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Blue Cross and Blue Shield of Minnesota and Blue Plus
November 2020
www.bluecrossmn.com Blue Cross® and Blue Shield® of Minnesota and Blue Plus® are nonprofit independent licensees of the Blue Cross and Blue Shield Association. Amerigroup Partnership Plan, LLC, an independent company, is delegated by Blue Plus to provide certain administrative services to Blue Plus health plans. BMNPEC-0671-20 October 2020 514961MNPENMUB
Minnesota Health Care Program Medical Policies
Note: Federal and state guidelines, including Minnesota Health Care Program (MHCP) policies, continue to
apply and supersede other policies. Applicable Amerigroup Medical Policies and Clinical Utilization
Management (UM) Guidelines, and MCG Care Guidelines are listed below.
MCG Care Guidelines Amerigroup licenses and utilizes the MCG Care Guidelines (currently the 24th edition) for inpatient level of
care to guide UM decisions. The five products licensed include the following:
1. Inpatient & Surgical Care (ISC): Manage, review and assess people facing hospitalization or surgery
proactively with nearly 400 condition-specific guidelines, goals, optimal care pathways and other
decision support tools.
2. General Recovery Care (GRC): Effectively manage complex cases where a single ISC guideline or set
of guidelines is insufficient, including the treatment of people with diagnostic uncertainty or multiple
diagnoses.
3. Recovery Facility Care (RFC): Coordinate an effective plan for transitioning people to skilled nursing
facilities (SNFs) and inpatient rehabilitation facilities (IRFs).
4. Chronic Care (CC): Evaluate needs, identify goals, develop personalized care plans and support
effective self-care. The modular design supports quick and efficient assessments and enables you to
manage multiple comorbidities and behavioral health (BH) conditions.
5. Behavioral Health Care (BHC): Provides evidence-based guidelines to help health care professionals
guide the effective treatment of patients with BH disorders.
Amerigroup has the right to customize MCG Care Guidelines based on determinations by its Medical Policy
and Technology Assessment Committee (MPTAC).
Access the Medical Policies:
Minnesota Department of Human Services MHCP policies Blue Cross and Blue Shield of Minnesota and Blue Plus (Blue Cross) policies Amerigroup policies:
o Medical Policies and Clinical UM Guidelines o Clinical Criteria
Blue Cross and Blue Shield of Minnesota and Blue Plus Minnesota Health Care Program Medical Policies
Page 2 of 17
Administrative policies
CG-ADMIN-01 Clinical UM Guideline for Prepayment Review Medical Necessity Determinations When No
Other Clinical UM Guideline Exists
ADMIN.00001 Medical Policy Formation
ADMIN.00002 Preventive Health Guidelines
ADMIN.00004 Medical Necessity Criteria
ADMIN.00005 Investigational Criteria
ADMIN.00006 Review of Services for Benefit Determinations in the Absence of a Company Applicable
Medical Policy or Clinical UM Guideline
Ancillary services
ANC.00007 Cosmetic and Reconstructive Services: Skin Related
ANC.00008 Cosmetic and Reconstructive Services of The Head and Neck
ANC.00009 Cosmetic and Services of the Trunk and Groin
CG-ANC-07 Inpatient Inter-facility Transfers
CG-ANC-08 Mobile Device-Based Health Management Applications
Behavioral health
MCG B-801-T Transcranial Magnetic Stimulation
MCG Care Guidelines BH — criteria for specific diagnosis will be applied as appropriate (excludes
residential substance abuse services)
DME
CG-DME-20 Orthopedic Footwear
CG-DME-39 Dynamic Low-Load Prolonged-Duration Stretch
CG-DME-44 Electric Tumor Treatment Field (TTF)
CG-OR-PR-02 Prefabricated and Prophylactic Knee Braces
CG-OR-PR-03 Custom-made Knee Braces
CG-OR-PR-05 Myoelectric Upper Extremity Prosthetic Devices
DME.00011 Electrical Stimulation as a Treatment for Pain and Related Conditions
