Drugs for Cystic Fibrosis 408 Entresto Step Therapy 063 Erythropoietin, Recombinant Human; Epoetin Alpha (Epogen and Procrit); Darbepoetin Alpha 262 (Aranesp) Esketamine Nasal Spray (Spravato) and Intravenous Ketamine for Treatment Resistant 087 Depression

Fentanyl, oral/transmucosal 113 Hypoactive Sexual Desire Disorder 131 Infertility Step Therapy 014 Injectable Specialty Medication Coverage 071 Glucagon-like Peptide-1 - GLP-1 - Receptor Agonists 282 ↳Prior Authorization/ Formulary Exception Form 434 Growth Hormone and Insulin-like Growth Factor 257 ↳Prior Authorization/ Formulary Exception Form 434 Hepatitis C Medication Management 344 HETLIOZ (tasimelteon) 697 Home Total Parenteral Nutrition (TPN) 296 ↳Prior Authorization Form 430 ↳Prior Authorization Form 430 IgE Receptor Binding Inhibitors, Omalizumab (Xolair) 017 Immune Modulating Drugs 004 Immunomodulators, Topical (This is not a medical policy document) 010 Influenza Drugs: Tamiflu and Relenza 440 Interferons Alpha and Gamma 052 ↳Prior Authorization/ Formulary Exception Form 434 Interleukin-2 (IL-2) 103 Intravenous Immunogammaglobulin (IVIg) 310 ↳Prior Authorization Form 430 Lorcaserin (Belviq) 572 Medical Benefit Prior Authorization Medication List 034 Med UM Pharmacy Prior Authorization 033 Medical and Surgical Management of Obesity including Anorexiants 379 Medications for Sickle Cell and Beta Thalassemia 083 Melanoma Vaccines 453 Monitored Anesthesia Care (MAC) 154 Mupirocin Step Policy 062 New Drug Approval Program 005 Non-Covered Drug List 433 ↳ Formulary Exception Form 434 Oncology Drugs 409 Ophthalmic Prostaglandins 346 Opioid and Opioid Combination Medication Management and Urine Drug Testing 102 Overactive Bladder Medications 170 Phosphodiesterase Type-5 Inhibitors for Pulmonary Arterial Hypertension 036 Pregabalin (Lyrica and Lyrica CR) 057 Probuphine (buprenorphine implant) 021 Proton Pump Inhibitors 030 Quality Care Dosing (QCD) Guidelines 621A Quality Care Dosing Guidelines Drug List 621B Restasis – Topical Ocular Hydrating Agents 426 Retail Pharmacy Prior Authorization Policy 049 RSV Immunoglobulin: Palivizumab (Synagis™) & RSV-IVIg & RespiGam) for Respiratory 422 Syncytial Virus ↳Prior Authorization Form 430 Sexual Dysfunction: Diagnosis and Therapy 078

Soliris and Ultomiris 093 Special Foods: Special Infant Formula, Enteral Formula, Ketogenic Diet for Seizures, and 304 Formula Infusion Pumps ↳Prior Authorization/ Formulary Exception Form 434 Spinal Muscular Atrophy (SMA) Medications 044 Sublingual Immunotherapy with Allergen-specific Extracts (SLIT) 681 Topical Testosterone 345

