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Medicare Medical Policies

Medicare provides policies guiding coverage of many medical services and interventions. These Medicare policies include statutes, regulations, national coverage determinations, local coverage determinations, and general coverage and benefit conditions in traditional Medicare (collectively referred to as "Medicare criteria").

When Medicare criteria are not fully established, as that term is defined in Medicare rules, Capital Blue Cross and/or our contracted third-party vendors, may develop and/or adopt additional policies and coverage criteria based on current evidence in widely used treatment guidelines or clinical literature, as permitted by law.

Find the policies you need, including for specialty care:

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Medicare Coverage Guidance

Medicare coverage and payment is contingent upon a determination that:

A service is in a covered benefit category
A service is not specifically excluded from Medicare coverage by the Social Security Act
The item or service is “reasonable and necessary” for the diagnosis or treatment of an illness or injury, to improve functioning of a malformed body member, or is a covered preventive service

These criteria are codified through rulemaking in the Code of Federal Regulations and/or applied in manual guidance, or are applied through coverage determinations. The Medicare Managed Care Manual Chapter 4 delineates Medicare Advantage Benefits and Beneficiary Protections and specifically Section 90 provides guidance on Coverage Determinations.

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Capital Medical Policies

Each medical policy includes:

Policy criteria — The internal coverage criteria including a summary of evidence that was considered during the development of these criteria.
Rationale — An explanation of the evidence that supports the adoption of the coverage criteria used to make a medical necessity determination.
References — A list of the sources of evidence used to develop the policy.

Medicare criteria take precedence. Capital Blue Cross policies will be used when Medicare criteria are incomplete or have not been provided.

Coverage criteria provide clinical benefits that are highly likely to outweigh any clinical harms, including harms resulting from delayed or decreased access to items or services. Each policy provides one or more of the following Clinical Benefits:

Minimize safety risk or concern.
Minimize harmful or ineffective interventions.
Assure appropriate level of care.
Assure appropriate duration of service for interventions.
Assure that recommended medical prerequisites have been met.
Assure appropriate site of treatment or service.

Current Capital coverage criteria policies can be found by clicking on the titles below:

Policy number	Policy title	Clinical benefit(s)
2.087	Actigraphy	1,2
3.017	Air and Water Ambulance Services	5
6.015	Airway Clearance Devices	1,2,5
2.001	Allergy Testing and Immunotherapy	1,2
2.304	Autism Spectrum Disorders	1,2
1.119	Balloon Ostial Dilation for the Treatment of CRS and RARS	5
2.317	BCR ABL1 Testing in Chronic Myelogenous Leukemia and Acute Lymphoblastic Leukemia	5
2.064	Biofeedback and Neurofeedback Therapy	3
2.190	Bioimpedance Devices for Detection and Management of Lymphedema	1,2
2.081	Bronchial Thermoplasty	2
2.051	Cardiac Hemodynamic Monitoring for the Mgmt of Heart Failure in the Outpatient Setting	2
2.267	Circulating Tumor Dna And Circulating Tumor Cells For Cancer Management (Liquid Biopsy)	2
2.093	Confocal Laser Endomicroscopy	1,2
1.044	Corneal Surgery, Implantation of Intrastromal Corneal Ring Segment, and Corneal Topography Photokeratoscopy	5
1.004	Cosmetic and Reconstructive Surgery	2, 5
1.088	Cryoablation of Tumors Located in the Kidney, Lung, Breast, Pancreas or Bone	1,5
1.121	Cryosurgical Ablation of Primary or Metastatic Liver Tumors	1,2,5
2.234	Cytochrome P450 Genotype Guided Treatment Strategy	2
4.033	Diagnosis and Treatment of Dry Eye Syndrome	1,2
4.041	Dry Needling of Trigger Points for Myofascial Pain	1,2
6.026	Durable Medical Equipment (DME) and Supplies	5
2.011	Dynamic Posturography	1,2
1.090	Endovascular Grafts for Abdominal Aortic Aneurysms	5
2.391	Evaluation of Biomarkers for Alzheimer Disease	1, 2, 5
2.259	Expanded Molecular Panel Testing of Cancers to Identify Targeted Therapies	2, 5
4.002	Experimental and Investigational Procedures	1,2,5
2.034	Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions	1,2
2.028	Eye Care	1,2
2.069	Gastric Electrical Stimulation	5
1.144	Gender Affirming Surgery	1,2,5
2.245	Gene Expression Based Assays for Cancers of Unknown Primary	2
2.315	Gene Expression Profile Testing and Circulating Tumor DNA testing for Predicting Recurrence in Colon Cancer	2
2.280	Gene Expression Profiling and Protein Biomarkers for the Management, Diagnosis, and Cancer Risk Assessment of Prostate Cancer	5,2
2.396	Gene Expression Profiling for Cutaneous Melanoma	2
2.360	Gene Expression Profiling for Melanoma	2,5
2.323	General Approach to Evaluating Utility of Genetic Panels	5
2.326	General Approach to Genetic Testing	2, 5
2.325	Genetic Cancer Susceptibility Panels Using Next Generation Sequencing	2
2.050	Genetic Testing for Alzheimer's Disease	2
2.242	Genetic Testing for DD, ID, Autism Spectrum Disorder and CA	2
2.264	Genetic Testing for Diagnosis and Management of Mental Health Conditions	1,2
2.257	Genetic Testing for Duchenne and Becker Muscular Dystrophy	5
2.246	Genetic Testing for Familial Cutaneous Malignant Melanoma	5
2.357	Genetic Testing for FLT3, NPM1 and CEBPA Variants in Cytogenetically Normal Acute Myeloid Leukemia	5, 2
2.308	Genetic Testing for Helicobacter Pylori Treatment	2
2.318	Genetic Testing for Hereditary Pancreatitis	5
2.253	Genetic Testing for Inherited Thrombophilia	5
2.310	Genetic Testing for Lipoprotein(a) Variant(s) as a Decision Aid for Aspirin Treatment	2
5.013	Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes	5
2.260	Genetic Testing for Macular Degeneration	2
2.273	Genetic Testing for Mitochondrial Disorders	5
2.248	Genetic Testing for Predisposition to Inherited Hypertrophic Cardiomyopathy	1,2
2.255	Genetic Testing for PTEN Hamartoma Tumor Syndrome	5
2.355	Genetic Testing for the Diagnosis of Inherited Peripheral Neuropathies	5
2.306	Genotype-Guided Warfarin Dosing	2
2.384	Germline Genetic Testing for Hereditary Diffuse Gastric Cancer (CDH1,CTNNA1)	3, 5
9.014	Heart-Lung Transplant	5
2.021	Hyperthermic Intraperitoneal Chemotherapy for Select Intra-Abdominal and Pelvic Malignancies	1,2,5
1.019	Implantable Bone-Conduction and Bone-Anchored Hearing Prosthetic Devices	5
1.058	Implantable Infusion Pumps for Pain and Spasticity	5
6.047	Interferential Current Stimulation	2
1.120	Interventions for Progressive Scoliosis	2
6.058	Intraocular Lenses, Spectacle Correction, and Iris Prosthesis	2
2.389	Intraocular Radiotherapy for Age-Related Macular Degeneration	1
2.167	Intravenous Anesthetics for the Treatment of Chronic Pain	1,2
4.005	Intravenous Chelation Therapy	5
2.278	Invasive Prenatal (Fetal) Diagnostic Testing	1,2,5
2.277	Investigational Miscellaneous Genetic and Molecular Tests	2
8.001	Investigational Physical Medicine and Specialized Physical Medicine Interventions (Outpatient)	3, 2
1.162	Irreversible Electroporation of Tumors Located in the Liver, Pancreas, Kidney or Lung	2
9.012	Islet Transplantation	2
9.013	Isolated Small Bowel Transplant and Small Bowel-Liver and Multivisceral Transplant	5
2.281	JAK2, MPL, and CALR Testing for Myeloproliferative Neoplasms	5
9.005	Kidney Transplants Pancreas Transplants and Simultaneous Kidney Pancreas Transplants	5
2.309	KIF6 Genotyping for Predicting Cardiovascular Risk and or Effectiveness of Statin Therapy	1,2
2.354	Laboratory and Genetic Testing for Use of 5-Flourouracil in Patients with Cancer	2
2.046	Light Therapies	3, 5
9.006	Liver Transplant and Combined Liver-Kidney Transplant	3, 5
9.015	Lung and Lobar Lung Transplant	5
6.027	Lysis of Epidural Adhesions	2
5.053	Magnetic Resonance‒Guided Focused Ultrasound	1,2
4.038	Measurement of Exhaled Nitric Oxide and Exhaled Breath Condensate in Diag-Mgmt of Asthma and other Resp Disorders	1,2
6.039	Mechanical Stretching Devices for Contracture and Joint Stiffness	2,5
4.003	Medical Necessity
2.084	Minimally Invasive Ablation Procedures for Morton and Other Peripheral Neuromas	2
2.241	Molecular Analysis for Targeted Therapy for Non-Small Cell Lung Cancer	1,2,5
2.275	Molecular Markers in Fine Needle Aspirates of the Thyroid	2
2.266	Molecular Testing for The Management of Pancreatic Cysts, Barrett Esophagus, And Solid Pancreaticobiliary Lesions	2
2.387	Multicancer Early Detection Testing	2
2.270	Multimarker Serum Testing Related to Ovarian Cancer	2
6.051	Neuromuscular and Functional Neuromuscular Electrical Stimulation	5, 2
2.379	Next-Generation Sequencing For The Assessment of Measurable Residual Disease	2,5
2.261	Noninvasive Fetal RHD Genotyping Using Cell-Free Fetal DNA	2
2.252	Noninvasive Techniques for the Evaluation and Monitoring of Patients with Chronic Liver Disease	1,2
2.071	Nonpharmacologic Treatment of Rosacea	2
2.372	Occipital Nerve Stimulation	2
8.004	Occupational Therapy (Outpatient)	3
2.103	Off-Label use of Medications and other Interventions	3
4.019	Oncological Applications of Photodynamic Therapy including Barrett's Esophagus	5
2.383	Orphan Drugs and Humanitarian Use Devices	1
2.080	Orthopedic Applications of Stem Cell Therapy Including Allograft and Bone Substitute Products Used with Autologous Bone Marrow	2
2.097	Paraspinal Surface Electromyography to Evaluate and Monitor Back Pain	1,2
1.134	Percutaneous and Implantable Tibial Nerve Stimulation	2
2.092	Percutaneous Electrical Nerve Field Stimulation, Cranial Electrotherapy Stimulation, Auricular Electrostimulation, and External Trigeminal Nerve Stimulation	1,2
1.124	Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, Biacuplasty and Intraosseous Basivertebral Nerve Ablation	2
2.218	Pharmacogenomic and Metabolite Markers for Patients with Inflammatory Bowel Disease Treated with Thiopurines	5
2.088	Pharyngometry and Rhinometry	1,2
4.008	Photodynamic or Photocoagulation Therapy for Choroidal Neovascularization	2
5.008	Positron Emission Mammography	2
7.009	Preimplantation Genetic Testing	1,2
2.343	Proteogenomic Testing for Patients With Cancer	2
1.084	Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors	2,5
1.055	Radiofrequency Ablation of Primary or Metastatic Liver Tumors	5
1.103	Reconstructive Breast Surgery including Management of Breast Implants, External Breast Prosthesis and Post Mastectomy Bras	2
1.033	Sacral Nerve Neuromodulation-Stimulation and Pelvic Floor Stimulation Devices	3
1.130	Semi-Implantable and Fully Implantable Middle Ear Hearing Aid	1,2,5
8.011	Sensory Integration and Auditory Integration Therapy	2
2.222	Serum Antibody Markers for Diagnosing Inflammatory Bowel Disease	1,2
2.269	Serum Biomarkers for Human Epididymis Protein 4 - HE4	2
2.388	Somatic Biomarker Testing for Immune Checkpoint Inhibitor Therapy (MSI/MMR, PD-L1, TMB)	5
2.316	Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment of Metastatic Colorectal Cancer	5
2.364	Somatic Genetic Testing to Select Individuals with Melanoma or Glioma for Targeted Therapy or Immunotherapy	2
6.032	Speech Generating Devices	5
8.002	Speech Therapy Outpatient	2
4.046	Sphenopalatine Ganglion Block For Headache	2
1.069	Spinal Cord and Dorsal Root Ganglion Stimulation	5
2.373	Step Therapy Treatment of Stage 4	3
1.140	Steroid-Eluting Sinus Stents	1,2,5
2.345	Subcutaneous Hormone Pellet Implants	1,2
1.114	Subtalar Arthroereisis	1,2
1.163	Surgery for Groin Pain in Athletes	2
1.128	Surgical Treatment of Snoring and Obstructive Sleep Apnea	2,5
1.161	Surgical Treatments for Breast Cancer Related Lymphedema	2,5
2.066	Technologies for the Evaluation of Skin Lesions Suspected of Malignancy	2,5
5.017	Thermography	1,2
1.026	Total Artificial Hearts and Implantable Ventricular Assist Devices	5
1.057	Transmyocardial Revascularization	2
4.034	Transvaginal and Transurethral Radiofrequency Tissue Remodeling for Urinary Stress Incontinence	1,2
4.043	Treatments of the Prostate	2, 5
2.072	Trigger Point and Tender Point Injections	2
5.036	Ultrasonographic Measurement of Carotid Intimal Medial Thickness as an Assessment of Subclinical Atherosclerosis	2
6.052	Upper Limb Prostheses	2, 5
2.065	Vertebral Axial Decompression	1,2
2.208	Viral Tropism Testing	5
4.007	Vision Therapy	1,2
5.033	Wireless Capsule Endoscopy for Gastrointestinal (GI) Disorders	2
4.028	Wound and Burn Management and Specialized Treatment Centers	2,5