DME.00024 Transtympanic Micropressure for the Treatment of Ménière’s Disease
DME.00025 Self-operated Spinal Unloading Devices
DME.00030 Altered Auditory Feedback Devices for the Treatment of Stuttering
DME.00038 Static Progressive Stretch (SPS) and Patient-Actuated Serial Stretch (PASS) Devices
DME.00041 Low Intensity Therapeutic Ultrasound for the Treatment of Pain
DME.00042 Electronic Positional Devices for the Treatment of Obstructive Sleep Apnea
Drugs and injectables
ING-CC-0099 Abraxane (paclitaxel, protein-bound)
Blue Cross and Blue Shield of Minnesota and Blue Plus Minnesota Health Care Program Medical Policies
Page 3 of 17
ING-CC-0065 Agents for Hemophilia A and von Willebrand Disease
Drugs and injectables (continued)
ING-CC-0148 Agents for Hemophilia B
ING-CC-0025 Aldurazyme (laronidase)
ING-CC-0094 Alimta (pemetrexed)
ING-CC-0073 Alpha-1 Proteinase Inhibitor Therapy
ING-CC-0083 Aristada Initio (aripiprazole lauroxil)
ING-CC-0122 Arzerra (ofatumumab)
ING-CC-0096 Asparagine Specific Enzymes (Oncaspar pegaspargase and Asparlas calaspargase pegol-mknl
only)
ING-CC-0116 Bendamustine agents (Bendeka, Treanda, Belrapzo)
ING-CC-0107 Bevacizumab for Non-ophthalmologic Indications (Avastin, Mvasi, and Zirabev only)
ING-CC-0126 Blincyto (blinatumomab)
ING-CC-0137 Cablivi (caplacizumab-yhdp)
ING-CC-0002 Colony Stimulating Factor Agents
ING-CC-0041 Complement Inhibitors (for Ultomiris ravulizumab only)
ING-CC-0123 Cyramza (ramucirumab)
ING-CC-0052 Dihydroergotamine (DHE) injection
ING-CC-0093 Docetaxel
ING-CC-0098 Doxorubicin liposome
ING-CC-0136 Drug dosage, frequency, and route of administration
ING-CC-0035 Duopa (carbidopa and levodopa enteral suspension)
ING-CC-0163 Durysta (bimatoprost implant)
ING-CC-0024 Elaprase (idursufase)
ING-CC-0051 Enzyme Replacement Therapy for Gaucher Disease
ING-CC-0106 Erbitux (cetuximab)
ING-CC-0001 Erythropoiesis Stimulating Agents
ING-CC-0155 Ethyol (amifostine)
ING-CC-0021 Fabrazyme (agalsidase beta)
ING-CC-0103 Faslodex (fulvestrant)
ING-CC-0039 GamaSTAN Immune Globulin (human)
ING-CC-0087 Gamifant (emapalumab-lzsg)
ING-CC-0121 Gazyva (obinutuzumab)
ING-CC-0102 GnRH Analogs for oncologic indications
ING-CC-0061 GnRH Analogs for the Treatment of Non-oncologic Indications
ING-CC-0108 Halaven (eribulin)
Blue Cross and Blue Shield of Minnesota and Blue Plus Minnesota Health Care Program Medical Policies
Page 4 of 17
ING-CC-0130 Imfinzi (durvalumab)
ING-CC-0003 Immunoglobulins
Drugs and injectables (continued)
ING-CC-0045 Increlex (mecasermin)
Blue Cross II-29 Intra-articular Hyaluronan Injections for Osteoarthritis
ING-CC-0031 Intravitreal Corticosteroid Implants (Ozurdex, Retisert, Iluvien)
ING-CC-0100 Istodax (romidepsin)
ING-CC-0090 Ixempra (ixabepilone)
ING-CC-0164 Jelmyto (mitomycin gel)
ING-CC-0070 Jetrea (ocriplasmin)
ING-CC-0114 Jevtana (cabazitaxel)
ING-CC-0115 Kadcyla (ado-trastuzumab)
ING-CC-0057 Krystexxa (pegloticase)
ING-CC-0150 Kymriah (tisagenlecleucel)
ING-CC-0120 Kyprolis (carfilzomib)
ING-CC-0104 Levoleucovorin Agents (Fusilev, Khapzory)
ING-CC-0018 Lumizyme (alglucosidase alfa)
ING-CC-0132 Mylotarg (gemtuzumab ozogamicin)
ING-CC-0023 Naglazyme (galsulfase)
ING-CC-0036 Naltrexone implantable pellets
ING-CC-0111 Nplate (romiplostim)
ING-CC-0058 Octreotide agents
ING-CC-0141 Off-Label Drug and Approved Orphan Drug Use
ING-CC-0110 Perjeta (pertuzumab)
ING-CC-0040 Prialt (ziconotide)
ING-CC-0067 Prostacyclin Infusion and Inhalation Therapy
ING-CC-0118 Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy (Azedra, Zevalin)
ING-CC-0075 Rituximab Agents for Non-Oncologic Indications
ING-CC-0161 Sarclisa (isatuximab-irfc)
ING-CC-0159 Scenesse (afamelanotide)
ING-CC-0149 Select Clotting Agents for Bleeding Disorders
ING-CC-0056 Selected Injectable 5HT3 Antiemetic Agents
ING-CC-0059 Selected Injectable NK-1 Antiemetic Agents
