CurrentBlue Cross Blue Shield - MassachusettsPolicy 132

Medicare Advantage Management

Administrative guidelines governing coverage determination sources, prior authorization processes, and utilization management for Medicare Advantage products administered by Blue Cross Blue Shield of Massachusetts (BCBSMA); affects providers and Medicare Advantage members.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyMedicare Advantage Management

Policy CodePolicy 132

Change TypeMultiple additions, removals, delegations, and clarifications

Effective DateOct 1, 2020

Next Review Date

Key ActionDetermine if prior authorization is required via Carelon; if required, request prior authorization from Carelon (1-866-745-1783) or via ProviderPortal.

SourceLink

POLICY UPDATE CHANGES

LCD: Respiratory Pathogen Panel Testing (L39027) added to MP 045.

MP 140 Radiofrequency Volumetric Tissue Reduction for Nasal Obstruction (VivAer) added. Effective 4/1/2025.

Removed NCD 20.8.4 Leadless Pacemakers from MP 038 Leadless Cardiac Pacemakers.

MP 035 Temporomandibular Joint Disorder clarified; CPT codes 21073 and 21116 removed and prior authorization is no longer required for those codes effective 4/1/2025.

MP 161 Percutaneous Revascularization Procedures for Lower Extremity Peripheral Arterial Disease added. Effective 3/1/2025.

MP 110 Meniscal Allografts and Other Meniscal Implants retired effective 3/1/2025; coverage determined by InterQual.

BCBSMA delegated utilization management of molecular genetic testing to Carelon Medical Benefits Management for Medicare Advantage products; prior authorization through Carelon required effective 1/1/2025.

MP 103 Implantable Peripheral Nerve Stimulation for Chronic Pain Conditions added. Effective 11/1/2024.

Prior authorization information removed from MP 543 Negative Pressure Wound Therapy in the Outpatient Setting; prior authorization no longer required effective 11/1/2024.

Multiple new medical policies (MP 114, 115, 116, 117, 118, 119) for cardiac imaging and procedures added, posted 9/1/2024 and effective 10/1/2024.

The following policies were added: MP #142 Air Ambulance Transport; MP #146 Ground Ambulance; MP #158 Outpatient Pediatric Pain Rehabilitation Centers; MP #139 Diagnostic Laboratory Services.

The following commercial policies were retired: MP #060 Transurethral Water Vapor Thermal Therapy for Benign Prostatic Hyperplasia.

LCD: Select Minimally Invasive GERD Procedures (L35080) added.

Outpatient prior authorization is required for Medicare Advantage for #077 Scenesse (afamelanotide) for Treatment of Erythropoietic Protoporphyria effective 2/1/2021.

The following commercial policies were retired: MP #285 Placental/Umbilical Cord Blood as a Source of Stem Cells; MP #448 Computed Tomography Perfusion Imaging of the Brain.

The following commercial policies were retired: MP #137 Magnetoencephalography/ Magnetic Source Imaging retired.

MP #639 Radioimmunoscintigraphy Imaging with Indium-111 Capromab Pendetide for Prostate Cancer retired.

Investigational HCPCS code A9507 added to MP #400.

MP #723 ST2 Assay for Chronic Heart Failure and Heart Transplant Rejection retired; merged into policy #530 Laboratory Tests Post Transplant and for Heart Failure.

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

2020-10-01effective date

1/1/2025Carelon delegation

manyPA requirement

NCD/LCDcoverage hierarchy

1delegations noted

Coverage Determination & Prior Authorization Criteria

Coverage determination and prior authorization criteria

Coverage determinations for Medicare Advantage follow a hierarchy and prior authorization pathway:

ALL of the following

If an applicable CMS National Coverage Determination (NCD) exists for a service, BCBSMA must follow the NCD for Medicare Advantage members.
Source: CMS NCD requirement
If no NCD applies, and a Local Coverage Determination (LCD) exists from the Medicare Administrative Contractor (MAC) for the member's residence jurisdiction, BCBSMA follows that LCD.
Source: LCD follows jurisdiction of member's residence
For molecular diagnostic tests, follow Palmetto GBA MolDX LCDs for the member's jurisdiction when applicable; if no MolDX LCD applies, follow delegated Carelon guidelines or BCBSMA medical policy as indicated.
Source: MolDX and Carelon delegation

