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Billing chart: Updates to payable procedures, policy clarifications, and experimental determinations

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Summarizes recent updates, clarifications, and classifications for procedure codes and related Blue Cross Blue Shield of Michigan billing and medical policy guidelines; intended for providers submitting claims and verifying coverage criteria.

Policy Summary

PayerBlue Cross Blue Shield - Michigan

PolicyBilling chart: Updates to payable procedures, policy clarifications, and experimental determinations

Policy CodePolicy N/A

Change TypeMultiple material updates to coverage criteria, coding, and prior authorization requirements

Effective Datevarious (examples: Feb 1, 2025; June 1, 2025; July 1, 2025)

Next Review DateN/A

Key ActionObtain and document required prior authorization and indication-specific clinical documentation (e.g., prior bisphosphonate trial for denosumab; CPAP failure for hypoglossal stimulation).

SourceLink

POLICY UPDATE CHANGES

Medical policy statements and inclusion/exclusion criteria were updated for multiple procedures (examples: low-level laser therapy, histotripsy of the liver, panniculectomy, hypoglossal nerve stimulation, allogeneic HCT, bariatric surgery).

Codes *0648T and *0649T were designated experimental for noninvasive evaluation/monitoring of chronic liver disease.

Histotripsy of the liver (0686T) considered established for certain malignant liver tumors when specific clinical criteria are met.

Low-level laser therapy deemed established for select indications; high-power laser therapy remains experimental and exclusions list expanded.

Intraoperative margin assessment technologies (e.g., MarginProbe, LumiSystem) are considered experimental/investigational for breast-conserving surgery.

The medical policy statement and exclusionary criteria for vagus nerve stimulation were updated, effective July 1, 2025.

Inclusionary and exclusionary criteria for MRI of the breast were updated, effective July 1, 2025.

Wireless capsule endoscopy policy, including exclusions (patency capsule and magnetically controlled capsule), was updated, effective July 1, 2025.

Inclusionary and exclusionary criteria for sleep disorder diagnosis and non-surgical OSA treatments were updated, effective July 1, 2025.

Medical policy statements and inclusion/exclusion criteria have been updated effective July 1, 2025 for enteral nutrition and total parenteral nutrition.

Several drugs and biologics (Soliris for pediatric gMG, Omvoh for Crohn's disease, Conexxence and other denosumab products) were added/updated with coverage statements and dosing.

Digital health technologies list updated; specific products (Freespira, NightWare, RelieVRx, Stanza) are considered experimental/investigational.

Magnetic pelvic floor stimulation therapies (including Flyte system) are considered experimental/investigational and Flyte specifically excluded effective July 1, 2025.

Evolysse HA gel products are not considered a covered benefit effective Feb. 20, 2025.

Xbryk (denosumab-dssb) is considered established when criteria are met, effective Feb. 13, 2025.

Coverage criteria for Xgeva/Xgeva biosimilars, Prolia/Prolia biosimilars updated with indication-specific requirements and trial/failure of IV bisphosphonate or bisphosphonate intolerance.

Zevaskyn (prademagene zamikeracel) is covered for its FDA-approved indications effective April 29, 2025 with specific dosing and administration details.

Daratumumab (Darzalex) approved for off-label use to treat other encephalitis and encephalomyelitis effective Feb. 1, 2024.

Tislelizumab (Tevimbra) payable for new FDA-updated indications including first-line ESCC in combination with platinum chemotherapy effective March 4, 2025.

Fam-trastuzumab deruxtecan (Enhertu) payable for updated indications including HR-positive, HER2-low/ultralow breast cancer effective Jan. 28, 2025 and approved off-label payments for selected malignancy sites.

Tocilizumab-aazg (Tyenne) payable for updated FDA-approved indications including CAR T cell–induced CRS and hospitalized COVID-19 with specified respiratory support.

multipleprocedure codes listed or updated in this chart

3examples with new effective dates noted

>=1procedures reclassified experimental/investigational

severaldetailed clinical criteria added/updated

July 1, 2025common effective date for many updates

Coverage Criteria and Clinical Indications

Histotripsy — Established Indications

Covered when ALL of the following are met

Histotripsy inclusion criteria: Histotripsy treatment of primary or metastatic liver tumors may be considered established when a multidisciplinary group has evaluated and documented that recurrent or persistent liver tumors have not responded to other available therapies (surgery, chemotherapy, radiation therapy or other locoregional/ablative therapies) and continuation of those treatments would pose an unacceptable risk; AND patient is at least 18 years of age; AND ECOG performance status 0–2; AND tumor longest diameter is ≤3 cm; AND no more than three tumors are targeted for treatment.as stated

Requires documentation of multidisciplinary evaluation

Hypoglossal nerve stimulation (adult)

Covered when ALL of the following are met

Adult hypoglossal nerve stimulation criteria: Individual is ≥18 years of age; AND apnea–hypopnea index (AHI) is ≥15 and ≤100 events/hour; AND total number of central apneas is ≤25% of total AHI; AND documented failure of, or intolerance to, CPAP despite attempts to improve compliance (CPAP failure defined per policy); AND non‑concentric retropalatal obstruction on drug‑induced sleep endoscopy (DISE) or equivalent confirmation as described; AND body mass index (BMI) ≤35 kg/m2; AND the diagnostic sleep study used to document AHI was performed within 24 months of the first consultation.

Policy Summary

PayerBlue Cross Blue Shield - Michigan

PolicyBilling chart: Updates to payable procedures, policy clarifications, and experimental determinations

Policy CodePolicy N/A

Change TypeMultiple material updates to coverage criteria, coding, and prior authorization requirements

Effective Datevarious (examples: Feb 1, 2025; June 1, 2025; July 1, 2025)

Next Review DateN/A

Key ActionObtain and document required prior authorization and indication-specific clinical documentation (e.g., prior bisphosphonate trial for denosumab; CPAP failure for hypoglossal stimulation).

