Policy Bulletins
The Policy Bulletins listed below represent our catalogue of medical and claim payment policies. If you are looking for a specific type of policy, choose a category from the menu on the right. You may also use the search function in the top menu to search for policies by word or phrase.
 
   

Policy #
Policy Bulletin Title
Show details for
MA08.028c
Abatacept (Orencia®) for Injection for Intravenous Use
MA11.010a
Abortion
MA12.003a
Acute Care Facility Inpatient Transfers
Show details for
MA08.066c
Ado-Trastuzumab Emtansine (Kadcyla®)
MA08.033b
Agalsidase beta (Fabrazyme®)
MA12.007a
Air Ambulance Services
MA08.015c
Alemtuzumab (Lemtrada™)
MA08.036c
Alglucosidase alfa (e.g., Lumizyme®)
MA07.055c
Allergy Immunotherapy
MA06.015c
AlloMap™ Molecular Expression Testing for Heart Transplant Rejection
MA08.050a
Alpha 1-Antitrypsin Therapy (e.g., Prolastin-C®, Aralast NP™, Glassia™, Zemaira™)
Show details for
MA00.026g
Always Bundled Procedure Codes
MA07.005c
Ambulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) Devices
MA07.026e
Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring
MA01.001
Anesthesia Services for a Cancelled or Discontinued Procedure
Show details for
MA05.010d
Ankle-Foot/Knee-Ankle-Foot Orthoses
MA07.018b
Anorectal Manometry, Electromyography (EMG) of Anorectal or Urethral Sphincters; Biofeedback Training for Perineal Muscles and Anorectal or Urethral Sphincters
MA06.001e
Apheresis Therapy
MA11.072
Application and Removal of Tattoos
Show details for
MA08.091c
Aprepitant (Cinvanti™), Fosaprepitant Dimeglumine (Emend®), Granisetron (Sustol®), and Rolapitant (Varubi®)
Show details for
MA11.105f
Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma
MA11.011c
Artificial Hearts and Ventricular Assist Devices (VADs)
MA11.044f
Artificial Intervertebral Disc Insertion
MA08.085b
Asparaginase Erwinia Chrysanthemi (Erwinaze®)
MA06.020a
Autologous Blood Services (Collection, Storage, Transfusion, and Perioperative Salvage)
MA11.082c
Autologous Chondrocyte Implantation (ACI)/Carticel® and Other Cell-based Treatments of Focal Articular Cartilage Lesions
Show details for
MA05.005c
Automatic External Cardioverter Defibrillators (Wearable and Nonwearable)
MA07.027b
Autonomic Nervous System Testing
MA11.100e
Balloon Catheter Dilation of Sinus Ostia for Treatment of Chronic Rhinosinusitis
MA08.057a
Belimumab (Benlysta®) for Intravenous Use
Show details for
MA08.072e
Bevacizumab (Avastin®) and Related Biosimilars
Show details for
MA00.037h
Billing for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility Campus
MA07.010a
Biofeedback Therapy
MA07.052
Bioimpedance for the Detection of Lymphedema
MA06.022f
Biomarkers for Oncology
Show details for
MA11.047c
Blepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/Canthopexy
MA08.058c
Blinatumomab (Blincyto®)
MA11.049c
Bone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing Aids
MA08.037f
Bortezomib (Bortezomib for Injection, Velcade®)
Show details for
MA08.017d
Botulinum Toxin Agents
Show details for
MA08.068d
Brentuximab Vedotin (Adcetris®)
MA11.006b
Bronchial Thermoplasty
MA08.099a
Burosumab-twza (Crysvita®)
MA08.054b
Cabazitaxel (Jevtana®)
MA08.101
Canakinumab (Ilaris®)
MA05.052b
Canes and Crutches
Show details for
MA10.002b
Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Programs
MA00.006f
Care Management and Care Planning Services
MA08.062d
Carfilzomib (Kyprolis™)
Show details for
MA00.012b
Cast and Splint Applications and Associated Supplies Provided in the Office Setting