Tests

Medical Technology Assessment Investigational (Non-Covered) Services List 400 Actigraphy 533 AIM High Technology Radiology Management Program CPT and HCPCS Codes 900 Ambulatory Event Monitors and Mobile Outpatient Cardiac Telemetry 347 Analysis of Human DNA in Stool Samples as a Technique for Colorectal Cancer Screening 557 Antigen Leukocyte Antibody Test 673 Automated Ambulatory Blood Pressure Monitoring for the Diagnosis of Hypertension in Patients 206 with Elevated Office Blood Pressure Automated Point of Care Nerve Conduction Tests 222 Autonomic Nervous System Testing 713 Biomarkers for Diagnosis & Cancer Risk Assessment of Prostate Cancer 336 Bone Turnover Markers for Diagnosis and Management of Osteoporosis and Diseases Associated 549 with High Bone Turnover Breast Duct Endoscopy 493 Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting 287 Cardiovascular Risk Panels 664 Chromoendoscopy as an Adjunct to Colonoscopy 904 Computed Tomography Perfusion Imaging of the Brain 448 Computer-Aided Evaluation of Malignancy with Magnetic Resonance Imaging of the Breast 578 Computer-Assisted Navigation Orthopedic Procedure 594 Confocal Laser Endomicroscopy 618 Corneal Endothelial Microscopy-Specular Microscopy 050 Diagnosis and Management of Idiopathic Environmental Intolerance or Clinical Ecology 264 Dopamine Transporter Imaging with Single Photon Emission Computed Tomography 918 Drug Testing in Pain Management and Substance Use Disorder Treatment 674 Dynamic Posturography To Assess Vestibular Dysfunction 263 Dynamic Spinal Visualization and Vertebral Motion Analysis 195 Electromagnetic Navigation Bronchoscopy 203 Electromyography and Nerve Conduction Studies 701 Endobrachial Ultrasound for Diagnosis and Staging of Lung Cancer 715 Endovascular Therapies for Extracranial Vertebral Artery Disease 730 Epithelial Cell Cytology in Breast Cancer Risk Assessment and High-Risk Patient Management – 492 Ductal Lavage and Suction Collection Systems Expanded Molecular Panel Testing of Cancers to Identify Targeted Therapies 790 Fecal Analysis in the Diagnosis of Intestinal Dysbiosis 556 Fecal Calprotectin Testing 329 Flow Cytometry for Cell Analysis 341 Genetic Testing for Familial Cutaneous Malignant Melanoma 300 Handheld Radiofrequency Spectroscopy for Intraoperative Assessment of Surgical Margins during 546 Breast-Conserving Surgery High-Sensitivity C-Reactive Protein 032

Home Uterine Activity Monitoring 043 Homocysteine Testing in the Screening, Diagnosis, and Management of Cardiovascular Disease 016 and Venous Thromboembolic Disease Hydrogel Spacer use During Radiotherapy for Prostate Cancer 743 Identification of Microorganisms Using Nucleic Acid Probe 555 Immune Cell Function Assay in Solid Organ Transplantation 182 In Vivo Analysis of Colorectal Polyps 521 Ingestible pH and Pressure Capsule 045 Intracellular Micronutrient Analysis 073 InVitro Chemoresistance and Chemosensitivity Assays 253 Laboratory Tests for Heart and Kidney Transplant Rejection 530 Leukocyte Histamine Release Test 589 Magnetic Resonance MRI, MRA, MRV, MRS 106 Magnetoencephalography and Magnetic Source Imaging 137 Measurement of Lipoprotein-Associated Phospholipase A2 - Lp-PLA2 - in the Assessment of 558 Cardiovascular Risk Measurement of Serum Antibodies to Selected Biologic Agents 917 Medicare Part D Coverage Determination Request Form 442 Mineral Density Studies 450 Molecular Testing in the Management of Pulmonary Nodules 029 Multianalyte Assays with Algorithmic Analyses for Predicting Risk of Type 2 Diabetes 654 Multianalyte Assays with Algorithmic Analysis for the Evaluation and Monitoring of Patients with 921 Chronic Liver Disease Multibiomarker Disease Activity Blood Test for Rheumatoid Arthritis 677 Multispectral Digital Skin Lesion Analysis 748 Multitarget Polymerase Chain Reaction Testing for Diagnosis of Bacterial Vaginosis 711 Myocardial Strain Imaging 112 Myocardial Sympathetic Innervation Imaging in Patients with Heart Failure 576 Nerve Fiber Density Measurement 393 Neurofeedback 515 Neuropsychological Testing 039 Non-Invasive Vascular Studies - Duplex Scans 691 Novel Biomarkers in Risk Assessment and Management of Cardiovascular Disease 283 Nutrient - Nutritional Panel Testing 745 Ophthalmologic Techniques That Evaluate the Posterior Segment for Glaucoma 053 Optical Coherence Tomography for Imaging of Coronary Arteries 915 Optical Coherence Tomography of the Anterior Eye Segment 084 Paraspinal Surface Electromyography - SEMG - to Evaluate and Monitor Back Pain 517 Preimplantation Genetic Testing 088 Preventive Screening Tests (This is not a medical policy document) 413 Proteomic Testing for Systemic Therapy in Non-Small Cell Lung Cancer 709 Psychological Testing 363 Quantitative Assay for Measurement of HER2 Total Protein Expression and HER2 Dimers 397 Quantitative Electroencephalography as a Diagnostic Aid for Attention-Deficit Hyperactivity 554 Disorder Radiofrequency Ablation of Peripheral Nerves to Treat Pain 794 Radioimmunoscintigraphy Imaging and Monoclonal Antibody Imaging Using In-111 Satumomab 638 Pendetide - OncoScint - or Tc-99m Arcitumomab - IMMU-4, CEA-Scan Radioimmunoscintigraphy Imaging and Monoclonal Antibody Imaging Using Technetium-99m 640 Nofetumomab Merpentan - Verluma

