CurrentBlue Cross Blue Shield - WisconsinPolicy N/A

Clinical Criteria for MAE Coverage — Transmittals Issued for Chapter 1, Part 4

A chapter index and transmittals listing coverage determinations for multiple clinical areas (prevention, radiology, pharmacology) within MAE coverage; intended for providers and payers referencing which sections and transmittals apply.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyClinical Criteria for MAE Coverage — Chapter 1, Part 4 transmittals

Policy CodePolicy N/A

Change TypeIndex/transmittal listing (no substantive clinical criteria)

Effective Date01-30-26

Next Review DateN/A

Key ActionWhen requesting authorization reference the active section number and effective date for the specific clinical policy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

200+numbered transmittals/sections referenced

Part 4document chapter

Manyrepeated transmittal entries

Multipleitems marked retired

1chapter/part referenced

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.

Coverage Criteria and Transmittal Index Notes

Magnetic Resonance Angiography (RETIRED) referenced multiple times in MRI-related transmittals.

Multiple FDG PET indications marked (RETIRED) (lung cancer, esophageal cancer, colorectal cancer, lymphoma, melanoma, head and neck cancers, breast cancer, thyroid cancer, soft tissue sarcoma, testicular cancers, other cancer indications, infection/inflammation, beta amyloid PET in dementia — among others).

Other procedures shown as (RETIRED) include Xenon Scan, Nuclear Radiology Procedure, and Thermography in various index lines.

No explicit coverage criteria or decision logic are present in the provided transmittal snippets — confirm that no criteria were omitted from source ingestion.

No explicit coverage exclusions or 'not medically necessary' statements are present in these excerpts.

The transmittal index includes wound treatment-related entries (e.g., Blood-Derived Products for Chronic Non-Healing Wounds; Electrical Stimulation and Electromagnetic Therapy; Noncontact Normothermic Wound Therapy) with effective dates, but these entries do not contain embedded criteria in the captured text.

Several transmittal lines consist primarily of index mappings (numeric keys mapped to policy/transmittal headings) and repeated placeholder punctuation; these contain no actionable coverage language.

Where retirements are indicated, callers should surface those retirements in the policy UI since the transmittal index references retired subsections rather than active criteria.

Because no criteria group is present in these transmittals, downstream rendering should not create a 'medically necessary when' criteria block for this section.

Referenced Policy Sections and Code Listings

Referenced policy sectionsmixed

270	Wound Treatment (chapter/policy grouping)
270.1	Electrical Stimulation (ES) and Electromagnetic Therapy for the Treatment of Wounds
270.2	Noncontact Normothermic Wound Therapy (NNWT)
270.3	Blood-Derived Products for Chronic Non-Healing Wounds
270.4	Treatment of Decubitus Ulcers

Referenced policy sections (not billing codes)mixed

No codes listed

Transmittal headings / sectionsmixed

270	Wound Treatment
270.1	Electrical Stimulation (ES) and Electromagnetic Therapy for the Treatment of Wounds
270.2	Noncontact Normothermic Wound Therapy (NNWT)

Prior Authorization, Documentation, and Billing Risks

Prior Authorization

Prior Authorization and Billing Guidance

Some sections in this transmittal index reference specific policy sections; where a section is active, follow that section's prior authorization rules rather than assuming none. Several entries in the listing do not specify prior authorization requirements in the transmittal text — no PA is stated in these catalog entries. Portions of the source are excerpts and prior authorization is not specified in those excerpts; verify the full policy section for PA details before billing. Items shown as RETIRED (for example, Magnetic Resonance Angiography entries) indicate retired sections — billing under retired section codes may lead to denial or require alternative coding; confirm current active policy before submission. This part of the document primarily enumerates transmittals and serves as an index/listing for Chapter 1, Part 4; it contains only transmittal listing text and does not itself establish clinical or PA rules. The chapter index references 270.2 - Noncontact Normothermic Wound Therapy (NNWT) and related wound-treatment sections (270.1, 270.3, 270.4) — see those sections for coverage, documentation, and authorization requirements. No explicit denial triggers or step-therapy rules are provided in the transmittal listing; absence of a rule here does not imply coverage. Providers: consult the full text of each referenced section for any prior authorization, documentation, or billing requirements before delivering or billing services.

Reference specific section for prior authorization when a section is active — do not rely on the index alone.
Transmittal listings shown here do not specify prior authorization requirements.
Prior authorization is not specified in many excerpts of this index — verify the full policy section for PA details.

Document Background and Scope

The provided pages are a table of contents and transmittal index for Chapter 1, Part 4, showing coverage determinations across multiple topics (including radiology and wound treatment). The excerpt is an index of transmittals, lists many repeated entries, and highlights retired subsections and effective dates but does not contain the underlying clinical criteria themselves.