ING-CC-0072 Selective Vascular Endothelial Growth Factor (VEGF) Antagonists (Avastin, Macugen, Mvasii,
and Zirabev only)
ING-CC-0142 Somatuline Depot (lanreotide)
Blue Cross and Blue Shield of Minnesota and Blue Plus Minnesota Health Care Program Medical Policies
Page 5 of 17
ING-CC-0008 Subcutaneous Hormonal Implants (estrogen implants only)
ING-CC-0113 Sylvant (siltuximab)
ING-CC-0162 Tepezza (teprotumumab-trbw)
ING-CC-0101 Torisel (temsirolimus)
ING-CC-0165 Trodelvy (sacituzumab govitecan)
ING-CC-0105 Vectibix (panitumumab)
ING-CC-0095 Velcade (bortezomib)
Drugs and injectables (continued)
ING-CC-0097 Vidaza (azacitidine)
ING-CC-0017 Xiaflex (clostridial collagenase histolyticum) injection
ING-CC-0112 Xofigo (Radium Ra 223 Dichloride)
ING-CC-0151 Yescarta (axicabtagene ciloleucel)
ING-CC-0109 Zaltrap (ziv-aflibercept)
ING-CC-0019 Zoledronic acid agents
ING-CC-0140 Zulresso (brexanolone)
Genetic testing
Blue Cross VI-09 Genetic Testing
CG-GENE-05 Genetic Testing For DMD Mutations (Duchenne Or Becker Muscular Dystrophy)
CG-MED-88 Preimplantation Genetic Diagnosis Testing
CG-GENE-07 BCR-ABL Mutation Analysis
CG-GENE-09 Genetic Testing For CHARGE Syndrome
CG-GENE-11 Genotype Testing for Individual Genetic Polymorphisms To Determine Drug Metabolizer Status
CG-GENE-13 Genetic Testing for Inherited Diseases
CG-GENE-17 RET Proto-oncogene Testing for Endocrine Gland Cancer Susceptibility
CG-GENE-18 Genetic Testing for TP53 Mutations
CG-GENE-19 Detection And Quantification Of Tumor DNA Using Next Generation Sequencing In Lymphoid
Cancers
CG-GENE-20 Epidermal Growth Factor Receptor (EGFR) Testing
GENE.00003 Genetic Testing And Biochemical Markers for The Diagnosis of Alzheimer’s Disease
GENE.00007 Cardiac Ion Channel Genetic Testing
GENE.00010 Panel and Other Multi-Gene Testing for Polymorphisms to Determine Drug-Metabolizer Status
GENE.00016 Gene Expression Profiling for Colorectal Cancer
GENE.00017 Genetic Testing for Diagnosis and Management of Hereditary Cardiomyopathies (Including
Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy)
GENE.00018 Gene Expression Profiling for Cancers of Unknown Primary Site
GENE.00020 Gene Expression Profile Tests for Multiple Myeloma
Blue Cross and Blue Shield of Minnesota and Blue Plus Minnesota Health Care Program Medical Policies
Page 6 of 17
GENE.00024 DNA-Based Testing for Adolescent Idiopathic Scoliosis
GENE.00025 Proteogenomic Testing for the Evaluation of Malignant Tumors
GENE.00033 Genetic Testing for Inherited Peripheral Neuropathies
GENE.00034 Sensigene® Fetal Rhd Genotyping Test
GENE.00036 Genetic Testing For Hereditary Pancreatitis
GENE.00037 Genetic Testing For Macular Degeneration
Genetic testing (continued)
GENE.00038 Genetic Testing For Statin-Induced Myopathy
GENE.00039 Genetic Testing For Frontotemporal Dementia (FTD)
GENE.00042 Genetic Testing For Cerebral Autosomal Dominant Arteriopathy With Subcortical Infarcts And
Leukoencephalopathy Syndrome
GENE.00047 Methylenetetrahydrofolate Reductase Mutation Testing
GENE.00049 Circulating Tumor DNA Testing For Cancer (Liquid Biopsy)
GENE.00050 Gene Expression Profiling For Coronary Artery Disease
GENE.00051 Bronchial Gene Expression Classification for the Diagnostic Evaluation of Lung Cancer
GENE.00052 Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling
GENE.00053 Metagenomic Sequencing for Infectious Disease in the Outpatient Setting
GENE.00054 Paired DNA and Messenger RNA (mRNA) Genetic Testing to Detect, Diagnose, and Manage
Cancer
GT-01
Genetic Testing for Hereditary Cancer Susceptibility
Lynch Syndrome
Hereditary Breast and Ovarian Cancer Syndrome (BRCA1, BRCA2)
Hereditary Paraganglioma-Pheochromocytoma Syndrome
PALB2
Prostate Cancer
Von Hippel-Landau
GT-03
Genetic Testing for Reproductive Carrier Screen and Prenatal
Carrier Screening for Familial Disease
Fragile X
Cystic Fibrosis
Spinal Muscular Atrophy
Hemoglobinopathies
