CurrentEmpire BluecrossPolicy N/A

Clinical Criteria for MAE Coverage — Chapter 1, Part 4 transmittals index

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This section lists transmittals and table-of-contents entries for Clinical Criteria for MAE Coverage (Chapter 1, Part 4), acting as an index of policy topics, transmittal numbers, and effective dates for referenced sub-policies.

Policy Summary

PayerEmpire Bluecross

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

Policy CodePolicy N/A

Change TypeInformational / transmittal index update

Effective Date05-29-26

Last ReviewSep 12, 2007

Next Review DateN/A

Key ActionReference the listed subpolicy transmittals (Chapter 1, Part 4) when confirming prior authorization or documentation requirements for a specific service.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

13808Rev.

05-29-26Issued

200+ entriesTransmittals listed

2007-09-12Last review

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.

CurrentEmpire BluecrossPolicy N/A

Clinical Criteria for MAE Coverage — Chapter 1, Part 4 transmittals index

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Policy Summary

PayerEmpire Bluecross

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

Policy CodePolicy N/A

Change TypeInformational / transmittal index update

Effective Date05-29-26

Last ReviewSep 12, 2007

Next Review DateN/A

Key ActionReference the listed subpolicy transmittals (Chapter 1, Part 4) when confirming prior authorization or documentation requirements for a specific service.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

13808Rev.

05-29-26Issued

200+ entriesTransmittals listed

2007-09-12Last review

Coverage Criteria Index Notes

This section is an index/transmittal listing for Chapter 1, Part 4 and contains no operational coverage criteria, medical necessity determinations, or exclusion rules. The entries shown are table-of-contents style transmittal lines that reference subpolicy numbers and effective dates but do not specify coverage criteria or medical necessity language.

Several indexed items in this transmittal listing are marked RETIRED. Specifically, Magnetic Resonance Spectroscopy (220.2.1) and Magnetic Resonance Angiography (MRA) (220.3) are labeled RETIRED in the index. These are index-status annotations and not active coverage criteria within this excerpt.

Multiple entries in the radiology listings are identified as RETIRED. The transmittal index repeatedly marks Positron Emission Tomography (PET) Scans (220.6) and Magnetic Resonance Angiography (MRA) subsections as RETIRED. These notations appear in the index only and do not include replacement coverage language in this fragment.

This part of the transmittal index lists radiology subsections where PET and MRA are repeatedly shown as RETIRED. The listings are index lines (repeated slot numbers) and do not include active coverage criteria, exclusion statements, or medical necessity determinations for those services in this excerpt.

The transmittal fragments in this excerpt do not present any explicit coverage exclusions. Entries are index/transmittal lines (for example, mammograms and other radiology slots) and show status annotations such as RETIRED where applicable, but do not define exclusion criteria within these fragments.

Transmittal index lines and table-of-contents entries shown here do not specify any coverage exclusions. The listings reference policy subsection numbers and effective dates (and sometimes "RETIRED" status) but do not contain exclusion language or actionable exclusion rules in the transmittal entries presented.

These transmittal/index fragments provide repeated references to screening and radiology policy numbers (for example, 210.13 and 210.14) but contain no explicit coverage exclusions. The content is an administrative index without exclusion or denial statements in the visible lines.

The excerpted transmittal entries function as an index for Chapter 1, Part 4 and do not include coverage criteria. Multiple repeated transmittal slots enumerate policy subsection numbers (including repeated references to 210.15 – PrEP for HIV) but do not provide criteria, exclusions, or medical necessity conclusions in these fragments.

The transmittal/index text included here contains no medical necessity statements. It lists policy subsection headings, effective dates, and status annotations but does not articulate medical necessity determinations or clinical coverage rules within the shown lines.

Across the transmittal listings shown, no explicit exclusions are specified. Where topics are inactive they are labeled RETIRED, but the index lines themselves do not provide exclusion criteria or prescriptive exclusion language.

This fragment contains transmittal headings and repeated references to subsection numbers (for example, 210.15 and radiology sections) but does not include explicit exclusions. The index entries are administrative and do not define excluded services in the excerpt provided.

The index labels Magnetic Resonance Angiography (MRA) as RETIRED in multiple slots; however, there are no accompanying 'not medically necessary' (NMN) determinations in these fragments. The annotations indicate index status only.

No 'not-medically-necessary' statements appear in the transmittal excerpts shown. The text lists headings such as High Intensity Behavioral Counseling (HIBC) and policy numbers with repeated slot enumerations but does not include NMN language in these lines.

