Minnesota Health Care Program Medical Policies...Blue Cross and Blue Shield of Minnesota and Blue Plus Minnesota Health Care Program Medical Policies Page 2 of 13 Administrative policies

Blue Cross and Blue Shield of Minnesota and Blue Plus

November 2020

www.bluecrossmn.com Blue Cross® and Blue Shield® of Minnesota and Blue Plus® are nonprofit independent licensees of the Blue Cross and Blue Shield Association. Amerigroup Partnership Plan, LLC, an independent company, is delegated by Blue Plus to provide certain administrative services to Blue Plus health plans. BMNPEC-0671-20 October 2020 514961MNPENMUB

Minnesota Health Care Program Medical Policies

Note: Federal and state guidelines, including Minnesota Health Care Program (MHCP) policies, continue to

apply and supersede other policies. Applicable Amerigroup Medical Policies and Clinical Utilization

Management (UM) Guidelines, and MCG Care Guidelines are listed below.

MCG Care Guidelines Amerigroup licenses and utilizes the MCG Care Guidelines (currently the 24th edition) for inpatient level of

care to guide UM decisions. The five products licensed include the following:

1. Inpatient & Surgical Care (ISC): Manage, review and assess people facing hospitalization or surgery

proactively with nearly 400 condition-specific guidelines, goals, optimal care pathways and other

decision support tools.

2. General Recovery Care (GRC): Effectively manage complex cases where a single ISC guideline or set

of guidelines is insufficient, including the treatment of people with diagnostic uncertainty or multiple

diagnoses.

3. Recovery Facility Care (RFC): Coordinate an effective plan for transitioning people to skilled nursing

facilities (SNFs) and inpatient rehabilitation facilities (IRFs).

4. Chronic Care (CC): Evaluate needs, identify goals, develop personalized care plans and support

effective self-care. The modular design supports quick and efficient assessments and enables you to

manage multiple comorbidities and behavioral health (BH) conditions.

5. Behavioral Health Care (BHC): Provides evidence-based guidelines to help health care professionals

guide the effective treatment of patients with BH disorders.

Amerigroup has the right to customize MCG Care Guidelines based on determinations by its Medical Policy

and Technology Assessment Committee (MPTAC).

Access the Medical Policies:

Minnesota Department of Human Services MHCP policies Blue Cross and Blue Shield of Minnesota and Blue Plus (Blue Cross) policies Amerigroup policies:

o Medical Policies and Clinical UM Guidelines o Clinical Criteria

https://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=DHS16_157386

https://www.bluecrossmn.com/providers/medical-policy-and-utilization-management

https://provider.publicprograms.bluecrossmn.com/minnesota-provider/medical-policies-and-clinical-guidelines

https://www.anthem.com/pharmacyinformation/clinicalcriteria

Blue Cross and Blue Shield of Minnesota and Blue Plus Minnesota Health Care Program Medical Policies

Page 2 of 17

Administrative policies

CG-ADMIN-01 Clinical UM Guideline for Prepayment Review Medical Necessity Determinations When No

Other Clinical UM Guideline Exists

ADMIN.00001 Medical Policy Formation

ADMIN.00002 Preventive Health Guidelines

ADMIN.00004 Medical Necessity Criteria

ADMIN.00005 Investigational Criteria

ADMIN.00006 Review of Services for Benefit Determinations in the Absence of a Company Applicable

Medical Policy or Clinical UM Guideline

Ancillary services

ANC.00007 Cosmetic and Reconstructive Services: Skin Related

ANC.00008 Cosmetic and Reconstructive Services of The Head and Neck

ANC.00009 Cosmetic and Services of the Trunk and Groin

CG-ANC-07 Inpatient Inter-facility Transfers

CG-ANC-08 Mobile Device-Based Health Management Applications

Behavioral health

MCG B-801-T Transcranial Magnetic Stimulation

MCG Care Guidelines BH — criteria for specific diagnosis will be applied as appropriate (excludes

residential substance abuse services)

DME

CG-DME-20 Orthopedic Footwear

CG-DME-39 Dynamic Low-Load Prolonged-Duration Stretch

CG-DME-44 Electric Tumor Treatment Field (TTF)

CG-OR-PR-02 Prefabricated and Prophylactic Knee Braces

CG-OR-PR-03 Custom-made Knee Braces

CG-OR-PR-05 Myoelectric Upper Extremity Prosthetic Devices

DME.00011 Electrical Stimulation as a Treatment for Pain and Related Conditions

DME.00024 Transtympanic Micropressure for the Treatment of Ménière’s Disease

DME.00025 Self-operated Spinal Unloading Devices

DME.00030 Altered Auditory Feedback Devices for the Treatment of Stuttering

DME.00038 Static Progressive Stretch (SPS) and Patient-Actuated Serial Stretch (PASS) Devices

