Blue Cross Blue Shield - Massachusetts Coverage Criteria
- Blue Cross Blue Shield - Massachusetts prior authorization
- All Blue Cross Blue Shield - Massachusetts policy updates
Latest Blue Cross Blue Shield - Massachusetts coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Spinal fusion and decompression surgery (cervical, thoracic, lumbar)Medical necessity criteria for non‑elective and elective spinal fusions and decompression procedures (including laminectomy, discectomy, corpectomy, laminoplasty) for commercial and Medicare members as specified by the payer.All Blue Cross Blue Shield - Massachusetts updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Spine Surgery: Cervical, Lumbar and Thoracic Decompression and/or FusionMedical necessity criteria and coverage guidance for cervical, thoracic, and lumbar spinal decompression and fusion procedures, covering elective and non-elective indications and required documentation (including preoperative smoking documentation for certain elective fusions).All Blue Cross Blue Shield - Massachusetts updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-01Formulary Exception / Non-covered Drug Prior AuthorizationDefines BCBSMA prior authorization and formulary exception criteria for coverage of non-formulary or non-covered prescription drugs for commercial members under the BCBSMA formulary; excludes Medicare Advantage. Affects prescribers requesting coverage exceptions and pharmacy operations processing prior authorizations.All Blue Cross Blue Shield - Massachusetts updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-04-01Neurology & Neurosurgery — Coverage Criteria and Policy Updates (Spine Fusion, Neuromodulation, DBS, MEG)Summarizes new and revised neurology/neurosurgery medical policies, investigational determinations, coding and prior authorization updates, and changes to InterQual applicability that affect BCBSMA providers and prior authorization processes.All Blue Cross Blue Shield - Massachusetts updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-15Cardiology and Pulmonology Medical Policy Group — Coverage Criteria Summary and UpdatesGovernance and update summary for BCBSMA Cardiology and Pulmonology medical policies, listing policies with recent coverage changes, those without updates, and administrative notes for providers and stakeholders.All Blue Cross Blue Shield - Massachusetts updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-01Total Facet Arthroplasty (Lumbar) — Coverage CriteriaThis policy governs coverage and prior authorization requirements for total facet arthroplasty (posterior vertebral joint replacement) in the lumbar spine for Blue Cross Blue Shield of Massachusetts members across commercial and Medicare products.All Blue Cross Blue Shield - Massachusetts updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-02-24Hematology and Oncology Medical Policy Group - Coverage Criteria and UpdatesSummary of the Hematology and Oncology Medical Policy Group meeting, agenda items, policy updates, and related policy references affecting Blue Cross Blue Shield - Massachusetts medical policy management for oncology and hematology.All Blue Cross Blue Shield - Massachusetts updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-01-01Antihyperlipidemic agents prior authorization and quantity limitsDefines prior authorization, quantity limit, and clinical coverage criteria for specified antihyperlipidemic medications for BCBSMA commercial members (excludes Medicare Advantage). Applies to medications covered under pharmacy and/or medical benefits per formulary status.All Blue Cross Blue Shield - Massachusetts updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-01-01GLP-1 and GLP-1/GIP Agonist Drugs for Anti-Obesity Management and Other Non-Obesity ConditionsThis pharmacy medical policy governs prior authorization, coverage criteria, and approval durations for GLP-1 and GLP-1/GIP agonist medications for anti-obesity management (and other FDA-approved indications) for BCBSMA commercial members with formulary coverage. It does not apply to Medicare Advantage and excludes members on the BCBSMA Focused Formulary where these drugs are not covered.All Blue Cross Blue Shield - Massachusetts updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-01-01GLP-1 and GLP-1/GIP Agonist Drugs for Anti-Obesity Management and Other Non-Obesity ConditionsDefines prior authorization, coverage criteria, and continuation requirements for GLP-1 and GLP-1/GIP agonist medications for obesity and specified non-obesity indications for BCBSMA commercial formularies. Applies to providers requesting coverage for affected members under BCBSMA commercial plans.All Blue Cross Blue Shield - Massachusetts updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-12-01Catheter Ablation for Cardiac ArrhythmiasThis policy governs medical necessity, coverage criteria, prior authorization, and coding for catheter ablation used to treat specified supraventricular and ventricular arrhythmias in eligible commercial and Medicare Advantage members. Catheter ablation for atrial fibrillation is excluded and addressed under Policy 141.All Blue Cross Blue Shield - Massachusetts updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-12-01Liposuction for Lipedema and LymphedemaThis policy defines medical necessity, prior authorization, coding, and coverage criteria for lipectomy or liposuction to treat documented lipedema and lymphedema for Blue Cross Blue Shield - Massachusetts members.All Blue Cross Blue Shield - Massachusetts updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-05-01916_cardiac_rehabilitation_policyDefines medical necessity criteria, investigational indications, prior authorization rules, and coding for outpatient cardiac rehabilitation services for commercial members of Blue Cross Blue Shield Massachusetts.All Blue Cross Blue Shield - Massachusetts updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-01-01Biofeedback for Headache DisordersThis policy governs coverage of biofeedback therapy