Radioimmunoscintigraphy Imaging and Monoclonal Antibody Imaging with Indium-111 Capromab 639 Pendetide for Prostate Cancer Retinal Telescreening for Diabetic Retinopathy 065 Rhinomanometry and Acoustic or Optical Rhinometry 586 Saturation Biopsy for Diagnosis and Staging of Prostate Cancer 307 Scintimammography, Breast-Specific Gamma Imaging, and Molecular Breast Imaging 494 Sensory Evoked Potentials. Somatosensory, Visual, and Auditory Evoked Potentials and Intra- 211 operative Neurophysiologic Monitoring Serological Diagnosis of Celiac Disease 138 Serum Antibodies for the Diagnosis of Inflammatory Bowel Disease 551 Serum Biomarker Human Epididymis Protein 4 - HE4 290 Serum Biomarker Panel Testing for Systemic Lupus Erythematosus and Other Connective Tissue 702 Diseases Serum Biomarker Tests for Multiple Sclerosis 676 Sexual Dysfunction: Diagnosis and Therapy 078 Signal-Averaged Electrocardiography (SAECG) 134 Systems Pathology in Prostate Cancer 250 Thermography 342 Temporomandibular Joint Dysfunction 035 Ultrasonographic Evaluation of Skin Lesions 303 Ultrasonographic Measurement of Carotid Intima-Medial Thickness as an Assessment of 547 Subelinical Atherosclerosis Ultrasound: Breast, Cranial, Duplex, Fetal, Obstetrical, Intravascular, Prostate, Transvaginal, 007 Transrectal and Other Uses Ultrasound for the Evaluation of Paranasal Sinuses 445 Urinary Metabolite Tests for Adherence to Direct-Acting Antiviral 742 Vertebral Fracture Assessment with Densitometry 449 Vitamin D Assay Testing 746 Whole-Body Computed Tomography Scan as a Screening Test 447 Whole Body Dual X-Ray Absorptiometry to Determine Body Composition 577 Wireless Capsule Endoscopy as a Diagnostic Technique in Disorders of the Small Bowel, 185 Esophagus, and Colon Wireless Pressure Sensors in Endovascular Aneurysm Repair 306

Treatments Medical Technology Assessment Investigational (Non-Covered) Services List 400 Ablation Procedures for Peripheral Neuromas 719 Absorbable Nasal Implant for Treatment of Nasal Valve Collapse 186 Accelerated Breast Irradiation and Brachytherapy Boost After Breast-Conserving Surgery for Early 326 Stage Breast Cancer Adoptive Immunotherapy 455 Alcohol Injections for Treatment of Peripheral Morton Neuromas 642 Allogeneic Hematopoietic Cell transplantation for Myelodysplastic Syndromes and Myeloproliferative 155 Neoplasms Amniotic Membrane and Amniotic Fluid 643 Intravenous Anesthetics for the Treatment of Chronic Pain and Depression 291 Artificial Intervertebral Disc - Cervical Spine 585 Artificial Intervertebral Disc - Lumbar Spine 592 Assisted Reproductive Technology Services Form for Policy #086 Infertility Diagnosis and 694 Treatment