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Capital Coverage Criteria

Preauthorization for acute inpatient care, long term acute care hospital (LTACH), behavioral health services, and select procedures will be conducted using Optum’s InterQual^® criteria.

InterQual criteria are an industry standard set of objective evidence-based utilization management (UM) criteria for level of care placement and medical necessity determinations, including length of stay. These criteria are specific and comprehensive clinical guidelines developed by a highly trained clinical team who performs unbiased, systematic review and clinical appraisal of the evidence to help ensure the criteria reflect the best available clinical evidence. The criteria are updated frequently to remain current with the latest evidence.

The clinical benefit of using InterQual criteria to manage these levels of care include:

Minimize safety risk or concern.
Minimize harmful or ineffective interventions.
Assure appropriate level of care.
Assure appropriate duration and/or frequency of interventions.
Assure that recommended medical prerequisites have been met.
Assure appropriate site of treatment or service.

If you are not currently a Capital Blue Cross Member or Provider, learn more information about accessing Capital Coverage Criteria.

Current Capital Blue Cross Member or Provider, learn more information about accessing Capital Coverage Criteria. If you are not already logged in to your secure account, you will be prompted to log in or register.

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Behavioral Health Services

Preauthorization for select behavioral health services will be performed using Change Healthcare’s InterQual^® criteria. InterQual criteria are an industry standard set of objective evidence-based UM criteria for level of care placement and medical necessity determinations, including length of stay for mental health services.

The clinical benefit of using InterQual criteria to manage these levels of care include:

Minimize safety risk or concern.
Minimize harmful or ineffective interventions.
Assure appropriate level of care.
Assure appropriate duration and/or frequency of interventions.
Assure that recommended medical prerequisites have been met.
Assure appropriate site of treatment or service.

Preauthorization for select substance use disorder services will be performed using the American Society of Addiction Medicine (ASAM) criteria.

ASAM criteria are an industry standard collection of guidelines for level of care placement and medical necessity determinations, including length of stay for substance use disorder services.

The clinical benefits of using ASAM criteria to manage these levels of care include:

Minimize safety risk or concern.
Minimize harmful or ineffective interventions.
Assure appropriate level of care.
Assure appropriate duration and/or frequency of interventions.
Assure that recommended medical prerequisites have been met.
Assure appropriate site of treatment or service.

If you are not currently a Capital Blue Cross Member or Provider, learn more information about accessing Capital Coverage Criteria.

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High tech Radiology, Select Cardiac Imaging, and Radiation Oncology Services

Preauthorization for high tech radiology, select cardiac imaging, and radiation oncology services will be performed using medical policies administered by Evolent Specialty Services, Inc. (Evolent). On behalf of Capital Blue Cross, Evolent, reviews certain medical specialty requests to see if they are medically necessary and a covered service under the Capital Blue Cross benefit plan.

Each of Evolent's medical policies in the chart below align with one of the following clinical benefit categories:

Minimize safety risk or concern.
Minimize harmful or ineffective intervention.
Assure appropriate level of care.
Assure appropriate duration and/or frequency of intervention.
Assure recommended medical prerequisites have been met.
Assure appropriate site of treatment or service.

Policy name	Policy number	Clinical benefit category (as described above)
Abdomen CTA (angiography)	Evolent_CG_034-1	1,2,5
Abdomen Pelvis CTA (angiography)	Evolent_CG_069	1,2,5
Bone Marrow MRI	Evolent_CG_059	2
Brain (head) CTA	Evolent_CG_004-1	1,2,5
Brain (head) MRS (Magnetic Resonance Spectroscopy)	Evolent_CG_003	1,2,4
Coronary Artery Calcium Scoring by: Electron-Beam Tomography (EBCT) or Non-Contrast Coronary Computed Tomography (Non-Contract CCT)	Evolent_CG_029	2,5
CT (Virtual) Colonoscopy Diagnostic	Evolent_CG_033-1	1,2,5
Cerebral Perfusion CT	Evolent_CG_015	1,2,5
Chest CTA	Evolent_CG_022-1	1,2,5
CCTA Aortogram with Runoff	Evolent_CG_035	1,2,5
Coding Standard for Dosimetry Planning		1,2,4
Coding Standard for Image Guidance		1,2,4
Coding Standard for Physician Treatment Management		1,2,4
Coding Standard for Physics		1,2,4
Coding Standard for Simulations		1,2,4
Coding Standard for Treatment Devices		1,2,4
Lower Extremity CTA/CTV	Evolent_CG_061-1	1,2,5
Magnetic Resonance Elastography (MRE)	Evolent_CG_2038	1,2,5
MUGA (Multiple Gated Acquisition) Scan	Evolent_CG_027	2,5
Neck CTA	Evolent_CG_012-1	1,2,5
Pelvis CTA (angiography)	Evolent_CG_038	1,2,5
Radiation Therapy Services	Evolent_CG_7000	1,2,4
Proton Beam Radiation Therapy and Neutron Beam Radiation Therapy Services	Evolent_CG_7001	1,2,4
Upper Extremity CTA/CTV	Evolent_CG_061-2	1,2,5

Learn more about accessing Evolent medical policies.

