CurrentBlue Cross Blue Shield - MassachusettsPolicy 125

Medicare Advantage Part B Medical Utilization Management

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Governs preservice authorization, medical necessity criteria, and HCPCS coding guidance for Medicare Advantage Part B drugs, biologics, immune globulins, botulinum toxins, select devices and supplies for Blue Cross Blue Shield of Massachusetts Medicare HMO and PPO members.

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CurrentBlue Cross Blue Shield - MassachusettsPolicy 125

Medicare Advantage Part B Medical Utilization Management

Customize your policy alerts

Sign up for Blue Cross Blue Shield - Massachusetts Policy 125 alerts

Get alerted when Policy 125 changes without checking for updates manually.

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Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyMedicare Advantage Part B Medical Utilization Management

Policy CodePolicy 125

Change TypeAdded diabetic suppliesremoved Aduhelmadded HCPCS J0174

Effective Date

Next Review Date

Key ActionSubmit a preservice authorization form or call Pharmacy Operations for Part B medications administered in outpatient, home infusion, or home settings.

SourceLink

POLICY UPDATE CHANGES

Policy updated to include Diabetic Glucose Monitors and Supplies.

Policy updated to remove Aduhelm (aducanumab-avwa) from the policy.

HCPCS code J0174 assigned for lecanemab-irmb (Leqembi) included in policy.

~40+listed drugs, biologics and devices in table of covered items

MultipleHCPCS codes listed for Part B medications and immune globulins

RequiredPreservice authorization for outpatient/office/home infusion settings

Preferred vs Non-preferredDevice coverage distinction for diabetic glucose monitors/supplies

Coverage and Medical Necessity Criteria

Medical necessity basis

Covered when following CMS or FDA-based criteria are met.

General criteria: Coverage and medical necessity will follow CMS National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) when available; in the absence of CMS guidance, criteria will follow the medically accepted indication supported by FDA labeling and Medicare‑approved medical references.

From Prior Authorization Information and NCD/LCD guidance

Diabetic glucose monitors and supplies coverage

Coverage depends on preferred status and documented prior use.

Preferred devices/supplies will be covered without a preservice authorization.

Preferred devices listed in document

Non-preferred devices

Evidence of prior use: There must be evidence of a BCBSMA claim OR prescriber‑documented use of two preferred devices/supplies.
Documentation requirement
Indication requirement: The device must be used for a medically accepted indication supported by FDA labeling or Medicare‑approved medical references.
Clinical indication must align with FDA/Medicare references

Preservice authorization is not required when medications are administered in inpatient settings, urgent care centers, and the emergency department. Preservice authorization is required, however, for medications billed under the member’s medical benefit when administered in outpatient settings such as a clinician/physician office, home infusion providers, home health care, outpatient hospital (including dialysis), and surgical day settings. Prescribers may submit relevant clinical information to Blue Cross Blue Shield of Massachusetts Pharmacy Operations as noted in the policy.

Aduhelm (aducanumab-avwa) was removed from this policy effective 3/1/2024. The policy history notes Biogen's discontinuation of Aduhelm on January 31, 2024, and documents the policy change reflecting removal of the product from coverage guidance.

Applicable HCPCS/Coding and Quantity Limits

Applicable HCPCS Codes (excerpt 1)HCPCS

J0585	Injection, onabotulinumtoxinA unit
J0586	Injection, abobotulinumtoxinA 5 Units
J0587
J0588	Injection, incobotulinumtoxinA unit
J2357	Injection, omalizumab, 5 mg
J2182	Injection, mepolizumab 1 mg
J0517	Injection, benralizumab; 1 mg
J2786	Injection, reslizumab
J2350	Injection, ocrelizumab; 1 mg
J3380	Injection, vedolizumab 1 mg

1–10 of 21

1/3

Applicable HCPCS Codes (excerpt 2)HCPCS

J1559	Injection, immune globulin (hizentra)
J1560	Injection, immune globulin over 10 CC
J1561	Injection, immune globulin 500 mg
J1562	Injection, immune globulin (vivaglobin) 100 mg
J1568	Injection, 500 mg
J2791	Injection, rho(d) immune globulin (Rhophylac), 100 IU
J0174	Injection, lecanemab-irmb (Leqembi) intravenous
J0175	Injection, donanemab-azbt
J2323	Injection, natalizumab; 1 mg
J2329	Injection of ublituximab

inv-07: Blood glucose test strips quantity limit

Quantity limit — non-insulin users100 blood glucose test strips per 90 days

Quantity limit — insulin users400 blood glucose test strips per 90 days

Unit and periodMeasured in strips per 90-day period

inv-16: Blood glucose test strips — quantity summary

Preferred vs non-preferred summaryPreferred diabetic glucose devices/supplies are covered without preservice authorization; non-preferred may be covered with evidence of BCBSMA claim or prescriber-documented use of two preferred devices and FDA/Medicare-supported indication

Preferred devices examples

Prescriber and Provider Requirements

Prior Authorization

Obtain preservice authorization for Part B drugs in outpatient/home settings

Preservice authorization is required for Part B medications administered using a member's medical benefit in outpatient settings including clinician/physician office, home infusion therapy provider, home health care provider, outpatient hospital and dialysis settings, and surgical care day. Inpatient, urgent care center, and emergency department settings are not subject to this preservice authorization requirement.