Auditory Brainstem Implant 481 Balloon Dilation of the Eustachian Tube 018 Balloon Sinuplasty for Treatment of Chronic Sinusitis 582 Baroreflex Stimulation Devices 595 Benign Skin Lesions 707 Bioengineered Skin and Soft Tissue Substitutes 663 Biofeedback as a Treatment of Chronic Pain 210 Biofeedback as a Treatment of Fecal Incontinence or Constipation 308 Biofeedback as a Treatment of Urinary Incontinence 173 Biofeedback for Miscellaneous Indications 187 Biofeedback for the Treatment of Headache 152 Biofeedback: Complementary Medicine, Mind-Body, Alternative, Holistic, Naturopathic and Other 178 Therapies Brachytherapy for Clinically Localized Prostate Cancer Using Permanently Implanted Seeds 175 Bronchial Thermoplasty 284 Cardiac Rehabilitation in the Outpatient Setting 916 Cellular Immunotherapy for Prostate Cancer 268 Cerebrospinal Fluid and Urinary Biomarkers for Alzheimer Disease 581 Charged-Particle - Proton or Helium Ion - Radiation Therapy 437 Chelation Therapy 122 Chimeric Antigen Receptor Therapy for Hematologic Malignancies 066 Cochlear Implant 478 Cognitive Rehabilitation 439 Complementary Medicine: Mind-Body, Alternative, Holistic, Naturopathic and Other Therapies 178 Corneal Collagen Cross-linking 905 Cranial Electrotherapy Stimulation and Auricular Electrostimulation 362 Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate, or Dermatologic 260 Tumors Deep Brain Stimulation 473 Diagnosis and Treatment of Chronic Cerebrospinal Venous Insufficiency in Multiple Sclerosis 352 Diagnosis and Treatment of Sacroiliac Joint Pain 320 Donor Lymphocyte Infusion for Malignancies Treated with an Allogeneic Hematopoietic Cell 338 Transplant Dry Needling and Trigger Point Injections for Myofascial Pain 792 Electrical Bone Growth Stimulation of the Appendicular Skeleton 499 Electrical Stimulation for the Treatment of Arthritis 302 Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures 498 Electronic Brachytherapy for Nonmelanoma Skin Cancer 739 Electrostimulation and Electromagnetic Therapy for Treating Wounds 655 Elzonris (tagraxofusp-erzs) for the Treatment of Blastic Plasmacytoid Dendritic Cell Neoplasm 009 Elzonris Prior Authorization Request Form MP 009 928 End-Diastolic Pneumatic Compression Boot as a Treatment of Peripheral Vascular Disease or 648 Lymphedema Endobronchial Brachytherapy 091 Endoscopic Radiofrequency Ablation or Cryoablation for Barrett’s Esophagus 218 Endovascular Procedures for Intracranial Arterial Disease - Atherosclerosis and Aneurysms 323 Enhanced External Counterpulsation (EECP) for Chronic Stable Angina or Congestive Heart 649 Failure Endoscopic retrograde cholangiopancreatography (ERCP) with Laser or Electrohydraulic 209 Lithotripsy Epidural Steroid Injections for Neck and Back Pain 690

Extracorporeal Photopheresis 248 Eyelid Thermal Pulsation for the Treatment of Dry Eye Syndrome 613 Focal Treatments for Prostate Cancer 733 Functional Neuromuscular Electrical Stimulation 201 Gas Permeable Scleral Contact Lens 371 Gastric Electrical Stimulation 636 Genotype-Guided Tamoxifen Treatment 067 Hematopoietic Cell Transplantation for Acute Myeloid Leukemia 150 Hematopoietic Stem Cell Transplantation for Non-Hodgkin Lymphomas 143 High-Dose Rate Temporary Prostate Brachytherapy 353 Hippotherapy 560 Hyperbaric Oxygen Therapy 653 Implantable Bone-Conduction and Bone-Anchored Hearing Aids 479 Implantable Miniature Telescope (IMT) 464 Infertility Diagnosis and Treatment 086 Influenza Drugs: Tamiflu and Relenza 440 Inhaled Nitric Oxide as a Treatment of Hypoxic Respiratory Failure in Neonates 100 Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence 471 Injections for osteoarthritis 427 Insulin Potentiation Therapy 532 Intensity-Modulated Radiation Therapy (IMRT): Abdomen and Pelvis 165 Intensity-Modulated Radiation Therapy (IMRT): Cancer of the Head and Neck or Thyroid 164 Intensity Modulated Radiation Therapy (IMRT): Central Nervous System Tumors 910 Intensity-Modulated Radiation Therapy (IMRT): Breast and Lung 163 Intensity Modulated Radiation Therapy (IMRT): Prostate 090 Interferential Stimulation for Treatment of Pain 509 Interventions for Progressive Scoliosis 550 Intracavitary Balloon Catheter Brain Brachytherapy for Malignant Gliomas or Metastasis to the 602 Brain Intraocular Radiation Therapy for Age-Related Macular Degeneration 610 Intraoperative Radiation Therapy, Selective Internal Radiation Therapy (also see 277 for 278 stereotactic radiosurgery) Intravenous Antibiotic Therapy and Associated Diagnostic Testing for Lyme Disease 171 Intravitreal Angiogenesis Inhibitors for Choroidal Vascular Conditions 343 Intravitreal Angiogenesis Inhibitors for Retinal Vascular Conditions 401 Intravitreal and Punctum Corticosteroid Implants 272 Iontophoresis and Phonophoresis as a Transdermal Technique for Drug Delivery 095 Isolated Limb Perfusion or Infusion for Malignant Melanoma 124 Laparoscopic and Percutaneous Techniques for the Myolysis of Uterine Fibroids 244 Laser Treatment of Onychomycosis 562 Left-Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation 334 Light Therapy for Psoriasis 698 Lipid Apheresis 465 Low-Level Laser Therapy 522 Lysis of Epidural Adhesions 598 Manipulation under Anesthesia 483 Measurement of Exhaled Nitric Oxide and Exhaled Breath Condensate in the Diagnosis and 524 Management of Respiratory Disorders Medical and Surgical Management of Obesity including Anorexiants 379