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Select Diagnostic and Surgical Cardiology Services

Preauthorization for select cardiac surgeries and procedures will be performed using medical policies administered by TurningPoint.

Each of TurningPoint’s medical policies in the chart below align with one of the following clinical benefit categories:

Minimize safety risk or concern.
Minimize harmful or ineffective intervention.
Assure appropriate level of care.
Assure appropriate duration and/or frequency of intervention.
Assure recommended medical prerequisites have been met.
Assure appropriate site of treatment or service.

Policy name	Policy number	Clinical benefit category (as described above)
Implantable Cardioverter Defibrillator	CA-1001	2,3,5,6
Pacemaker	CA-1003	2,3,5,6
Coronary Artery Bypass Grafting	CA-1005	2,3,5,6
Coronary Angioplasty and Stenting	CA-1006	2,3,5,6
Non-Coronary Angioplasty and Endovascular Stent	CA-1007	2,3,5,6
Implantable Cardiac Monitoring	CA-1008	2,3,5,6
Wearable Cardioverter Defibrillator	CA-1009	2,5,6
Valve Replacement	CA-1011	2,3,5,6
Peripheral Revascularization	CA-1012	2,3,5,6
Diagnostic Coronary Angiography	CA-1013	2,3,5,6
Cardiac Contractility Modulation	CA-1018	2,3,5,6
Peripheral Diagnostic Angiogram and Venogram	CA-1019	2,3,5,6

Learn more information on accessing TurningPoint’s medical policies.

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Select Musculoskeletal Services Including Hip, Knee, Shoulder, and Spine Procedures

Preauthorization for select musculoskeletal services including hip, knee, shoulder, and spine procedures will be performed using medical policies administered by TurningPoint.

Each of TurningPoint’s medical policies in the chart below align with one of the following clinical benefit categories:

Minimize safety risk or concern.
Minimize harmful or ineffective intervention.
Assure appropriate level of care.
Assure appropriate duration and/or frequency of intervention.
Assure recommended medical prerequisites have been met.
Assure appropriate site of treatment or service.

Policy name	Policy number	Clinical benefit category (as described above)
Total Hip Replacement	OR-1001	2,5,6
Total Knee Replacement	OR-1002	2,5,6
Lumbar Disc Replacement	OR-1003	2,5,6
Lumbar Spinal Fusion	OR-1004	2,5,6
Bone Morphogenetic Protein	OR-1005	2
Cervical Disc Replacement	OR-1006	2,5,6
Cervical Laminectomy and Discectomy	OR-1007	2,5,6
Lumbar Laminectomy, Discectomy, and Laminotomy	OR-1008	2,5,6
Sacroiliac Joint Fusion	OR-1009	2,5,6
Thoracic Laminectomy or Discectomy	OR-1010	2,5,6
Thoracic Spinal Fusion	OR-1011	2,5,6
Cervical Spinal Fusion	OR-1012	2,5,6
ACL Repair	OR-1013	2,5,6
Treatment of Osteochondral Defects	OR-1014	2,5,6
Acromioplasty and Rotator Cuff Repair	OR-1018	2,5,6
Shoulder Fusion	OR-1019	2,5,6
Surgery for Spinal Deformity	OR-1020	2,5,6
Shoulder Replacement	OR-1023	2,5,6
Vertebral Augmentation	OR-1024	2,5,6
Femoroacetabular Arthroscopy	OR-1025	2,5,6
Hip Resurfacing	OR-1026	2,5,6
Meniscal Allograft Transplantation	OR-1027	2,5,6
Partial Knee Replacement	OR-1028	2,5,6
Knee Arthroscopy	OR-1029	2,5,6
Hip Arthroscopy	OR-1031	2,5,6
Computer Assisted Navigation	OR-1035	2,5,6
Shoulder Procedures	OR-1036	2,5,6
Spinal Devices	OR-1037	2,5,6
Sacral Decompression	OR-1038	2,5,6
Manipulation Under Anesthesia	OR-1040	2
Hip Osteotomy	OR-1042	2,5,6
MPFL Reconstruction	OR-1043	2,5,6
Osteotomies for Spinal Deformity	OR-1045	2,5,6
Bone Graft Substitutes	OR-1046	2
Orthopedic Application of Stem Cell Therapy	OR-1047	2
Percutaneous Tenotomy	OR-1049	2
Hip Core Decompression	OR-1050	2,6

Learn more information on accessing TurningPoint’s medical policies.

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Medical Drugs, Biologics and Diabetes Supplies

Prior authorization for medical specialty drugs, biologics and diabetes supplies will be performed using medical policies administered by Prime Therapeutics. Diabetes supplies prior authorization policies apply to non-preferred Continuous Glucose Monitors, Diabetic Monitors and Diabetic Test Strips. Diabetic supplies benefit limit policies apply to preferred and non-preferred products. On behalf of Capital Blue Cross, Prime Therapeutics LLC assists in the administration of our prescription drug program. Prime Therapeutics LLC is an independent pharmacy benefit manager.

Each of Prime Therapeutics’ medical policies in the chart below align with one of the following clinical benefit categories:

Minimize safety risk or concern.
Minimize harmful or ineffective intervention.
Assure appropriate level of care.
Assure appropriate duration and/or frequency of intervention.
Assure recommended medical prerequisites have been met.
Assure appropriate site of treatment or service.

Please Note: Drug search can be performed by selecting Ctrl + F and typing the drug name in the search bar.

Learn more information:

J-Code	Medication Name	Policy	Clinical Benefit
A9513	LUTETIUM LU 177 DOTATATE (Lutathera)	MPS Medicare Part B Utilization Management Review	1, 2, 4
A9607	LUTETIUM LU 177 VIPIVOTIDE TETRAXETAN (Pluvicto)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J0129	ABATACEPT (Orencia)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J0180	AGALSIDASE BETA (Fabrazyme)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J0202	ALEMTUZUMAB (Lemtrada)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J0217	VELMANASE ALFA-TYCV (Lamzede)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J0218	OLIPUDASE ALFA-RPCP (Xenpozyme)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J0219	AVALGLUCOSIDASE ALFA-NGPT (Nexviazyme)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J0221	ALGLUCOSIDASE ALFA (Lumizyme)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J0222	PATISIRAN (Onpattro)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J0223	GIVOSIRAN (Givlaari)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J0224	LUMASIRAN (Oxlumo)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J0225	VUTRISIRAN (Amvuttra)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J0490	BELIMUMAB (Benlysta IV)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J0491	ANIFROLUMAB-FNIA (Saphnelo)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J0567	CERLIPONASE ALFA (Brineura)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J0584	BUROSUMAB-TWXA (Crysvita)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J0596	C1 ESTERASE INHIBITOR [RECOMBINANT] (Ruconest)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J0597	C1 INHIBITOR (HUMAN) (Berinert)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J0598	C1 INHIBITOR (HUMAN) (Cinryze)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J0638	CANAKINUMAB (Ilaris)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J0717	CERTOLIZUMAB PEGOL (Cimzia)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J0791	CRIZANLIZUMAB-TMCA (Adakveo)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J0870	IMETELSTAT (Rytelo)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J0896	LUSPATERCEPT-AAMT (Reblozyl)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J0897	DENOSUMAB (Prolia)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J0897	DENOSUMAB (Xgeva)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J1203	CIPAGLUCOSIDASE ALFA-ATGA (Pombiliti)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J1290	ECALLANTIDE (Kalbitor)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J1301	EDARAVONE (Radicava)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J1302	SUTIMLIMAB-JOME (Enjaymo)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J1303	RAVULIZUMAB-CWVZ (Ultomiris)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J1304	TOFERSEN (Qalsody)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J1305	EVINACUMAB-DGNB (Evkeeza)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J1306	INCLISIRAN (Leqvio)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J1307	CROVALIMAB-AKKZ (Piasky)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J1322	ELOSULFASE ALFA (Vimizim)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J1323	ELRANATAMAB-BCMM (Elrexfio)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J1326	ZOLBETUXIMAB-CLZB (Vyloy)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J1411	ETRANACOGENE DEZAPARVOVEC-DRLB (Hemgenix)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J1412	VALOCTOCOGENE ROXAPARVOVEC-RVOX (Roctavian)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J1413	DELANDISTROGENE MOXEPARVOVEC-ROKL (Elevidys)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J1414	FIDANACOGENE ELAPARVOVEC-DZKT (Beqvez)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J1426	CASIMERSEN (Amondys-45)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J1427	VILTOLARSEN (Viltepso)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J1428	ETEPLIRSEN (Exondys-51)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J1429	GOLODIRSEN (Vyondys-53)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J1448	TRILACICLIB (Cosela)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J1454	FOSNETUPITANT/PALONOSETRON (Akynzeo IV)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J1458	GALSULFASE (Naglazyme)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J1551	SUBCUTANEOUS IMMUNE GLOBULIN (Cutaquig)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J1552	INTRAVENOUS IMMUNE GLOBULIN (Alyglo)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J1554	INTRAVENOUS IMMUNE GLOBULIN (Asceniv)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J1576	INTRAVENOUS IMMUNE GLOBULIN (Panzyga)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J1599	INTRAVENOUS IMMUNE GLOBULIN (Yimmugo)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J1599	INTRAVENOUS IMMUNE GLOBULIN (Gammagard ERC)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J1602	GOLIMUMAB (Simponi_ARIA)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J1627	GRANISETRON EXTENDED-RELEASE (Sustol)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J1628	GUSELKUMAB (Tremfya IV)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J1743	IDURSULFASE (Elaprase)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J1747	SPESOLIMAB-SBZO (Spevigo)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J1786	IMIGLUCERASE (Cerezyme)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J1823	INEBILIZUMAB-CDON (Uplizna)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J1931	LARONIDASE (Aldurazyme)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J2182	MEPOLIZUMAB (Nucala)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J2267	MIRIKIZUMAB-MRKZ (Omvoh IV)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J2323	NATALIZUMAB (Tysabri)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J2326	NUSINERSEN (Spinraza)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J2327	RISANKIZUMAB-RZAA (Skyrizi IV)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J2329	UBLITUXIMAB-XIIY (Briumvi)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J2350	OCRELIZUMAB (Ocrevus)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J2351	OCRELIZUMAB AND HYALURONIDASE-OCSQ (Ocrevus Zunovo)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J2357	OMALIZUMAB (Xolair)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J2468	PALONOSETRON (AVYXA) (Palonosetron)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J2469	PALONOSETRON (Aloxi)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J2507	PEGLOTICASE (Krystexxa)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J2508	PEGUNIGALSIDASE-IWXJ (Elfabrio)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J2781	