Show details for
MA11.054c
Cataract Surgery
MA11.060c
Catheter Ablation of Cardiac Arrhythmias
MA08.089c
Cerliponase alfa (Brineura®)
MA05.009
Cervical Traction Devices for In-home Use
Show details for
MA08.031d
Cetuximab (Erbitux®)
MA11.103a
Chemical Peels
MA08.093e
Chimeric Antigen Receptor (CAR) Therapy
MA10.004f
Chiropractic Services
MA06.030
Circulating Tumor Cell (CTC) Assay
MA08.004p
Coagulation Factors
Show details for
MA06.032
Cobalamin (Vitamin B12), Folic Acid, and Homocysteine Testing
MA11.039d
Cochlear Implantation
MA05.035b
Cold Therapy Devices
MA05.036b
Commode Chairs
MA12.001c
Complementary and Integrative Health Services
MA07.042
Complete Decongestive Therapy (CDT)
MA11.112
Composite Tissue Allotransplantation of the Hand(s) and Face
MA05.045a
Compression Garments
MA11.088b
Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedure
MA09.014a
Computer Aided Detection (CAD) System for Use with Chest Radiographs
MA00.049
Consultation Services
Show details for
MA00.002f
Continuous Glucose Monitors and Artificial Pancreas Device Systems (APDS)
MA01.004a
Continuous Local Delivery of Anesthesia to Operative Sites Using an Elastomeric Infusion Pump
MA05.019a
Continuous Passive Motion (CPM) Devices in the Home Setting
MA09.004b
Contrast Agents Used in Conjunction with Echocardiography
Show details for
MA07.046e
Corneal Pachymetry Using Ultrasound
MA12.009
Cosmetic Procedures
MA05.040b
Coverage of Medical Devices
MA05.066a
Cranial Electrotherapy Stimulation
MA00.044b
Criteria for Reimbursement of Emergency Room Services
MA11.022a
Cryosurgical Ablation of the Prostate Gland
MA08.079e
Daratumumab (Darzalex™)
MA10.005b
Day Rehabilitation
Show details for
MA11.014e
Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails
MA11.005c
Deep Brain Stimulation (DBS)
MA11.102g
Denervation of the Spinal Nerves for Chronic Pain
Show details for
MA08.052g
Denosumab (Prolia®, Xgeva®), Romosozumab-aqqg (Evenity™)
MA08.074
Deoxycholic Acid (Kybella™)
MA00.032b
Direct Access to Obstetrics/Gynecology (OB/GYN) Services
MA08.021b
Dofetilide (Tikosyn®) Use in the Inpatient Setting
MA07.041b
Drug-Eluting Beads and Bland Embolization for the Treatment of Hepatic Malignancies
MA05.028d
Durable Medical Equipment (DME) Not Subject to a Rental to Purchase Maximum
Show details for
MA05.044g
Durable Medical Equipment (DME)
MA08.044e
Eculizumab (Soliris®) and Related Biosimilars, Ravulizumab-cwvz (Ultomiris™)
MA08.092a
Edaravone (Radicava™)
MA05.059
Electrical Continence Aid
Hide details for
MA07.013d
Electrical Stimulation and Electromagnetic Stimulation for the Treatment of Wounds
MA07.013d
Attachment A (ICD-10 Coding) to MA07.013d Electrical Stimulation and Electromagnetic Stimulation for the Treatment of Wounds
Show details for
MA07.050f
Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
MA09.011a
Electron Beam Computed Tomography (EBCT) for Screening Evaluations
MA08.104b
Emapalumab-lzsg (Gamifant®)
MA11.065d
Endometrial Ablation
MA11.012d
Endovascular Grafts for Abdominal Aortic Aneurysms, Aortic-Iliac Aneurysms, and Infrarenal Aortic Aneurysms
MA11.062
Endovascular Stent-Graft Repair of Thoracic Aortic Aneurysms and Nonaneurysmal Lesions
MA08.113
Enfortumab vedotin-ejfv (Padcev™)
MA08.003d
Enteral Nutritional Therapy
MA08.023b
Enzyme Replacement for the Treatment of Gaucher's Disease
MA08.034d
Enzyme Replacement Therapy for Mucopolysaccharidosis (e.g., Aldurazyme®, Elaprase®, Vimizim®, Naglazyme®, Mepsevii™, etc.)