These fragments do not contain statements that services are 'not medically necessary.' They are index/transmittal entries for screening and radiology topics, repeating subsection numbers and effective-date slots without NMN conclusions.

No 'not medically necessary' statements are present in this portion of the transmittal index. The listings enumerate policy subsection references (including repeated references to 210.15 – PrEP) and status notes, but do not provide NMN determinations.

Policy Identifiers and Code Index

Chapter 1, Part 4 policy identifiersmixed

210.11	Intensive Behavioral Therapy for Cardiovascular Disease
210.12	Intensive Behavioral Therapy for Obesity
210.13	Screening for Hepatitis C Virus (HCV) in Adults
210.14	Lung Cancer Screening with Low Dose Computed Tomography (LDCT)

Prevention / Radiology policy identifiersmixed

220	Radiology (Prevention)
220.2	Magnetic Resonance Imaging (MRI)
220.2.1	Magnetic Resonance Spectroscopy (RETIRED)
220.3	Magnetic Resonance Angiography (RETIRED)
220.4	Mammograms

Indexed policy numbers (transmittal numbers)mixed

210.11

Intensive Behavioral Therapy for Cardiovascular Disease (listed adjacent to Counseling (HIBC) to Prevent STIs entries in index)

Indexed policy numbersmixed

210.10

Screening for Sexually Transmitted Infections (STIs) and High Intensity Behavioral Counseling (HIBC) to Prevent STIs

Transmittal enumerationsmixed

No codes listed

Policy section/transmittal codes listedmixed

210.11	Intensive Behavioral Therapy for Cardiovascular Disease
210.12	Intensive Behavioral Therapy for Obesity

Subsequent policy section listedmixed

210.13

Screening for Hepatitis C Virus (HCV) in Adults

Transmittal section identifiersmixed

210.12	Intensive Behavioral Therapy for Obesity
210.13	Screening for Hepatitis C Virus (HCV) in Adults

Referenced transmittal identifiersmixed

210.13	Screening for Hepatitis C Virus (HCV) in Adults
210.14	Lung Cancer Screening with Low Dose Computed Tomography (LDCT)

Referenced policy itemsmixed

210.13	Screening for Hepatitis C Virus (HCV) in Adults
210.14	Lung Cancer Screening with Low Dose Computed Tomography (LDCT)

No codes listedmixed

No codes listed

No explicit CPT/HCPCS/ICD codes in this fragmentmixed

No codes listed

Coding metadata

Coding metadataNo explicit CPT/HCPCS/ICD procedure or diagnosis codes listed in this transmittal index segment; entries are policy section identifiers (e.g., 210.11–210.15, 220, 220.1)

Code group examplesChapter 1, Part 4 identifiers shown: 210.11, 210.12, 210.13, 210.14

Radiology identifiersRadiology sections referenced: 220, 220.1 (CT)

RETIRED markersSome radiology subsections (e.g., MRA, PET) are marked RETIRED in the index rather than listing billable codes

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Index references sub-policies that may carry PA rules

This index references multiple sub-policies (e.g., Nesiritide; Nebulized Beta Adrenergic Agonist Therapy; 210.11–210.15 topics) that may have their own prior authorization rules; the index entries themselves do not define prior authorization requirements.

Examples listed in the index include 200.1 Nesiritide (Effective March 2, 2006) and 200.2 Nebulized Beta Adrenergic Agonist Therapy (Effective September 10, 2007).
Prevention and radiology subsections (210.x and 220.x) are enumerated and may carry separate subpolicy rules.

Prior Authorization

Prior authorization not specified in these transmittals — check subpolicies

The transmittal entries shown are index-only listings and do not state any prior authorization requirements; providers should review the full subpolicy pages for authorization details.

This segment lists screening and counseling transmittals but contains no PA language.

Background and Scope Summary

Background: the material is an index/table of contents and transmittal listing for Chapter 1, Part 4. It enumerates multiple clinical policy topics (for example, Intensive Behavioral Therapy sections, HCV screening, LDCT, and PrEP) and effective dates but does not provide operating clinical criteria within the shown lines.