SourceLink

On This Page

CPAP failure definition provided in policy (residual AHI ≥15 despite CPAP use or failure to use CPAP ≥4 hrs/night for ≥5 nights/week)

Hypoglossal nerve stimulation (Down syndrome youth)

Covered when ALL of the following are met

Down syndrome hypoglossal stimulation criteria: Individual age 13–21 years; AND prior adenotonsillectomy or documented contraindication to adenotonsillectomy, AND AHI >10 and <50 with total central and mixed apneas <25% of total AHI; AND one of the following: prior tracheostomy OR ineffective CPAP due to noncompliance, discomfort, persistent symptoms despite compliant use, or refusal to use device; AND BMI at or below the 95th percentile for age; AND non‑concentric retropalatal obstruction on DISE (DISE may be performed at implantation if prior in‑office exam suggests AP velum collapse).as stated

DISE is established to evaluate appropriateness of FDA‑approved hypoglossal nerve stimulation when other criteria are met

Low-Level Laser Therapy (LLLT)

Covered when ANY of the following are met

LLLT inclusions: Low‑level laser therapy (LLLT) is established when used for prevention of oral mucositis in individuals undergoing therapies associated with increased risk of oral mucositis, including chemotherapy, radiotherapy, or hematopoietic stem cell transplantation.as stated

High‑power (nonsurgical) laser therapy is considered experimental; LLLT is excluded for other listed indications (eg, musculoskeletal pain, wound healing, lymphedema, etc.)

Panniculectomy — Reconstructive criteria

Covered when ALL of the following are met (either pathway)

Panniculectomy pathway A: Individual has documented massive weight loss ≥100 pounds from bariatric surgery or dieting; AND a panniculus that hangs below the level of the pubis; AND at least six months have elapsed to ensure maximum weight loss and weight stability; AND the panniculus causes uncontrolled intertrigo unresponsive to conservative therapy, skin ulceration, skin necrosis or peau d'orange.as stated

Alternative pathway B allows coverage when panniculus hangs below pubis and causes uncontrolled intertrigo, ulceration or other specified skin changes without requirement for documented 100‑lb loss

Allogeneic Hematopoietic Cell Transplantation

Covered for selected indications as listed below

Allogeneic HCT categories: Allogeneic hematopoietic cell transplantation is established for selected diseases, including hemoglobinopathies (eg, sickle cell anemia, homozygous beta‑thalassemia), bone marrow failure syndromes (eg, aplastic anemia, hereditary and acquired forms), primary immunodeficiencies (multiple listed T‑cell, NK‑cell and neutrophil disorders and examples), inherited metabolic diseases (selected lysosomal and peroxisomal storage disorders except listed exclusions), and genetic disorders affecting skeletal tissue (examples such as infantile malignant osteopetrosis); conditioning regimens and eligibility are determined by the treating transplant center.disease‑specific

Condition‑specific eligibility, conditioning intensity and repeat transplant criteria described by disease in policy

Bariatric surgery — Coverage criteria

Covered when ALL of the following are met

Bariatric surgery criteria: Individual meets BMI thresholds per policy (eg, BMI ≥40 kg/m2 [≥37.5 kg/m2 for Asian population], OR BMI 35–39.9 kg/m2 [≥32.5 kg/m2 Asian] with one or more comorbidities, OR BMI 30–34.9 kg/m2 with type 2 diabetes [≥27.5 kg/m2 Asian]); AND age criteria met (generally 18–60 years with consideration >60 when physiologic age appropriate; pediatric criteria specified); AND multidisciplinary evaluation by an established bariatric program (medical, nutritional and mental health assessments) with documentation of prior participation in non‑surgical weight loss program; additional procedure‑specific criteria and exclusions apply.as stated

Some procedures (eg, long‑limb gastric bypass >150 cm, certain endoscopic procedures) are considered experimental and excluded

MRI of the breast — Screening and High-risk Criteria

Annual MRI of the breast is established for screening as an adjunct to mammography in certain individuals when ALL of the following are met:

Extremely dense breasts screening: Individual is aged ≥50 years; AND current mammogram documents extremely dense breasts; AND the individual does not meet any other increased‑risk category.age >=50

Frequency of supplemental screening MRI may be updated in future

High‑risk indications for MRI: Individuals meeting high‑risk criteria such as LCIS, ALH, ADH; genetic predisposition (BRCA1/2, PTEN, TP53, ATM, PALB2, etc.); lifetime risk ≥20% by validated models; prior chest radiation between ages 10–30; and other specified high‑risk factors.lifetime risk >=20%

Use validated risk models (eg, BOADICEA/CanRisk, BRCAPRO, Tyrer‑Cuzick)

MRI of the breast — Diagnostic/Surveillance

MRI of the breast is established for diagnostic indications when ANY of the following are met:

Diagnostic indications: Single follow‑up MRI at 6 months after a breast MRI with BI‑RADS category 3 findings; OR differentiation of a palpable mass from surgical scar; OR lesion characterization when other imaging is inadequate to localize lesion for biopsy; OR evaluation for suspected breast origin of metastatic cancer or malignant axillary node when mammography is negative; OR evaluation of pathologic nipple discharge after nondiagnostic mammography/ultrasound; OR suspected implant‑associated anaplastic large cell lymphoma when ultrasound is nondiagnostic.6 months for BI‑RADS 3 follow‑up

Also used for presurgical planning and extent‑of‑disease evaluation

Wireless capsule endoscopy — Indications

Wireless capsule endoscopy of the small bowel is established when ANY of the following are met:

Capsule indications: Initial diagnosis in suspected Crohn's disease when conventional diagnostic tests (CT/MR enterography, small‑bowel follow‑through, upper and lower endoscopy) are nondiagnostic; OR evaluation in established Crohn's disease with unexpected change in course or response to treatment; OR assessment of extent/management of known Crohn's disease; OR evaluation for suspected small‑bowel bleeding after inconclusive upper and lower endoscopy; OR surveillance of small bowel in hereditary GI polyposis syndromes (eg, familial adenomatous polyposis, Peutz‑Jeghers).N/A

Patency capsule and magnetically controlled wireless capsule are considered experimental/investigational and excluded

Non-surgical treatment of OSA — Coverage criteria

Positive airway pressure devices and oral appliances are established when specified clinical criteria are met:

APAP/CPAP/BiPAP coverage: APAP and CPAP are established for titration and treatment in adults with clinically significant OSA (defined as AHI/RDI/REI ≥15 events/hour, or ≥5 events/hour with one or more OSA‑related symptoms); BiPAP/APAP established for individuals who failed CPAP or when bilevel therapy is more effective.AHI/RDI/REI >=15 or >=5 with symptoms

No fixed weight‑change threshold for re‑titration

Oral appliance coverage: Diagnosis of OSA per thresholds AND a trial of CPAP has failed, is not tolerated, or is contraindicated; AND device is prescribed by a physician; AND device is custom‑fitted by a dentist (preferably with dental sleep medicine training); AND dental evaluation documents absence of temporomandibular dysfunction and periodontal disease.device custom‑fitted; RUL 5 years

Impressions, fabrication and adjustments included and not separately billable for first 90 days

Vagus nerve stimulation — Indications and exclusions

Implantable vagus nerve stimulators are established when criteria are met; nonimplantable transcutaneous devices and integrated neurostimulation systems are experimental.

Seizure indication: Implantable vagus nerve stimulation is established for seizures that are refractory to medical treatment (medically refractory defined as seizures despite therapeutic antiepileptic drug levels or inability to use such drugs due to intolerable adverse events).refractory seizures

Transcutaneous (nonimplantable) devices and integrated vagus nerve neurostimulation systems are considered experimental/investigational and excluded

Molecular testing in malignant gliomas

MGMT promoter methylation, IDH1/IDH2, 1p/19q co‑deletion, TERT and ATRX testing are established when used for malignant gliomas meeting specified criteria:

MGMT testing: MGMT promoter methylation analysis is established when tumor is consistent with high‑grade malignant glioma (eg, glioblastoma, anaplastic astrocytoma) and the patient is a candidate for temozolomide or radiation and results will direct therapy choices.N/A

Malignant gliomas include oligodendroglioma, astrocytoma, glioblastoma

IDH/1p19q/TERT/ATRX testing: IDH1/IDH2 mutation testing, 1p/19q co‑deletion, TERT and ATRX testing are established when tumor type is consistent with malignant glioma and used for diagnostic workup, staging, treatment selection and prognosis; 1p/19q co‑deletion testing is required at diagnosis and at recurrence/progression when indicated.N/A

Testing supports diagnostic classification and treatment decisions

Enteral nutrition

Covered when ALL of the following are met

Enteral nutrition inclusion: Medical record documents impairment that is long‑term or 'permanent' (ordinarily at least three months) as substantiated by physician; AND individual requires tube feedings to provide sufficient nutrients to maintain weight and strength due to dysfunction of structures permitting food to reach the small bowel or disease of the small bowel impairing digestion/absorption; AND a nutritional prescription is present in the medical record;

If criteria met, tube feeding supplies are covered; feeding pump requests require documentation of medical necessity

Total parenteral nutrition

Covered when ALL of the following are met

TPN inclusion: Individual can receive no more than 30% of caloric needs orally OR cannot benefit from tube feedings because of a malabsorptive disorder; AND nutrients and manner of administration must be specifically ordered by a physician and pre‑approved on an individual basis; AND diagnosis is consistent with listed conditions (eg, Crohn's disease, obstruction, short bowel syndrome, severe malabsorption, motility disorders, neonatal catastrophic GI anomalies, prolonged paralytic ileus).<=30% oral calories

TPN not covered for short‑term needs (<2 weeks), routine pre/postoperative care, or if providing ≤750 calories/day via TPN

Obstructive sleep apnea (OSA) devices

Coverage stance and clinical guidance

OSA device guidance: CPAP is more effective than oral appliances overall, particularly in severe OSA; individuals with severe OSA should have an initial CPAP trial and reasonable attempts to continue CPAP before switching to an oral appliance; oral appliances must meet device criteria (custom‑fabricated, mechanism advances mandible in ≤1 mm increments with protrusive range ≥5 mm, reversible, verifiable setting, adequate retention) to be considered; exclusions and experimental items (eg, prefabricated devices, PAP‑NAP, neuromuscular tongue stimulation, sleep positioning trainers) are specified.

Replacement of oral appliance considered at 5‑year RUL or earlier if clinical change

Denosumab products (Xgeva/Prolia and biosimilars)

Coverage provided when indication-specific requirements are met

Denosumab SREs/giant cell tumor/HCM/osteoporosis: Denosumab products (Xgeva/Xgeva biosimilars, Prolia/Prolia biosimilars, Xbryk and related denosumab agents) are covered when indication‑specific criteria are met: for prevention of skeletal‑related events in multiple myeloma or bone metastases, documentation that at least one IV bisphosphonate has been ineffective, not tolerated or is contraindicated and NCCN category 1 preferred agent is documented; for giant cell tumor of bone, confirmed diagnosis with radiologic measurable disease and unresectable disease or surgery likely to cause severe morbidity; for hypercalcemia of malignancy refractory to bisphosphonates, diagnosis of HCM with albumin‑corrected serum calcium (CSC) documented (policy cites CSC ≥12 mg/dL) and bisphosphonate failure; for osteoporosis (Prolia), FDA‑approved diagnosis and trial/failure of at least one bisphosphonate unless intolerant/contraindicated; not to be used in combination with anabolic agents or bisphosphonates; biosimilars covered when criteria met; trial/failure of preferred products per BCBS/BCN drug list required.CSC >=12 mg/dL for HCM; FRAX thresholds for some osteoporosis indications