MA11.026e
Epidural, Paravertebral Facet, and Sacroiliac Joint Injections for Spinal Pain Management
Show details for
MA08.056c
Eribulin Mesylate (Halaven®)
MA08.011e
Erythropoiesis Stimulating Agents (ESAs)
MA07.015a
Evaluation and Management (E&M) of Diabetic Peripheral Neuropathy with Loss of Protective Sensation (LOPS)
MA11.079c
Evaluation and Treatment of Erectile Dysfunction (ED)
Show details for
MA00.005t
Experimental/Investigational Services
MA05.033b
External Breast Prosthesis
MA07.012a
External Counterpulsation (ECP)
MA11.087b
Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions
MA04.002
Extraction of Bony Impacted Teeth and Exposure of Impacted Teeth
MA05.050a
Eye Prostheses and Scleral Cover Shell
MA00.040a
Facility Reporting of Observation Services
MA08.114
Fam-trastuzumab deruxtecan-nxki (Enhertu®)
MA07.006a
Fecal Microbiota Transplantation (FMT)
MA09.012a
Full-Body Computerized Tomography (CT) Scan Screening
MA06.010b
Genetic Testing for Inherited Breast Cancer 1 (BRCA1) and Breast Cancer 2 (BRCA2) Mutations
MA06.012c
Genetic Testing for Inherited Susceptibility to Colon Cancer and Microsatellite Instability Testing (Familial Adenomatous Polyposis and Lynch Syndrome)
Show details for
MA08.070c
Golimumab (Simponi® Aria™) Intravenous (IV) Injection
MA08.083b
Gonadotropin-Releasing Hormone Agonist (Eligard®, Lupron Depot®)
MA12.002b
Ground Ambulance Transport Services (Emergency and Nonemergency)
Show details for
MA11.046b
Hair Transplants and Cranial Prostheses (Wigs)
MA05.029b
Heating Pads and Heat Lamps
MA11.002h
Hematopoietic Stem Cell Transplantation
MA05.001c
High-Frequency Chest Wall Oscillation Devices
Show details for
MA09.002l
High-Technology Radiology Services
MA09.005a
High Osmolar Contrast Agents
MA05.022
Home-Use Light Box for the Treatment of Seasonal Affective Disorder (SAD)
Show details for
MA05.015c
Home Blood Glucose Monitors and Supplies
MA02.003a
Home Health Care Services
MA05.017b
Home Oxygen Therapy
Show details for
MA05.016f
Home Prothrombin Time Monitoring
MA05.061
Home Use of Interferential and Sequential Stimulation Devices
MA02.001a
Hospice Care
MA05.002c
Hospital Beds and Accessories
MA06.011a
Human Immunodeficiency Virus (HIV) Genotyping and Phenotyping
MA11.023i
Hyaluronan Acid Therapies for Osteoarthritis of the Knee
Show details for
MA07.001a
Hyperbaric Oxygen Therapy
MA07.017c
Hyperthermic Intraperitoneal Chemotherapy for Select IntraAbdominal and Pelvic Malignancies
MA08.096a
Ibalizumab-uiyk (Trogarzo™)
MA06.018a
Immune Cell Function Assay
Show details for
MA08.009h
Immune Globulin: Intravenous (IVIG), Subcutaneous (SCIG)
MA05.053g
Implantable and External Infusion Pumps
MA11.107c
Implantable Steroid-Eluting Sinus Stents
MA06.002b
In Vitro Allergy Testing
MA06.021d
In Vitro Chemosensitivity and Chemoresistance Assays
MA06.004a
In Vivo Allergy Sensitivity Testing
MA00.045d
Incident To and Non-Incident To Services Performed by Certified Registered Nurse Practitioners (CRNPs) and Physician Assistants (PAs)