DME.00041 Low Intensity Therapeutic Ultrasound for the Treatment of Pain

DME.00042 Electronic Positional Devices for the Treatment of Obstructive Sleep Apnea

Drugs and injectables

ING-CC-0099 Abraxane (paclitaxel, protein-bound)


Page 3 of 17

ING-CC-0065 Agents for Hemophilia A and von Willebrand Disease

Drugs and injectables (continued)

ING-CC-0148 Agents for Hemophilia B

ING-CC-0025 Aldurazyme (laronidase)

ING-CC-0094 Alimta (pemetrexed)

ING-CC-0073 Alpha-1 Proteinase Inhibitor Therapy

ING-CC-0083 Aristada Initio (aripiprazole lauroxil)

ING-CC-0122 Arzerra (ofatumumab)

ING-CC-0096 Asparagine Specific Enzymes (Oncaspar pegaspargase and Asparlas calaspargase pegol-mknl

only)

ING-CC-0116 Bendamustine agents (Bendeka, Treanda, Belrapzo)

ING-CC-0107 Bevacizumab for Non-ophthalmologic Indications (Avastin, Mvasi, and Zirabev only)

ING-CC-0126 Blincyto (blinatumomab)

ING-CC-0137 Cablivi (caplacizumab-yhdp)

ING-CC-0002 Colony Stimulating Factor Agents

ING-CC-0041 Complement Inhibitors (for Ultomiris ravulizumab only)

ING-CC-0123 Cyramza (ramucirumab)

ING-CC-0052 Dihydroergotamine (DHE) injection

ING-CC-0093 Docetaxel

ING-CC-0098 Doxorubicin liposome

ING-CC-0136 Drug dosage, frequency, and route of administration

ING-CC-0035 Duopa (carbidopa and levodopa enteral suspension)

ING-CC-0163 Durysta (bimatoprost implant)

ING-CC-0024 Elaprase (idursufase)

ING-CC-0051 Enzyme Replacement Therapy for Gaucher Disease

ING-CC-0106 Erbitux (cetuximab)

ING-CC-0001 Erythropoiesis Stimulating Agents

ING-CC-0155 Ethyol (amifostine)

ING-CC-0021 Fabrazyme (agalsidase beta)

ING-CC-0103 Faslodex (fulvestrant)

ING-CC-0039 GamaSTAN Immune Globulin (human)

ING-CC-0087 Gamifant (emapalumab-lzsg)

ING-CC-0121 Gazyva (obinutuzumab)

ING-CC-0102 GnRH Analogs for oncologic indications

ING-CC-0061 GnRH Analogs for the Treatment of Non-oncologic Indications

ING-CC-0108 Halaven (eribulin)


Page 4 of 17

ING-CC-0130 Imfinzi (durvalumab)

ING-CC-0003 Immunoglobulins


ING-CC-0045 Increlex (mecasermin)

Blue Cross II-29 Intra-articular Hyaluronan Injections for Osteoarthritis

ING-CC-0031 Intravitreal Corticosteroid Implants (Ozurdex, Retisert, Iluvien)

ING-CC-0100 Istodax (romidepsin)

ING-CC-0090 Ixempra (ixabepilone)

ING-CC-0164 Jelmyto (mitomycin gel)

ING-CC-0070 Jetrea (ocriplasmin)

ING-CC-0114 Jevtana (cabazitaxel)

ING-CC-0115 Kadcyla (ado-trastuzumab)

ING-CC-0057 Krystexxa (pegloticase)

ING-CC-0150 Kymriah (tisagenlecleucel)

ING-CC-0120 Kyprolis (carfilzomib)

ING-CC-0104 Levoleucovorin Agents (Fusilev, Khapzory)

ING-CC-0018 Lumizyme (alglucosidase alfa)

ING-CC-0132 Mylotarg (gemtuzumab ozogamicin)

ING-CC-0023 Naglazyme (galsulfase)

ING-CC-0036 Naltrexone implantable pellets

ING-CC-0111 Nplate (romiplostim)

ING-CC-0058 Octreotide agents

ING-CC-0141 Off-Label Drug and Approved Orphan Drug Use

ING-CC-0110 Perjeta (pertuzumab)

ING-CC-0040 Prialt (ziconotide)

ING-CC-0067 Prostacyclin Infusion and Inhalation Therapy

ING-CC-0118 Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy (Azedra, Zevalin)

ING-CC-0075 Rituximab Agents for Non-Oncologic Indications

ING-CC-0161 Sarclisa (isatuximab-irfc)

ING-CC-0159 Scenesse (afamelanotide)