Quantity limits align with FDA dosing; initial auth and renewal criteria vary by indication

Autism spectrum disorder - ABA therapy

Covered when ALL of the following are met

Autism ABA therapy: Full diagnostic criteria for autism spectrum disorder per the most recent DSM are met; AND maladaptive behavior affects personal safety or significantly interferes with function; AND services provided in Michigan are by or supervised by specified licensed clinicians (Licensed Behavior Analyst, psychiatrist with appropriate training, licensed psychologist, or authorized provider); AND individualized interventions with defined target behaviors, objective baseline and progress measures, documented interventions, and transitional/discharge plans are present; telemedicine may be used when appropriateness criteria are met.

Exclusions include services not meeting diagnostic criteria, services supervised by clinicians not authorized to provide ABA in Michigan, and services that are the legal responsibility of schools

Denosumab (Xgeva, Prolia, Xbryk) coverage criteria

Coverage of denosumab products (Xgeva/Xgeva biosimilars, Prolia/Prolia biosimilars, and Xbryk) is provided when indication-specific criteria are met.

Denosumab product coverage categories: Includes prevention of skeletal‑related events in multiple myeloma or bone metastases (Xgeva/Xgeomimics) when IV bisphosphonate trial/failure or intolerance is documented; giant cell tumor of bone when confirmed and measurable and unresectable or surgery would cause severe morbidity; hypercalcemia of malignancy refractory to bisphosphonates when HCM diagnosis and CSC documented; osteoporosis (Prolia) when FDA‑approved diagnosis and bisphosphonate trial/failure unless intolerant/contraindicated; biosimilars and Xbryk covered under similar, indication‑specific criteria.

Each category has specific documentation, quantity limits, authorization and renewal criteria as described in policy

Prevention of skeletal‑related events (Xgeva): Documentation that at least one IV bisphosphonate has been ineffective, not tolerated or contraindicated; AND NCCN category 1 preferred agent documented for the specific oncologic diagnosis.

Giant cell tumor of bone (Xgeva): Confirmed giant cell tumor of bone and radiologic measurable disease (CT or MRI); AND bone is unresectable or surgical resection likely to cause severe morbidity.

Hypercalcemia of malignancy (Xgeva): Diagnosis of hypercalcemia secondary to malignancy AND albumin‑corrected serum calcium (CSC) documented (policy cites CSC ≥12 mg/dL) AND documentation that at least one IV bisphosphonate has been ineffective, not tolerated or contraindicated.CSC >=12 mg/dL

Exact numeric CSC requirement appears in policy

Osteoporosis (Prolia): FDA‑approved diagnosis AND trial and failure of at least one bisphosphonate (IV if oral intolerance) unless intolerant or contraindicated; AND not used in combination with anabolic bone agents or bisphosphonates; FRAX thresholds apply for some cancer‑therapy related indications (hip ≥3% or major ≥20%).FRAX hip >=3% or major >=20% where specified

Trial/failure of preferred products per BCBS/BCN drug list required

Zevaskyn (prademagene zamikeracel)

Zevaskyn is covered for its FDA‑approved indication in RDEB with specified manufacturing and application limits.

Zevaskyn coverage: Autologous topical gene‑modified cell sheet therapy for wounds in recessive dystrophic epidermolysis bullosa (RDEB) is covered when FDA‑approved indication met; dosing is based on wound surface area with one sheet = 41.25 cm2 and up to 12 sheets may be manufactured and supplied; verify patient identity prior to application.max 12 sheets

Sheets are single‑dose cellular sheets derived from patient's biopsies; document wound surface area to determine number of sheets

Other biologic/cell therapy payable indication updates

Payer‑approved payments or updated payable indications for several biologic agents.

Daratumumab (Darzalex): Daratumumab is approved for off‑label use to treat certain encephalitis and encephalomyelitis (effective Feb 1, 2024) per the payer update.

URMBT excluded from this change

Tislelizumab (Tevimbra) is payable for updated FDA indications including first‑line use in combination with platinum chemotherapy for unresectable or metastatic esophageal squamous cell carcinoma (effective March 4, 2025).

Enhertu (fam‑trastuzumab deruxtecan): Enhertu is payable for updated FDA indication for HR‑positive, HER2‑low/ultralow breast cancer after progression on endocrine therapy; Blue Cross approved select off‑label malignancy site payments (effective Jan 28, 2025).

URMBT excluded

Tocilizumab (Tyenne): Tocilizumab‑aazg (Tyenne) is payable for CAR T cell–induced cytokine release syndrome in patients ≥2 years and for hospitalized adult COVID‑19 patients receiving systemic corticosteroids and requiring supplemental oxygen or greater respiratory support (effective Feb 28, 2025).

URMBT excluded

This chart identifies multiple devices, procedures and technologies that Blue Cross Blue Shield of Michigan classifies as experimental/investigational or explicitly excluded from coverage. Examples called out in policy include: platelet-rich plasma (autologous platelet concentrate or gel) for wound healing; intraoperative surgical margin assessment systems for breast‑conserving surgery (for example, fluorescence imaging devices); certain high‑power laser therapies (nonsurgical) and many listed bariatric and endoscopic bariatric procedures (for example, mini/loop gastric bypass, biliopancreatic bypass without duodenal switch, long‑limb gastric bypass >150 cm, intragastric balloons, endoscopic gastroplasty). The document notes these items lack sufficient evidence to demonstrate improvement in net health outcomes and therefore may be denied as not supported by evidence.