ALL of the following

If Carelon indicates prior authorization IS required, request prior authorization from Carelon (phone or ProviderPortal) and follow Carelon clinical guidelines for medical necessity.
Source: steps when PA is required through Carelon
If Carelon indicates prior authorization IS NOT required: determine if an NCD or LCD exists for the technology; if present, follow the NCD/LCD; if no NCD/LCD, apply Carelon guidelines for clinical review criteria; if criteria are not met but a clinical exception is needed, follow the Clinical Exception Process.
Source: steps when PA not required

Prior authorization and medical necessity criteria (summary)

Summary of prior authorization and medical necessity principles for Medicare Advantage Part B:

Primary clinical authority: medical necessity criteria will follow CMS NCD/LCD guidance when available.

CMS NCD/LCD guidance governs medical necessity

When CMS NCD/LCD guidance is absent, criteria will follow medically accepted indications supported by FDA labeling and other Medicare-accepted medical references.

Fallback to FDA labeling / medically accepted indications

Certain high-complexity therapies and diagnostics require specific prior authorization forms and processes (for example CAR T-cell therapies, gene therapies, and named drug therapies) as referenced in MP entries; use the named prior authorization request form where indicated.

Use specified PA forms per MP entries

All covered services may be audited or retrospectively reviewed for medical necessity even if prior authorization was not required; retain supporting documentation and submit authorizations electronically when recommended.

Selected MP coverage/prior auth rules

Selected examples of per-medical-policy outpatient prior authorization and coverage rules:

MP 143 (Hematopoietic Cell Transplantation): Prior authorization required for specified transplantation-related codes; NCD/LCD references apply.

Example: 38240, 38241 require PA

MP 146 (Ground Ambulance): For Medicare HMO Blue, prior authorization is required for non-emergent ambulance transports from a member's residence to a contracted facility and for chair car/van; emergency transports are not subject to prior authorization. For Medicare PPO Blue, prior authorization is required for any ground ambulance services.

Ground ambulance PA distinctions between HMO and PPO

MP 156 (Shoulder Resurfacing): Listed as 'This is not a covered service' in the outpatient policy excerpt.

Example of non-covered service

Selected MP coverage stances

Examples of coverage stances captured in policy entries:

'This is not a covered service' — multiple MPs list services as not covered (examples: MP 250, MP 254, MP 258).

Non-covered stance examples

'Prior authorization is not required' — numerous MPs indicate prior authorization is not required when criteria are met or per NCD/LCD (examples: MP 260, MP 449, MP 450).

No-PA stance examples

'Prior authorization is required' — many MPs require prior authorization for Medicare HMO Blue and Medicare PPO Blue for specified codes or services (examples shown throughout MP listings).

PA-required stance examples

Coverage examples and code-specific notes

Coverage examples and code-specific notes illustrating varied outcomes:

Bone Mineral Density studies (MP 449/450): NCDs apply; prior authorization is not required for many bone density procedures (codes such as 77086/0743T referenced; coverage when criteria met).

NCD referenced for BMD studies

Breast surgery (MP 428 and related MPs): Prior authorization is required for many reconstructive and cosmetic breast surgery CPT codes for Medicare products, with exceptions for breast cancer–related diagnoses where prior authorization may not be required.

Breast surgery PA nuance

Negative pressure wound therapy (MP 543): MP lists prior authorization not required for the outpatient setting overall, but specific CPTs (97605, 97606) are flagged as requiring prior authorization for Medicare HMO Blue and Medicare PPO Blue in other MP entries.

Example of mixed per-code vs per-policy PA status

Sample MP coverage/status entries from excerpt

Sample MP coverage/status entries from the excerpt (selected MPs and their outpatient prior authorization status):

MP 450 (Bone Mineral Density Studies): Prior authorization not required; NCD referenced.

MP 450 example

MP 453 (Melanoma Vaccines): This is not a covered service per MP entry.

MP 453 example

MP 492 (Epithelial Cell Cytology in Breast Cancer Risk Assessment): Prior authorization required per MP entry.

MP 492 example

MP 543 (Negative Pressure Wound Therapy — Outpatient): Prior authorization not required overall (policy-level), but specific CPTs flagged elsewhere may require PA for Medicare HMO/PPO.

MP 543 example

MP 900 (Advanced Imaging/Radiology codes): Prior authorization through Carelon is required for Medicare Advantage products.