ING-CC-0149 Select Clotting Agents for Bleeding Disorders

ING-CC-0056 Selected Injectable 5HT3 Antiemetic Agents

ING-CC-0059 Selected Injectable NK-1 Antiemetic Agents

ING-CC-0072 Selective Vascular Endothelial Growth Factor (VEGF) Antagonists (Avastin, Macugen, Mvasii,

and Zirabev only)

ING-CC-0142 Somatuline Depot (lanreotide)


Page 5 of 17

ING-CC-0008 Subcutaneous Hormonal Implants (estrogen implants only)

ING-CC-0113 Sylvant (siltuximab)

ING-CC-0162 Tepezza (teprotumumab-trbw)

ING-CC-0101 Torisel (temsirolimus)

ING-CC-0165 Trodelvy (sacituzumab govitecan)

ING-CC-0105 Vectibix (panitumumab)

ING-CC-0095 Velcade (bortezomib)


ING-CC-0097 Vidaza (azacitidine)

ING-CC-0017 Xiaflex (clostridial collagenase histolyticum) injection

ING-CC-0112 Xofigo (Radium Ra 223 Dichloride)

ING-CC-0151 Yescarta (axicabtagene ciloleucel)

ING-CC-0109 Zaltrap (ziv-aflibercept)

ING-CC-0019 Zoledronic acid agents

ING-CC-0140 Zulresso (brexanolone)

Genetic testing

Blue Cross VI-09 Genetic Testing

CG-GENE-05 Genetic Testing For DMD Mutations (Duchenne Or Becker Muscular Dystrophy)

CG-MED-88 Preimplantation Genetic Diagnosis Testing

CG-GENE-07 BCR-ABL Mutation Analysis

CG-GENE-09 Genetic Testing For CHARGE Syndrome

CG-GENE-11 Genotype Testing for Individual Genetic Polymorphisms To Determine Drug Metabolizer Status

CG-GENE-13 Genetic Testing for Inherited Diseases

CG-GENE-17 RET Proto-oncogene Testing for Endocrine Gland Cancer Susceptibility

CG-GENE-18 Genetic Testing for TP53 Mutations

CG-GENE-19 Detection And Quantification Of Tumor DNA Using Next Generation Sequencing In Lymphoid

Cancers

CG-GENE-20 Epidermal Growth Factor Receptor (EGFR) Testing

GENE.00003 Genetic Testing And Biochemical Markers for The Diagnosis of Alzheimer’s Disease

GENE.00007 Cardiac Ion Channel Genetic Testing

GENE.00010 Panel and Other Multi-Gene Testing for Polymorphisms to Determine Drug-Metabolizer Status

GENE.00016 Gene Expression Profiling for Colorectal Cancer

GENE.00017 Genetic Testing for Diagnosis and Management of Hereditary Cardiomyopathies (Including

Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy)

GENE.00018 Gene Expression Profiling for Cancers of Unknown Primary Site

GENE.00020 Gene Expression Profile Tests for Multiple Myeloma


Page 6 of 17

GENE.00024 DNA-Based Testing for Adolescent Idiopathic Scoliosis

GENE.00025 Proteogenomic Testing for the Evaluation of Malignant Tumors

GENE.00033 Genetic Testing for Inherited Peripheral Neuropathies

GENE.00034 Sensigene® Fetal Rhd Genotyping Test

GENE.00036 Genetic Testing For Hereditary Pancreatitis

GENE.00037 Genetic Testing For Macular Degeneration

Genetic testing (continued)

GENE.00038 Genetic Testing For Statin-Induced Myopathy

GENE.00039 Genetic Testing For Frontotemporal Dementia (FTD)

GENE.00042 Genetic Testing For Cerebral Autosomal Dominant Arteriopathy With Subcortical Infarcts And

Leukoencephalopathy Syndrome

GENE.00047 Methylenetetrahydrofolate Reductase Mutation Testing

GENE.00049 Circulating Tumor DNA Testing For Cancer (Liquid Biopsy)

GENE.00050 Gene Expression Profiling For Coronary Artery Disease

GENE.00051 Bronchial Gene Expression Classification for the Diagnostic Evaluation of Lung Cancer

GENE.00052 Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling

GENE.00053 Metagenomic Sequencing for Infectious Disease in the Outpatient Setting

GENE.00054 Paired DNA and Messenger RNA (mRNA) Genetic Testing to Detect, Diagnose, and Manage

Cancer

GT-01

Genetic Testing for Hereditary Cancer Susceptibility

Lynch Syndrome

Hereditary Breast and Ovarian Cancer Syndrome (BRCA1, BRCA2)

