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Medicare Medical Policies

Medicare provides policies guiding coverage of many medical services and interventions. These Medicare policies include statutes, regulations, national coverage determinations, local coverage determinations, and general coverage and benefit conditions in traditional Medicare (collectively referred to as "Medicare criteria").

When Medicare criteria are not fully established, as that term is defined in Medicare rules, Capital Blue Cross and/or our contracted third-party vendors, may develop and/or adopt additional policies and coverage criteria based on current evidence in widely used treatment guidelines or clinical literature, as permitted by law.

Find the policies you need, including for specialty care:

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Medicare Coverage Guidance

Medicare coverage and payment is contingent upon a determination that:

A service is in a covered benefit category
A service is not specifically excluded from Medicare coverage by the Social Security Act
The item or service is “reasonable and necessary” for the diagnosis or treatment of an illness or injury, to improve functioning of a malformed body member, or is a covered preventive service

These criteria are codified through rulemaking in the Code of Federal Regulations and/or applied in manual guidance, or are applied through coverage determinations. The Medicare Managed Care Manual Chapter 4 delineates Medicare Advantage Benefits and Beneficiary Protections and specifically Section 90 provides guidance on Coverage Determinations.

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Capital Medical Policies

Each medical policy includes:

Policy criteria — The internal coverage criteria including a summary of evidence that was considered during the development of these criteria.
Rationale — An explanation of the evidence that supports the adoption of the coverage criteria used to make a medical necessity determination.
References — A list of the sources of evidence used to develop the policy.

Medicare criteria take precedence. Capital Blue Cross policies will be used when Medicare criteria are incomplete or have not been provided.

Coverage criteria provide clinical benefits that are highly likely to outweigh any clinical harms, including harms resulting from delayed or decreased access to items or services. Each policy provides one or more of the following Clinical Benefits:

Minimize safety risk or concern.
Minimize harmful or ineffective interventions.
Assure appropriate level of care.
Assure appropriate duration of service for interventions.
Assure that recommended medical prerequisites have been met.
Assure appropriate site of treatment or service.

Current Capital coverage criteria policies can be found by clicking on the titles below:

Policy number	Policy title	Clinical benefit(s)
2.376	Ablation of Peripheral Nerves to Treat Pain	2, 5
2.087	Actigraphy	1,2
3.017	Air and Water Ambulance Services	5
6.015	Airway Clearance Devices	1,2,5
2.001	Allergy Testing and Immunotherapy	1,2
9.055	Allogeneic HCT for Genetic Diseases and Acquired Anemias	5
9.056	Allogeneic HCT for Myelodysplastic Syndromes and Myeloproliferative Neoplasms	5
2.036	Ambulatory Event Monitors and Mobile Cardiac Outpatient Telemetry	1, 5
2.149	Aqueous Shunts and Stents for Glaucoma	5
2.304	Autism Spectrum Disorders	1,2
1.157	Balloon Dilation of the Eustachian Tube	1,5
1.119	Balloon Ostial Dilation for the Treatment of CRS and RARS	5
1.142	Baroreflex Stimulation Device	2
2.317	BCR ABL1 Testing in Chronic Myelogenous Leukemia and Acute Lymphoblastic Leukemia	5
2.064	Biofeedback and Neurofeedback Therapy	3
2.190	Bioimpedance Devices for Detection and Management of Lymphedema	1,2
1.003	Blepharoplasty, Repair of Brow Ptosis, and Reconstructive Eyelid Surgery	5
2.081	Bronchial Thermoplasty	2
2.051	Cardiac Hemodynamic Monitoring for the Mgmt of Heart Failure in the Outpatient Setting	2
2.007	Cardiac Interventions in Heart Failure	2
8.005	Cardiac Rehabilitation in the Outpatient Setting	2
1.081	Cardioverter Defibrillators (Implantable and External)	1,2
2.267	Circulating Tumor Dna And Circulating Tumor Cells For Cancer Management (Liquid Biopsy)	2
6.013	Compression Devices for Treatment of Lymphedema and Peripheral Vascular Disease	5
2.093	Confocal Laser Endomicroscopy	1,2
6.004	Continuous Glucose Monitoring	2
6.040	Cooling Devices Used in the Outpatient Setting	2
1.044	Corneal Surgery, Implantation of Intrastromal Corneal Ring Segment, and Corneal Topography Photokeratoscopy	5
9.011	Corneal Transplant, Endothelial Keratoplasty, and Keratoprostheses	1,2,5
1.004	Cosmetic and Reconstructive Surgery	2, 5
4.048	Coverage with Evidence Development	1,5
1.088	Cryoablation of Tumors Located in the Kidney, Lung, Breast, Pancreas or Bone	1,5
1.121	Cryosurgical Ablation of Primary or Metastatic Liver Tumors	1,2,5
2.234	Cytochrome P450 Genotype Guided Treatment Strategy	2
2.381	Dengvaxia	1
1.092	Dental & Oral Surgery Procedures in a Facility	1,6
2.045	Diagnosis and Medical Management of Obstructive Sleep Apnea	2,5
4.033	Diagnosis and Treatment of Dry Eye Syndrome	1,2
2.380	Diagnosis and Treatment of Post Acute COVID (PASC)	3
5.048	Diagnosis and Treatment of Sacroiliac Joint Pain	1,2
2.050	Diagnostic Testing and Risk Assessment for Alzheimer Disease (Biochemical and Genetic)	2
2.004	Donor Lymphocyte Infusion for Hematologic Malignancies Treated with an Allogeneic HCT	5
4.041	Dry Needling of Trigger Points for Myofascial Pain	1,2
6.026	Durable Medical Equipment (DME) and Supplies	5
2.011	Dynamic Posturography	1,2
5.051	Dynamic Spinal Visualization and Vertebral Motion Analysis	1,2
1.150	Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures	5
1.118	Endoscopic Radiofrequency Ablation or Cryoblation for Barrett's Esophagus	1,2
1.090	Endovascular Grafts for Abdominal Aortic Aneurysms	5
2.032	Endovascular Procedures for Intracranial Arterial Disease (Atherosclerosis and Aneurysms)	1,2
1.149	Endovascular Therapies for Extracranial Vertebral Artery Disease	1,2
4.029	Evoked Potential Studies	1,2
2.386	Expanded Access	1,5
2.259	Expanded Molecular Panel Testing of Cancers to Identify Targeted Therapies	2, 5
4.002	Experimental and Investigational Procedures	1,2,5
2.034	Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions	1,2
2.028	Eye Care	1,2
2.018	Foot Care Services	3
2.069	Gastric Electrical Stimulation	5
1.144	Gender Affirming Surgery	1,2,5
2.245	Gene Expression Based Assays for Cancers of Unknown Primary	2
2.315	Gene Expression Profile Testing and Circulating Tumor DNA testing for Predicting Recurrence in Colon Cancer	2
2.360	Gene Expression Profiling for Melanoma	2,5
2.323	General Approach to Evaluating Utility of Genetic Panels	5
2.326	General Approach to Genetic Testing	2, 5
2.280	Genetic and Protein Biomarkers for the Management Diagnosis and Cancer Risk Assessment of Prostate Cancer	5,2
2.325	Genetic Cancer Susceptibility Panels Using Next Generation Sequencing	2
2.320	Genetic Testing for Alpha Thalassemia	2,5
2.251	Genetic Testing for Alpha1- Antitrypsin Deficiency	5
2.242	Genetic Testing for DD, ID, Autism Spectrum Disorder and CA	2
2.264	Genetic Testing for Diagnosis and Management of Mental Health Conditions	1,2
2.257	Genetic Testing for Duchenne and Becker Muscular Dystrophy	5
2.262	Genetic Testing for Epilepsy	2,5
2.246	Genetic Testing for Familial Cutaneous Malignant Melanoma	5
2.357	Genetic Testing for FLT3, NPM1 and CEBPA Variants in Cytogenetically Normal Acute Myeloid Leukemia	5, 2
2.308	Genetic Testing for Helicobacter Pylori Treatment	2
2.318	Genetic Testing for Hereditary Pancreatitis	5
2.253	Genetic Testing for Inherited Thrombophilia	5
2.310	Genetic Testing for Lipoprotein(a) Variant(s) as a Decision Aid for Aspirin Treatment	2
5.013	Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes	5
2.260	Genetic Testing for Macular Degeneration	2
2.273	Genetic Testing for Mitochondrial Disorders	5
2.276	Genetic Testing for Pathogenic FMR1 Variants (Including Fragile X Syndrome)	5
2.248	Genetic Testing for Predisposition to Inherited Hypertrophic Cardiomyopathy	1,2
2.255	Genetic Testing for PTEN Hamartoma Tumor Syndrome	5
2.355	Genetic Testing for the Diagnosis of Inherited Peripheral Neuropathies	5
2.306	Genotype-Guided Warfarin Dosing	2
2.211	Germline Genetic Testing for Hereditary Breast_Ovarian Cancer Syndrome and Other High-Risk Cancers (BRCA1, BRCA2, PALB2)	2,5
2.384	Germline Genetic Testing for Hereditary Diffuse Gastric Cancer (CDH1,CTNNA1)	3, 5
5.055	Handheld Spectroscopy for Breast Conserving Surgery	1,2
9.041	HCT for Acute Lymphoblastic Leukemia	5
9.040	HCT for Acute Myeloid Leukemia	5
9.053	HCT for Autoimmune Diseases	2, 5
9.038	HCT for Chronic Lymphocytic Leukemia and Small Lymphocytic Lymphoma	2,5
9.039	HCT for Chronic Myeloid Leukemia	2,5
9.050	HCT for CNS Embryonal Tumors, CNS Germ Cell Tumors and Ependymoma	2, 5
9.047	HCT for Epithelial Ovarian Cancer	2
9.043	HCT for Hodgkin Lymphoma	5
9.048	HCT for Miscellaneous Solid Tumors in Adults	2
9.042	HCT for Non-Hodgkin Lymphomas	5
9.044	HCT for Plasma Cell Dyscrasias, Including Multiple Myeloma and Poems Syndrome	2,5
9.045	HCT for Primary Amyloidosis	2,5
9.054	HCT for Solid Tumors of Childhood	2,5
9.046	HCT for Waldenstrom Macroglobulinemia	2,5
9.052	HCT in the Treatment of Germ-Cell Tumors	2,5
9.014	Heart-Lung Transplant	5
6.001	Hospital Beds, Accessories, and Pressure-Reducing Support Surfaces	3
2.021	Hyperthermic Intraperitoneal Chemotherapy for Select Intra-Abdominal and Pelvic Malignancies	1,2,5
1.019	Implantable Bone-Conduction and Bone-Anchored Hearing Prosthetic Devices	5
1.034	Implantable Electrical Nerve Stimulators	2, 3
1.058	Implantable Infusion Pumps for Pain and Spasticity	5
5.047	Ingestible pH and Pressure Capsule	1,2
2.079	Intensive Pediatric Feeding Programs	1,2,5
6.047	Interferential Current Stimulation	2
1.120	Interventions for Progressive Scoliosis	2
6.058	Intraocular Lenses, Spectacle Correction, and Iris Prosthesis	2
2.389	Intraocular Radiotherapy for Age-Related Macular Degeneration	1
2.167	Intravenous Anesthetics for the Treatment of Chronic Pain	1,2
2.026	Intravenous Antibiotic Therapy for Lyme Disease	1,2,5
4.005	Intravenous Chelation Therapy	5
2.278	Invasive Prenatal (Fetal) Diagnostic Testing	1,2,5
2.277	Investigational Miscellaneous Genetic and Molecular Tests	2
8.001	Investigational Physical Medicine and Specialized Physical Medicine Interventions (Outpatient)	3, 2
4.013	Iontophoresis Phonophoresis	2
9.012	Islet Transplantation	2
9.013	Isolated Small Bowel Transplant and Small Bowel-Liver and Multivisceral Transplant	5
2.281	JAK2, MPL, and CALR Testing for Myeloproliferative Neoplasms	5
9.005	Kidney Transplants Pancreas Transplants and Simultaneous Kidney Pancreas Transplants	5
2.309	KIF6 Genotyping for Predicting Cardiovascular Risk and or Effectiveness of Statin Therapy	1,2
2.354	Laboratory and Genetic Testing for Use of 5-Flourouracil in Patients with Cancer	2
7.027	Laparoscopic, Percutaneous, and Transcervical Techniques for Uterine Fibroid Myolysis	1,2
4.047	Laser Treatment of Vulvovaginal Atrophy and Vaginal Rejuvenation	3
1.127	Left-Atrial Appendage Closure Device for Stroke Prevention in Atrial Fibrillation	1,2
2.046	Light Therapies	3, 5
6.021	Low Intensity Pulsed Ultrasound Fracture Healing Device	2
1.097	Low Level Laser Therapy	1,2
6.042	Lower Limb Prostheses	5
9.015	Lung and Lobar Lung Transplant	5
6.027	Lysis of Epidural Adhesions	2
5.053	Magnetic Resonance‒Guided Focused Ultrasound	1,2
4.038	Measurement of Exhaled Nitric Oxide and Exhaled Breath Condensate in Diag-Mgmt of Asthma and other Resp Disorders	1,2
6.039	Mechanical Stretching Devices for Contracture and Joint Stiffness	2,5
4.003	Medical Necessity
1.015	Metabolic and Bariatric Surgery	2
2.090	Microwave Tumor Ablation	5
2.084	Minimally Invasive Ablation Procedures for Morton and Other Peripheral Neuromas	2
2.241	Molecular Analysis for Targeted Therapy for Non-Small Cell Lung Cancer	1,2,5
2.275	Molecular Markers in Fine Needle Aspirates of the Thyroid	2
2.266	Molecular Testing for The Management of Pancreatic Cysts, Barrett Esophagus, And Solid Pancreaticobiliary Lesions	2
2.387	Multicancer Early Detection Testing	2
2.270	Multimarker Serum Testing Related to Ovarian Cancer	2
8.012	Neural Therapy	2
6.051	Neuromuscular and Functional Neuromuscular Electrical Stimulation	5, 2
2.379	Next-Generation Sequencing For The Assessment of Measurable Residual Disease	2,5
2.261	Noninvasive Fetal RHD Genotyping Using Cell-Free Fetal DNA	2
2.252	Noninvasive Techniques for the Evaluation and Monitoring of Patients with Chronic Liver Disease	1,2
2.372	Occipital Nerve Stimulation	2
8.004	Occupational Therapy (Outpatient)	3
2.103	Off-Label use of Medications and other Interventions	3
2.385	Olinvyk (oliceridine)	1,2
2.083	Open and Thoracoscopic Approaches to Treat Atrial Fibrillation and Atrial Flutter (Maze and Rela)	1,2,5
2.056	Ophthalmologic Techniques That Evaluate the Posterior Eye Segment	2
2.303	Medications Used Under Heavy Sedation or General Anesthesia for Opioid Use Disorder	2
2.383	Orphan Drugs and Humanitarian Use Devices	1
1.101	Orthognathic Surgery	5
2.080	Orthopedic Applications of Stem Cell Therapy Including Allograft and Bone Substitute Products Used w Autologous Bone Marrow	2
2.005	Other Therapies of Hyperhidrosis	5
8.008	Outpatient Pulmonary Rehabilitation	2
2.097	Paraspinal Surface Electromyography to Evaluate and Monitor Back Pain	1,2
1.134	Percutaneous and Implantable Tibial Nerve Stimulation	2
2.092	Percutaneous Electrical Nerve Field Stimulation, Cranial Electrotherapy Stimulation, Auricular Electrostimulation, and External Trigeminal Nerve Stimulation	1,2
1.124	Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, Biacuplasty and Intraosseous Basivertebral Nerve Ablation	2
1.141	Peripheral Subcutaneous Field Stimulation PSFS	2
2.218	Pharmacogenomic and Metabolite Markers for Patients with Inflammatory Bowel Disease Treated with Thiopurines	5
2.088	Pharyngometry and Rhinometry	1,2
4.008	Photodynamic or Photocoagulation Therapy for Choroidal Neovascularization	2
5.008	Positron Emission Mammography	2
6.053	Postsurgical Home Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis	5
7.009	Preimplantation Genetic Testing	1,2
4.009	Procedures of Questionable Usefulness	2
2.343	Proteogenomic Testing for Patients With Cancer	2
1.084	Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors	2,5
1.055	Radiofrequency Ablation of Primary or Metastatic Liver Tumors	5
1.103	Reconstructive Breast Surgery including Management of Breast Implants, External Breast Prosthesis and Post Mastectomy Bras	2
1.156	Responsive Neurostimulation for the Treatment of Refractory Focal Epilepsy	1,5
2.071	Rosacea	2
1.033	Sacral Nerve Neuromodulation-Stimulation and Pelvic Floor Stimulation Devices	3
5.021	Scintimammography and Gamma Imaging of the Breast and Axilla	1,2
1.130	Semi-Implantable and Fully Implantable Middle Ear Hearing Aid	1,2,5
8.011	Sensory Integration and Auditory Integration Therapy	2
2.222	Serum Antibody Markers for Diagnosing Inflammatory Bowel Disease	1,2
2.269	Serum Biomarkers for Human Epididymis Protein 4 - HE4	2
1.094	Skin Contact Monochromatic Infrared Energy For Tx of Cutaneous Ulcers-Diabetic Neuropathy- and Misc Musculoskeletal Cond	2
2.388	Somatic Biomarker Testing for Immune Checkpoint Inhibitor Therapy (MSI/MMR, PD-L1, TMB)	5
2.316	Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment of Metastatic Colorectal Cancer	5
2.364	Somatic Genetic Testing to Select Individuals with Melanoma or Glioma for Targeted Therapy or Immunotherapy	2
6.032	Speech Generating Devices	5
8.002	Speech Therapy Outpatient	2
4.046	Sphenopalatine Ganglion Block For Headache	2
1.069	Spinal Cord and Dorsal Root Ganglion Stimulation	5
2.089	Stem Cell Therapy for Peripheral Arterial Disease	1,2
2.373	Step Therapy Treatment of Stage 4	3
1.140	Steroid-Eluting Sinus Stents	1,2,5
2.345	Subcutaneous Hormone Pellet Implants	1,2
1.114	Subtalar Arthroereisis	1,2
1.128	Surgical Treatment of Snoring and Obstructive Sleep Apnea	2,5
2.066	Technologies for the Evaluation of Skin Lesions Suspected of Malignancy	2,5
2.371	Therapeutic Radiopharmaceuticals for Neuroendocrine Tumors	5
5.017	Thermography	1,2
1.086	Thermal Capsulorrhaphy as a Treatment of Joint Instability	2
1.026	Total Artificial Hearts and Implantable Ventricular Assist Devices	5
1.135	Transcatheter Aortic Valve Implantation for Aortic Stenosis	2, 5
1.153	Transcatheter Mitral Valve Procedures	2, 5
1.139	Transcatheter Pulmonary Valve Implantation	5
6.020	Transcutaneous Electrical Nerve Stimulation	1,2
1.057	Transmyocardial Revascularization	2
4.034	Transvaginal and Transurethral Radiofrequency Tissue Remodeling for Urinary Stress Incontinence	1,2
1.095	Treatment of Menieres and Sudden Hearing Loss	2
2.038	Treatment of Tinnitus	2
1.061	Treatment of Varicose Veins-Venous Insufficiency	5
4.043	Treatments of the Prostate	2, 5
2.072	Trigger Point and Tender Point Injections	2
5.036	Ultrasonographic Measurement of Carotid Intimal Medial Thickness as an Assessment of Subclinical Atherosclerosis	2
6.052	Upper Limb Prostheses	2, 5
2.065	Vertebral Axial Decompression	1,2
5.046	Vertebral Fracture Assessment and Trabecular Bone Score	1,2
1.136	Vertical Expandable Prosthetic Titanium Rib	5
2.208	Viral Tropism Testing	5
4.007	Vision Therapy	1,2
5.037	Whole Body Dual X-Ray Absorptiometry to Determine Body Composition	1,2
2.324	Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders	5
5.033	Wireless Capsule Endoscopy for Gastrointestinal (GI) Disorders	2
4.028	Wound and Burn Management and Specialized Treatment Centers	2,5