Per-policy coverage/prior auth notes

Per-policy outpatient prior authorization or coverage notes (selected highlights):

MP 706 (Patient-Specific Instrumentation for Joint Arthroplasty): BCBSMA medical policy is followed; outpatient prior authorization status per MP entry (policy-level guidance applies).

MP 706 note

MP 709 (Proteomic Testing for Systemic Therapy in NSCLC): LCD: Molecular Pathology Procedures applies; prior authorization not required per MP entry.

MP 709 note

MP 716 (Responsive Neurostimulation): Procedure performed in the inpatient setting per MP entry (outpatient prior authorization not applicable).

MP 716 inpatient-only note

MP 954/954-series (Delegated molecular genetic testing management): Prior authorization through Carelon is required for Medicare Advantage products effective 1/1/2025.

Carelon delegation reminder

Gender-affirming surgery coverage notes

Gender-affirming surgical procedures and related coverage notes:

Extensive lists of gender-affirming surgical CPT codes require prior authorization for Medicare HMO Blue and Medicare PPO Blue (multiple CPTs listed across MP entries).

MP entries provide long code lists requiring PA

Some facial feminization, chest, and selected reconstructive codes are covered when they are required as part of medically necessary facial feminization or reconstruction—coverage is context-dependent and subject to prior authorization review.

Coverage may be allowed when medically necessary as part of facial feminization

CPT / HCPCS / J / Q Code Listings & Changes

Preimplantation Genetic Testing biopsy codesCPTCovered

89290	Biopsy, oocyte polar body or embryo blastomere, microtechnique; <=5 embryos (preimplantation genetic diagnosis)
89291	Biopsy, oocyte polar body or embryo blastomere, microtechnique; >5 embryos (preimplantation genetic diagnosis)

HCPCS/J-codes requiring prior authorization (selected list)HCPCSCovered

C9257; J0178; J0179; J0881; J0882; J0885; J0887; J0888; J0897; J1442; J1447; J1745; J2503; J2778; J7318; J7320; J7321; J7322; J7323; J7324; J7325; J7326; J7327; J7328; J7329; J7332; J9035; J9312; J9355; Q4081; Q5103-Q5121

Selected HCPCS/J-codes listed under MP entries that require prior authorization for Medicare products

CPT/procedure codesCPTCovered

21010, 21050, 21060, 21240, 21242, 21243, 29800, 29804, 15780-15783, 15830, 30400-30435, 30450, 11900-11901, 21120-21209, 21193-21199, 21206, 21208-21209, 21685, 42145, 93580

Procedure codes referenced in various MP entries with prior authorization requirements

Sample CPT/HCPCS codes requiring prior authorizationmixedCovered

95940	Motor Evoked Potential Testing (example listed requiring prior authorization)
36465	Example vein/venous insufficiency procedure code listed among codes requiring prior authorization

Medical technology noncovered CPT-4 T-codesCPTNot Covered

0623T	Medical Technology Assessment - Noncovered service code listed
0624T	Medical Technology Assessment - Noncovered service code listed
0625T	Medical Technology Assessment - Noncovered service code listed
0626T	Medical Technology Assessment - Noncovered service code listed

Vertebral fracture assessment coding guidanceCPTCovered

77086	Vertebral fracture assessment code followed by BCBSMA policy
0743T	Vertebral fracture assessment/biomechanical CT code followed by BCBSMA policy

CPTs mentioned with prior authorization statusCPTCovered

97605	Negative pressure wound therapy; part of codes requiring prior auth for Medicare HMO/PPO
97606	Negative pressure wound therapy; part of codes requiring prior auth for Medicare HMO/PPO
19318	Breast-related CPT flagged for prior authorization
15820	Blepharoplasty/related CPT flagged for prior authorization
15821	Blepharoplasty/related CPT flagged for prior authorization
15822	Blepharoplasty/related CPT flagged for prior authorization
15823	Blepharoplasty/related CPT flagged for prior authorization
67900	Eyelid procedure CPT flagged for prior authorization
67901	Eyelid procedure CPT flagged for prior authorization
67902	Eyelid procedure CPT flagged for prior authorization

1–10 of 14

1/2

Selected J-codes mentionedHCPCSCovered

J3398	Cell and Gene Therapy for Ocular Diseases (example listed requiring prior auth)
J3403	HCPCS added to MP 911

Aducanumab codesHCPCSCovered

J0174	Aducanumab for Alzheimer Disease (prior auth required)
J0175	Aducanumab for Alzheimer Disease (prior auth required)