Hereditary Paraganglioma-Pheochromocytoma Syndrome

PALB2

Prostate Cancer

Von Hippel-Landau

GT-03

Genetic Testing for Reproductive Carrier Screen and Prenatal

Carrier Screening for Familial Disease

Fragile X

Cystic Fibrosis

Spinal Muscular Atrophy

Hemoglobinopathies

Ashkenazi Jewish Carrier Screening

Other Ethnicity Carrier Screening

Preimplantation Genetic Screening and Diagnostic Testing of Embryos

Prenatal Cell-Free DNA Screening

GT-04

Genetic Testing for Single Gene and Multifactorial Conditions

Genetic Testing for Germline Conditions

Multifactorial (Non-Mendelian Conditions)

Chromosomal Microarray Analysis

GT-05

Pharmacogenomic Testing and Genetic Testing for Thrombotic Disorders

Pharmacogenomic Testing

Thrombophilia Testing


Page 7 of 17

GT-06

Molecular Testing of Solid and Hematologic Tumors and Malignancies

Breast Cancer

Cell-Free Testing

Minimal Residual Disease (MRD) Testing

Targeted Molecular Testing for NTRK Fusions

Targeted Somatic Testing for PIK3CA

Prostate Cancer (symptomatic cancer screening)

GT-07 Whole Exome and Whole Genome Sequencing


Page 8 of 17

Lab

CG-LAB-10 Zika Virus Testing

CG-LAB-11 Screening For Vitamin D Deficiency In Average Risk Individuals

CG-LAB-12 Testing For Oral And Esophageal Cancer

CG-LAB-13 Skin Nerve Fiber Density Testing

CG-LAB-14 Respiratory Viral Panel Testing in the Outpatient Setting

LAB.00003 In-Vitro Chemosensitivity Assays And In-Vitro Chemoresistance Assays

LAB.00011 Analysis Of Proteomic Patterns

LAB.00015 Detection Of Circulating Tumor Cells In The Blood As A Prognostic Factor For Cancer

LAB.00016 Fecal Analysis In The Diagnosis Of Intestinal Disorders

LAB.00019 Serum Markers For Liver Fibrosis In The Evaluation And Monitoring Of Chronic Liver Disease

LAB.00024 Immune Cell Function Assay

LAB.00025 Topographic Genotyping

LAB.00026 Systems Pathology Testing For Predicting Risk Of Prostate Cancer Progression And Recurrence

LAB.00027 Selected Blood, Serum, And Cellular Allergy And Toxicity Tests

LAB.00028 Serum Biomarker Tests For Multiple Sclerosis

LAB.00029 Rupture Of Membranes Testing In Pregnancy

LAB.00030 Measurement of Serum Concentrations of Monoclonal Antibody Drugs and Antibodies to

Monoclonal Antibody Drugs

LAB.00031 Advanced Lipoprotein Testing

LAB.00033 Protein Biomarkers For The Screening, Detection And Management Of Prostate Cancer

LAB.00034 Serological Antibody Testing For Helicobacter Pylori

LAB.00035 Multibiomarker Disease Activity Blood Tests For Rheumatoid Arthritis

LAB.00036 Multiplex Autoantigen Microarray Testing For Systemic Lupus Erythematosus

Medicine

SDM-01 Sleep Disorder Management

CG-MED-02 Esophageal Ph Monitoring

CG-MED-05 Ketogenic Diet For Treatment Of Intractable Seizures

CG-MED-19 Custodial Care

CG-MED-24 Electromyography And Nerve Conduction Studies

CG-MED-28 Iontophoresis For Medical Indications

CG-MED-32 Ancillary Services For Pregnancy Complications

CG-MED-35 Retinal Telescreening Systems


Page 9 of 17

Medicine (continued)

CG-MED-37 Intensive Programs For Pediatric Feeding Disorders

CG-MED-38 Inpatient Admission For Radiation Therapy For Cervical Or Thyroid Cancer

CG-MED-39 Bone Mineral Density Testing Measurement

CG-MED-40 External Ambulatory Event Monitors To Detect Cardiac Arrhythmias

CG-MED-44 Holter Monitors

CG-MED-45 Transrectal Ultrasonography

CG-MED-46 Electroencephalography and Video Electroencephalographic Monitoring

CG-MED-47 Fundus Photography

CG-MED-48 Scrotal Ultrasound

CG-MED-49 Auditory Brainstem Responses And Evoked Otoacoustic Emissions For Hearing Disorders

CG-MED-50 Visual, Somatosensory And Motor Evoked Potentials

CG-MED-51 Three-Dimensional Rendering Of Imaging Studies

CG-MED-53 Cervical Cancer Screening Using Cytology And Human Papillomavirus Testing