Policy Section Definitions and Abbreviations

Magnetic Resonance Spectroscopy / Angiography

Section220.2.1 - Magnetic Resonance Spectroscopy; 220.3 - Magnetic Resonance Angiography

StatusMagnetic Resonance Angiography is marked as (RETIRED) in multiple transmittal lines

ContextListed within Chapter 1, Part 4 transmittals under MRI/spectroscopy headings

RETIRED

MeaningIndicates the policy subsection is no longer active or has been superseded

OccurrenceMultiple subsections (e.g., Magnetic Resonance Angiography; several FDG PET subsections) are labeled RETIRED in the transmittals

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyClinical Criteria for MAE Coverage — Chapter 1, Part 4 transmittals

Policy CodePolicy N/A

Change TypeIndex/transmittal listing (no substantive clinical criteria)

Effective Date01-30-26

Next Review DateN/A

Key ActionWhen requesting authorization reference the active section number and effective date for the specific clinical policy.

SourceLink

On This Page

RETIRED sections (e.g., Magnetic Resonance Angiography entries) present billing risk; confirm current active policy before submission.

This section enumerates transmittals and is an index/listing for Chapter 1, Part 4; it contains only transmittal listing text.

The chapter references 270.2 (NNWT) and wound-treatment sections 270.1, 270.3, 270.4 — check those sections for coverage and PA rules.

No explicit denial triggers or step therapy rules are provided in these transmittal listings; absence here does not equal authorization.

Billing or authorization using a RETIRED subsection identifier may result in denial; reference active section numbers instead

Effective Date

Effective Date ExampleEffective July 1, 2004 (noted for wound treatment policies 270.1–270.3)

PurposeShows when a subsection or transmittal change became effective

UsageProviders should reference the effective date when checking applicability of a policy subsection

NNWT

AbbreviationNNWT = Noncontact Normothermic Wound Therapy

Policy ReferenceReferenced as policy 270.2 in Chapter 1, Part 4 transmittals

Definition in extractNo clinical definition provided in the transmittal excerpt; listed as a policy topic only

Blood-derived products

TopicBlood-derived products for chronic non-healing wounds

Policy ReferenceReferenced as policy 270.3 in the transmittals

Definition in extractNo definition or clinical criteria provided in this excerpt; listed with various effective dates

Decubitus ulcer treatment

TopicTreatment of decubitus ulcers

Policy ReferenceReferenced as policy 270.4 in the transmittals

Definition in extractNo further definition included in these transmittal excerpts

270.1 - Electrical Stimulation (ES) and Electromagnetic Therapy for the Treatment of Wounds

Policy270.1 - Electrical Stimulation (ES) and Electromagnetic Therapy for the Treatment of Wounds

Effective DateEffective July 1, 2004 (noted repeatedly in the transmittals)

Extraction NoteReferenced repeatedly in Chapter 1, Part 4 transmittals; no clinical criteria included in this excerpt

270.2 - Noncontact Normothermic Wound Therapy (NNWT)

Policy270.2 - Noncontact Normothermic Wound Therapy (NNWT)

ContextListed alongside 270.1 and 270.3 in the wound treatment transmittals

Definition in extractNo clinical criteria or definition provided in these chunks; appears as a transmittal heading

270.3 - Blood-Derived Products for Chronic Non-Healing Wounds

Policy270.3 - Blood-Derived Products for Chronic Non-Healing Wounds

ContextAppears with various effective dates noted in the transmittals; no criteria in this excerpt

Cross-referenceListed in the same wound treatment series as 270.1 and 270.2

Noncontact Normothermic Wound Therapy (NNWT) in transmittals

MentionNoncontact Normothermic Wound Therapy (NNWT) is named as a policy topic within the transmittals

PlacementListed in Chapter 1, Part 4 transmittals alongside wound treatment policies

Definition in excerptNo clinical definition provided in the available transmittal text

Electrical Stimulation (ES) and Electromagnetic Therapy in transmittals

MentionElectrical Stimulation (ES) and Electromagnetic Therapy is named as a policy topic within the transmittals

Policy ReferenceAppears as 270.1 in Chapter 1, Part 4 listings

Clinical detailNo definition or clinical criteria provided in these transmittal excerpts

270.1 - Electrical Stimulation (ES) and Electromagnetic Therapy referenced repeatedly

Frequency270.1 is referenced repeatedly across transmittal lines in this extract

Effective DateEffective July 1, 2004 is cited alongside 270.1 multiple times

ScopeListed under the 270 wound treatment series in Chapter 1, Part 4

270.2 - Noncontact Normothermic Wound Therapy (NNWT) referenced alongside 270.1

Co-reference270.2 - Noncontact Normothermic Wound Therapy (NNWT) is referenced alongside 270.1 in the transmittals

ContentAppears as a cross-reference without definitions or clinical criteria in this excerpt

Actionable NoteProviders should consult the full policy text for clinical criteria and authorization requirements