Ashkenazi Jewish Carrier Screening
Other Ethnicity Carrier Screening
Preimplantation Genetic Screening and Diagnostic Testing of Embryos
Prenatal Cell-Free DNA Screening
GT-04
Genetic Testing for Single Gene and Multifactorial Conditions
Genetic Testing for Germline Conditions
Multifactorial (Non-Mendelian Conditions)
Chromosomal Microarray Analysis
GT-05
Pharmacogenomic Testing and Genetic Testing for Thrombotic Disorders
Pharmacogenomic Testing
Thrombophilia Testing
Blue Cross and Blue Shield of Minnesota and Blue Plus Minnesota Health Care Program Medical Policies
Page 7 of 17
GT-06
Molecular Testing of Solid and Hematologic Tumors and Malignancies
Breast Cancer
Cell-Free Testing
Minimal Residual Disease (MRD) Testing
Targeted Molecular Testing for NTRK Fusions
Targeted Somatic Testing for PIK3CA
Prostate Cancer (symptomatic cancer screening)
GT-07 Whole Exome and Whole Genome Sequencing
Blue Cross and Blue Shield of Minnesota and Blue Plus Minnesota Health Care Program Medical Policies
Page 8 of 17
Lab
CG-LAB-10 Zika Virus Testing
CG-LAB-11 Screening For Vitamin D Deficiency In Average Risk Individuals
CG-LAB-12 Testing For Oral And Esophageal Cancer
CG-LAB-13 Skin Nerve Fiber Density Testing
CG-LAB-14 Respiratory Viral Panel Testing in the Outpatient Setting
LAB.00003 In-Vitro Chemosensitivity Assays And In-Vitro Chemoresistance Assays
LAB.00011 Analysis Of Proteomic Patterns
LAB.00015 Detection Of Circulating Tumor Cells In The Blood As A Prognostic Factor For Cancer
LAB.00016 Fecal Analysis In The Diagnosis Of Intestinal Disorders
LAB.00019 Serum Markers For Liver Fibrosis In The Evaluation And Monitoring Of Chronic Liver Disease
LAB.00024 Immune Cell Function Assay
LAB.00025 Topographic Genotyping
LAB.00026 Systems Pathology Testing For Predicting Risk Of Prostate Cancer Progression And Recurrence
LAB.00027 Selected Blood, Serum, And Cellular Allergy And Toxicity Tests
LAB.00028 Serum Biomarker Tests For Multiple Sclerosis
LAB.00029 Rupture Of Membranes Testing In Pregnancy
LAB.00030 Measurement of Serum Concentrations of Monoclonal Antibody Drugs and Antibodies to
Monoclonal Antibody Drugs
LAB.00031 Advanced Lipoprotein Testing
LAB.00033 Protein Biomarkers For The Screening, Detection And Management Of Prostate Cancer
LAB.00034 Serological Antibody Testing For Helicobacter Pylori
LAB.00035 Multibiomarker Disease Activity Blood Tests For Rheumatoid Arthritis
LAB.00036 Multiplex Autoantigen Microarray Testing For Systemic Lupus Erythematosus
Medicine
SDM-01 Sleep Disorder Management
CG-MED-02 Esophageal Ph Monitoring
CG-MED-05 Ketogenic Diet For Treatment Of Intractable Seizures
CG-MED-19 Custodial Care
CG-MED-24 Electromyography And Nerve Conduction Studies
CG-MED-28 Iontophoresis For Medical Indications
CG-MED-32 Ancillary Services For Pregnancy Complications
CG-MED-35 Retinal Telescreening Systems
Blue Cross and Blue Shield of Minnesota and Blue Plus Minnesota Health Care Program Medical Policies
Page 9 of 17
Medicine (continued)
CG-MED-37 Intensive Programs For Pediatric Feeding Disorders
CG-MED-38 Inpatient Admission For Radiation Therapy For Cervical Or Thyroid Cancer
CG-MED-39 Bone Mineral Density Testing Measurement
CG-MED-40 External Ambulatory Event Monitors To Detect Cardiac Arrhythmias
CG-MED-44 Holter Monitors
CG-MED-45 Transrectal Ultrasonography
CG-MED-46 Electroencephalography and Video Electroencephalographic Monitoring
CG-MED-47 Fundus Photography
CG-MED-48 Scrotal Ultrasound
CG-MED-49 Auditory Brainstem Responses And Evoked Otoacoustic Emissions For Hearing Disorders
CG-MED-50 Visual, Somatosensory And Motor Evoked Potentials
CG-MED-51 Three-Dimensional Rendering Of Imaging Studies
CG-MED-53 Cervical Cancer Screening Using Cytology And Human Papillomavirus Testing
CG-MED-54 Strapping
CG-MED-56 Non-Obstetrical Transvaginal Ultrasonography
CG-MED-57 Cardiac Stress Testing With Electrocardiogram