CG-MED-54 Strapping

CG-MED-56 Non-Obstetrical Transvaginal Ultrasonography

CG-MED-57 Cardiac Stress Testing With Electrocardiogram

CG-MED-59 Upper Gastrointestinal Endoscopy in Adults

CG-MED-62 Resting Electrocardiogram Screening In Adults

CG-MED-63 Treatment Of Hyperhidrosis

CG-MED-64 Transcatheter Ablation Of Arrhythmogenic Foci In The Pulmonary Veins As A Treatment Of

Atrial Fibrillation Or Atrial Flutter (Radiofrequency And Cryoablation)

CG-MED-65 Manipulation Under Anesthesia Of The Spine And Joints Other Than The Knee

CG-MED-68 Therapeutic Apheresis

CG-MED-69 Inhaled Nitric Oxide

CG-MED-70 Wireless Capsule Endoscopy For Gastrointestinal Imagine And The Patency Capsule

CG-MED-72 Hyperthermia For Cancer Therapy

CG-MED-74 Implantable Ambulatory Event Monitors And Mobile Cardiac Telemetry

CG-MED-76 Magnetic Source Imaging And Magnetoencephalography

CG-MED-77 SPECT/CT Fusion Imaging

CG-MED-79 Diaphragmatic/Phrenic Nerve Stimulation And Diaphragm Pacing Systems

CG-MED-81 High Intensity Focused Ultrasound (HIFU) for Oncologic Indications

CG-MED-84 Non-Obstetric Gynecologic Duplex Ultrasonography of the Abdomen and Pelvis in the Outpatient

Setting

CG-MED-86 Enhanced External Couterpulsation in the Outpatient Setting


Page 10 of 17


CG-MED-87 Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications

MED.00004 Technologies For The Evaluation Of Skin Lesions (Including Dermatoscopy, Epiluminescence Microscopy,

Videomicroscopy And Ultrasonography)

MED.00011 Sensory Stimulation For Brain-Injured Individuals In Coma Or Vegetative State

MED.00053 Noninvasive Measurement Of Left Ventricular End Diastolic Pressure In The Outpatient Setting

MED.00059 Idiopathic Environmental Illness

MED.00065 Hepatic Activation Therapy

MED.00082 Quantitative Sensory Testing

MED.00085 Antineoplaston Therapy

MED.00087 Imaging Techniques For Screening And Identification Of Cervical Cancer

MED.00090 Wireless Capsule For The Evaluation Of Suspected Gastric And Intestinal Motility Disorders

MED.00091 Rhinophototherapy

MED.00095 Anterior Segment Optical Coherence Tomography

MED.00097 Neural Therapy

MED.00098 Hyperoxemic Reperfusion Therapy

MED.00099 Electromagnetic Navigational Bronchoscopy

MED.00101 Physiologic Recording Of Tremor Using Accelerometer(S) And Gyroscope(S)

MED.00102 Ultrafiltration In Decompensated Heart Failure

MED.00103 Automated Evacuation Of Meibomian Gland

MED.00104 Noninvasive Measurement Of Advanced Glycation Endproducts (Ages) In The Skin

MED.00105 Bioimpedance Spectroscopy Devices For The Detection And Management Of Lymphedema

MED.00111 Intracardiac Ischemia Monitoring

MED.00112 Autonomic Testing

MED.00115 Outpatient Cardiac Hemodynamic Monitoring Using A Wireless Sensor For Heart Failure Management

MED.00116 Near-Infrared Spectroscopy Brain Screening For Hematoma Detection

MED.00117 Autologous Cell Therapy for the Treatment of Damaged Myocardium

MED.00118 Continuous Monitoring of Intraocular Pressure

MED.00121 Implantable Interstitial Glucose Sensors

MED.00122 Wilderness Programs

MED.00126 Fractional Exhaled Nitric Oxide and Exhaled Breath Condensate Measurements for Respiratory Disorders

MED.00127 Chelation Therapy


Page 11 of 17


MED.00128 Insulin Potentiation Therapy

MED.00130 Surface Electromyography Devices for Seizure Monitoring

MED.00131 Electronic Home Visual Field Monitoring

MED.00132 Adipose-Derived Regenerative Cell Therapy and Soft Tissue Augmentation Procedures

MED.00133 Ingestion Event Monitors

Blue Cross II-165 Lyme Disease: Diagnostic Testing and Intravenous Antibiotic Therapy

Blue Cross II-144 Cellular Immunotherapy for Prostate Cancer

Radiology

A1-01 Advanced Imaging of the Brain

PET Imaging of the Brain

AI-02 Advanced Imaging of the Chest

PET Imaging of the Chest

AI-03 Advanced Oncologic Imaging

PET Imaging for Oncologic Indications

AI-04 Advanced Imaging of the Extremities

PET Imaging of the Extremities

AI-05

Advanced Imaging of the Heart

Cardiac CT with Quantitative Evaluation of Coronary Calcification

Cardiac MRI

Myocardial Perfusion Imaging

Cardiac Blood Pool Imaging

Blue Cross V-07 MRI of The Breast

RAD.00034 Dynamic Spinal Visualization (Including Digital Motion X-Ray And Cineradiography/ Videofluoroscopy)