Q-codes addedHCPCSCovered

Q2055	CAR T-cell related code — prior auth noted for Medicare HMO/PPO Blue
Q2056	CAR T-cell related code — prior auth noted for Medicare HMO/PPO Blue

Temporomandibular Joint Disorder coding changesCPT

21073	CPT code removed from prior authorization; no longer requires prior auth
21116	CPT code removed from prior authorization; no longer requires prior auth

Investigational HCPCSHCPCS

A9507

Investigational HCPCS code added to MP #400

inv-21: Carelon genetic test PA effective date — delegations effective date

Effective dateJanuary 1, 2025

ScopeDelegation applies to utilization management of molecular genetic (molecular genetic testing) for Medicare Advantage products

Authorization vendorCarelon Medical Benefits Management

RequirementPrior authorization through Carelon is required per Carelon Clinical Guidelines for molecular genetic tests

Authorization Requests, Submission & Documentation Guidance

Prior Authorization

Authorization submission and claims review guidance

Medicare Advantage providers must verify whether prior authorization is required through Carelon before ordering services subject to the Radiology Management Program, Advanced Imaging, Quality Care Cancer Program, Genetic Testing Management, and selected outpatient medical policies. If prior authorization is required through Carelon, submit requests via the Carelon ProviderPortal or call 1-866-745-1783 and follow Carelon's instructions. Electronic submission is recommended. Claims payment is contingent on member eligibility, benefit availability at time of claim receipt, and medical necessity; services may be audited or reviewed retrospectively even if prior authorization was not required.

Verify member-specific PA requirements in Provider Central (www.bluecrossma.com/provider) > eTools > Carelon Medical Benefits Management or via Carelon ProviderPortal (registration required).
If Carelon PA is required: submit through Carelon ProviderPortal or call 1-866-745-1783; follow Carelon clinical guideline steps.
Recommend electronic submission of authorization requests; see the Utilization Management section of the Blue Cross Blue Book for details.
Claims are subject to eligibility, benefits, and medical necessity checks; retrospective reviews may be performed prior to payment.

Key Definitions & Terms

inv-47: MAC — Medicare Administrative Contractors definition and reference

DefinitionMedicare Administrative Contractors (MACs) are private health care insurers awarded geographic jurisdiction to process Medicare Part A and Part B medical claims or DME claims for Medicare Fee-For-Service beneficiaries.

Use in policyBCBSMA follows MAC-published Local Coverage Determinations (LCDs) based on member residence jurisdiction when making coverage determinations for Medicare Advantage.

Access noteTo review LCDs, providers must accept the CMS licensing agreement on the CMS webpage.

inv-48: Carelon delegation — Carelon Medical Benefits Management delegated for utilization management of molecular genetic testing (effective date noted)

Delegated entityCarelon Medical Benefits Management

Effective date

Policy Change Log

11/01/2025retirement

MP 147 Zulresso (Brexanolone) for the treatment of post-partum depression retired; effective 11/1/2025.

12/01/2025addition

MP 065 Urinary Test for Renal Allograft Rejection; MP 111 Tumor Treating Fields Therapy; and MP 126 Catheter Ablation for Cardiac Arrhythmias added; effective 12/1/2025.

03/01/2025addition

MP 161 Percutaneous Revascularization Procedures for Lower Extremity Peripheral Arterial Disease and MP 177 Low-Dose Radiotherapy for Non-Oncologic Indications added; effective 3/1/2025.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyMedicare Advantage Management

Policy CodePolicy 132

Change TypeMultiple additions, removals, delegations, and clarifications

Effective DateOct 1, 2020

Next Review Date

Key ActionDetermine if prior authorization is required via Carelon; if required, request prior authorization from Carelon (1-866-745-1783) or via ProviderPortal.

SourceLink

On This Page

Claims review and documentation guidance

Effective Jan 1, 2025, utilization management of molecular genetic testing for Medicare Advantage was delegated to Carelon and requires prior authorization per Carelon Clinical Guidelines (exclusions and BCBSMA Policy #088 noted).