Definitions and Term Glossary

Transmittal

Example transmittal entry200.1 - Nesiritide for Treatment of Heart Failure Patients (Effective March 2, 2006)

Adjacent entry200.2 - Nebulized Beta Adrenergic Agonist Therapy for Lung Diseases (Effective September 10, 2007)

FunctionThese lines are transmittal/index entries listing section numbers and effective dates

Transmittal (policy update/index entry)

Short transmittal label210.10 - Screening for Sexually Transmitted Infections (STIs) and High Intensity Behavioral Counseling (HIBC)

Related label210.11 - Intensive Behavioral Therapy for Cardiovascular Disease

Policy Summary

PayerEmpire Bluecross

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

Policy CodePolicy N/A

Change TypeInformational / transmittal index update

Effective Date05-29-26

Last ReviewSep 12, 2007

Next Review DateN/A

Key ActionReference the listed subpolicy transmittals (Chapter 1, Part 4) when confirming prior authorization or documentation requirements for a specific service.

SourceLink

On This Page

Transmittal slot count

Transmittal slotsEnumerated transmittal slots repeat 1–34 across multiple sections (e.g., Pharmacology 200, Prevention 210, Radiology 220)

Example sections using 1–34 slots200 (Pharmacology), 210 (Prevention), 220 (Radiology) all list slot numbers 1–34 repeatedly

PurposeSlots are index positions for transmittal entries, not procedural codes

ImplicationProviders should use section+slot mapping to find the detailed subpolicy elsewhere in the manual

Check the referenced subpolicy (e.g., 210.1–210.15) for any specific authorization rules.

Prior Authorization

Prior authorization not specified in this index fragment

This fragment is an index-only section and does not specify prior authorization or authorization procedures.

Entries repeat policy numbers (e.g., 210.11, 210.12) without authorization language.
Index content indicates topics and effective dates rather than operational PA requirements.

Prior Authorization

Transmittal index entries list dates/RETIRED status; no PA stated

The transmittal index lists effective dates and RETIRED statuses for subpolicies but does not state prior authorization requirements within the listings themselves.

Examples: Ultrasound Diagnostic Procedures (Effective May 22, 2007); PET Scans noted as RETIRED (Effective April 6, 2009).
Retired entries are index annotations and do not include PA instructions.

Prior Authorization

No prior authorization stated in shown transmittals

No prior authorization requirements are specified in the transmittal listings shown in this portion of the document.

Magnetic Resonance Angiography is marked RETIRED in the index; no PA instructions accompany the listing.
Mammogram and related radiology transmittal lines enumerate entries without PA language.

Prior Authorization

Prior authorization not specified in provided transmittals

The provided transmittal lines enumerate policy items and effective dates only; they do not specify prior authorization for the referenced topics.

Multiple repeated lines for 220.3 (MRA, RETIRED) and 220.4 (Mammograms) contain no authorization criteria.
Index entries are administrative and not procedural authorization statements.

Prior Authorization

Index listing only — no prior authorization specified

This fragment contains only transmittal index lines and does not identify any prior authorization requirements.

Transmittal listing repeats topics (e.g., 210.11 Intensive Behavioral Therapy) without PA language.
Providers should consult the specific subpolicy for any authorization rules.

Prior Authorization

Prior authorization not specified in this excerpt

No prior authorization requirements are stated in the excerpted transmittal listings.

High Intensity Behavioral Counseling (HIBC) and 210.10 entries are listed without PA statements.
The section functions as an index/table of contents, not a PA policy.

Prior Authorization

Transmittal index — no PA language present

These index entries list policy numbers and transmittal slots but do not state any prior authorization requirements.

Lines enumerate 210.11/210.12 transmittals repeatedly; no authorization language appears.
Index provides mapping only; review subpolicy pages for PA rules.

Prior Authorization

Prior authorization not specified in this fragment

The fragment is an index of transmittal mappings and does not indicate prior authorization requirements.

210.13 (HCV screening) appears repeatedly as an index entry without PA text.
Providers must refer to the detailed subpolicy for authorization guidance.

Prior Authorization

Index-only transmittal listing — PA not stated

No prior authorization requirements are specified in the transmittal listing shown; entries list policy numbers and transmittal indices only.

Transmittal enumeration repeats without operational PA or submission instructions.
Retired/noted statuses are administrative and not PA directives.

Prior Authorization

No prior authorization requirements specified here

The transmittal listings do not state any prior authorization requirements for the referenced screening topics within this excerpt.

210.13 (HCV) and 210.14 (LDCT) are listed with transmittal numbers but no PA statements.
This section serves as a contents/index rather than an authorization policy.

Prior Authorization

No PA requirements stated in these transmittal listings

The transmittal index entries shown do not include prior authorization language; they only enumerate policy numbers and indices.

Repeated lines for LDCT and HCV screening list transmittal positions without PA criteria.
Providers should consult the specific subsection (e.g., 210.14) for authorization details.