PEGCETACOPLAN (Syfovre)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J2782	AVACINCAPTAD PEGOL (Izervay)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J2796	ROMIPLOSTIM (Nplate)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J2840	SEBELIPASE ALFA (Kanuma)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J2998	PLASMINOGEN, HUMAN-TVMH (Ryplazim)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J3032	EPTINEZUMAB-JJMR (Vyepti)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J3055	TALQUETAMAB-TGVS (Talvey)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J3060	TALIGLUCERASE ALFA (Elelyso)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J3111	ROMOSOZUMAB-AQQG (Evenity)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J3241	TEPROTUMUMAB-TRBW (Tepezza)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J3245	TILDRAKIZUMAB-ASMN (Ilumya)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J3262	TOCILIZUMAB (Actemra IV)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J3263	TORIPALIMAB-TPZI (Loqtorzi)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J3304	TRIAMCINOLONE ACETONIDE (Zilretta)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J3358	USTEKINUMAB (Stelara/Ustekinumab (IV))	MPS Medicare Part B Utilization Management Review	1, 2, 4
J3380	VEDOLIZUMAB (Entyvio)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J3385	VELAGLUCERASE ALFA (Vpriv)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J3391	ATIDARSAGENE AUTOTEMCEL (Lenmeldy)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J3392	EXAGAMGLOGENE AUTOTEMCEL (Casgevy)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J3393	BETIBEGLOGENE AUTOTEMCEL (Zynteglo)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J3394	LOVOTIBEGLOGENE AUTOTEMCEL (Lyfgenia)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J3397	VESTRONIDASE ALFA-VJBK (Mepsevii)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J3398	VORETIGENE NEPARVOVEC-RZYL (Luxturna)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J3399	ONASEMNOGENE ABEPARVOVAC-XIOI (Zolgensma)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J3401	BEREMAGENE GEPERPAVEC-SVDT (Vyjuvek)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J3402	REMESTEMCEL-L-RKND (Ryoncil)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J3403	REVAKINAGENE TARORETCEL-LWEY (Encelto)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J3490	NEDOSIRAN (Rivfloza)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J3590	TOCILIZUMAB-ANOH (Tocilizumab IV)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J3590	USTEKINUMAB-HMNY (Starjemza IV)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J3590	NIPOCALIMAB-AAHU (Imaavy)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J3590	PRADEMAGENE ZAMIKERACEL (Zevaskyn)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J3590	SATRALIZUMAB-MWGE (Enspryng)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J3590	ELAPEADEMASE-LVLR (Revcovi)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J3590	ELIVALDOGENE AUTOTEMCEL (Skysona)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J3590	ELADOCAGENE EXUPARVOVEC-TNEQ (Kebilidi)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J3590	OMIDUBICEL-ONLV (Omisirge)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J3590	DENOSUMAB-DSSB (Denosumab-dssb)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J7170	EMICIZUMAB-KXWH (Hemlibra)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J7171	APADAMTASE ALFA (Adzynma)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J7172	MARSCTACIMAB-HNCQ (Hympavzi)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J7173	CONCIZUMAB-MTCI (Alhemo)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J7174	FITUSIRAN (Qfitlia)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J7175	COAGULATION FACTOR X (HUMAN) (Coagadex)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J7179	VON WILLEBRAND FACTOR (RECOMBINANT) (Vonvendi)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J7180	FACTOR VIII CONCENTRATE (HUMAN) (Corifact)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J7181	COAGULATION FACTOR XIII A-SUBUNIT (RECOMBINANT) (Tretten)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J7182	ANTIHEMOPHILIC FACTOR (RECOMBINANT) (Novoeight)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J7183	VON WILLEBRAND FACTOR/COAGULATION FACTOR VIII COMPLEX (Wilate)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J7185	ANTIHEMOPHILIC FACTOR (RECOMBINANT) (Xyntha)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J7186	ANTIHEMOPHILIC FACTOR/VON WILLEBRAND FACTOR COMPLEX (HUMAN) (Alphanate)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J7187	ANTIHEMOPHILIC FACTOR/VON WILLEBRAND FACTOR COMPLEX (HUMAN) (Humate-P)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J7188	ANTIHEMOPHILIC FACTOR (RECOMBINANT), PORCINE SEQUENCE (Obizur)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J7189	COAGULATION FACTOR VIIA (RECOMBINANT) (Novoseven RT)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J7190	ANTIHEMOPHILIC FACTOR (HUMAN) (Hemofil M)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J7190	ANTIHEMOPHILIC FACTOR (HUMAN) (Koate DVI)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J7192	ANTIHEMOPHILIC FACTOR (RECOMBINANT) (Advate)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J7192	ANTIHEMOPHILIC FACTOR (RECOMBINANT) (Recombinate)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J7193	COAGULATION FACTOR IX (HUMAN) (Alphanine SD)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J7194	FACTOR IX COMPLEX (Profilnine)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J7195	COAGULATION FACTOR IX (RECOMBINANT) (BeneFIX)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J7198	ANTI-INHIBITOR COAGULANT COMPLEX (Feiba NF/VF)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J7200	COAGULATION FACTOR IX (RECOMBINANT) (Rixubis)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J7201	COAGULATION FACTOR IX (RECOMBINANT), FC FUSION PROTEIN (Alprolix)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J7202	COAGULATION FACTOR IX (RECOMBINANT), ALBUMIN FUSION PROTEIN (Idelvion)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J7203	COAGULATION FACTOR IX (RECOMBINANT), GLYCOPEGYLATED (Rebinyn)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J7204	ANTIHEMOPHILIC FACTOR (RECOMBINANT), GLYCOPEGYLATED-EXEI (Esperoct)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J7205	ANTIHEMOPHILIC FACTOR (RECOMBINANT), FC FUSION PROTEIN (Eloctate)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J7207	ANTIHEMOPHILIC FACTOR (RECOMBINANT), PEGYLATED (Adynovate)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J7208	ANTIHEMOPHILIC