CG-MED-59 Upper Gastrointestinal Endoscopy in Adults
CG-MED-62 Resting Electrocardiogram Screening In Adults
CG-MED-63 Treatment Of Hyperhidrosis
CG-MED-64 Transcatheter Ablation Of Arrhythmogenic Foci In The Pulmonary Veins As A Treatment Of
Atrial Fibrillation Or Atrial Flutter (Radiofrequency And Cryoablation)
CG-MED-65 Manipulation Under Anesthesia Of The Spine And Joints Other Than The Knee
CG-MED-68 Therapeutic Apheresis
CG-MED-69 Inhaled Nitric Oxide
CG-MED-70 Wireless Capsule Endoscopy For Gastrointestinal Imagine And The Patency Capsule
CG-MED-72 Hyperthermia For Cancer Therapy
CG-MED-74 Implantable Ambulatory Event Monitors And Mobile Cardiac Telemetry
CG-MED-76 Magnetic Source Imaging And Magnetoencephalography
CG-MED-77 SPECT/CT Fusion Imaging
CG-MED-79 Diaphragmatic/Phrenic Nerve Stimulation And Diaphragm Pacing Systems
CG-MED-81 High Intensity Focused Ultrasound (HIFU) for Oncologic Indications
CG-MED-84 Non-Obstetric Gynecologic Duplex Ultrasonography of the Abdomen and Pelvis in the Outpatient
Setting
CG-MED-86 Enhanced External Couterpulsation in the Outpatient Setting
Blue Cross and Blue Shield of Minnesota and Blue Plus Minnesota Health Care Program Medical Policies
Page 10 of 17
Medicine (continued)
CG-MED-87 Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications
MED.00004 Technologies For The Evaluation Of Skin Lesions (Including Dermatoscopy, Epiluminescence Microscopy,
Videomicroscopy And Ultrasonography)
MED.00011 Sensory Stimulation For Brain-Injured Individuals In Coma Or Vegetative State
MED.00053 Noninvasive Measurement Of Left Ventricular End Diastolic Pressure In The Outpatient Setting
MED.00059 Idiopathic Environmental Illness
MED.00065 Hepatic Activation Therapy
MED.00082 Quantitative Sensory Testing
MED.00085 Antineoplaston Therapy
MED.00087 Imaging Techniques For Screening And Identification Of Cervical Cancer
MED.00090 Wireless Capsule For The Evaluation Of Suspected Gastric And Intestinal Motility Disorders
MED.00091 Rhinophototherapy
MED.00095 Anterior Segment Optical Coherence Tomography
MED.00097 Neural Therapy
MED.00098 Hyperoxemic Reperfusion Therapy
MED.00099 Electromagnetic Navigational Bronchoscopy
MED.00101 Physiologic Recording Of Tremor Using Accelerometer(S) And Gyroscope(S)
MED.00102 Ultrafiltration In Decompensated Heart Failure
MED.00103 Automated Evacuation Of Meibomian Gland
MED.00104 Noninvasive Measurement Of Advanced Glycation Endproducts (Ages) In The Skin
MED.00105 Bioimpedance Spectroscopy Devices For The Detection And Management Of Lymphedema
MED.00111 Intracardiac Ischemia Monitoring
MED.00112 Autonomic Testing
MED.00115 Outpatient Cardiac Hemodynamic Monitoring Using A Wireless Sensor For Heart Failure Management
MED.00116 Near-Infrared Spectroscopy Brain Screening For Hematoma Detection
MED.00117 Autologous Cell Therapy for the Treatment of Damaged Myocardium
MED.00118 Continuous Monitoring of Intraocular Pressure
MED.00121 Implantable Interstitial Glucose Sensors
MED.00122 Wilderness Programs
MED.00126 Fractional Exhaled Nitric Oxide and Exhaled Breath Condensate Measurements for Respiratory Disorders
MED.00127 Chelation Therapy
Blue Cross and Blue Shield of Minnesota and Blue Plus Minnesota Health Care Program Medical Policies
Page 11 of 17
Medicine (continued)
MED.00128 Insulin Potentiation Therapy
MED.00130 Surface Electromyography Devices for Seizure Monitoring
MED.00131 Electronic Home Visual Field Monitoring
MED.00132 Adipose-Derived Regenerative Cell Therapy and Soft Tissue Augmentation Procedures
MED.00133 Ingestion Event Monitors
Blue Cross II-165 Lyme Disease: Diagnostic Testing and Intravenous Antibiotic Therapy
Blue Cross II-144 Cellular Immunotherapy for Prostate Cancer
Radiology
A1-01 Advanced Imaging of the Brain
PET Imaging of the Brain
AI-02 Advanced Imaging of the Chest
PET Imaging of the Chest