Prior Authorization

Transmittal listing only — no PA specified

This example enumerates transmittal listings but does not state prior authorization requirements; it is an index of policy items.

210.15 (PrEP) entries are listed with index numbers but contain no PA instructions.
Index entries are administrative cross-references only.

Prior Authorization

Prior authorization not specified (none listed)

No prior authorization requirements are stated in this section; entries list policy numbers and transmittal indices only.

Multiple 210.13–210.15 lines appear without authorization language.
The listing indicates topics and transmittal positions, not PA processes.

Note

Provider-actions placeholder — administrative header only

This metadata/header fragment is a provider-actions placeholder and contains no operational requirements.

Document header shows chapter and revision information but no PA or provider instructions.
The index functions as a table of contents for transmittals.

Step Therapy

No step therapy requirements in index entries

No step therapy requirements are described in the transmittal index entries included in this document segment.

Screening and counseling transmittals (210.x) are listed without step therapy rules.
Step therapy, if applicable, would be stated in the detailed subpolicy rather than the index.

Step Therapy

No step therapy stated — index only

This excerpt contains only transmittal/index listings and does not describe any step therapy requirements.

Repeated listings for 210.11–210.12 show no step therapy language.
Refer to full subpolicy text for any step therapy rules.

Step Therapy

Index contains no step therapy rules

No step therapy requirements are specified in these transmittal listing chunks.

Radiology transmittals (220.x) list items and RETIRED flags but include no step therapy rules.
Index entries are administrative references only.

Step Therapy

No step therapy requirements provided

No step therapy information is provided in this transmittal index fragment.

Ultrasound and PET transmittal entries list effective dates or RETIRED status without step therapy instructions.
Providers should consult the applicable subpolicy for step therapy details.

Step Therapy

No step therapy requirements in these fragments

These transmittal entries do not include step therapy rules; they serve as an index to subpolicies where such rules would be stated if applicable.

Mammogram and MRA entries are index lines with RETIRED flags and no step therapy content.
Consult the detailed policy section for any step therapy.

Documentation Required

Index lists transmittal titles and effective dates; no documentation requirements

This portion lists transmittal titles and effective dates but does not specify documentation or submission requirements for providers.

Examples: 200.1 Nesiritide (Effective March 2, 2006); 200.2 Nebulized Beta Adrenergic Agonist Therapy (Effective September 10, 2007); 210.2.1 HPV testing (Effective July 9, 2015).
The index format records effective dates and transmittal positions, not provider documentation steps.

Documentation Required

No documentation requirements specified in these transmittals

This segment contains only transmittal headings and effective dates for preventive screening/counseling policies and does not include provider documentation requirements.

Entries such as 210.4 Smoking Cessation (RETIRED) and 210.5 Diabetes Screening list effective dates without documentation instructions.
Providers should review the referenced policy for any documentation expectations.

Documentation Required

Index-only listings — no documentation rules

No documentation or provider action requirements are specified in the transmittal listings shown; the index records topic names and dates only.

Repeated lines for 210.11–210.12 do not include submission or charting instructions.
Any required documentation would be found in the full subpolicy.

Documentation Required

Effective dates shown; documentation requirements not specified

The index lists effective dates for certain subpolicies (for example, Ultrasound Diagnostic Procedures effective May 22, 2007; PET Scans effective April 6, 2009) but does not articulate provider documentation requirements here.

PET Scans are noted as RETIRED (Effective April 6, 2009) in the index.
Effective date entries are administrative and do not convey documentation steps.

Documentation Required

No provider documentation requirements in index

This transmittal index contains no documentation or provider action requirements; it is a mapping of policy topics to transmittal slots and dates.

High Intensity Behavioral Counseling (HIBC) and related entries are listed repeatedly without documentation guidance.
Providers must consult the detailed policy subsection for documentation criteria.

Denial Risk

No denial triggers or authorization rules in this index

No explicit authorization or denial rules appear in this section; it functions as a transmittal/index list and contains no denial triggers.

The document header and table of contents enumerate transmittal items but do not define denial or authorization criteria.
Any denial triggers would be located in the substantive subpolicy text rather than the index.

Denial Risk

No denial triggers in transmittal listings

The transmittal listings do not contain explicit authorization or denial triggers; the section enumerates transmittals and effective dates only.

Screening transmittals (210.x) are listed without denial or PA language.
Providers should not infer denial criteria from this index; consult the referenced policies.

Denial Risk

Index-only content — no denial triggers

This administrative transmittal listing does not specify provider authorization prerequisites or denial triggers.