FACTOR (RECOMBINANT), PEGYLATED-AUCL (Jivi)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J7209	ANTIHEMOPHILIC FACTOR (RECOMBINANT) (Nuwiq)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J7210	ANTIHEMOPHILIC FACTOR (RECOMBINANT), SINGLE CHAIN (Afstyla)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J7211	ANTIHEMOPHILIC FACTOR (RECOMBINANT) (Kovaltry)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J7212	COAGULATION FACTOR VIIA (RECOMBINANT) (Sevenfact)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J7213	COAGULATION FACTOR IX (RECOMBINANT) (Ixinity)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J7214	ANTIHEMOPHILIC FACTOR (RECOMBINANT), FC-VWF-XTEN FUSION PROTEIN-EHTL (Altuviiio)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J7352	AFAMELANOTIDE (Scenesse)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9011	DATOPOTAMAB DERUXTECAN-DLNK (Datroway)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9015	ALDESLEUKIN (Proleukin)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9021	ASPARAGINASE ERWINIA CHRYSANTHEMI (RECOMBINANT)-RYWN (Rylaze)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9022	ATEZOLIZUMAB (Tecentriq)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9023	AVELUMAB (Bavencio)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9024	ATEZOLIZUMAB-HYALURONIDASE-TQJS (Tecentriq Hybreza)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9026	TARLATAMAB-DLLE (Imdelltra)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9028	NOGAPENDEKIN ALFA INBAKICEPT-PMLN (Anktiva)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9029	NADOFARAGENE FIRADENOVEC-VNCG (Adstiladrin)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9038	AXATILIMAB-CSFR (Niktimvo)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9039	BLINATUMOMAB (Blincyto)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9042	BRENTUXIMAB VEDOTIN (Adcetris)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9043	CABAZITAXEL (Jevtana)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9047	CARFILZOMIB (Kyprolis)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9061	AMIVANTAMAB-VMJW (Rybrevant)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9063	MIRVETUXIMAB SORAVTANSINE-GYNX (Elahere)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9064	CABAZITAXEL (cabazitaxel (Sandoz))	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9119	CEMIPLIMAB-RWLC (Libtayo)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9144	DARATUMUMAB+HYALURONIDASE-FIHJ (Darzalex Faspro)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9145	DARATUMUMAB (Darzalex)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9161	DENILEUKIN DIFTITOX-CXDL) (Lymphir)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9173	DURVALUMAB (Imfinzi)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9177	ENFORTUMAB VEDOTIN-EJFV (Padcev)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9179	ERIBULIN (Halaven)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9204	MOGAMULIZUMAB-KPKC (Poteligeo)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9205	IRINOTECAN LIPOSOME (Onivyde)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9210	EMAPALUMAB-LZSG (Gamifant)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9223	LURBINECTEDIN (Zepzelca)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9227	ISATUXIMAB-IRFC (Sarclisa)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9228	IPILIMUMAB (Yervoy)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9259	PACLITAXEL ALBUMIN-BOUND (paclitaxel albumin-bound (American Regent))	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9264	PACLITAXEL PROTEIN-BOUND (Abraxane)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9266	PEGASPARGASE (Oncaspar)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9269	TAGRAXOFUSP-ERZS (Elzonris)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9271	PEMBROLIZUMAB (Keytruda)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9272	DOSTARLIMAB-GXLY (Jemperli)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9273	TISOTUMAB VEDOTIN-TFTV (Tivdak)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9274	TEBENTAFUSP-TEBN (Kimmtrak)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9275	COSIBELIMAB-IPDL (Unloxcyt)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9276	ZANIDATAMAB-HRII (Ziihera)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9281	MITOMYCIN (Jelmyto)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9286	GLOFITAMAB-GXBM (Columvi)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9289	NIVOLUMAB AND HYALURONIDASE-NVHY (Opdivo Qvantig)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9298	NIVOLUMAB/RELATLIMAB-RMBW (Opdualag)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9299	NIVOLUMAB (Opdivo)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9301	OBINUTUZUMAB (Gazyva)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9303	PANITUMUMAB (Vectibix)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9304	PEMETREXED (Pemfexy)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9306	PERTUZUMAB (Perjeta)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9308	RAMUCIRUMAB (Cyramza)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9309	POLATUZUMAB VEDOTIN-PIIQ (Polivy)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9316	PERTUZUMAB, TRASTUZUMAB, HYALURONIDASE-ZZXF (Phesgo)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9317	SACITUZUMAB GOVITECAN-HZIY (Trodelvy)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9318	ROMIDEPSIN (romidepsin)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9319	ROMIDEPSIN (Istodax)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9321	EPCORITAMAB-BYSP (Epkinly)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9324	PEMETREXED (Pemrydi RTU)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9329	TISLELIZUMAB-JSGR (Tevimbra)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9331	SIROLIMUS-ALBUMIN-BOUND (Fyarro)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9332	EFGARTIGIMOD ALFA-FCAB (Vyvgart)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9333	ROZANOLIXIZUMAB-NOLI (Rystiggo)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9334	EFGARTIGIMOD ALFA-FCAB AND HYALURONIDASE-QVFC (Vyvgart Hytrulo)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9345	RETIFANLIMAB-DLWR (Zynyz)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9347	TREMELIMUMAB-ACTL (Imjudo)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9348	NAXITAMAB (Danyelza)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9349	TAFASITAMAB-CXIX (Monjuvi)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9350	MOSUNETUZUMAB-AXGB (Lunsumio)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9352	