AI-03 Advanced Oncologic Imaging
PET Imaging for Oncologic Indications
AI-04 Advanced Imaging of the Extremities
PET Imaging of the Extremities
AI-05
Advanced Imaging of the Heart
Cardiac CT with Quantitative Evaluation of Coronary Calcification
Cardiac MRI
Myocardial Perfusion Imaging
Cardiac Blood Pool Imaging
Blue Cross V-07 MRI of The Breast
RAD.00034 Dynamic Spinal Visualization (Including Digital Motion X-Ray And Cineradiography/ Videofluoroscopy)
RAD.00037 Whole Body Computed Tomography Scanning
RAD.00038 Use Of 3D, 4D Or 5D Ultrasound In Maternity Care
RAD.00044 Magnetic Resonance Neurography
RAD.00052 Positional MRI
RAD.00053 Cervical And Thoracic Discography
RAD.00057 Near-Infrared Coronary Imaging And Near-Infrared Intravascular Ultrasound Coronary Imaging
RAD.00059 Transcatheter Arterial Chemoembolization and Transcatheter Arterial Embolization for Malignant Lesions
Outside the Liver Except Central Nervous System and Spinal Cord
RAD.00062 Intravascular Optical Coherence Tomography
RAD.00063 Magnetization-Prepared Rapid Acquisition Gradient Echo Magnetic Resonance Imaging (MPRAGE MRI)
RAD.00064 Myocardial Sympathetic Innervation Imaging With or Without Single-Photon Emission Computed
Tomography (SPECT)
CG-SURG-98 Prostate Biopsy Using MRI Fusion Techniques
Blue Cross and Blue Shield of Minnesota and Blue Plus Minnesota Health Care Program Medical Policies
Page 12 of 17
Radiation therapy
Radiation therapy (continued)
CG-THER-RAD-07 Intravascular Brachytherapy (Coronary And Non-Coronary)
THER-RAD.00008 Neutron Beam Radiotherapy
THER-RAD.00012 Electrophysiology-Guided Noninvasive Stereotactic Cardiac Radioablation
Rehabilitation
CG-REHAB-02 Outpatient Cardiac Rehabilitation
CG-REHAB-03 Pulmonary Rehabilitation
REHAB.00003 Hippotherapy
Surgery
Blue Cross IV-123 Gender Affirming Procedures for Gender Dysphoria
Blue Cross XI-03 Site of Service for Selected Outpatient Procedures: Outpatient Hospital and Ambulatory Surgery Center
IP-01 Interventional Pain – Epidural Injection Procedures
IP-02 Interventional Pain – Paravertebral Facet Injection/Nerve Block/Neurolysis
IP-03 Interventional Pain – Regional Sympathetic Nerve Block
IP-04 Interventional Pain – Sacroiliac Joint Injections
IP-05 Interventional Pain – Spinal Cord Stimulators
JO-01
Joint Surgery – Hip Procedures
Hip Arthroplasty
Hip Arthroscopy
JO-02
Joint Surgery – Knee Procedures
Knee Arthroplasty
Knee Arthroscopy and Open Procedures
Meniscal Allograft Transplantation of the Knee
Treatment of Osteochondral Defects
JO-03
Joint Surgery – Shoulder Procedures
Shoulder Arthroplasty
Shoulder Arthroscopy and Open Procedures
SP-01 Spine – Bone Graft Substitutes and Bone Morphogenic Proteins
SP-02 Spine – Cervical Arthroplasty
SP-03 Spine – Cervical Decompression
SP-04 Spine – Lumbar Arthroplasty
SP-05 Spine – Lumbar Discectomy, Foraminotomy, and Laminotomy
SP-06 Spine – Lumbar Fusion and Treatment of Spinal Deformity
SP-07 Spine – Lumbar Laminectomy
SP-08 Spine – Sacroiliac Joint Fusion
SP-09 Spine – Vertebroplasty/Kyphoplasty
Blue Cross and Blue Shield of Minnesota and Blue Plus Minnesota Health Care Program Medical Policies
Page 13 of 17
CG-SURG-01 Colonoscopy
CG-SURG-03 Blepharoplasty, Blepharoptosis Repair And Brow Lift
CG-SURG-05 Maze Procedure
CG-SURG-07 Vertical Expandable Prosthetic Titanium Rib
Surgery (continued)
CG-SURG-08 Sacral Nerve Stimulation As A Treatment Of Neurogenic Bladder Secondary To Spinal Cord Injury
CG-SURG-11 Surgical Treatment For Dupuytren’s Contracture
CG-SURG-12 Penile Prosthesis Implantation
CG-SURG-15 Endometrial Ablation
CG-SURG-17 Trigger Point Injections
CG-SURG-18 Septoplasty
CG-SURG-24 Functional Endoscopic Sinus Surgery
CG-SURG-25 Injection Treatment For Morton's Neuroma
CG-SURG-28 Transcatheter Uterine Artery Embolization
CG-SURG-29 Lumbar Discography
CG-SURG-31 Treatment Of Keloids And Scar Revision