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Capital Coverage Criteria

Preauthorization for acute inpatient care, long term acute care hospital (LTACH), outpatient observation services, and select procedures will be conducted using Change Healthcare's InterQual^® criteria.

InterQual criteria are an industry standard set of objective evidence-based utilization management (UM) criteria for level of care placement and medical necessity determinations, including length of stay. These criteria are specific and comprehensive clinical guidelines developed by a highly trained clinical team who performs unbiased, systematic review and clinical appraisal of the evidence to help ensure the criteria reflect the best available clinical evidence. The criteria are updated frequently to remain current with the latest evidence.

The clinical benefit of using InterQual criteria to manage these levels of care include:

Minimize safety risk or concern.
Minimize harmful or ineffective interventions.
Assure appropriate level of care.
Assure appropriate duration and/or frequency of interventions.
Assure that recommended medical prerequisites have been met.
Assure appropriate site of treatment or service.

If you are not currently a Capital Blue Cross Member or Provider, learn more information about accessing Capital Coverage Criteria.

Current Capital Blue Cross Member or Provider, learn more information about accessing Capital Coverage Criteria. If you are not already logged in to your secure account, you will be prompted to log in or register.

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Behavioral Health Services

Preauthorization for select behavioral health services will be performed using Change Healthcare’s InterQual^® criteria. InterQual criteria are an industry standard set of objective evidence-based UM criteria for level of care placement and medical necessity determinations, including length of stay for mental health services.

The clinical benefit of using InterQual criteria to manage these levels of care include:

Minimize safety risk or concern.
Minimize harmful or ineffective interventions.
Assure appropriate level of care.
Assure appropriate duration and/or frequency of interventions.
Assure that recommended medical prerequisites have been met.
Assure appropriate site of treatment or service.

Preauthorization for select substance use disorder services will be performed using the American Society of Addiction Medicine (ASAM) criteria.

ASAM criteria are an industry standard collection of guidelines for level of care placement and medical necessity determinations, including length of stay for substance use disorder services.

The clinical benefits of using ASAM criteria to manage these levels of care include:

Minimize safety risk or concern.
Minimize harmful or ineffective interventions.
Assure appropriate level of care.
Assure appropriate duration and/or frequency of interventions.
Assure that recommended medical prerequisites have been met.
Assure appropriate site of treatment or service.