for primary headache disorders (migraine, tension-type, and cluster headache) for Blue Cross Blue Shield Massachusetts members and describes authorization, coding, and medical necessity criteria for Commercial products.All Blue Cross Blue Shield - Massachusetts updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-11-01Obstetrical Ultrasound & Ultrasound for Family PlanningDefines medical necessity and coverage criteria for obstetrical ultrasound across trimesters and for ultrasound related to intrauterine device (IUD) placement and family planning; applies to Commercial members (HMO, POS, PPO, Indemnity) of Blue Cross Blue Shield - Massachusetts.All Blue Cross Blue Shield - Massachusetts updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-10-14Transthoracic Echocardiography (TTE) — Medical Necessity and Coverage CriteriaMedical necessity policy for transthoracic echocardiography (including stress echocardiography) for commercial members of Blue Cross Blue Shield Massachusetts; describes indications, frequency guidance, and when TTE is considered medically necessary.All Blue Cross Blue Shield - Massachusetts updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-10-01Percutaneous Coronary Intervention (PCI) Coverage CriteriaDefines medical necessity, coding, and authorization expectations for PCI (including diagnostic cardiac catheterization, intravascular imaging, and physiologic measurements) for commercial members of Blue Cross Blue Shield Massachusetts.All Blue Cross Blue Shield - Massachusetts updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-08-01Medicare Advantage Part B Medical Utilization ManagementGoverns 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.All Blue Cross Blue Shield - Massachusetts updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-07-01Botulinum toxin agents (formulary, indications, prior authorization)BCBSMA policy governing prior authorization, formulary status, and medical necessity criteria for botulinum toxin products for Commercial members (including HMO, POS, PPO and indemnity) and related pharmacy operations.All Blue Cross Blue Shield - Massachusetts updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-07-01Botulinum toxin products (formulary status and coverage criteria)This policy governs prior authorization, medical necessity, and formulary placement for botulinum toxin agents for BCBSMA commercial members, including preferred and non-preferred agents, on-label and select off-label indications.All Blue Cross Blue Shield - Massachusetts updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-07-01Colony Stimulating Factors prior authorization and coverageThis policy governs prior authorization, coverage criteria, and formulary status for colony stimulating factors (G-CSF and GM-CSF) for BCBSMA commercial and Medicare Advantage members when billed to the medical benefit; it informs providers about required documentation and delegated Medical Utilization Management to Carelon MBM.All Blue Cross Blue Shield - Massachusetts updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-07-01Inhaled medications for Asthma and COPD (prior authorization and quantity limits)Covers prior authorization, quantity limit (Quality Care Dosing) requirements, formulary status, and medical necessity criteria for inhaled medications used to treat Asthma and COPD for BCBSMA commercial plans; includes provider documentation and individual consideration processes.All Blue Cross Blue Shield - Massachusetts updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-07-01Topical ocular hydrating agents and related ophthalmic medications (prior authorization)Defines prior authorization, quantity limits, coverage criteria, and approval lengths for topical ocular hydrating agents and selected ophthalmic medications for BCBSMA commercial members; applies to providers requesting coverage under the BCBSMA formulary.All Blue Cross Blue Shield - Massachusetts updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-07-01Topical ocular hydrating agents and related ophthalmic medications prior authorizationThis policy governs prior authorization, quantity limits, and medical necessity criteria for topical ocular hydrating agents and selected ophthalmic medications for commercial BCBSMA members with formulary prescription coverage.All Blue Cross Blue Shield - Massachusetts updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-04-01Gene therapies for sickle cell disease (Casgevy, Lyfgenia) — Coverage CriteriaCoverage criteria, coding, and authorization requirements for exagamglogene autotemcel (Casgevy) and lovotibeglogene autotemcel (Lyfgenia) for treatment of sickle cell disease for Blue Cross Blue Shield - Massachusetts members.All Blue Cross Blue Shield - Massachusetts updates
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Tool Description
Search Blue Cross Blue Shield - Massachusetts coverage criteria and medical necessity requirements across 21,000+ policies from 170+ payers.
Search a drug (“Wegovy”), a procedure (“knee replacement”), or a policy name, then filter by payer, specialty, policy type, or effective year. Or start from the largest publishers: UnitedHealthcare coverage criteria and Cigna coverage criteria.
Each result links the full policy page, which lists the clinical requirements, covered codes, and effective dates from the source document.
Pair a criteria search with the prior authorization lookup for approval requirements, the timely filing lookup for claim deadlines, the live policy updates feed for the newest payer publications, and payer profiles for contacts and coverage context.
FAQ
Coverage criteria are the specific clinical requirements a payer sets for covering a drug, procedure, or service: diagnoses, symptom duration, prior treatments tried, age limits, and documentation. They are published inside medical policies and clinical criteria documents, and a claim or authorization that does not meet them is denied as not medically necessary.
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