RAD.00037 Whole Body Computed Tomography Scanning

RAD.00038 Use Of 3D, 4D Or 5D Ultrasound In Maternity Care

RAD.00044 Magnetic Resonance Neurography

RAD.00052 Positional MRI

RAD.00053 Cervical And Thoracic Discography

RAD.00057 Near-Infrared Coronary Imaging And Near-Infrared Intravascular Ultrasound Coronary Imaging

RAD.00059 Transcatheter Arterial Chemoembolization and Transcatheter Arterial Embolization for Malignant Lesions

Outside the Liver Except Central Nervous System and Spinal Cord

RAD.00062 Intravascular Optical Coherence Tomography

RAD.00063 Magnetization-Prepared Rapid Acquisition Gradient Echo Magnetic Resonance Imaging (MPRAGE MRI)

RAD.00064 Myocardial Sympathetic Innervation Imaging With or Without Single-Photon Emission Computed

Tomography (SPECT)

CG-SURG-98 Prostate Biopsy Using MRI Fusion Techniques


Page 12 of 17

Radiation therapy

Radiation therapy (continued)

CG-THER-RAD-07 Intravascular Brachytherapy (Coronary And Non-Coronary)

THER-RAD.00008 Neutron Beam Radiotherapy

THER-RAD.00012 Electrophysiology-Guided Noninvasive Stereotactic Cardiac Radioablation

Rehabilitation

CG-REHAB-02 Outpatient Cardiac Rehabilitation

CG-REHAB-03 Pulmonary Rehabilitation

REHAB.00003 Hippotherapy

Surgery

Blue Cross IV-123 Gender Affirming Procedures for Gender Dysphoria

Blue Cross XI-03 Site of Service for Selected Outpatient Procedures: Outpatient Hospital and Ambulatory Surgery Center

IP-01 Interventional Pain – Epidural Injection Procedures

IP-02 Interventional Pain – Paravertebral Facet Injection/Nerve Block/Neurolysis

IP-03 Interventional Pain – Regional Sympathetic Nerve Block

IP-04 Interventional Pain – Sacroiliac Joint Injections

IP-05 Interventional Pain – Spinal Cord Stimulators

JO-01

Joint Surgery – Hip Procedures

Hip Arthroplasty

Hip Arthroscopy

JO-02

Joint Surgery – Knee Procedures

Knee Arthroplasty

Knee Arthroscopy and Open Procedures

Meniscal Allograft Transplantation of the Knee

Treatment of Osteochondral Defects

JO-03

Joint Surgery – Shoulder Procedures

Shoulder Arthroplasty

Shoulder Arthroscopy and Open Procedures

SP-01 Spine – Bone Graft Substitutes and Bone Morphogenic Proteins

SP-02 Spine – Cervical Arthroplasty

SP-03 Spine – Cervical Decompression

SP-04 Spine – Lumbar Arthroplasty

SP-05 Spine – Lumbar Discectomy, Foraminotomy, and Laminotomy

SP-06 Spine – Lumbar Fusion and Treatment of Spinal Deformity

SP-07 Spine – Lumbar Laminectomy

SP-08 Spine – Sacroiliac Joint Fusion

SP-09 Spine – Vertebroplasty/Kyphoplasty


Page 13 of 17

CG-SURG-01 Colonoscopy

CG-SURG-03 Blepharoplasty, Blepharoptosis Repair And Brow Lift

CG-SURG-05 Maze Procedure

CG-SURG-07 Vertical Expandable Prosthetic Titanium Rib

Surgery (continued)

CG-SURG-08 Sacral Nerve Stimulation As A Treatment Of Neurogenic Bladder Secondary To Spinal Cord Injury

CG-SURG-11 Surgical Treatment For Dupuytren’s Contracture

CG-SURG-12 Penile Prosthesis Implantation

CG-SURG-15 Endometrial Ablation

CG-SURG-17 Trigger Point Injections

CG-SURG-18 Septoplasty

CG-SURG-24 Functional Endoscopic Sinus Surgery

CG-SURG-25 Injection Treatment For Morton's Neuroma

CG-SURG-28 Transcatheter Uterine Artery Embolization

CG-SURG-29 Lumbar Discography

CG-SURG-31 Treatment Of Keloids And Scar Revision

CG-SURG-34 Diagnostic Infertility Surgery

CG-SURG-36 Adenoidectomy

CG-SURG-37 Destruction Of Pre-Malignant Skin Lesions

CG-SURG-40 Cataract Removal Surgery For Adults

CG-SURG-41 Surgical Strabismus Correction

CG-SURG-44 Coronary Angiography In The Outpatient Setting

CG-SURG-46 Myringotomy And Tympanostomy Tube Insertion

CG-SURG-49 Endovascular Techniques (Percutaneous Or Open Exposure) For Arterial Revascularization Of The Lower