If you are not currently a Capital Blue Cross Member or Provider, learn more information about accessing Capital Coverage Criteria.

Current Capital Blue Cross Member or Provider, learn more information about accessing Capital Coverage Criteria. If you are not already logged in to your secure account, you will be prompted to log in or register.

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High tech Radiology, Select Cardiac Imaging, and Radiation Oncology Services

Preauthorization for high tech radiology, select cardiac imaging, and radiation oncology services will be performed using medical policies administered by Evolent Specialty Services, Inc. (Evolent). On behalf of Capital Blue Cross, Evolent, reviews certain medical specialty requests to see if they are medically necessary and a covered service under the Capital Blue Cross benefit plan.

Each of Evolent's medical policies in the chart below align with one of the following clinical benefit categories:

Minimize safety risk or concern.
Minimize harmful or ineffective intervention.
Assure appropriate level of care.
Assure appropriate duration and/or frequency of intervention.
Assure recommended medical prerequisites have been met.
Assure appropriate site of treatment or service.

Policy name	Policy number	Clinical benefit category (as described above)
Abdomen CTA (angiography)	Evolent_CG_034-1	1,2,5
Abdomen Pelvis CTA (angiography)	Evolent_CG_069	1,2,5
Anal Cancer	Evolent_CG_125	1,2,4
Bone Marrow MRI	Evolent_CG_059	2
Brain (head) CTA	Evolent_CG_004-1	1,2,5
Brain (head) MRS (Magnetic Resonance Spectroscopy)	Evolent_CG_003	1,2,4
Breast Cancer	Evolent_CG_120	1,2,4
Bone Cancer	Evolent_CG_126	1,2,4
Brachytherapy - Low Dose Radiation (LDR), High Dose Radiation (HDR)	Evolent_CG_224-1	1,2,4
Coronary Artery Calcium Scoring by: Electron-Beam Tomography (EBCT) or Non-Contrast Coronary Computed Tomography (Non-Contract CCT)	Evolent_CG_029	2,5
CT (Virtual) Colonoscopy Diagnostic	Evolent_CG_033-1	1,2,5
Colorectal Cancer	Evolent_CG_121	1,2,4
Cerebral Perfusion CT	Evolent_CG_015	1,2,5
Cervical Cancer	Evolent_CG_127	1,2,4
Central Nervous System - Primary	Evolent_CG_128	1,2,4
Central Nervous System - Metastases	Evolent_CG_128-1	1,2,4
Chest CTA	Evolent_CG_022-1	1,2,5
CCTA Aortogram with Runoff	Evolent_CG_035	1,2,5
Coding Standard for Dosimetry Planning		1,2,4
Coding Standard for Image Guidance		1,2,4
Coding Standard for Physician Treatment Management		1,2,4
Coding Standard for Physics		1,2,4
Coding Standard for Simulations		1,2,4
Coding Standard for Treatment Devices		1,2,4
Endometrial Cancer	Evolent_CG_129	1,2,4
Gastric Cancer	Evolent_CG_130	1,2,4
Head and Neck Cancer	Evolent_CG_131	1,2,4
Hodgkin Lymphoma	Evolent_CG_132	1,2,4
Hyperthermia	Evolent_CG_227	1,2,4
Intraoperative Radiation Therapy (IORT)	Evolent_CG_226	1,2,4
Lower Extremity CTA/CTV	Evolent_CG_061-1	1,2,5
MUGA (Multiple Gated Acquisition) Scan	Evolent_CG_027	2,5
Metastatic Disease	Evolent_CG_228	1,2,4
Non-Hodgkin’s Lymphoma	Evolent_CG_133	1,2,4
Neck CTA	Evolent_CG_012-1	1,2,5
Non-Cancerous Conditions	Evolent_CG_135	1,2,4
Non-Small Cell Lung Cancer	Evolent_CG_122	1,2,4
Neutron Beam Therapy (NBT)	Evolent_CG_229	1,2,4
Pelvis CTA (angiography)	Evolent_CG_038	1,2,5
Prostate Cancer	Evolent_CG_124	1,2,4
Pancreatic Cancer	Evolent_CG_134	1,2,4
Proton Beam Therapy	Evolent_CG_221	1,2,4
Small Cell Lung Cancer	Evolent_CG_123	1,2,4
Skin Cancer	Evolent_CG_136	1,2,4
Stereotactic Radiotherapy (SRS), Stereotactic Body Radiation Therapy (SBRT)	Evolent_CG_222	1,2,4
Upper Extremity CTA/CTV	Evolent_CG_061-2	1,2,5
2D – 3D Conformal Radiation Therapy (CRT)	Evolent_CG_225	1,2,4

Learn more about accessing Evolent medical policies.

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Select Diagnostic and Surgical Cardiology Services

Beginning in March of 2025, providers will be able to submit requests to TurningPoint for preauthorization for Capital members for dates of service on or after April 1, 2025.

Preauthorization for select cardiac surgeries and procedures will be performed using medical policies administered by TurningPoint.

Each of TurningPoint’s medical policies in the chart below align with one of the following clinical benefit categories:

Minimize safety risk or concern.
Minimize harmful or ineffective intervention.
Assure appropriate level of care.
Assure appropriate duration and/or frequency of intervention.
Assure recommended medical prerequisites have been met.
Assure appropriate site of treatment or service.

Policy name	Policy number	Clinical benefit category (as described above)
Implantable Cardioverter Defibrillator	CA-1001	2,3,5,6
Pacemaker	CA-1003	2,3,5,6
Coronary Artery Bypass Grafting	CA-1005	2,3,5,6
Coronary Angioplasty and Stenting	CA-1006	2,3,5,6
Non-Coronary Angioplasty and Endovascular Stent	CA-1007	2,3,5,6
Implantable Cardiac Monitoring	CA-1008	2,3,5,6
Wearable Cardioverter Defibrillator	CA-1009	2,5,6
Valve Replacement	CA-1011	2,3,5,6
Peripheral Revascularization	CA-1012	2,3,5,6
Diagnostic Coronary Angiography	CA-1013	2,3,5,6
Cardiac Contractility Modulation	CA-1018	2,3,5,6
Peripheral Diagnostic Angiogram and Venogram	CA-1019	2,3,5,6

Learn more information on accessing TurningPoint’s medical policies.

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Select Musculoskeletal Services Including Hip, Knee, Shoulder, and Spine Procedures

Preauthorization for select musculoskeletal services including hip, knee, shoulder, and spine procedures will be performed using medical policies administered by TurningPoint.

Each of TurningPoint’s medical policies in the chart below align with one of the following clinical benefit categories:

Minimize safety risk or concern.
Minimize harmful or ineffective intervention.
Assure appropriate level of care.
Assure appropriate duration and/or frequency of intervention.
Assure recommended medical prerequisites have been met.
Assure appropriate site of treatment or service.