Drug‑induced sleep endoscopy (DISE) is only considered established when used to assess candidacy for FDA‑approved hypoglossal nerve stimulation and only when all hypoglossal stimulation criteria are met. DISE performed for other indications is considered experimental/investigational and not a covered benefit.

The policy explicitly lists several surgical and endoluminal bariatric procedures and capsule technologies as experimental/investigational and excluded from coverage. Examples include the mini (loop) gastric bypass (Billroth II anastomosis), biliopancreatic bypass without duodenal switch, long‑limb gastric bypass procedures (>150 cm), laparoscopic gastric plication, and primary endoscopic bariatric procedures (eg, intragastric balloons, endoscopic gastroplasty, aspiration therapy). In the wireless capsule endoscopy section, the patency capsule (eg, Given AGILE™) and the magnetically controlled wireless capsule (eg, NaviCam®) are considered experimental/investigational and excluded.

Oral appliances are covered only when device and clinical criteria are met; the policy excludes several oral‑appliance‑related items. Exclusions include management of snoring without obstructive sleep apnea, prefabricated (non‑custom) devices such as over‑the‑counter mouth guards, and diagnostic/screening tests performed by a dentist (for example, questionnaires, pulse oximetry or laryngometry used as screening). Custom prescription and dental fitting requirements are emphasized for covered oral appliances.

Policy clarifications note that snoring without sleep apnea is excluded from coverage for OSA devices. In addition, CPAP/BiPAP/APAP devices or intraoral appliances that do not meet the specified device and clinical criteria are considered experimental/investigational and not covered. The policy also lists several device categories as experimental, including palate/mandible expansion devices, nasal EPAP, oral pressure therapy, neuromuscular tongue stimulation, and sleep positioning trainers with vibration.

Evolysse Smooth and Evolysse Form (hyaluronic acid gel products) are explicitly identified as not a covered benefit effective Feb. 20, 2025.

The document repeats a payer position for several specialty drugs and biologics stating "This drug isn't a benefit for URMBT." This language appears alongside entries for Xbryk (denosumab‑dssb), Zevaskyn, daratumumab (Darzalex), Enhertu and Tyenne, indicating the exclusion of URMBT for these products in the listed entries.

Hypoglossal nerve stimulation is covered only when all inclusion criteria are satisfied (for example, age, AHI thresholds, BMI, CPAP failure/intolerance and DISE findings). When an individual does not meet the specified inclusion criteria, hypoglossal nerve stimulation is considered experimental/investigational (not medically necessary) and is not covered.

Use of wireless capsule endoscopy outside the listed, established indications is considered not medically necessary/experimental. Specifically excluded indications include routine evaluation of the esophagus (eg, GERD), evaluation for ulcerative colitis, evaluation of the colon, initial acute upper GI bleeding, and use in suspected obstruction without appropriate selection; the policy also notes patency capsules and magnetically controlled capsules are experimental.

Total parenteral nutrition (TPN) is a covered benefit only when strict clinical criteria are documented (for example, oral intake provides no more than 30% of caloric needs or tube feeding is not possible/beneficial). TPN is explicitly not covered when criteria are unmet, for short‑term needs (generally <2 weeks), for routine perioperative care, or when providing ≤750 calories/day by TPN.

The policy classifies several digital therapeutics as experimental/investigational and not a covered benefit. Named products include Freespira, NightWare, RelieVRx and Stanza for all listed indications.

For denosumab products (including Prolia and biosimilars) the policy states they will not be used in combination with any anabolic bone modifying agent or bisphosphonate. Use of Prolia in combination with anabolic agents or bisphosphonates is explicitly disallowed.

Procedure, CPT/HCPCS and Related Codes

Highlighted procedure codesmixed

0232T
G0460
G0465
P9020
S9055
0648T	Noninvasive evaluation/monitoring of chronic liver disease — considered experimental
0649T	Noninvasive evaluation/monitoring of chronic liver disease — considered experimental
0686T	Histotripsy of the liver — established for selected malignant tumors when criteria met
0552T	Low-level and high-power laser therapy — LLLT established for select indications; high-power laser experimental

Surgical and intraoperative assessment codesCPT

19499
0546T
0945T
A9615
21120-21123
21141-21143
21145-21146
21193

Transplant, bariatric, experimental groupsmixed

38204-38205,38207-38215,38230,38240,38242-38243	Allogeneic bone marrow transplant related CPT codes
81267-81268,81370-81383	Genetic testing codes listed alongside transplant policies
43644-43645,43770-43775,43843,43845-43848,43886-43888,43999	Bariatric surgery and related procedure codes
E0770,E0735,C1827,0908T-0912T	Experimental codes listed for vagus nerve stimulation and related items

Experimental / Bariatric and related codesCPTExperimental

E0770	listed as experimental
E0735	listed as experimental
C1827	listed as experimental
0908T	listed as experimental
0909T	listed as experimental
0910T	listed as experimental
0911T	listed as experimental
0912T	listed as experimental

Mixed codes appearing in investigational/established sectionsmixed

64400	procedure listed (nerve blocks) — policy lists as investigational for headaches
64555	listed under investigational procedures
71250	imaging code listed near policies
81120	molecular/genetic testing codes for gliomas
81479	Not otherwise classified procedure — used in multiple policy areas
81500	pharmacogenetic testing codes listed as experimental
90624	vaccine code referenced

Sleep study (home) codesCPTCovered

G0398	home sleep apnea test — referenced
G0399	home sleep apnea test — referenced

Durable medical equipment / neurostimulation relatedHCPCS

A7030	durable medical equipment codes listed near neurostimulation
E0470	equipment code listed