Medicare Advantage Management 132 Melanoma Vaccines 453 Methadone Treatment and Intensive Detoxification or Ultra-Rapid Detoxification for Opiate 274 Addiction Microwave Tumor Ablation 912 Monitored Anesthesia Care - (MAC) 154 MRI-Guided Focused Ultrasound - MRgFUS 243 Multimarker Serum Testing Related to Ovarian Cancer 249 Navigated Transcranial Magnetic Stimulation 596 Negative Pressure Wound Therapy in the Outpatient Setting 543 Neural Therapy 914 Noncontact Ultrasound Treatment for Wounds 657 Occipital Nerve Stimulation 237 Oncologic Applications of Photodynamic Therapy, Including Barrett’s Esophagus 454 Orthopedic Applications of Platelet-Rich Plasma 737 Orthopedic Applications of Stem Cell Therapy 254 Orthoptic Training for the Treatment of Vision or Learning Disabilities 611 Outpatient Cognitive Rehabilitation 660 Outpatient Psychotherapy 423 Outpatient Pulmonary Rehabilitation 136 Ovarian and Internal Iliac Vein Embolization as a Treatment of Pelvic Congestion Syndrome 266 Patient-Specific Instrumentation (eg, Cutting Guides) for Joint Arthroplasty 706 Pelvic Floor Stimulation as a Treatment of Urinary Incontinence and Fecal Incontinence 470 Percutaneous Balloon Kyphoplasty and Mechanical Vertebral Augmentation 485 Percutaneous Electrical Nerve Stimulation – PENS - and Percutaneous Neuromodulation Therapy 172 - PNT Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, and Biacuplasty 482 Percutaneous Vertebroplasty and Sacroplasty 484 Photocoagulation of Macular Drusen 607 Photodynamic Therapy for Choroidal Neovascularization 599 Phototherapeutic Keratectomy 597 Phototherapy PUVA UV-B and Targeted Phototherapy 059 Phrenic Nerve Stimulation for Central Sleep Apnea 955 Placental or Umbilical Cord Blood as a Source of Stem Cells 285 Plasma Exchange 466 Plugs for Fistula Repair 528 Percutaneous Tibial Nerve Stimulation 583 Preauthorization Request Form for 379 Surgical Management of Obesity Policy 047 Progenitor Cell Therapy for the Treatment of Damaged Myocardium Due to Ischemia 652 Prolotherapy, Joint Sclerotherapy and Ligamentous Injections with Sclerosing Agents 183 Prostatic Urethral Lift 744 Quantitative Sensory Testing 258 Radioactive Seed Localization of Nonpalpable Breast Lesions 469 Radioembolization for Primary and Metastatic Tumors of the Liver 292 Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors 259 Radiofrequency Ablation of Primary or Metastatic Liver Tumors 286 Radiofrequency Ablation of the Renal Sympathetic Nerves as a Treatment for Resistant 919 Hypertension Radiofrequency Coblation Tenotomy for Musculoskeletal Conditions 080