Policy name	Policy number	Clinical benefit category (as described above)
Total Hip Replacement	OR-1001	2,5,6
Total Knee Replacement	OR-1002	2,5,6
Lumbar Disc Replacement	OR-1003	2,5,6
Lumbar Spinal Fusion	OR-1004	2,5,6
Bone Morphogenetic Protein	OR-1005	2
Cervical Disc Replacement	OR-1006	2,5,6
Cervical Laminectomy and Discectomy	OR-1007	2,5,6
Lumbar Laminectomy, Discectomy, and Laminotomy	OR-1008	2,5,6
Sacroiliac Joint Fusion	OR-1009	2,5,6
Thoracic Laminectomy or Discectomy	OR-1010	2,5,6
Thoracic Spinal Fusion	OR-1011	2,5,6
Cervical Spinal Fusion	OR-1012	2,5,6
ACL Repair	OR-1013	2,5,6
Treatment of Osteochondral Defects	OR-1014	2,5,6
Revision of Hip Replacement	OR-1016	2,5,6
Revision of Total Knee Replacement	OR-1017	2,5,6
Acromioplasty and Rotator Cuff Repair	OR-1018	2,5,6
Shoulder Fusion	OR-1019	2,5,6
Surgery for Spinal Deformity	OR-1020	2,5,6
Shoulder Replacement	OR-1023	2,5,6
Vertebral Augmentation	OR-1024	2,5,6
Femoroacetabular Arthroscopy	OR-1025	2,5,6
Hip Resurfacing	OR-1026	2,5,6
Meniscal Allograft Transplantation	OR-1027	2,5,6
Partial Knee Replacement	OR-1028	2,5,6
Knee Arthroscopy	OR-1029	2,5,6
Hip Arthroscopy	OR-1031	2,5,6
Computer Assisted Navigation	OR-1035	2,5,6
Shoulder Procedures	OR-1036	2,5,6
Spinal Devices	OR-1037	2,5,6
Sacral Decompression	OR-1038	2,5,6
Manipulation Under Anesthesia	OR-1040	2
Hip Osteotomy	OR-1042	2,5,6
MPFL Reconstruction	OR-1043	2,5,6
Osteotomies for Spinal Deformity	OR-1045	2,5,6
Bone Graft Substitutes	OR-1046	2
Orthopedic Application of Stem Cell Therapy	OR-1047	2
Percutaneous Tenotomy	OR-1049	2
Hip Core Decompression	OR-1050	2,6

Learn more information on accessing TurningPoint’s medical policies.

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Medical Drugs, Biologics and Diabetes Supplies

Prior authorization for medical specialty drugs, biologics and diabetes supplies will be performed using medical policies administered by Prime Therapeutics. Diabetes supplies prior authorization policies apply to non-preferred Continuous Glucose Monitors, Diabetic Monitors and Diabetic Test Strips. Diabetic supplies benefit limit policies apply to preferred and non-preferred products. On behalf of Capital Blue Cross, Prime Therapeutics LLC assists in the administration of our prescription drug program. Prime Therapeutics LLC is an independent pharmacy benefit manager.

Each of Prime Therapeutics’ medical policies in the chart below align with one of the following clinical benefit categories:

Minimize safety risk or concern.
Minimize harmful or ineffective intervention.
Assure appropriate level of care.
Assure appropriate duration and/or frequency of intervention.
Assure recommended medical prerequisites have been met.
Assure appropriate site of treatment or service.