Entries are index lines (e.g., 210.11–210.12) and do not include denial criteria.
Operational denial rules would be found in detailed policy sections.

Denial Risk

No denial criteria stated in these entries

No explicit denial triggers or authorization requirements are specified in these transmittal index fragments.

Radiology entries (220.x) list RETIRED flags and transmittal positions but no denial language.
Consult the applicable subpolicy for denial conditions.

Denial Risk

No authorization or denial criteria in this index fragment

No explicit authorization or denial criteria are present in the transmittal listing shown; it is an administrative index of policy items.

Ultrasound and PET entries include dates and RETIRED notations without denial guidance.
Providers should review the detailed policy text for denial criteria.

Denial Risk

Transmittal index — no denial triggers specified

No denial triggers or authorization requirements are specified in these transmittal listings; the text is a map of topics to transmittal numbers.

Mammogram and MRA listings repeat without operational denial statements.
Any denial triggers will be in the substantive subpolicy documents.

Used as a short index label to locate full subpolicy text and transmittal slots

RETIRED

StatusRETIRED — referenced subpolicy is no longer active in this policy set

Example topics marked RETIRED220.2.1 Magnetic Resonance Spectroscopy (RETIRED); 220.3 Magnetic Resonance Angiography (RETIRED); 220.6 PET Scans (RETIRED)

Index implicationRetired items remain in index for historical/reference purposes only

Effective date

Effective date (example)Transmittal effective dates are shown adjacent to subpolicy entries (e.g., 200.1 Effective March 2, 2006; 220.5 Effective May 22, 2007)

Index usageEffective dates in the index identify when the subpolicy/transmittal took effect

No coverage criteria hereThis index lists effective dates but does not contain the subpolicy clinical criteria

RETIRED (MRA example)

Example RETIRED mapping220.3 - Magnetic Resonance Angiography (RETIRED) appears repeatedly in the radiology index

ContextListed among mammogram transmittal slots (1–34) as retired entries

Provider noteConsult active subpolicy sections for current coverage; retired items are not active guidance

High Intensity Behavioral Counseling (HIBC)

TermHigh Intensity Behavioral Counseling (HIBC)

Referenced purposeCounseling to prevent sexually transmitted infections (STIs) (listed under 210.10)

Definition noteIndex lists HIBC entries without providing an operational definition in this excerpt; see full subpolicy for details

Intensive Behavioral Therapy (IBT)

TermIntensive Behavioral Therapy (IBT)

Referenced applicationsListed for cardiovascular disease (210.11) and obesity (210.12)

Definition noteIndex references IBT but does not include operational criteria in this excerpt; consult the full subpolicy sections for details

Transmittals for Chapter 1, Part 4

Transmittals coverageTransmittals for Chapter 1, Part 4 are enumerated across sections (200, 210, 220) with repeated slot numbers used to index subpolicies

ExamplesSections include pharmacology (200), prevention (210), and radiology (220)

Index functionThis listing functions as a table of contents/transmittal index for Chapter 1, Part 4

Transmittals for Chapter 1, Part 4 (alternate)

Alternate transmittal entryRadiology transmittals (220) and subitems (220.1 CT) are listed with repeated slot numbers 1–34 across the index

Examples220 - Radiology; 220.1 - Computed Tomography (CT)

UseAlternate index lines map prevention entries to radiology sub-sections for navigation

Definitions placeholder

Definition placeholderIndex entries here act as labels and status markers (e.g., RETIRED) rather than clinical definitions

Examples of markersRETIRED and Effective date markers adjacent to section numbers

Actionable noteRefer to the full subpolicy text for operational definitions and clinical criteria

210.15 - PrEP for HIV

Policy reference210.15 - Pre-Exposure Prophylaxis (PrEP) for Human Immunodeficiency Virus (HIV) appears repeatedly in the index

Index roleListed across multiple transmittal slots (e.g., Prevention slots 11–34 and Radiology crossover lines)

ImplicationUse this index to locate the full 210.15 subpolicy for coverage criteria and requirements

220 / 220.1 - Radiology / CT

Radiology subsections220 / 220.1 - Radiology and Computed Tomography (CT) are listed as policy areas in the index

Slot repetitionCT subitems (220.1) use repeated slot numbers 1–34 mirroring other chapter index entries

Status indicatorsSome radiology subsections are marked RETIRED (see 220.2.1, 220.3, 220.6) while others list effective dates (e.g., 220.5 Ultrasound)