Repetitive Transcranial Magnetic Stimulation (rTMS) 297 Request for Clinical Exception to BCBSMA Charged Particle Proton Beam Policy and Notification 678 Request for Clinical Exception to BCBSMA Intensity Modulated Radiation Therapy (IMRT) Policy 325 and Notification Repository Corticotropin Injection (H.P Acthar Gel) 064 Responsive Neurostimulation for the Treatment of Refractory Focal Epilepsy 716 Routine Foot Care and Debridement of Toenails 385 Sacral Nerve Neuromodulation/Stimulation 153 Scenesse afamelanotide for the treatment of Erythropoietic protoporphyria 077 Semi-Implantable and Fully Implantable Middle Ear Hearing Aid 480 Sensory Integration Therapy 659 Sexual Dysfunction: Diagnosis and Therapy 078 Sphenopalatine Ganglion Block for Headache 026 Spinal Cord and Dorsal Root Ganglion Stimulation 472 Stem-cell Therapy for Peripheral Arterial Disease 348 Stereotactic Radiosurgery and Stereotactic Body Radiotherapy 277 Suprachoroidal Delivery of Pharmacologic Agents 609 Surgical and Transesophageal Endoscopic Procedures to Treat Gastroesophageal Reflux 920 Disease Surgical Ventricular Restoration 544 Temporomandibular Joint Dysfunction 035 Therapeutic Radiopharmaceuticals in Oncology 028 Thermal Capsulorrhaphy as a Treatment of Joint Instability 591 Threshold Electrical Stimulation as a Treatment of Motor Disorders 321 Transanal Radiofrequency Treatment of Fecal Incontinence 309 Transcatheter Arterial Chemoembolization - TACE - to Treat Primary or Metastatic Liver 634 Malignancies Transmyocardial Revascularization 651 Transpupillary Thermotherapy for Treatment of Choroidal Neovascularization 600 Transtympanic Micropressure Applications as a Treatment of Meniere’s Disease 508 Transvaginal and Transurethral Radiofrequency Tissue Remodeling for Urinary Stress 523 Incontinence Transurethral Water Vapor Thermal Therapy for Benign Prostatic Hyperplasia 060 Treatment of Tinnitus 267 Treatment of Varicose Veins and Venous Insufficiency 238 Trigger Point and Tender Point Injections 604 Ultrafiltration in Decompensated Heart Failure 542 Vagus Nerve Blocking Therapy for Treatment of Obesity 644 Vagus Nerve Stimulation 474 Vertebral Axial Decompression 603 Vision Services 675 Zolgensma (onasemnogene abeparvovec-xioi) for Spinal Muscular Atrophy 008 ZulressoTM (Brexanolone) for the Treatment of Post-Partum Depression 147

Devices & Equipment Medical Technology Assessment Investigational (Non-Covered) Services List 400 Automated Ambulatory Blood Pressure Monitoring for the Diagnosis of Hypertension in Patients 206 with Elevated Office Blood Pressure Bioimpedance Devices for the Detection of Lymphedema 261 Biventricular Pacemakers – Cardiac Resynchronization Therapy for the Treatment of Heart Failure 101

Continuous or Intermittent Monitoring of Glucose in Interstitial Fluid and Artificial Pancreas Device 107 Systems Continuous Passive Motion in the Home Setting 407 Cooling Devices Used in the Outpatient Setting 510 Diaphragm Pacing Stimulation 593 Electrical Stimulation Devices for Psychiatric and Neurological Conditions 157 Esophageal pH Monitoring 069 Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions 081 Home Cardiorespiratory Monitoring 224 Home Uterine Activity Monitoring 043 Insulin Delivery Devices: Pumps, Pens, and Jet Injectors 332 Leadless Cardiac Pacemakers 038 Microprocessor Controlled Prostheses for the Lower Limb 133 Myoelectric Prosthetic and Components for the Upper Limb 227 Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Disorders 120 Patient-Actuated End Range Motion Stretching Devices 721 Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers 354 Postsurgical Outpatient Use of Limb Compression Devices for Venous Thromboembolism 541 Prophylaxis Powered Exoskeleton for Ambulation in Patients with Lower Limb Disabilities 718 Retinal Prosthesis 606 Sexual Dysfunction: Diagnosis and Therapy 078 Transcutaneous Electrical Nerve Stimulation 003 Total Artificial Hearts and Implantable Ventricular Assist Devices 280 Ultrasound Accelerated Fracture Healing Device 497 Wearable Cardioverter Defibrillators 042