CG-SURG-34 Diagnostic Infertility Surgery
CG-SURG-36 Adenoidectomy
CG-SURG-37 Destruction Of Pre-Malignant Skin Lesions
CG-SURG-40 Cataract Removal Surgery For Adults
CG-SURG-41 Surgical Strabismus Correction
CG-SURG-44 Coronary Angiography In The Outpatient Setting
CG-SURG-46 Myringotomy And Tympanostomy Tube Insertion
CG-SURG-49 Endovascular Techniques (Percutaneous Or Open Exposure) For Arterial Revascularization Of The Lower
Extremities
CG-SURG-51 Outpatient Cystourethroscopy
CG-SURG-55 Intracardiac Electrophysiological Studies And Catheter Ablation
CG-SURG-56 Diagnostic Fiberoptic Flexible Laryngoscopy
CG-SURG-57 Diagnostic Nasal Endoscopy
CG-SURG-58 Radioactive Seed Localization Of Non-Palpable Breast Lesions
CG-SURG-59 Vena Cava Filters
CG-SURG-61 Cryosurgical Ablation or Radiofrequency Ablation to Treat Solid Tumors Outside the Liver
CG-SURG-63 Cardiac Resynchronization Therapy (CRT) With Or Without An Implantable Cardioverter Defibrillator
(CRT/ICD) For The Treatment Of Heart Failure
CG-SURG-70 Gastric Electrical Stimulation
Blue Cross and Blue Shield of Minnesota and Blue Plus Minnesota Health Care Program Medical Policies
Page 14 of 17
CG-SURG-71 Reduction Mammaplasty
CG-SURG-72 Endothelial Keratoplasty
CG-SURG-73 Balloon Sinus Ostial Dilation
CG-SURG-74 Total Ankle Replacement
Surgery (continued)
CG-SURG-75 Transanal Endoscopic Microsurgical (TEM) Excision Of Rectal Lesions
CG-SURG-76 Carotid, Vertebral And Intracranial Artery Stent Placement With Or Without Angioplasty
CG-SURG-77 Refractive Surgery
SURG.00026 Deep Brain, Cortical, and Cerebellar Stimulation
SURG.00043 Electrothermal Shrinkage of Joint Capsules, Ligaments and Tendons
SURG.00044 Breast Ductal Examination and Fluid Cytology Analysis
SURG.00045 Extracorporeal Shock Wave Therapy
SURG.00047 Transendoscopic Therapy for Gastroesophageal.Reflux Disease, Dysphagia, and Gastroparesis
SURG.00052 Percutaneous Vertebral Disc and Vertebral Endplate Procedures
SURG.00053 Unicondylar Interpositional Spacer
SURG.00056 Transanal Radiofrequency Treatment of Fecal Incontinence
SURG.00061 Presbyopia and Astigmatism-Correcting Intraocular Lenses
SURG.00062 Ovarian And Internal Iliac Vein Embolization as a Treatment of Pelvic Congestion Syndrome
SURG.00070 Photocoagulation of Macular Drusen
SURG.00071 Percutaneous and Endoscopic Spinal Surgery
SURG.00072 Lysis of Epidural Adhesions
SURG.00073 Epiduroscopy
SURG.00075 Intervertebral Stabilization Devices
SURG.00076 Nerve Graft After Prostatectomy
SURG.00077 Uterine Fibroid Ablation: Laparoscopic or Percutaneous Image Guided Techniques
SURG.00079 Nasal Valve Suspension
SURG.00082 Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedures of the Appendicular
System
SURG.00084 Implantable Middle Ear Hearing Aids
SURG.00088 Coblation® Therapies for Musculoskeletal Conditions
SURG.00089 Self-Expanding Absorptive Sinus Ostial Dilation
SURG.00092 Implanted Devices for Spinal Stenosis
SURG.00095 Viscocanalostomy and Canaloplasty
SURG.00096 Surgical and Ablative Treatments for Chronic Headaches
Blue Cross and Blue Shield of Minnesota and Blue Plus Minnesota Health Care Program Medical Policies
Page 15 of 17
SURG.00097 Vertebral Body Stapling and Tethering for the Treatment Of Scoliosis in Children
and Adolescents
SURG.00098 Mechanical Embolectomy for Treatment of Acute Stroke
SURG.00099 Convection Enhanced Delivery of Therapeutic Agents to the Brain
SURG.00100 Cryoablation For Plantar Fasciitis And Plantar Fibroma
Surgery (continued)
SURG.00101 Suprachoroidal Injection of a Pharmacologic Agent
SURG.00102 Artificial Anal Sphincter for the Treatment of Severe Fecal Incontinence
SURG.00103 Intraocular Anterior Segment Aqueous Drainage Devices (Without Extraocular Reservoir)
SURG.00104 Extraosseous Subtalar Joint Implantation and Subtalar Arthroereisis
SURG.00105 Bicompartmental Knee Arthroplasty