J-Code	Medication Name	Policy Number	Clinical Benefit
J3380	VEDOLIZUMAB FOR IV SOLUTION 300 MG	PS PartB PA AR0223	1, 2, 4
J0256	ALPHA1-PROTEINASE INHIBITOR (HUMAN) FOR IV SOLN 500 MG	PS PartB PA AR0223	1, 2, 4
J2840	SEBELIPASE ALFA IV SOLN 20 MG/10ML (2 MG/ML)	PS PartB PA AR0223	1, 2, 4
J0897	DENOSUMAB INJ 120 MG/1.7ML	PS PartB PA AR0223	1, 2, 4
J3399	ONASEMNOGENE ABEPARVOVEC-XIOI 3X8.3 ML SUSP KIT	PS PartB PA AR0223	1, 2, 4
J1823	INEBILIZUMAB-CDON IV SOLN 100 MG/10ML (10 MG/ML)	PS PartB PA AR0223	1, 2, 4
J9296	PEMETREXED DISODIUM IV SOLN 500 MG/20ML (BASE EQUIV)	PS PartB PA AR0223	1, 2, 4
J0129	ABATACEPT SUBCUTANEOUS SOLN PREFILLED SYRINGE 50 MG/0.4ML	PS PartB PA AR0223	1, 2, 4
J9305	PEMETREXED DISODIUM FOR IV SOLN 1000 MG (BASE EQUIV)	PS PartB PA AR0223	1, 2, 4
J0598	C1 ESTERASE INHIBITOR (HUMAN) FOR IV INJ 500 UNIT	PS PartB PA AR0223	1, 2, 4
J9347	TREMELIMUMAB-ACTL SOLN FOR IV INFUSION 300 MG/15ML	PS PartB PA AR0223	1, 2, 4
J9331	SIROLIMUS PROTEIN-BOUND PARTICLES FOR IV SUSP 100 MG	PS PartB PA AR0223	1, 2, 4
J0593	LANADELUMAB-FLYO SOLN PREF SYRINGE 150 MG/ML	PS PartB PA AR0223	1, 2, 4
J2786	RESLIZUMAB IV INFUSION SOLN 100 MG/10ML (10 MG/ML)	PS PartB PA AR0223	1, 2, 4
J9302	OFATUMUMAB CONC FOR IV INFUSION 100 MG/5ML	PS PartB PA AR0223	1, 2, 4
J1411	ETRANACOGENE DEZAPARVOVEC-DRLB IV SUSP 32 X 10 ML PACK	PS PartB PA AR0223	1, 2, 4
J9294	PEMETREXED DISODIUM IV SOLN 1 GM/40ML (BASE EQUIV)	PS PartB PA AR0223	1, 2, 4
J9303	PANITUMUMAB IV SOLN 100 MG/5ML	PS PartB PA AR0223	1, 2, 4
J3398	VORETIGENE NEPARVOVEC-RZYL 5000000000000 VG/ML INTRAOC SUSP	PS PartB PA AR0223	1, 2, 4
J9264	PACLITAXEL PROTEIN-BOUND PARTICLES FOR IV SUSP 100 MG	PS PartB PA AR0223	1, 2, 4
J9173	DURVALUMAB SOLN FOR IV INFUSION 120 MG/2.4ML (50 MG/ML)	PS PartB PA AR0223	1, 2, 4
J1460	IMMUNE GLOBULIN (HUMAN) IM INJ	PS PartB PA AR0223	1, 2, 4
J1602	GOLIMUMAB IV SOLN 50 MG/4ML	PS PartB PA AR0223	1, 2, 4
J0257	ALPHA1-PROTEINASE INHIBITOR (HUMAN) INJ 1000 MG/50ML	PS PartB PA AR0223	1, 2, 4
J0224	LUMASIRAN SODIUM SUBCUTANEOUS SOLN 94.5 MG/0.5ML	PS PartB PA AR0223	1, 2, 4
J9042	BRENTUXIMAB VEDOTIN FOR IV SOLN 50 MG	PS PartB PA AR0223	1, 2, 4
J9354	ADO-TRASTUZUMAB EMTANSINE FOR IV SOLN 100 MG	PS PartB PA AR0223	1, 2, 4
J9022	ATEZOLIZUMAB IV SOLN 840 MG/14ML	PS PartB PA AR0223	1, 2, 4
J0221	ALGLUCOSIDASE ALFA FOR IV SOLN 50 MG	PS PartB PA AR0223	1, 2, 4
J0584	BUROSUMAB-TWZA INJ 10 MG/ML	PS PartB PA AR0223	1, 2, 4
J9299	NIVOLUMAB IV SOLN 240 MG/24ML	PS PartB PA AR0223	1, 2, 4
J9271	PEMBROLIZUMAB IV SOLN 100 MG/4ML (25 MG/ML)	PS PartB PA AR0223	1, 2, 4
J9321	EPCORITAMAB-BYSP SUBCUTANEOUS SOLN 48 MG/ 0.8ML	PS PartB PA AR0223	1, 2, 4
J1304	TOFERSEN INTRATHECAL SOLN 100 MG/15ML (6.7 MG/ML)	PS PartB PA AR0223	1, 2, 4
J9358	FAM-TRASTUZUMAB DERUXTECAN-NXKI FOR IV SOLN 100 MG	PS PartB PA AR0223	1, 2, 4
J0517	BENRALIZUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 30 MG/ML	PS PartB PA AR0223	1, 2, 4
J2802	ROMIPLOSTIM FOR INJ 125 MCG	PS PartB PA AR0223	1, 2, 4
A9513	LUTETIUM LU 177 DOTATATE IV SOLN 370 MBQ/ML (10 MCI/ML)	PS PartB PA AR0223	1, 2, 4
J9145	DARATUMUMAB IV SOLN 100 MG/5ML	PS PartB PA AR0223	1, 2, 4
J9381	TEPLIZUMAB-MZWV IV SOLN 2 MG/2ML (1 MG/ML)	PS PartB PA AR0223	1, 2, 4
J9349	TAFASITAMAB-CXIX FOR IV SOLN 200 MG	PS PartB PA AR0223	1, 2, 4
J1322	ELOSULFASE ALFA SOLN FOR IV INFUSION 5 MG/5ML (1 MG/ML)	PS PartB PA AR0223	1, 2, 4
J3262	TOCILIZUMAB IV INJ 80 MG/4ML	PS PartB PA AR0223	1, 2, 4
J2326	NUSINERSEN INTRATHECAL SOLN 12 MG/5ML (2.4 MG/ML)	PS PartB PA AR0223	1, 2, 4
J0202	ALEMTUZUMAB IV INJ 12 MG/1.2ML (10 MG/ML)	PS PartB PA AR0223	1, 2, 4
J2998	PLASMINOGEN, HUMAN-TVMH FOR IV SOLN 68.8 MG	PS PartB PA AR0223	1, 2, 4
J9359	LONCASTUXIMAB TESIRINE-LPYL FOR IV SOLN 10 MG	PS PartB PA AR0223	1, 2, 4
J9316	PERTUZUMAB-TRASTUZ-HYALURON-ZZXF INJ 60 MG-60 MG-2000 UNT/ML	PS PartB PA AR0223	1, 2, 4
J2820	SARGRAMOSTIM LYOPHILIZED FOR INJ 250 MCG	PS PartB PA AR0223	1, 2, 4
J0491	ANIFROLUMAB-FNIA IV SOLN 300 MG/2ML	PS PartB PA AR0223	1, 2, 4
J1305	EVINACUMAB-DGNB IV SOLN 345 MG/2.3ML (150 MG/ML)	PS PartB PA AR0223	1, 2, 4
J2777	FARICIMAB-SVOA INTRAVITREAL INJ 6 MG/0.05ML (120 MG/ML)	PS PartB PA AR0223	1, 2, 4
J0717	CERTOLIZUMAB PEGOL FOR INJ KIT 2 X 200 MG	PS PartB PA AR0223	1, 2, 4
J2323	NATALIZUMAB FOR IV INJ CONC 300 MG/15ML	PS PartB PA AR0223	1, 2, 4
J2357	OMALIZUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 150 MG/ML	PS PartB PA AR0223	1, 2, 4
J3241	TEPROTUMUMAB-TRBW FOR IV SOLN 500 MG	PS PartB PA AR0223	1, 2, 4
J1743	IDURSULFASE SOLN FOR IV INFUSION 6 MG/3ML (2 MG/ML)	PS PartB PA AR0223	1, 2, 4
J9297	PEMETREXED DISODIUM IV SOLN 100 MG/4ML (BASE EQUIV)	PS PartB PA AR0223	1, 2, 4
J1301	EDARAVONE INJ 30 MG/100ML (0.3 MG/ML)	PS PartB PA AR0223	1, 2, 4
J2350	OCRELIZUMAB SOLN FOR IV INFUSION 300 MG/10ML	PS PartB PA AR0223	1, 2, 4
J0896	LUSPATERCEPT-AAMT FOR SUBCUTANEOUS INJ 75 MG	PS PartB PA AR0223	1, 2, 4
J1786	IMIGLUCERASE FOR INJ 400 UNIT	PS PartB PA AR0223	1, 2, 4
J9400	ZIV-AFLIBERCEPT IV SOLN 100 MG/4ML (FOR INFUSION)	PS PartB PA AR0223	1, 2, 4
J3245	TILDRAKIZUMAB-ASMN SUBCUTANEOUS SOLN PREF SYRINGE 100 MG/ML	PS PartB PA AR0223	1, 2, 4
J9309	POLATUZUMAB VEDOTIN-PIIQ FOR IV SOLUTION 140 MG	PS PartB PA AR0223	1, 2, 4
J3385	VELAGLUCERASE ALFA FOR INJ 400 UNIT	PS PartB PA AR0223	1, 2, 4
J1428	ETEPLIRSEN IV SOLN 500 MG/10ML (50 MG/ML)	PS PartB PA AR0223	1, 2, 4
J9176	ELOTUZUMAB FOR IV SOLN 300 MG	PS PartB PA AR0223	1, 2, 4
J9348	NAXITAMAB-GQGK IV SOLN 40 MG/10ML (4 MG/ML)	PS PartB PA AR0223	1, 2, 4
J1426	CASIMERSEN IV SOLN 100 MG/2ML (50 MG/ML)	PS PartB PA AR0223	1, 2, 4
J7352	AFAMELANOTIDE ACETATE IMPLANT 16 MG	PS PartB PA AR0223	1, 2, 4
J3060	TALIGLUCERASE ALFA FOR INJ 200 UNIT	PS PartB PA AR0223	1, 2, 4
J0218	OLIPUDASE ALFA-RPCP FOR IV SOLN 20 MG	PS PartB PA AR0223	1, 2, 4
J9037	BELANTAMAB MAFODOTIN-BLMF FOR IV SOLN 100 MG	PS PartB PA AR0223	1, 2, 4
J2507	PEGLOTICASE INJ 8 MG/ML (FOR IV INFUSION)	PS PartB PA AR0223	1, 2, 4
J3358	USTEKINUMAB IV SOLN 130 MG/26ML (5 MG/ML) (FOR IV INFUSION)	PS PartB PA AR0223	1, 2, 4
J9023	AVELUMAB SOLN FOR IV INFUSION 200 MG/10ML (20 MG/ML)	PS PartB PA AR0223	1, 2, 4
J1302	SUTIMLIMAB-JOME IV SOLN 1100 MG/22ML (50 MG/ML)	PS PartB PA AR0223	1, 2, 4
J9274	TEBENTAFUSP-TEBN IV SOLN 100 MCG/0.5ML	PS PartB PA AR0223	1, 2, 4
J9047	CARFILZOMIB FOR INJ 60 MG	PS PartB PA AR0223	1, 2, 4