Surgeries Medical Technology Assessment Investigational (Non-Covered) Services List 400 Adrenal-to-Brain Transplantation 627 Allogeneic Hematopoietic Cell Transplantation for Genetic Diseases and Acquired Anemias 190 Allogeneic Pancreas Transplant 328 Aqueous Shunts and Stents for Glaucoma 223 Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions 111 Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions 374 Automated Percutaneous and Percutaneous Discectomy 231 Axial Lumbosacral Interbody Fusion 404 Bone Morphogenetic Protein 097 Carotid Stent Placement 219 Catheter Ablation as Treatment for Atrial Fibrillation 141 Closure Devices for Patent Foramen Ovale and Artial Septal Defects 121 Composite Tissue Allotransplantation of the Hand and Face 662 Continuous Passive Motion (CPM) in the Home Setting 407 Whole Gland Cryoablation of the Prostate 149 Cryosurgical Ablation of Primary or Metastatic Liver Tumors 633 Decompression of the Intervertebral Disc Using Laser Energy - Laser Discectomy - or 271 Radiofrequency Coblation - Nucleoplasty Embryonic Mesencephalic Transplantation for the Treatment of Parkinson’s Disease 625 Endobronchial Valves 313 Endometrial Ablation 331

Endothelial Keratoplasty 180 Endovascular Grafts for Abdominal Aortic Aneurysms 098 Endovascular Stent Grafts for Disorders of the Thoracic Aorta 233 Extracorporeal Membrane Oxygenation 726 Facet Arthroplasty 174 Facet Joint Denervation 140 Heart Transplant 197 Heart/Lung Transplant 269 Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia 076 Hematopoietic Cell Transplantation for Autoimmune Diseases 192 Hematopoietic Cell Transplantation for Chronic Lymphocytic Leukemia and Small Lymphocytic 074 Lymphoma Hematopoietic Cell Transplantation for Chronic Myelogenous Leukemia 212 Hematopoietic Cell Transplantation for CNS Embryonal Tumors and Ependymoma 205 Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer 204 Hematopoietic Cell Transplantation for Hodgkin Lymphoma 207 Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors in Adults 191 Hematopoietic Cell Transplantation for Plasma Cell Dyscracias, Including Multiple Myeloma and 075 POEMS Syndrome Hematopoietic Cell Transplantation for Primary Amyloidosis 181 Hematopoietic Cell Transplantation for Solid Tumors of Childhood 208 Hematopoietic Cell Transplantation in the Treatment of Germ-Cell Tumors 247 Hematopoietic Stem-Cell Transplantation for Waldenstrom Macroglobutinemia 322 Hip Resurfacing 046 Hyperthermic Intraperitoneal Chemotherapy for Select Intra-Abdominal and Pelvic Malignancies 048 Image-Guided Minimally Invasive Decompression for Spinal Stenosis 240 Implantable Cardioverter Defibrillator 070 Implantation of Intrastromal Corneal Ring Segments 235 Interspinous and Interlaminar Stabilization - Distraction Devices - Spacers 584 Interspinous Fixation – Fusion Devices 436 Islet Transplantation 324 Isolated Small Bowel Transplant 631 Keratoprosthesis 221 Kidney Transplant 196 Liver Transplant and Combined Liver-Kidney Transplant 198 Lung and Lobar Lung Transplant 015 Lung Volume Reduction Surgery for Severe Emphysema 364 Medical and Surgical Management of Obesity including Anorexiants 379 Meniscal Allografts and Other Meniscal Implants 110 Minimally Invasive Coronary Artery Bypass Graft Surgery 553 Nerve Graft in Association with Radical Prostatectomy 590 Open and Thoracoscopic Approaches to Treat Atrial Fibrillation - Maze and Related Procedures 356 Penile Revascularization: Surgery for Vasculogenic (See Sexual Dysfunction Diagnosis & 078 Therapy under Treatments) Peroral Endoscopic Myotomy for Treatment of Esophageal Achalasia 451 Plastic Surgery: Reconstructive, Restorative, and Cosmetic Services 068 Preauthorization Request Form for 379 Surgical Management of Obesity Policy 047 Reconstructive Breast Surgery-Management of Breast Implants 428 Reduction Mammaplasty for Breast-Related Symptoms 703 Sexual Dysfunction: Diagnosis and Therapy 078

