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    v1.0.28
    OpenPayerPolicy UpdatesCardiologyBlue Cross Blue Shield MA Cardiology Policy Update…
    Ask Trek AI about this page
    CurrentBlue Cross Blue Shield - MassachusettsPolicy N/A

    Cardiology and Pulmonology Medical Policy Group — Coverage Criteria Summary and Updates

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    Governance and update summary for BCBSMA Cardiology and Pulmonology medical policies, listing policies with recent coverage changes, those without updates, and administrative notes for providers and stakeholders.

    Policy Summary
    PayerBlue Cross Blue Shield - Massachusetts
    PolicyCardiology and Pulmonology Medical Policy Group — Coverage Criteria Summary and Updates
    Policy CodePolicy N/A
    Change TypeMixed clinical and administrative updates
    Effective DateMar 15, 2026
    Last ReviewMar 27, 2025
    Next Review DateN/A
    Key ActionObtain prior authorization for specified outpatient procedures and medications per the Outpatient Prior Authorization Code List.
    SourceLink
    POLICY UPDATE CHANGES

    Leadless Cardiac Pacemakers policy updated with literature review; medically necessary statements added for Aveir DR, Micra, and Aveir single- and dual-chamber systems where individuals are medically eligible for a conventional pacing system.

    Codes 0440T, 0441T, 0442T will be removed from MP #221 and considered investigational effective September 1, 2025.

    Baroreflex stimulation therapy for treatment-resistant hypertension removed as device is no longer marketed for this indication.

    Added expanded FDA indication for Tezspire.

    Added expanded indication for Repatha and updated formatting and references.

    ~30+policies with no coverage updates
    Mar 27, 2025literature review through

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    3/15/2026policy effective date

    Coverage Criteria and Policy Changes

    Leadless Cardiac Pacemakers - Medically Necessary

    Medically necessary statements were added for leadless cardiac pacing systems when ALL of the following are met:

    Leadless pacing medical necessity: Medically necessary for Micra and Aveir single-chamber transcatheter pacing systems and Aveir DR dual-chamber leadless pacing system for individuals who are medically eligible for a conventional pacing system

    Based on structured clinical input and literature review through March 27, 2025

    Renal Sympathetic Nerve Ablation

    Policy revised statements:

    Renal nerve ablation: Radiofrequency ablation of the renal sympathetic nerves is medically necessary for treatment-resistant hypertension

    Ultrasound ablation of renal sympathetic nerves noted separately

    Baroreflex stimulation therapy for individuals with treatment‑resistant hypertension has been removed from the policy because the device is no longer marketed for this indication.

    Effective September 1, 2025, CPT codes 0440T, 0441T, and 0442T will be considered investigational and therefore not covered; these codes are being removed from MP #221.

    Coding and Billing

    Codes removed / considered investigationalCPTNot Covered
    0440TCode removed from MP #221 and considered investigational effective September 1, 2025
    0441TCode removed from MP #221 and considered investigational effective September 1, 2025
    0442TCode removed from MP #221 and considered investigational effective September 1, 2025
    Outpatient Prior Authorization Code Listmixed
    No codes listed
    Med UM Drug List (medications requiring prior authorization under medical benefits)mixed
    No codes listed

    Provider Actions and Authorization Requirements

    Prior Authorization

    Obtain prior authorization for specified outpatient procedures and medications

    Certain outpatient procedures and medications administered in the outpatient setting require prior authorization as specified in the Outpatient Prior Authorization Code List and MED UM Drug List; submit authorization requests per BCBSMA outpatient prior authorization processes before scheduling or administering these services.

    • See Outpatient Prior Authorization Code List (072) for outpatient procedure codes requiring authorization
    • See MED UM Drug List (034) for medications requiring authorization under medical benefits
    Denial Risk

    Prior authorization required — risk of denial if not obtained

    Certain outpatient procedure codes require prior authorization per the Outpatient Prior Authorization Code List; failure to obtain required prior authorization may result in claim denial or retrospective payment denial.

    Background and Scope

    This document is an administrative summary from the Cardiology and Pulmonology Medical Policy Group listing recent policy updates, reviews, and administrative notes. It records literature review activity through March 27, 2025 and documents specific policy changes such as removal of baroreflex stimulation therapy for treatment‑resistant hypertension because the device is no longer marketed, and the reclassification of CPT codes 0440T, 0441T, and 0442T as investigational effective September 1, 2025.

    Definitions and Key Terms

    Medically necessary statement (leadless pacing)
    ApplicabilityMedically necessary statements for leadless pacing systems apply to individuals who are medically eligible for a conventional pacing system.
    Covered devices namedMicra and Aveir single‑chamber transcatheter pacing systems, and Aveir DR dual‑chamber leadless pacing system.
    Basis for criteriaMedical necessity criteria were based on responses to structured requests for clinical input and literature review through March 27, 2025.
    Effective dateEffective 11/1/2025 (policy updated with literature review through March 27, 2025).
    Scope of changeMedically necessary statements added for Aveir DR, Micra, and Aveir single‑ and dual‑chamber systems; minor refinements made to other policy statements with intent unchanged.
    Policy Summary
    PayerBlue Cross Blue Shield - Massachusetts
    PolicyCardiology and Pulmonology Medical Policy Group — Coverage Criteria Summary and Updates
    Policy CodePolicy N/A
    Change TypeMixed clinical and administrative updates
    Effective DateMar 15, 2026
    Last ReviewMar 27, 2025
    Next Review DateN/A
    Key ActionObtain prior authorization for specified outpatient procedures and medications per the Outpatient Prior Authorization Code List.
    SourceLink
    On This Page
    Coverage Criteria and Policy ChangesCoding and BillingProvider Actions and Authorization RequirementsBackground and ScopeDefinitions and Key Terms
    • Confirm whether the outpatient procedure code is listed on the Outpatient Prior Authorization Code List (072) prior to service
    • If prior authorization is not obtained when required, the claim may be denied
    Documentation Required

    Contact and reference lists for authorization and documentation

    For Medical Policy Group meeting information or questions about these policies, contact ebr@bcbsma.com. Refer to the Outpatient Prior Authorization Code List (072) and the MED UM Drug List (034) for applicable procedure and drug authorization requirements when preparing documentation for prior authorization requests.

    • Email ebr@bcbsma.com for Medical Policy Group meeting information
    • Reference Outpatient Prior Authorization Code List (072) and MED UM Drug List (034) for authorization requirements
    Prior Authorization

    Verify prior authorization requirement for outpatient procedure codes

    Prior authorization is required for certain outpatient procedure codes as identified in the Outpatient Prior Authorization Code List; verify code-level requirements before performing outpatient procedures to ensure coverage.

    • Check the Outpatient Prior Authorization Code List (072) to determine if the procedure code requires prior authorization
    • Obtain prior authorization per BCBSMA processes when a code is listed