Show details for
MA08.019f
Infliximab and Related Biosimilars
MA05.021a
Injectable Dermal Fillers
MA00.023a
Inpatient Hospital Readmission
MA07.048a
Instrument-Based Vision Screening
MA08.024f
Interleukin-5 (IL-5) Antagonist (e.g., Cinqair®, Nucala®) and IL-5 Receptor Antagonist (e.g., Fasenra®)
MA07.051f
Intraoperative Neurophysiological Testing
MA07.025d
Intrauterine Systems (IUSs) (e.g., Mirena®, Skyla®, Liletta®, Kyleena®)
Show details for
MA07.016b
Intravenous Chelation Therapy
MA00.022
Intravenous (IV) Administration of Fluids as a Treatment of a Medical Condition or for the Preparation of Pharmaceuticals, Biologics, and other Substances
Show details for
MA08.073f
Intravitreal Injection of Vascular Endothelial Growth Factor (VEGF) Antagonists and Related Biosimilars
Show details for
MA08.059f
Ipilimumab (Yervoy®)
MA11.007a
Islet Cell Transplantation
MA05.013c
Knee Orthoses
MA11.067d
Labiaplasty
MA07.031a
Laboratory-Based Vestibular Function Testing
Show details for
MA00.030o
Laboratory Services for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products
Show details for
MA08.090b
Lanreotide (Somatuline® Depot)
MA05.067b
Leadless Pacemakers
MA11.070a
Lipectomy and Liposuction
MA06.007c
Loss-of-Heterozygosity-Based Topographic Genotyping with PathFinderTG®
MA07.036c
Low-Level Laser Therapy
MA09.008a
Low Osmolar Contrast Agents
Show details for
MA05.024c
Lower Limb Prostheses
MA11.048c
Lumbar Interspinous Process Decompression System
MA08.110
Luspatercept–aamt (Reblozyl®)
MA06.006d
Lyme Disease: Diagnosis and Intravenous (IV) Antibiotic Treatment
MA11.095a
Lysis of Epidural Adhesions
MA07.014
Magnetic Pelvic Floor Stimulation (MPFS)
MA09.021c
Magnetic Resonance Imaging (MRI)--Guided Focused Ultrasound Ablation
MA09.010b
Magnetic Resonance Imaging (MRI) Contrast Agents
MA07.039a
Magnetoencephalography (MEG) with Magnetic Source Imaging (MSI)
MA11.091b
Manipulation Under Anesthesia
Show details for
MA05.026a
Manual Wheelchairs
MA00.038a
Marijuana for Medical Use
MA07.044b
Measurement of Exhaled Nitric Oxide and Breath Condensate in the Diagnosis and Management of Asthma and Other Respiratory Disorders
MA06.019c
Measurement of Serum Antibodies to and Measurement of Serum Levels of Biologics
MA05.043a
Mechanical Stretching Devices for the Treatment of Joint Stiffness or Contractures
MA07.024c
Medical and Surgical Treatment of Temporomandibular Joint Disorder
MA12.008
Medical Necessity
Show details for
MA08.007q
Medicare Part B vs. Part D Crossover Drugs
Show details for
MA11.081a
Meniscal Allograft Transplantation
MA11.080a
Mentoplasty or Genioplasty
MA11.098
Migraine Deactivation Surgery
MA03.009d
Modifier 24: Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During a Postoperative Period
Show details for
MA03.003g
Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service









Connect with Us        


© 2017 Independence Blue Cross.
Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.