Shoulder Resurfacing 156 Small Bowel, Liver, and Multivisceral Transplant 632 Stereotactic Radiofrequency Pallidotomy for the Treatment of Parkinsons Disease 626 Stereotactic Radiosurgery and Stereotactic Body Radiotherapy 277 Steroid-Eleuting Sinus Stents 800 Subtalar Arthroereisis 299 Surgery for Athletic Pubalgia 695 Surgical and Debulking Treatments for Lymphedema 037 Surgical Deactivation of Headache Trigger Sites 801 Surgical Interruption of Pelvic Nerve Pathways for Primary and Secondary Dysmenorrhea 570 Surgical Treatment of Femoroacetabular Impingement 145 Surgical and Non-Surgical Treatment of Gynecomastia 661 Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome 130 Transcutaneous Electrical Nerve Stimulation 003 Total Ankle Replacement 193 Transanal Endoscopic Microsurgery 200 Transcatheter Aortic-Valve Implantation for Aortic Stenosis 392 Transcatheter Mitral Valve Repair 692 Transcatheter Pulmonary Valve Implantation 403 Gender Affirming Services (Transgender Services) 189 Treatment of Hyperhidrosis excluding Botulinum Toxin 406 Vertical Expandable Prosthetic Titanium Rib 305 Viscocanalostomy and Canaloplasty 372

Other Advanced Imaging of the Heart CPT and HCPCS Codes 971 Advanced Imaging of the Heart 972 Advanced Imaging Radiology 968 AIM Abdomen and Pelvic Imaging CPT and Diagnoses Codes 930 AIM Brain Imaging CPT and Diagnoses Codes 931 AIM Chest Imaging CPT and Diagnoses Codes 932 AIM Extremity Imaging CPT and Diagnoses Codes 933 AIM Genetic Testing Management Program CPT and HCPCS Codes 957 AIM Head and Neck Imaging CPT and Diagnoses Codes 934 AIM Oncologic Imaging CPT, HCPCS and Diagnoses Codes 929 AIM Spine Imaging CPT and Diagnoses Codes 935 AIM Vascular Imaging CPT and Diagnoses Codes 936 AudioHealth Library 506 Directory of Documents (this document) 411 E-Blue Review - for Physicians to comment on Medical Policy 500 Fecal Microbiota Transplantation 682 Genetic Testing for Commercial and Medicare Advantage 954 Medical Policy Review Schedule 501 Medical Technology Assessment Guidelines 350 Medical Technology Assessment Investigational (Non-Covered) Services List 400 Medicare Advantage High Technology Radiology & Sleep Disorder Management 923 Medicare Advantage Part B Step Therapy 020 Outpatient Prior Authorization Code List 072 Prior Authorization Request Form for Artificial Intervertebral Disc Cervical Spine MP 585 952

Prior Authorization Request Form for CAR T-Cell Therapy Services for Treatment of Diffuse Large 924 B-cell Lymphoma MP 066 Prior Authorization Request Form for CAR T-Cell Therapy Services for B-cell Acute Lymphoblastic 925 Leukemia (tisagenlecleucel) MP 066 Prior Authorization Request Form for Gender Affirming Services (Transgender Services) MP 189 901 Prior Authorization Request Form for Electrolysis for Gender Affirming Services MP 189 902 Prior Authorization Request Form for Esketamine Nasal Spray and Intravenous Ketamine for 094 Treatment Resistant Depression Preauthorization Request Form for Gene Therapy for Inherited Retinal Dystrophy for MP 911 926 Prior Authorization Request Form for Myoelectric Prosthetic and Components for the Upper Limb 938 MP 227 Prior Authorization Request Form for Therapeutic Radiopharmaceuticals in Oncology Lutetium 958 177 Prior Authorization Request Form for Zolgensma (onasemnogene abeparvovec-xioi) for Spinal 085 Muscular Atrophy MP 008 Prior Authorization Request Form for Zulresso (Brexanalone) for the Treatment of Postpartum 148 Depression Request for Clinical Exception to BCBSMA Stereotactic Radiosurgery and Stereotactic Body 922 Radiation Therapy - SBRT - Policy Sleep Disorder Management 969 Sleep Disorder Management CPT and HCPCS Codes 970

This document is designed for informational purposes only and is not an authorization, or an explanation of benefits, or a contract. Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage. Medical technology is constantly changing, and we reserve the right to review and update our policies periodically.