CG-SURG-101 Ablative Techniques as aTreatment For Barrett's Esophagus
SURG.00107 Prostate Saturation Biopsy
SURG.00111 Axial Lumbar Interbody Fusion
SURG.00007 Vagus Nerve Stimulation
SURG.00112 Occipital Nerve Stimulation
SURG.00113 Artificial Retinal Devices
SURG.00114 Facet Joint Allograft Implants for Facet Disease
CG-SURG-94 Keratoprosthesis
SURG.00116 High Resolution Anoscopy Screening for Anal Intraepithelial Neoplasia and Squamous Cell Cancer of the
Anus
CG-SURG-95 Sacral Nerve Stimulation and Percutaneous Tibial Nerve Stimulation for Urinary and Fecal Incontinence;
Urinary Retention
SURG.00118 Bronchial Thermoplasty
SURG.00119 Endobronchial Valve Devices
SURG.00120 Internal Rib Fixation Systems
SURG.00121 Transcatheter Heart Valve Procedures (For TAVR And TPVI Only)
CG-SURG-106 Venous Angioplasty with or without Stent Placement or Venous Stenting Alone
SURG.00123 Transmyocardial/Perventricular Device Closure of Ventricular Septal Defects
SURG.00124 Carotid Sinus Baroreceptor Stimulation Devices
SURG.00125 Radiofrequency And Pulsed Radiofrequency Treatment Of Trigger Point Pain
SURG.00126 Irreversible Electroporation
SURG.00128 Implantable Left Atrial Hemodynamic Monitor
SURG.00129 Oral, Pharyngeal And Maxillofacial Surgical Treatment For Obstructive Sleep Apnea Or Snoring
SURG.00130 Annulus Closure After Discectomy
Blue Cross and Blue Shield of Minnesota and Blue Plus Minnesota Health Care Program Medical Policies
Page 16 of 17
SURG.00131 Lower Esophageal Sphincter Augmentation Devices For The Treatment Of Gastroesophageal Reflux Disease
SURG.00132 Drug-Eluting Devices For Maintaining Sinus Ostial Patency
SURG.00134 Interspinous Process Fixation Devices
SURG.00135 Radiofrequency Ablation Of The Renal Sympathetic Nerves
CG-SURG-96 Intraocular Telescope
Surgery (continued)
SURG.00137 Focused Microwave Thermotherapy For Breast Cancer
SURG.00138 Laser Treatment For Onychomycosis
CG-SURG-102 Alcohol Septal Ablation for Treatment of Hypertrophic Cardiomyopathy
SURG.00139 Intraoperative Assessment Of Surgical Margins During
SURG.00140 Peripheral Nerve Blocks For Treatment Of Neuropathic Pain
SURG.00141 Doppler-Guided Transanal Hemorrhoidal Dearterialization
SURG.00142 Genicular Nerve Blocks And Ablation For Chronic Knee Pain
SURG.00143 Perirectal Spacers For Use During Prostate Radiotherapy
SURG.00144 Occipital Nerve Block Therapy For The Treatment Of Headache And Occipital Neuralgia
SURG.00145 Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices
And Artificial Hearts)
SURG.00146 Extracorporeal Carbon Dioxide Removal
SURG.00147 Synthetic Cartilage Implant For Metatarsophalangeal Joint Disorders
SURG.00148 Spectral Analysis Of Prostate Tissue By Fluorescence Spectroscopy
SURG.00149 Percutaneous Ultrasonic Ablation Of Soft Tissue
SURG.00150 Leadless Pacemaker
SURG.00151 Balloon Dilation Of Eustachian Tube
SURG.00153 Cardiac Contractility Modulation Therapy
SURG.00154 Microsurgical Procedures for the Treatment of Lymphedema
SURG.00155 Cryoneurolysis for Treatment of Peripheral Nerve Pain
CG-SURG-92 Paraesophageal Hernia Repair
CG-SURG-93 Angiographic Evaluation And Endovascular Intervention For Dialysis Access Circuit Dysfunction
SURG.00152 Wireless Cardiac Resynchronization Therapy For Left Ventricular Pacing
Blue Cross IV-152 Transcatheter Mitral Valve Repair
CG-SURG-99 Panniculectomy And Abdominoplasty
Blue Cross IV-144 Visocanalostomy And Canaloplasty For The Treatment Of Glaucoma
Transplant
Blue Cross and Blue Shield of Minnesota and Blue Plus Minnesota Health Care Program Medical Policies
Page 17 of 17
CG-TRANS-03 Donor Lymphocyte Infusion For Hematologic Malignancies After Allogeneic Hematopoietic Progenitor Cell
Transplantation
TRANS.00004 Cell Transplantation (Mesencephalic, Adrenal-Brain And Fetal Xenograft)
TRANS.00016 Umbilical Cord Blood Progenitor Cell Collection, Storage And Transplantation