Mixed referenced CPT/HCPCS/other codesmixed

J2267	Soliris (eculizumab) - referenced for pediatric gMG dosing
J3490	Unclassified drugs - referenced across multiple drug entries
J3590	Unclassified biologics - referenced across multiple drug entries
B4100	Listed as experimental (in context of devices) in the document
B4034	Listed in experimental device code list
E0715	Enteral/TPN related supply codes referenced
E0716	Enteral/TPN related supply codes referenced
E1905	Device code referenced in pelvic floor stimulation section

Referenced HCPCS/J-codes in this excerptHCPCS

J3490	Unclassified drugs (listed in document alongside denosumab references)
J3590	Unclassified biologics (listed in document alongside denosumab references)
J9145	Cellular therapy administration (listed with Zevaskyn)
J9239	Daratumumab (Darzalex) reference in document
J9358	Tislelizumab (Tevimbra) reference in document
Q5135	Fam-trastuzumab deruxtecan (Enhertu) reference in document

AHI / RDI thresholds for OSA — Clinically significant OSA and hypoglossal stimulation

Clinically significant OSAAHI or RDI ≥15 events/hour OR AHI/RDI ≥5 events/hour with one or more OSA-related signs/symptoms (e.g., excessive daytime sleepiness, hypertension, cardiovascular disease or stroke).

Hypoglossal stimulation inclusion (adult)AHI ≥15 and ≤100 events/hour; central apneas ≤25% of total AHI; BMI ≤35 kg/m2; documented CPAP failure or intolerance; qualifying DISE findings or equivalent confirmation; sleep study within 24 months of consultation.

Pediatric adenotonsillectomy thresholdAHI or RDI ≥5 events/hour OR AHI/RDI ≥1.5 events/hour with excessive daytime sleepiness, behavioral problems, or hyperactivity.

BMI thresholds for bariatric surgery (including Asian adjustments)

Class 3 BMI threshold (general)BMI ≥40 kg/m2 (≥37.5 kg/m2 in the Asian population).

Class 2 BMI with comorbidityBMI 35–39.9 kg/m2 (≥32.5 kg/m2 in the Asian population) with one or more co-morbid conditions (eg, degenerative joint disease, hypertension, sleep apnea).

Class 1 BMI with type 2 diabetesBMI 30–34.9 kg/m2 (≥27.5 kg/m2 in the Asian population) when the individual has type 2 diabetes.

Histotripsy tumor thresholds — Age, ECOG, tumor size and count limits

Minimum age and performance statusPatient must be at least 18 years of age and have ECOG 0–2.

Tumor size limitTargeted tumor must be ≤3 cm in longest diameter.

Maximum tumor countNo more than three tumors may be targeted for treatment.

OSA severity thresholds — Adult and pediatric AHI/RDI/REI

Adult OSA severityAHI, RDI or REI ≥15 events/hour OR ≥5 events/hour with one or more OSA-related signs/symptoms (eg, excessive daytime sleepiness, hypertension, cardiovascular disease or stroke).

Pediatric OSA severityAHI or RDI ≥5 events/hour OR AHI/RDI ≥1.5 events/hour with excessive daytime sleepiness, behavioral problems, or hyperactivity.

Home sleep study codes referencedG0398 and G0399 referenced for home sleep apnea testing (see coding section).

Long-limb gastric bypass length

Long-limb threshold>150 cm limb length for gastric bypass is considered experimental/investigational.

Examples listed as experimentalLoop (mini) gastric bypass and biliopancreatic bypass without duodenal switch are also listed among experimental bariatric procedures.

Albumin-corrected serum calcium (CSC) threshold

CSC threshold for HCMAlbumin-corrected serum calcium (CSC) ≥12 mg/dL (3.0 mmol/L) required for hypercalcemia of malignancy criteria documentation.

Bisphosphonate documentationDocumentation that at least one IV bisphosphonate has been ineffective, not tolerated, or contraindicated is required where specified.

10-year fracture probability thresholds

Hip fracture 10-year probability threshold10-year probability of hip fracture ≥3% meets threshold for certain denosumab/Prolia indications.

Major osteoporotic fracture threshold10-year probability of a major osteoporosis-related fracture ≥20% meets threshold for certain denosumab/Prolia indications.

FRAX useFRAX or validated 10-year risk models referenced to determine these thresholds for treatment decisions (eg, men on ADT or women on aromatase inhibitors).

TPN oral caloric intake threshold

Oral intake limit for TPN eligibilityIndividual can receive no more than 30% of caloric needs orally to meet TPN inclusion criteria.

TPN ordering and approvalNutrients and administration must be specifically ordered by a physician and pre-approved on an individual consideration basis.

10-year fracture risk thresholds (FRAX)

FRAX fracture risk thresholds (repeat)Hip fracture ≥3% or major osteoporotic fracture ≥20% used as thresholds for certain osteoporosis treatment indications.

Bisphosphonate trial requirementAt least one bisphosphonate (oral or IV if oral not tolerated) must have been ineffective, not tolerated, or contraindicated unless specified otherwise.

Zevaskyn sheet area and manufacturing limits

Single sheet areaOne Zevaskyn sheet covers 41.25 cm2 (5.5 cm x 7.5 cm).

Maximum sheets manufacturedUp to 12 Zevaskyn sheets may be manufactured from patient biopsies and supplied for potential use.

Identity verificationVerify patient identity prior to Zevaskyn application and document wound surface area to determine number of sheets.

Hypercalcemia of malignancy — CSC documentation requirement

CSC documentation required for HCMHypercalcemia of malignancy coverage requires documentation of albumin-corrected serum calcium (CSC) values; policy cites CSC threshold but full numeric detail is presented elsewhere (see HCM criteria).

Bisphosphonate failure documentationDocumentation that at least one IV bisphosphonate has been ineffective, not tolerated, or contraindicated is required for HCM denosumab use.