Extremities

CG-SURG-51 Outpatient Cystourethroscopy

CG-SURG-55 Intracardiac Electrophysiological Studies And Catheter Ablation

CG-SURG-56 Diagnostic Fiberoptic Flexible Laryngoscopy

CG-SURG-57 Diagnostic Nasal Endoscopy

CG-SURG-58 Radioactive Seed Localization Of Non-Palpable Breast Lesions

CG-SURG-59 Vena Cava Filters

CG-SURG-61 Cryosurgical Ablation or Radiofrequency Ablation to Treat Solid Tumors Outside the Liver

CG-SURG-63 Cardiac Resynchronization Therapy (CRT) With Or Without An Implantable Cardioverter Defibrillator

(CRT/ICD) For The Treatment Of Heart Failure

CG-SURG-70 Gastric Electrical Stimulation


Page 14 of 17

CG-SURG-71 Reduction Mammaplasty

CG-SURG-72 Endothelial Keratoplasty

CG-SURG-73 Balloon Sinus Ostial Dilation

CG-SURG-74 Total Ankle Replacement

Surgery (continued)

CG-SURG-75 Transanal Endoscopic Microsurgical (TEM) Excision Of Rectal Lesions

CG-SURG-76 Carotid, Vertebral And Intracranial Artery Stent Placement With Or Without Angioplasty

CG-SURG-77 Refractive Surgery

SURG.00026 Deep Brain, Cortical, and Cerebellar Stimulation

SURG.00043 Electrothermal Shrinkage of Joint Capsules, Ligaments and Tendons

SURG.00044 Breast Ductal Examination and Fluid Cytology Analysis

SURG.00045 Extracorporeal Shock Wave Therapy

SURG.00047 Transendoscopic Therapy for Gastroesophageal.Reflux Disease, Dysphagia, and Gastroparesis

SURG.00052 Percutaneous Vertebral Disc and Vertebral Endplate Procedures

SURG.00053 Unicondylar Interpositional Spacer

SURG.00056 Transanal Radiofrequency Treatment of Fecal Incontinence

SURG.00061 Presbyopia and Astigmatism-Correcting Intraocular Lenses

SURG.00062 Ovarian And Internal Iliac Vein Embolization as a Treatment of Pelvic Congestion Syndrome

SURG.00070 Photocoagulation of Macular Drusen

SURG.00071 Percutaneous and Endoscopic Spinal Surgery

SURG.00072 Lysis of Epidural Adhesions

SURG.00073 Epiduroscopy

SURG.00075 Intervertebral Stabilization Devices

SURG.00076 Nerve Graft After Prostatectomy

SURG.00077 Uterine Fibroid Ablation: Laparoscopic or Percutaneous Image Guided Techniques

SURG.00079 Nasal Valve Suspension

SURG.00082 Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedures of the Appendicular

System

SURG.00084 Implantable Middle Ear Hearing Aids

SURG.00088 Coblation® Therapies for Musculoskeletal Conditions

SURG.00089 Self-Expanding Absorptive Sinus Ostial Dilation

SURG.00092 Implanted Devices for Spinal Stenosis

SURG.00095 Viscocanalostomy and Canaloplasty

SURG.00096 Surgical and Ablative Treatments for Chronic Headaches


Page 15 of 17

SURG.00097 Vertebral Body Stapling and Tethering for the Treatment Of Scoliosis in Children

and Adolescents

SURG.00098 Mechanical Embolectomy for Treatment of Acute Stroke

SURG.00099 Convection Enhanced Delivery of Therapeutic Agents to the Brain

SURG.00100 Cryoablation For Plantar Fasciitis And Plantar Fibroma

Surgery (continued)

SURG.00101 Suprachoroidal Injection of a Pharmacologic Agent

SURG.00102 Artificial Anal Sphincter for the Treatment of Severe Fecal Incontinence

SURG.00103 Intraocular Anterior Segment Aqueous Drainage Devices (Without Extraocular Reservoir)