Carelon delegation and PA requirement

Carelon-managed advanced imaging

inv-22: Medicare HMO/PPO prior auth requirement — summary note about prior auth required for specified procedures and codes per MP entries

SummaryPrior authorization is required for specified procedures and CPT/HCPCS codes as indicated in individual MP entries for Medicare HMO Blue and Medicare PPO Blue

Examples of codes requiring PA38240, 38241, S2142, S2150, 38241, S2150, 15820–15823, 67900–67908, 97605, 97606

How to determine PACheck the MP entry in the directory for the outpatient prior authorization designation (required / not required / not covered) per member's product

Prior Authorization

Air and ground ambulance authorization rules

Air and ground ambulance services have distinct prior authorization rules for Medicare HMO Blue and Medicare PPO Blue. Air ambulance transports are treated as time-sensitive and typically subject to retrospective documentation review prior to payment. Ground ambulance authorization varies by transport type, origin/destination, and whether the transport is emergent or non-emergent.

Air ambulance: For Medicare HMO Blue, prior authorization is required; for Medicare PPO Blue, prior authorization is not required. All air ambulance claims must include supporting documentation and will be reviewed for medical necessity; a retrospective review is commonly performed prior to payment.
Ground ambulance: For Medicare HMO Blue, prior authorization is required for all non-emergent transports from a member's residence to a contracted facility/provider; emergency transports do not require prior authorization. Prior authorization is required for non-emergency transports between facilities when the patient is an inpatient and for involuntary psychiatric facility transports.
For Medicare PPO Blue, prior authorization is required for any ground ambulance services and for involuntary psychiatric facility transports.
Definitions: A member's 'residence' is where they make their home and dwell permanently or for an extended period.

Documentation Required

Air ambulance documentation and review

Because air ambulance events are often urgent or emergent, claims must be submitted with comprehensive supporting documentation and will undergo medical necessity review (often retrospectively) before payment is authorized.

Include transport records, clinical notes, origin/destination details, and justification of medical necessity with the claim.
Retrospective reviews may result in denial if documentation does not support medical necessity even when prior authorization was not feasible due to emergency circumstances.

Prior Authorization

Eyelid / blepharoplasty related CPTs — prior authorization

Specific eyelid, blepharoplasty, blepharoptosis repair, and brow ptosis repair CPT codes require prior authorization for Medicare HMO Blue and Medicare PPO Blue. Confirm PA requirements prior to scheduling.

Blepharoplasty and related codes requiring prior authorization: 15820, 15821, 15822, 15823, 67900, 67901, 67902, 67903, 67904, 67906, 67908.
Use the Massachusetts Collaborative Prior Authorization Form OR the Blue Cross Blue Shield of Massachusetts Pre-certification Request Form when submitting PA requests for these services.

Note

Outpatient Prior Authorization general statuses

Many outpatient medical policy entries specify whether prior authorization is required, not required, or that the service is not covered. Providers should consult the specific MP for outpatient PA status before rendering services.

Examples of status variations in outpatient MPs: 'Prior authorization is required', 'Prior authorization is not required', and 'This is not a covered service'.
Some procedures are indicated to be performed in the inpatient setting rather than outpatient; verify the MP for site-of-service guidance.
Where forms are indicated, use the Massachusetts Collaborative Prior Authorization Form or BCBSMA Pre-certification Request Form as directed by the MP.

Prior Authorization

HCPCS / J / Q code prior authorization requirements

Certain HCPCS, J- and Q-codes require prior authorization for Medicare HMO Blue and Medicare PPO Blue. Check the Commercial and Medicare Policy Directory code lists and the MP references (e.g., MP 900, MP 954/957) for full code lists and submission instructions.

Examples of HCPCS/J/Q codes requiring PA for Medicare products include (not exhaustive): C9257; J0178; J0179; J0881; J0882; J0885; J0887; J0888; J0897; J1442; J1447; J1745; J2503; J2778; J7318–J7332 series; J9035; J9312; J9355; Q4081; Q5103–Q5121 series; Q2055, Q2056.
Advanced Imaging/Radiology CPT and HCPCS codes (MP 900) require prior authorization through Carelon for Medicare Advantage products.
Carelon Genetic Testing Management Program (MP 954/957) — prior authorization through Carelon is required for molecular genetic tests for Medicare Advantage effective 1/1/2025; see MP 957 for CPT/HCPCS code lists used by Carelon.
Some specialty drug and therapy codes also require PA and may have dedicated PA request forms (see MP listings).

Note

Removal of prior authorization requirement

Prior authorization requirements can be removed or changed by policy updates. Providers should note recent removals to avoid unnecessary PA submissions.