Prior Authorization, Documentation, and Billing Actions

Prior Authorization

Prior authorization and criteria required

Certain procedures listed in this chart require prior authorization and supporting documentation demonstrating that all applicable inclusion and exclusion criteria are met (for example, histotripsy of the liver and hypoglossal nerve stimulation have specific clinical criteria that must be documented).

Document multidisciplinary evaluation and tumor/patient criteria for histotripsy when applicable.
Document AHI, CPAP trial/failure, DISE findings, BMI, and timing of sleep study for hypoglossal nerve stimulation.

Prior Authorization

Prior authorization for OSA devices

Durable medical equipment for OSA—such as custom oral appliances—and positive airway pressure devices (CPAP/BiPAP/APAP) require prior authorization or pre-approval when prescribed to meet the policy's clinical criteria; oral appliances must be prescribed and custom fitted by a dentist with a dental evaluation documented.

Ensure device is custom-fitted and include dental evaluation documenting absence of TMJ dysfunction and periodontal disease.
Include documentation of diagnosis (AHI/RDI/REI thresholds) and prior CPAP trial/failure when applicable.

Prior Authorization

Denosumab prior authorization

Denosumab products (including Xgeva, Prolia and related biosimilars) require prior authorization with documentation of indication-specific criteria such as prior bisphosphonate trial/failure or intolerance and relevant diagnostic evidence.

For SRE prevention or HCM, document that at least one IV bisphosphonate was ineffective, not tolerated, or contraindicated.
For giant cell tumor, provide radiologic evidence of measurable disease (CT or MRI).
For osteoporosis, document FDA‑approved diagnosis and prior bisphosphonate trial/failure unless intolerant/contraindicated.

Prior Authorization

Soliris (eculizumab) PA

Soliris (eculizumab) for pediatric generalized myasthenia gravis is payable per the updated FDA indication and dosing; prior authorization is expected with documentation of the weight‑based dosing schedule.

Include patient weight and dosing schedule per the pediatric dosing recommendations in the prior authorization request.

Prior Authorization

Prior authorization for denosumab products and Zevaskyn

Prior authorization is required for denosumab products and Zevaskyn; requests must include indication‑specific documentation (for denosumab: prior bisphosphonate trial/failure or intolerance as required; for Zevaskyn: wound surface area and manufacturing limits).

Align quantity limits and authorization period with FDA‑recommended dosing and stated renewal criteria for denosumab products.
For Zevaskyn, document wound surface area (1 sheet = 41.25 cm2) and verify patient identity prior to application.

Step Therapy

Therapy sequencing for hypoglossal stimulation

Hypoglossal nerve stimulation is considered only after documented failure or intolerance of CPAP or after an adequate trial of an oral appliance; CPAP failure and prior therapy attempts must be documented.

Document CPAP failure as defined (residual AHI ≥15 despite CPAP use or failure to use CPAP ≥4 hours/night for ≥5 nights/week).
If DISE is used, document non‑concentric retropalatal obstruction per policy requirements.

Step Therapy

CPAP trial before oral appliance

A trial of CPAP is required and should be attempted before switching to an oral appliance for individuals with severe OSA; documentation of the CPAP trial and attempts to maintain CPAP therapy must be provided.

For severe OSA, ensure records show initial CPAP trial and documentation of attempts to continue CPAP prior to approval of an oral appliance.
Include sleep study results meeting clinically significant OSA thresholds (AHI/RDI/REI ≥15 or ≥5 with symptoms).

Step Therapy

Denosumab step therapy

Coverage of denosumab products requires trial and failure of preferred products as specified on the Blue Cross and BCN medical utilization management drug list; authorization requests must document prior trials per that step‑therapy requirement.

Document trials and outcomes of preferred agents listed on BCBS/BCN drug lists before requesting denosumab coverage.
Do not use Prolia in combination with anabolic bone agents or bisphosphonates.

Step Therapy

Step therapy for biosimilars

Step therapy applies to biosimilars: trial and failure of preferred products specified in the Blue Cross and BCN utilization management drug list is required prior to coverage of biosimilar products for FDA‑labeled indications.

Include documentation of trials of preferred products and reasons for failure/intolerance when submitting a biosimilar prior authorization.

Documentation Required

Allogeneic HCT documentation

Clinical documentation submitted for allogeneic hematopoietic cell transplantation must demonstrate that attending staff at the transplant center considered contraindications and overall suitability as part of the evaluation.

Include documentation of the transplant center's multidisciplinary assessment and consideration of contraindications in the record.

Documentation Required

Bariatric revision documentation

Medical records for bariatric revision must document the date and type of the previous procedure and the factors that precipitated failure or complications necessitating revision; if revision is due to non‑adherence or weight regain, the patient must re‑qualify and meet initial preoperative criteria.

Provide prior procedure date/type and objective documentation of anatomic/technical failure or complications when requesting revision surgery.
If indication is weight regain/non‑adherence, include evidence that the patient meets initial bariatric criteria before approval.

Documentation Required

Enteral nutrition documentation

For enteral nutrition, the medical record must document that the impairment is long‑term or 'permanent' (ordinarily at least three months) and that tube feeding is necessary to maintain weight and strength; a nutrition prescription must be present.

Document permanence (physician justification) and include a current nutritional prescription in the chart.
If requesting a feeding pump, provide supporting documentation of medical necessity.

Documentation Required

Denosumab documentation

For denosumab requests, documentation must show that prior IV bisphosphonate therapy was ineffective, not tolerated, or contraindicated when that requirement applies to the indication.

Include prior bisphosphonate treatment details (agent, route, dates, and reason for discontinuation) in the authorization documentation.
For hypercalcemia of malignancy, document albumin‑corrected serum calcium (CSC) values as required.

Documentation Required

Required clinical documentation for denosumab and Prolia

Providers must document indication‑specific evidence for denosumab and Prolia requests (for example, confirmed giant cell tumor with radiologic measurable disease, diagnosis of hypercalcemia of malignancy with CSC values, or FDA‑approved osteoporosis diagnosis and T‑score trends for renewals).