J9308	RAMUCIRUMAB IV SOLN 100 MG/10ML (FOR INFUSION)	PS PartB PA AR0223	1, 2, 4
J0180	AGALSIDASE BETA FOR IV SOLN 5 MG	PS PartB PA AR0223	1, 2, 4
J9247	MELPHALAN FLUFENAMIDE HCL FOR IV SOLN 20 MG	PS PartB PA AR0223	1, 2, 4
J0490	BELIMUMAB FOR IV SOLN 400 MG	PS PartB PA AR0223	1, 2, 4
J9228	IPILIMUMAB SOLN FOR IV INFUSION 200 MG/40ML (5 MG/ML)	PS PartB PA AR0223	1, 2, 4
J9203	GEMTUZUMAB OZOGAMICIN FOR IV SOLN 4.5 MG	PS PartB PA AR0223	1, 2, 4
J1427	VILTOLARSEN IV SOLN 250 MG/5ML (50 MG/ML)	PS PartB PA AR0223	1, 2, 4
J0791	CRIZANLIZUMAB-TMCA IV SOLN 100 MG/10ML	PS PartB PA AR0223	1, 2, 4
J0223	GIVOSIRAN SODIUM SUBCUTANEOUS SOLN 189 MG/ML	PS PartB PA AR0223	1, 2, 4
J9380	TECLISTAMAB-CQYV SUBCUTANEOUS SOLN 153 MG/1.7ML (90 MG/ML)	PS PartB PA AR0223	1, 2, 4
J1931	LARONIDASE SOLN FOR IV INFUSION 2.9 MG/5ML (500 UNIT/5ML)	PS PartB PA AR0223	1, 2, 4
J9345	RETIFANLIMAB-DLWR IV SOLN 500 MG/20ML (25 MG/ML)	PS PartB PA AR0223	1, 2, 4
J2182	MEPOLIZUMAB FOR INJ 100 MG	PS PartB PA AR0223	1, 2, 4
J9281	MITOMYCIN FOR PYELOCALYCEAL SOLN 40 MG	PS PartB PA AR0223	1, 2, 4
J9301	OBINUTUZUMAB SOLN FOR IV INFUSION 1000 MG/40ML (25 MG/ML)	PS PartB PA AR0223	1, 2, 4
J0225	VUTRISIRAN SODIUM SOLN PREFILLED SYRINGE 25 MG/0.5ML	PS PartB PA AR0223	1, 2, 4
J1429	GOLODIRSEN IV SOLN 100 MG/2ML (50 MG/ML)	PS PartB PA AR0223	1, 2, 4
J0219	AVALGLUCOSIDASE ALFA-NGPT FOR IV SOLN 100 MG	PS PartB PA AR0223	1, 2, 4
J9223	LURBINECTEDIN FOR IV SOLN 4 MG	PS PartB PA AR0223	1, 2, 4
J0222	PATISIRAN SODIUM IV SOLN 10 MG/5ML (2 MG/ML) (BASE EQUIV)	PS PartB PA AR0223	1, 2, 4
J9298	NIVOLUMAB-RELATLIMAB-RMBW 240-80 MG/20ML	PS PartB PA AR0223	1, 2, 4
J9273	TISOTUMAB VEDOTIN-TFTV FOR IV SOLUTION 40 MG	PS PartB PA AR0223	1, 2, 4
J9063	MIRVETUXIMAB SORAVTANSINE-GYNX IV SOLN 100 MG/20ML	PS PartB PA AR0223	1, 2, 4
J1458	GALSULFASE SOLN FOR IV INFUSION 1 MG/ML	PS PartB PA AR0223	1, 2, 4
J9311	RITUXIMAB-HYALURONIDASE HUMAN INJ 1400-23400 MG-UNIT/11.7ML	PartB ST CBC AR0223	1, 4, 5
Q5104	INFLIXIMAB-ABDA FOR IV INJ 100 MG	PartB ST CBC AR0223	1, 4, 5
Q5114	TRASTUZUMAB-DKST FOR IV SOLN 420 MG	PartB ST CBC AR0223	1, 4, 5
J2778	RANIBIZUMAB INTRAVITREAL SOLN PREF SYR 0.3 MG/0.05ML	PartB ST CBC AR0223	1, 4, 5
Q5130	PEGFILGRASTIM-PBBK SOLN PREFILLED SYRINGE 6 MG/0.6ML	PartB ST CBC AR0223	1, 4, 5
Q5125	FILGRASTIM-AYOW INJ SOLN 300 MCG/ML	PartB ST CBC AR0223	1, 4, 5
J7318	SODIUM HYALURONATE INTRA-ARTICULAR GEL PREF SYR 60 MG/3ML	PartB ST CBC AR0223	1, 4, 5
Q5112	TRASTUZUMAB-DTTB FOR IV SOLN 150 MG	PartB ST CBC AR0223	1, 4, 5
Q5124	RANIBIZUMAB-NUNA INTRAVITREAL INJ 0.5 MG/0.05ML (10 MG/ML)	PartB ST CBC AR0223	1, 4, 5
Q5113	TRASTUZUMAB-PKRB FOR IV SOLN 150 MG	PartB ST CBC AR0223	1, 4, 5
J7326	CROSS-LINKED HYALURONATE GEL PREFILLED SYRINGE 30 MG/3ML	PartB ST CBC AR0223	1, 4, 5
J7329	SODIUM HYALURONATE INTRA-ARTICULAR SOLN PREF SYR 25 MG/2.5ML	PartB ST CBC AR0223	1, 4, 5
J0179	BROLUCIZUMAB-DBLL INTRAVITREAL SOLN PREF SYRINGE 6 MG/0.05ML	PartB ST CBC AR0223	1, 4, 5
J1449	EFLAPEGRASTIM-XNST SOLN PREFILLED SYRINGE 13.2 MG/0.6ML	PartB ST CBC AR0223	1, 4, 5
J9312	RITUXIMAB IV SOLN 100 MG/10ML	PartB ST CBC AR0223	1, 4, 5
J0642	LEVOLEUCOVORIN FOR IV SOLN 175 MG	PartB ST CBC AR0223	1, 4, 5
Q5123	RITUXIMAB-ARRX IV SOLN 500 MG/50ML (10 MG/ML)	PartB ST CBC AR0223	1, 4, 5
Q0138	FERUMOXYTOL INJ 510 MG/17ML (30 MG/ML) (ELEMENTAL FE)	PartB ST CBC AR0223	1, 4, 5
J9355	TRASTUZUMAB FOR IV SOLN 150 MG	PartB ST CBC AR0223	1, 4, 5
J0641	LEVOLEUCOVORIN CALCIUM FOR IV INJ 50 MG (BASE EQUIV)	PartB ST CBC AR0223	1, 4, 5
J0178	AFLIBERCEPT INTRAVITREAL SOLN PREF SYR 2 MG/0.05ML	PartB ST CBC AR0223	1, 4, 5
Q5127	PEGFILGRASTIM-FPGK SOLN PREFILLED SYRINGE 6 MG/0.6ML	PartB ST CBC AR0223	1, 4, 5
J1437	FERRIC DERISOMALTOSE (ONE DOSE) IV SOL 1000 MG/10ML (FE EQ)	PartB ST CBC AR0223	1, 4, 5
J7320	SODIUM HYALURONATE INTRA-ARTICULAR SOLN PREF SYR 25 MG/2.5ML	PartB ST CBC AR0223	1, 4, 5
J7321	SODIUM HYALURONATE INTRA-ARTICULAR SOLN PREF SYR 25 MG/2.5ML	PartB ST CBC AR0223	1, 4, 5
Q5129	BEVACIZUMAB-ADCD IV SOLN 400 MG/16ML (FOR INFUSION)	PartB ST CBC AR0223	1, 4, 5
J2503	PEGAPTANIB SODIUM INTRAVITREOUS INJ 0.3 MG/90 MICROLITER	PartB ST CBC AR0223	1, 4, 5
J7328	SODIUM HYALURONATE INTRA-ARTICULAR SOLN PREF SYR 16.8 MG/2ML	PartB ST CBC AR0223	1, 4, 5
J7322	HYALURONAN INTRA-ARTICULAR SOLN PREFILLED SYRINGE 24 MG/3ML	PartB ST CBC AR0223	1, 4, 5
J9035	BEVACIZUMAB IV SOLN 100 MG/4ML (FOR INFUSION)	PartB ST CBC AR0223	1, 4, 5
J1300	ECULIZUMAB IV SOLN 300 MG/30ML (10 MG/ML) (FOR INFUSION)	PartB ST CBC AR0223	1, 4, 5
J9356	TRASTUZUMAB-HYALURONIDASE-OYSK INJ 600-10000 MG-UNIT/5ML	PartB ST CBC AR0223	1, 4, 5
J1078	AFLIBERCEPT INTRAVITREAL INJ 2 MG/0.05ML (40 MG/ML)	PartB ST CBC AR0223	1, 4, 5
Q5120	PEGFILGRASTIM-BMEZ SOLN PREFILLED SYRINGE 6 MG/0.6ML	PartB ST CBC AR0223	1, 4, 5
Q5108	PEGFILGRASTIM-JMDB SOLN PREFILLED SYRINGE 6 MG/0.6ML	PartB ST CBC AR0223	1, 4, 5
Q5126	BEVACIZUMAB-MALY IV SOLN 100 MG/4ML (FOR INFUSION)	PartB ST CBC AR0223	1, 4, 5
J7332	SODIUM HYALURONATE INTRA-ARTICULAR SOLN PREF SYR 20 MG/2ML	PartB ST CBC AR0223	1, 4, 5
Q5122	PEGFILGRASTIM-APGF SOLN PREFILLED SYRINGE 6 MG/0.6ML	PartB ST CBC AR0223	1, 4, 5
J7331	SODIUM HYALURONATE INTRA-ARTICULAR SOLN PREF SYR 20 MG/2ML	PartB ST CBC AR0223	1, 4, 5
Q5121	INFLIXIMAB-AXXQ FOR IV INJ 100 MG	PartB ST CBC AR0223	1, 4, 5
J1439	FERRIC CARBOXYMALTOSE IV SOLN 750 MG/15ML (FE EQUIVALENT)	PartB ST CBC AR0223	1, 4, 5
J9033	BENDAMUSTINE HCL FOR IV SOLN 100 MG	PartB ST CBC AR0223	1, 4, 5
J7324	HYALURONAN INTRA-ARTICULAR SOLN PREFILLED SYRINGE 30 MG/2ML	PartB ST CBC AR0223	1, 4, 5
J7327	HYALURONAN INTRA-ARTICULAR SOLN PREFILLED SYRINGE 88 MG/4ML	PartB ST CBC AR0223	1, 4, 5
Q5128	RANIBIZUMAB-EQRN INTRAVITREAL INJ 0.5 MG/0.05ML (10 MG/ML)	PartB ST CBC AR0223	1, 4, 5
E2102	CONTINUOUS GLUCOSE MONITOR RECEIVER ADJUNCTIVE NON-IMPLANTED	PartB CGM PA CBC AR0224	2, 4, 5
E2103	CONTINUOUS GLUCOSE MONITOR RECEIVER/READER NON-ADJUNCTIVE NON-IMPLANTED	PartB CGM PA CBC AR0224	2, 4, 5
E0607	DIABETIC TESTING MONITORS	PartB DTS PA CBC AR0224	2, 4, 5
A4238	CONTINUOUS GLUCOSE MONITOR SENSOR/TRANSMITTER ADJUNCTIVE NON-IMPLANTED	PartB CGM PA CBC AR0224	2, 4, 5
A4239	CONTINUOUS GLUCOSE MONITOR SENSOR/TRANSMITTER NON-ADJUNCTIVE NON-IMPLANTED	PartB CGM PA CBC AR0224	2, 4, 5
A4253	DIABETIC TESTING STRIPS	PartB DTS PA CBC AR0224	2, 4, 5