Example: Prior authorization was removed for MP 543 Negative Pressure Wound Therapy in the Outpatient Setting effective 11/1/2024 — do not submit PA for MP 543 after that effective date.
Effective January 1, 2025, utilization management of molecular genetic testing for Medicare Advantage was delegated to Carelon and requires prior authorization through Carelon (see MP 954/957).

ScopeUtilization management and prior authorization of molecular genetic testing for Medicare Advantage products per Carelon Clinical Guidelines

inv-49: medical necessity — definition/reference within policy

DefinitionMedical necessity: services are reviewed to determine if they meet plan medical necessity requirements; claims payment is based on eligibility, benefit availability, and medical necessity.

Review implicationsAll covered services, even those not requiring authorization, may be audited or retrospectively reviewed for medical necessity.

Submission recommendationSubmit authorization requests electronically; retain supporting documentation for potential review.

inv-50: residence — member's residence definition (place where member makes their home and dwells permanently or for extended period)

DefinitionA member's 'residence' is the place where he or she makes their home and dwells permanently, or for an extended period of time.

UsageMember residence determines the MAC jurisdiction for applicable LCDs used in coverage determinations.

ContextReferenced in ambulance and other MP rules where residence-based criteria apply.

inv-51: residence definition repeated — place where member makes their home and dwells permanently or for an extended period

Definition (repeat)Member's 'residence' is defined as the place where he or she makes their home and dwells permanently, or for an extended period of time.

RelevanceUsed to determine applicable LCDs and certain prior authorization rules (e.g., non-emergent ambulance transports).

NoteAppears verbatim in the directory guidance for ambulance and other MPs.

inv-52: Outpatient Prior Authorization — directory designation definitions (required / not required / inpatient / not covered)

DefinitionOutpatient Prior Authorization: directory designation indicating whether prior authorization is required, not required, the service is not covered, or is inpatient-only for the specified MP entry.

FormsUse Massachusetts Collaborative Prior Authorization Form or BCBSMA Pre-certification Request Form when required; some therapies have specific request forms.

ApplicationEach MP entry lists the Outpatient Prior Authorization designation for Medicare Advantage products (HMO/PPO) and any product-specific rules.

inv-53: NCD/LCD — National Coverage Determination or Local Coverage Determination and how BCBSMA references them

DefinitionNCD/LCD: National Coverage Determination (NCD) or Local Coverage Determination (LCD) cited alongside BCBSMA policy guidance to indicate which external CMS determinations apply to a Medical Policy (MP).

HierarchyIf an NCD exists, BCBSMA follows the NCD; if an LCD exists for the member's MAC jurisdiction, BCBSMA follows the LCD; when no LCD exists, BCBSMA medical policies or MolDX LCDs are followed as applicable.

MolDX noteFor molecular diagnostics, Palmetto GBA MolDX LCDs are followed when no jurisdictional MolDX LCD exists.

inv-54: Outpatient Prior Authorization status — statuses shown and meaning

Status listOutpatient Prior Authorization statuses include: 'Prior authorization is required', 'Prior authorization is not required', 'This is not a covered service', and 'This procedure is performed in the inpatient setting.'

InterpretationEach MP entry displays one of these statuses to indicate PA expectations for Medicare Advantage products.

Product-specificitySome statuses differ by product (e.g., Medicare HMO Blue vs Medicare PPO Blue); check MP entry for product-specific designation.

inv-55: Carelon — Carelon prior authorization reference

ReferenceCarelon is the external prior authorization vendor referenced for Medicare Advantage prior authorization processing (Carelon Medical Benefits Management).

Use casesCarelon handles prior authorization for Advanced Imaging/Radiology CPT/HCPCS codes and other MPs (e.g., MP 900, MP 923, MP 937, MP 938).

SubmissionRequests may be submitted via Carelon per instructions in the directory; some MPs reference Carelon-specific request forms.

inv-56: Gender-affirming surgery priors — definition/context for code lists requiring PA

ContextGender-affirming surgical CPT code lists require prior authorization for Medicare HMO Blue and Medicare PPO Blue.

ScopeExtensive lists of CPT codes for chest, facial, and genital procedures are specified in the directory; providers must obtain PA when listed.