SURG.00104 Extraosseous Subtalar Joint Implantation and Subtalar Arthroereisis

SURG.00105 Bicompartmental Knee Arthroplasty

CG-SURG-101 Ablative Techniques as aTreatment For Barrett's Esophagus

SURG.00107 Prostate Saturation Biopsy

SURG.00111 Axial Lumbar Interbody Fusion

SURG.00007 Vagus Nerve Stimulation

SURG.00112 Occipital Nerve Stimulation

SURG.00113 Artificial Retinal Devices

SURG.00114 Facet Joint Allograft Implants for Facet Disease

CG-SURG-94 Keratoprosthesis

SURG.00116 High Resolution Anoscopy Screening for Anal Intraepithelial Neoplasia and Squamous Cell Cancer of the

Anus

CG-SURG-95 Sacral Nerve Stimulation and Percutaneous Tibial Nerve Stimulation for Urinary and Fecal Incontinence;

Urinary Retention

SURG.00118 Bronchial Thermoplasty

SURG.00119 Endobronchial Valve Devices

SURG.00120 Internal Rib Fixation Systems

SURG.00121 Transcatheter Heart Valve Procedures (For TAVR And TPVI Only)

CG-SURG-106 Venous Angioplasty with or without Stent Placement or Venous Stenting Alone

SURG.00123 Transmyocardial/Perventricular Device Closure of Ventricular Septal Defects

SURG.00124 Carotid Sinus Baroreceptor Stimulation Devices

SURG.00125 Radiofrequency And Pulsed Radiofrequency Treatment Of Trigger Point Pain

SURG.00126 Irreversible Electroporation

SURG.00128 Implantable Left Atrial Hemodynamic Monitor

SURG.00129 Oral, Pharyngeal And Maxillofacial Surgical Treatment For Obstructive Sleep Apnea Or Snoring

SURG.00130 Annulus Closure After Discectomy


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SURG.00131 Lower Esophageal Sphincter Augmentation Devices For The Treatment Of Gastroesophageal Reflux Disease

SURG.00132 Drug-Eluting Devices For Maintaining Sinus Ostial Patency

SURG.00134 Interspinous Process Fixation Devices

SURG.00135 Radiofrequency Ablation Of The Renal Sympathetic Nerves

CG-SURG-96 Intraocular Telescope

Surgery (continued)

SURG.00137 Focused Microwave Thermotherapy For Breast Cancer

SURG.00138 Laser Treatment For Onychomycosis

CG-SURG-102 Alcohol Septal Ablation for Treatment of Hypertrophic Cardiomyopathy

SURG.00139 Intraoperative Assessment Of Surgical Margins During

SURG.00140 Peripheral Nerve Blocks For Treatment Of Neuropathic Pain

SURG.00141 Doppler-Guided Transanal Hemorrhoidal Dearterialization

SURG.00142 Genicular Nerve Blocks And Ablation For Chronic Knee Pain

SURG.00143 Perirectal Spacers For Use During Prostate Radiotherapy

SURG.00144 Occipital Nerve Block Therapy For The Treatment Of Headache And Occipital Neuralgia

SURG.00145 Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices

And Artificial Hearts)

SURG.00146 Extracorporeal Carbon Dioxide Removal

SURG.00147 Synthetic Cartilage Implant For Metatarsophalangeal Joint Disorders

SURG.00148 Spectral Analysis Of Prostate Tissue By Fluorescence Spectroscopy

SURG.00149 Percutaneous Ultrasonic Ablation Of Soft Tissue

SURG.00150 Leadless Pacemaker

SURG.00151 Balloon Dilation Of Eustachian Tube

SURG.00153 Cardiac Contractility Modulation Therapy

SURG.00154 Microsurgical Procedures for the Treatment of Lymphedema

SURG.00155 Cryoneurolysis for Treatment of Peripheral Nerve Pain

CG-SURG-92 Paraesophageal Hernia Repair

CG-SURG-93 Angiographic Evaluation And Endovascular Intervention For Dialysis Access Circuit Dysfunction

SURG.00152 Wireless Cardiac Resynchronization Therapy For Left Ventricular Pacing

Blue Cross IV-152 Transcatheter Mitral Valve Repair

CG-SURG-99 Panniculectomy And Abdominoplasty

Blue Cross IV-144 Visocanalostomy And Canaloplasty For The Treatment Of Glaucoma

Transplant


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CG-TRANS-03 Donor Lymphocyte Infusion For Hematologic Malignancies After Allogeneic Hematopoietic Progenitor Cell

Transplantation

TRANS.00004 Cell Transplantation (Mesencephalic, Adrenal-Brain And Fetal Xenograft)

TRANS.00016 Umbilical Cord Blood Progenitor Cell Collection, Storage And Transplantation

Documents

Minnesota Health Care Program Medical Policies...Blue Cross and Blue Shield of Minnesota and Blue Plus Minnesota Health Care Program Medical Policies Page 2 of 13 Administrative policies