Learn more information on the Prior Authorization policies; Step Therapy policies; Continuous Glucose Monitoring PA policies; Diabetic Testing Supplies PA policies; Continuous Glucose Monitoring Benefit Limit policies; and Diabetic Testing Supplies Benefit Limit policies.

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Laboratory Services

Coverage criteria related to specialized laboratory services can be found in the following policies:

Policy number	Policy title	Clinical benefit(s)
G2159	B-Hemolytic Streptococcus Testing	2
G2022	Biomarker Testing for Autoimmune Rheumatic Disease	2, 4
G2123	Biomarker Testing for Multiple Sclerosis and Related Neurologic Diseases	2
G2150	Biomarkers For Myocardial Infarction and Chronic Heart Failure	2, 4
G2051	Bone Turnover Markers Testing	2
G2050	Cardiovascular Disease Risk Assessment	2, 4, 5
G2043	Celiac Disease Testing	2, 5
G2174	Coronavirus Testing in the Outpatient Setting	1, 2, 5
G2006	Diabetes Mellitus Testing	2, 5
G2056	Diagnosis of Idiopathic Environmental Intolerance	2, 4, 5
M2057	Diagnosis of Vaginitis including Multi-target PCR Testing	2
G2157	Diagnostic Testing of Common Sexually Transmitted Infections	2, 4, 5
G2119	Diagnostic Testing of Influenza	2, 5
G2011	Diagnostic Testing of Iron Homeostasis and Metabolism	2, 5
G2059	Epithelial Cell Cytology In Breast Cancer Risk Assessment	2
G2138	Evaluation of Dry Eyes	2, 5
G2060	Fecal Analysis in the Diagnosis of Intestinal Dysbiosis	2, 5
G2061	Fecal Calprotectin Testing	2
F2019	Flow Cytometry	2, 4, 5
G2154	Folate Testing	2
G2173	Gamma-Glutamyl Transferase (GGT)	2, 4, 5
G2155	General Inflammation Testing	2, 5
G2044	Helicobacter Pylori Testing	2, 4, 5
M2097	Identification Of Microorganisms Using Nucleic Acid Probes	2
G2098	Immune Cell Function Assay	2
G2100	In Vitro Chemoresistance and Chemosensitivity Assays	2
G2099	Intracellular Micronutrient Analysis	2
G2143	Lyme Disease Testing	2, 5
G2107	Measurement of Thromboxane Metabolites for ASA Resistance	2
M2112	Nerve Fiber Density Testing	5
M2172	Onychomycosis Testing	2, 5
G2113	Oral Cancer Screening and Testing	2, 5
G2153	Pancreatic Enzyme Testing for Acute Pancreatitis	2, 5
G2164	Parathyroid Hormone, Phosphorus, Calcium, and Magnesium Testing	2, 5
G2149	Pathogen Panel Testing	5
G2055	Prenatal Testing for Fetal Aneuploidy	2, 3, 5
T2015	Prescription Medication and Illicit Drug Testing in the Outpatient Setting	5
G2007	Prostate Biopsies	3
G2120	Salivary Hormone Testing	2, 5
G2151	Serum Testing For Evidence Of Mild Traumatic Brain Injury	2
G2063	Testing for Diagnosis of Active or Latent Tuberculosis	2, 5
G2158	Testing for Vector-Borne Infections	2, 5
G2013	Testosterone	5
G2045	Thyroid Disease Testing	5
M2091	Transplant Rejection Testing	2, 5
G2125	Urinary Tumor Markers For Bladder Cancer	2, 5
G2156	Urine Culture Testing for Bacteria	5
G2014	Vitamin B12 and Methylmalonic Acid Testing	3
G2005	Vitamin D Testing	2, 5

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Dental Services

Dental’s Utilization Review Guidelines

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Updated December 28, 2023

Y0016_24WBST_M

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Dental Services

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