Submit requests using the preservice authorization form or call Pharmacy Operations at (800) 366-7778.
Preservice authorization applies when medications are billed under the member's medical benefit in the listed outpatient/home settings.

Step Therapy

Document use of two preferred devices before non-preferred diabetic supplies covered

Before BCBSMA will cover a non-preferred diabetic glucose device or supply, the request must document prior use of two Preferred devices/supplies; preferred devices are covered without preservice authorization.

Initial Authorization Rules

Initial therapy authorization

Initial authorization follows CMS NCD/LCD guidance or, when absent, FDA labeling and Medicare‑approved references.

Initial authorization: Medical necessity for initial therapy will follow CMS NCDs/LCDs when available; otherwise FDA labeling and Medicare‑approved medical references determine criteria.

General instruction from Prior Authorization Information

Step Therapy Requirements for Diabetic Supplies

Step	Requirement	Coverage status
1
Documented use of two Preferred devices/supplies or evidence of a BCBSMA claim showing such use is required before covering Non-preferred diabetic glucose devices/supplies.
Covered with criteria

Site-of-Care Preservice Authorization

Prior Authorization

Preservice authorization required for outpatient, home infusion, and ambulatory settings

Preservice authorization is required when medications are administered in outpatient settings billed to the medical benefit, including physician office, home infusion, home health, outpatient hospital, dialysis, and surgical day settings.

Preservice authorization is not required for inpatient, urgent care center, or emergency department settings.
Requests may be submitted using the preservice authorization form or by phone to Pharmacy Operations.

Policy Background and Scope

Medical necessity determinations in this policy follow CMS National and Local Coverage Determinations (NCDs/LCDs) and associated CMS guidance when available. In the absence of CMS guidance, medical necessity criteria default to FDA labeling and other Medicare‑approved medical references to define covered indications and requirements for Part B drugs, biologics, devices, and supplies.

Definitions and Basis for Coverage

inv-13: Medical necessity basis (definitions)

Primary guidanceCoverage and medical necessity follow CMS National and Local Coverage Determinations (NCDs/LCDs) when available

Secondary guidanceIn the absence of applicable CMS guidance, criteria follow FDA labeling and medically accepted references approved by Medicare

ApplicationThis approach applies to Part B drugs, biologics, devices and supplies referenced in the policy (e.g., diabetic glucose monitors and supplies)

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyMedicare Advantage Part B Medical Utilization Management

Policy CodePolicy 125

Change TypeAdded diabetic suppliesremoved Aduhelmadded HCPCS J0174

Effective Date

Next Review Date

Key ActionSubmit a preservice authorization form or call Pharmacy Operations for Part B medications administered in outpatient, home infusion, or home settings.

SourceLink

On This Page

OneTouch Ultra, OneTouch Verio, Freestyle Freedom, Freestyle Lite, Precision Neo (see device list in policy)

Test strip quantity summary100 strips per 90 days (non-insulin users) ; 400 strips per 90 days (insulin users)

Preferred devices/supplies will be covered without a preservice authorization.
Non-preferred items require evidence of prior use of two Preferred devices/supplies.

Documentation Required

Submit preservice authorization form or call Pharmacy Operations and provide clinical documentation

Prescribers must submit preservice authorization requests by completing the preservice authorization form on the last page of the document or by calling BCBSMA Pharmacy Operations; relevant clinical information may be sent to BCBSMA Pharmacy Operations at the address provided.

Complete the preservice authorization form included with the policy or call Pharmacy Operations at (800) 366-7778 to request authorization verbally.
Send supporting clinical documentation to: Blue Cross Blue Shield of Massachusetts, Pharmacy Operations Department, 25 Technology Place, Hingham, MA 02043.

Denial Risk

Denials possible for non-preferred devices without evidence of prior use

Requests for non-preferred diabetic glucose devices/supplies may be denied unless there is evidence of a BCBSMA claim or prescriber-documented use of two Preferred devices/supplies.

Ensure submitted documentation clearly shows prior use of two Preferred devices or a BCBSMA claim documenting such use to avoid denial.