Product applicabilityApplies to both Medicare HMO Blue and Medicare PPO Blue as indicated in the MP entries.

inv-57: Delegation — high-level note about delegation to Carelon Medical Benefits Management

Delegation statementBCBSMA has delegated utilization management to Carelon Medical Benefits Management for specific services (e.g., molecular genetic testing) where noted.

Effective exampleDelegation for molecular genetic testing effective January 1, 2025; prior authorization must be obtained through Carelon for delegated services.

ImplicationProviders must follow Carelon Clinical Guidelines for utilization management of delegated services as specified in MP entries.

inv-58: prior authorization — generic definition/term reference

DefinitionPrior authorization: a process where authorization must be obtained before outpatient services are provided when an MP entry designates 'Prior authorization is required.'

Process guidanceDetermine if PA is required via the directory/MP entry or via Carelon; use Massachusetts Collaborative Prior Authorization Form or BCBSMA Pre-certification Request Form when applicable.

Claims implicationsEven if PA is not required, claims remain subject to eligibility, benefit availability, and medical necessity review and may be audited or reviewed retrospectively.

03/01/2025retirement

MP 110 Meniscal Allografts and Other Meniscal Implants retired effective 3/1/2025; coverage determined by InterQual.

04/01/2025addition

MP 140 Radiofrequency Volumetric Tissue Reduction for Nasal Obstruction (VivAer) and MP 188 Irreversible Electroporation of Tumors added; effective 4/1/2025.

04/01/2025revision

MP 035 Temporomandibular Joint Disorder clarified: CPT codes 21073 and 21116 removed and prior authorization is no longer required for those codes effective 4/1/2025.

05/01/2025retirement

Multiple policies retired (e.g., MP 065 Retinal Telescreening for Diabetic Retinopathy; MP 180 Endothelial Keratoplasty; MP 176 Surgical Left Atrial Appendage Occlusion Devices retired effective 5/1/2025).

09/01/2025note_update

MP 428 note added indicating prior authorization is not required for breast cancer–related diagnoses; effective 9/1/2025.

03/15/2026additionLatest

MP 224 Tonic Motor Activation for Restless Legs Syndrome added and HCPCS code J3403 added to MP 911; effective 3/1/2026 and J3403 effective 3/15/2026.

04/2021addition

Multiple policies added including MP 142 Air Ambulance Transport, MP 146 Ground Ambulance, MP 158 Outpatient Pediatric Pain Rehabilitation Centers, and MP 139 Diagnostic Laboratory Services; LCDs for minimally invasive GERD procedures and fluid jet system treatment for LUTS/BPH were added.

02/01/2021addition

Outpatient prior authorization required for Medicare Advantage for #077 Scenesse (afamelanotide) for treatment of erythropoietic protoporphyria effective 2/1/2021.

10/01/2020creation

New document created; effective 10/1/2020 (initial policy document release).

11/2020retirement

Multiple commercial policies retired (e.g., MP 343, MP 401, MP 638, MP 640, MP 654) as noted in late 2020 updates.

11/01/2020retirement

MP #639 Radioimmunoscintigraphy Imaging with Indium-111 Capromab Pendetide for Prostate Cancer retired and investigational HCPCS code A9507 added to MP 400.

For related read-with references, consult the BCBSMA policy directory entries that support outpatient prior authorization processes and code lists. See MP 072 — Outpatient Prior Authorization Code List for the full set of codes that require prior authorization for commercial plans and as a cross-reference for Medicare entries.

Refer to MP 400 — Medical Technology Assessment Non‑Covered Services List for codes and technologies identified as not covered and to MP 350 — Medical Technology Assessment Guidelines for analytic approach and assessment criteria used in coverage determinations.

For musculoskeletal coding and clinical guidance, see MP 220 — Musculoskeletal Services Management and MP 221 — Musculoskeletal Services Management CPT and HCPCS Codes (code‑level mappings and facility/procedure guidance).

Utilization management and delegated genetic testing oversight are detailed in the Carelon program materials: MP 954 — Carelon Genetic Testing Management Program and MP 957 — Carelon Genetic Testing Management Program CPT and HCPCS Codes; note that Carelon is the delegated UM vendor for molecular genetic testing effective 1/1/2025 and prior authorization through Carelon is required for those tests.

Additional cross-references include MP 072, MP 400, MP 220, MP 221, MP 350, MP 954, and MP 957 which should be used in conjunction with this policy when determining prior authorization requirements, coverage status, or when referencing code‑specific guidance in the outpatient prior authorization directory.