For giant cell tumor: include CT or MRI showing measurable disease and rationale for unresectability or high surgical morbidity.
For Prolia renewals: provide documentation of improved or stable T‑scores while on therapy.

Documentation Required

Zevaskyn administration documentation

For Zevaskyn administration, verify the patient's identity prior to topical application and document wound surface area to determine the number of sheets requested (one sheet = 41.25 cm2; up to 12 sheets may be manufactured).

Record wound surface area calculation and the number of Zevaskyn sheets requested in the medical record.
Confirm and document patient identity before application as part of the administration record.

Denial Risk

Intraoperative margin assessment—denial risk

Use of intraoperative margin assessment technologies (for example, MarginProbe, LumiSystem, computer‑aided fluorescence imaging) during breast‑conserving surgery is considered experimental/investigational and may be denied if billed.

Do not expect coverage for intraoperative margin assessment devices; prior authorization is unlikely to be approved given experimental classification.

Denial Risk

Denial risks for experimental/investigational procedures

Procedures and devices classified as experimental/investigational (examples include endoscopic primary bariatric procedures, long‑limb gastric bypass >150 cm, patency capsule use, and magnetically controlled wireless capsule) will be denied as not supported by evidence.

Before submitting, confirm that the requested procedure is not listed in the policy's experimental/exclusionary sections to avoid denial.
Examples specifically listed as experimental include long‑limb gastric bypass >150 cm and patency/magnetically controlled capsules.

Denial Risk

OSA device exclusions

Use of CPAP, BiPAP/APAP that do not meet the policy's specified criteria, and intraoral appliances that do not meet the listed device criteria (including prefabricated non‑custom devices), are considered experimental/investigational and are not covered.

Ensure PAP devices meet clinical indication thresholds and that oral appliances are custom‑fabricated with required dental documentation to avoid denial.
Prefabricated mouth guards and dentist‑performed screening tests are excluded and not payable.

Denial Risk

Denosumab prior bisphosphonate requirement

Coverage of denosumab products (Xgeva/Xbryk/Prolia and biosimilars) requires documentation that at least one IV bisphosphonate trial was ineffective, not tolerated, or contraindicated for certain indications; absence of this documentation may trigger denial.

Include prior IV bisphosphonate therapy details and clinical rationale for denosumab use when the indication requires it.
For HCM, include albumin‑corrected serum calcium (CSC) values alongside bisphosphonate failure documentation.

Background and Scope

This billing chart provides background context for providers and billing staff: it summarizes policy‑level clinical inclusion and exclusion criteria and the payer classification of procedures and technologies as established versus experimental/investigational. The entries are intended to guide coverage determinations, prior authorization expectations and documentation needed for claim review.

Key Definitions and Thresholds

Clinically significant OSA definition

Clinically significant OSA definition (summary)Clinically significant OSA is defined as AHI or RDI ≥15 events/hour, or AHI/RDI ≥5 events/hour with one or more OSA-related signs or symptoms (eg, excessive daytime sleepiness, hypertension, cardiovascular disease or stroke).

Use in device coverageThese thresholds are referenced throughout coverage for CPAP/APAP/BiPAP and oral appliances and guide treatment/titration decisions.

Pediatric threshold notePediatric thresholds differ: AHI/RDI ≥5 or ≥1.5 with symptoms as specified in pediatric criteria sections.

CPAP failure definition

CPAP failure definitionResidual AHI ≥15 despite CPAP use OR failure to use CPAP ≥4 hours per night for ≥5 nights per week.

Implication for further therapyCPAP failure documentation is required before hypoglossal nerve stimulation is considered; trial attempts to improve compliance should be documented.

Clinically significant OSA thresholds (adult)

Adult clinically significant thresholdsAdults: AHI, RDI or REI ≥15 events/hour OR ≥5 events/hour with one or more OSA-related signs/symptoms (eg, excessive daytime sleepiness, hypertension, cardiovascular disease or stroke).

Pediatric clinically significant thresholdsPediatrics: AHI or RDI ≥5 events/hour OR AHI/RDI ≥1.5 events/hour with daytime sleepiness, behavioral problems or hyperactivity.

Application to device coverageThese thresholds are used to determine eligibility for APAP/CPAP/BiPAP and oral appliances per policy criteria.

Pathologic nipple discharge definition

Pathologic nipple discharge definitionPersistent and reproducible on exam, spontaneous, unilateral, single duct, and clear or bloody.

Use in imaging criteriaPathologic nipple discharge is a diagnostic indication for breast MRI when mammography and ultrasound are nondiagnostic.

Permanence definition — Enteral nutrition

Operational permanence definitionPermanence does not require impossibility of future improvement; physicians may substantiate long and indefinite duration, ordinarily at least three months, to meet the permanence test for enteral nutrition documentation.

Documentation implicationMedical records must document long-term impairment and necessity for tube feeding to maintain weight/strength when claiming enteral nutrition benefits.

Zevaskyn — Definition

Zevaskyn definitionAn autologous cell sheet-based gene therapy for wounds in RDEB consisting of up to 12 single-dose cellular sheets (41.25 cm2 each) containing patient gene-modified cells with functional COL7A1.

Indication and administrationTopical application on wounds; dosing based on wound surface area with identity verification prior to application.

Tyenne (tocilizumab-aazg) — Definition and indicated uses

Tyenne (tocilizumab-aazg) definitionAn interleukin-6 receptor antagonist indicated for CAR T cell–induced severe or life-threatening cytokine release syndrome (age ≥2 years) and for hospitalized adult COVID-19 patients receiving systemic corticosteroids and requiring supplemental oxygen or greater respiratory support.

URMBT notePolicy notes this drug isn't a benefit for URMBT.