TRABECTEDIN (Yondelis)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9353	MARGETUXIMAB-CMKB (Margenza)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9354	ADO-TRASTUZUMAB EMTANSINE (Kadcyla)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9358	FAM-TRASTUZUMAB DERUXTECAN-NXKI (Enhertu)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9359	LONCASTUXIMAB TESIRINE-LPYL (Zynlonta)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9376	POZELIMAB-BBFG (Veopoz)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9380	TECLISTAMAB-CQYV (Tecvayli)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9381	TEPLIZUMAB-MZWV (Tzield)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9382	ZENOCUTUZUMAB-ZBCO (Bizengri)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9400	ZIV-AFLIBERCEPT (Zaltrap)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9999	TELISOTUZUMAB VEDOTIN-TLLV (Emrelis)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9999	MITOMYCIN (Zusduri)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9999	LINVOSELTAMAB-GCPT (Lynozyfic)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9999	LIFILEUCEL (Amtagvi)	MPS Medicare Part B Utilization Management Review	1, 2, 4
J9999	PENPULIMAB-KCQX (Penpulimab-KCQX)	MPS Medicare Part B Utilization Management Review	1, 2, 4
Q2057	AFAMITRESGENE AUTOLEUCEL (Tecelra)	MPS Medicare Part B Utilization Management Review	1, 2, 4
Q2058	OBECABTAGENE AUTOLEUCEL (Aucatzyl)	MPS Medicare Part B Utilization Management Review	1, 2, 4
Q5098	USTEKINUMAB-SRLF (Imuldosa IV)	MPS Medicare Part B Utilization Management Review	1, 2, 4
Q5099	USTEKINUMAB-STBA (Steqeyma/Ustekinumab-STBA (IV))	MPS Medicare Part B Utilization Management Review	1, 2, 4
Q5100	USTEKINUMAB-KFCE (Yesintek IV)	MPS Medicare Part B Utilization Management Review	1, 2, 4
Q5106	EPOETIN ALFA-EPBX (Retacrit)	MPS Medicare Part B Utilization Management Review	1, 2, 4
Q5133	TOCILIZUMAB-BAVI (Tofidence)	MPS Medicare Part B Utilization Management Review	1, 2, 4
Q5134	NATALIZUMAB-SZTN (Tyruko)	MPS Medicare Part B Utilization Management Review	1, 2, 4
Q5135	TOCILIZUMAB-AAZG (Tyenne IV/Tocilizumab-AAZG IV)	MPS Medicare Part B Utilization Management Review	1, 2, 4
Q5136	DENOSUMAB-BBDZ (Jubbonti)	MPS Medicare Part B Utilization Management Review	1, 2, 4
Q5136	DENOSUMAB-BBDZ (Wyost)	MPS Medicare Part B Utilization Management Review	1, 2, 4
Q5138	USTEKINUMAB-AUUB (Wezlana IV)	MPS Medicare Part B Utilization Management Review	1, 2, 4
Q5154	OMALIZUMAB-IGEC (Omlyclo / omalizumab)	MPS Medicare Part B Utilization Management Review	1, 2, 4
Q5156	TOCILIZUMAB-ANOH (Avtozma IV)	MPS Medicare Part B Utilization Management Review	1, 2, 4
Q5157	DENOSUMAB-BMWO (Stoboclo)	MPS Medicare Part B Utilization Management Review	1, 2, 4
Q5157	DENOSUMAB-BMWO (Osenvelt)	MPS Medicare Part B Utilization Management Review	1, 2, 4
Q5158	DENOSUMAB-BNHT (Bomyntra/Denosumab-BNHT)	MPS Medicare Part B Utilization Management Review	1, 2, 4
Q5158	DENOSUMAB-BNHT (Conexxence/Denosumab-BNHT)	MPS Medicare Part B Utilization Management Review	1, 2, 4
Q5159	DENOSUMAB-DSSB (Ospomyv)	MPS Medicare Part B Utilization Management Review	1, 2, 4
Q5159	DENOSUMAB-DSSB (Xbryk)	MPS Medicare Part B Utilization Management Review	1, 2, 4
Q9997	USTEKINUMAB-TTWE (Pyzchiva IV)	MPS Medicare Part B Utilization Management Review	1, 2, 4
Q9998	USTEKINUMAB-AEKN (Selarsdi/ustekinumab)	MPS Medicare Part B Utilization Management Review	1, 2, 4
Q9999	USTEKINUMAB-AUUB (Otulfi/Ustekinumab-AAUZ (IV))	MPS Medicare Part B Utilization Management Review	1, 2, 4
J0177	AFLIBERCEPT (Eylea HD)	Capital BC Medicare Part B ST	1, 4, 5
J0178	AFLIBERCEPT (Eylea)	Capital BC Medicare Part B ST	1, 4, 5
J0179	BROLUCIZUMAB-DBLL (Beovu)	Capital BC Medicare Part B ST	1, 4, 5
J0641	LEVOLEUCOVORIN CALCIUM (Fusilev)	Capital BC Medicare Part B ST	1, 4, 5
J0642	LEVOLEUCOVORIN SODIUM (Khapzory)	Capital BC Medicare Part B ST	1, 4, 5
J1299	ECULIZUMAB (Soliris)	Capital BC Medicare Part B ST	1, 4, 5
J1437	FERRIC DERISOMALTOSE (Monoferric)	Capital BC Medicare Part B ST	1, 4, 5
J1439	FERRIC CARBOXYMALTOSE (Injectafer)	Capital BC Medicare Part B ST	1, 4, 5
J1442	FILGRASTIM (Neupogen)	Capital BC Medicare Part B ST	1, 4, 5
J1449	EFLAPEGRASTIM-XNST (Rolvedon)	Capital BC Medicare Part B ST	1, 4, 5
J2777	FARICIMAB-SVOA (Vabysmo)	Capital BC Medicare Part B ST	1, 4, 5
J2778	RANIBIZUMAB (Lucentis)	Capital BC Medicare Part B ST	1, 4, 5
J2786	RESLIZUMAB (Cinqair)	Capital BC Medicare Part B ST	1, 4, 5
J7318	HYALURONAN OR DERIVATIVE (Durolane)	Capital BC Medicare Part B ST	1, 4, 5
J7320	HYALURONAN OR DERIVATIVE (Genvisc 850)	Capital BC Medicare Part B ST	1, 4, 5
J7321	HYALURONAN OR DERIVATIVE (Hyalgan)	Capital BC Medicare Part B ST	1, 4, 5
J7321	HYALURONAN OR DERIVATIVE (Supartz)	Capital BC Medicare Part B ST	1, 4, 5
J7321	HYALURONAN OR DERIVATIVE (Visco-3)	Capital BC Medicare Part B ST	1, 4, 5
J7322	HYALURONAN OR DERIVATIVE (Hymovis)	Capital BC Medicare Part B ST	1, 4, 5
J7324	HYALURONAN OR DERIVATIVE (Orthovisc)	Capital BC Medicare Part B ST	1, 4, 5
J7326	HYALURONAN OR DERIVATIVE (Gel-One)	Capital BC Medicare Part B ST	1, 4, 5
J7327	HYALURONAN OR DERIVATIVE (Monovisc)	Capital BC Medicare Part B ST	1, 4, 5
J7328	HYALURONAN OR DERIVATIVE (Gelsyn-3)	Capital BC Medicare Part B ST	1, 4, 5
J7329	HYALURONAN OR DERIVATIVE (TriVisc)	Capital BC Medicare Part B ST	1, 4, 5
J7331	HYALURONAN OR DERIVATIVE (Synojoynt)	Capital BC Medicare Part B ST	1, 4, 5
J7332	SODIUM HYALURONATE (Triluron)	Capital BC Medicare Part B ST	1, 4, 5
J9033	BENDAMUSTINE (Treanda)	Capital BC Medicare Part B ST	1, 4, 5
J9035	BEVACIZUMAB (Avastin)	Capital BC Medicare Part B ST	1, 4, 5
J9056	BENDAMUSTINE (Vivimusta)	Capital BC Medicare Part B ST	1, 4, 5
J9311	RITUXIMAB AND HYALURONIDASE HUMAN (Rituxan Hycela)	Capital BC Medicare Part B ST	1, 4, 5
J9312	RITUXIMAB (Rituxan)	Capital BC Medicare Part B ST	1, 4, 5
J9355	TRASTUZUMAB (Herceptin)	Capital BC Medicare Part B ST	1, 4, 5
J9356	TRASTUZUMAB-HYALURONIDASE-OYSK (Herceptin Hylecta)	Capital BC Medicare Part B ST	1, 4, 5
J9361	EFBEMALENOGRASTIM ALFA-VUXW (Ryzneuta)	Capital BC Medicare Part B ST	1, 4, 5
J9999	GEMCITABINE (Avgemsi)	Capital BC Medicare Part B ST	1, 4, 5
J9999	BEVACIZUMAB-NWGD (Jobevne)	Capital BC Medicare Part B ST	1, 4, 5
J9999	BEVACIZUMAB-TNJN (Avzivi)	Capital BC Medicare Part B ST	1, 4, 5
Q0138	FERUMOXYTOL INJECTION (Feraheme)	Capital BC Medicare Part B ST	1, 4, 5
Q5104	INFLIXIMAB-ABDA (Renflexis)	Capital BC Medicare Part B ST	1, 4, 5
Q5108	PEGFILGRASTIM-CBQV (Fulphila)	Capital BC Medicare Part B ST	1, 4, 5
Q5112	TRASTUZUMAB-DTTB (Ontruzant)	Capital BC Medicare Part B ST	1, 4, 5
Q5113	TRASTUZUMAB-PKRB (Herzuma/Trastuzumab-PKRB)	Capital BC Medicare Part B ST	1, 4, 5
Q5114	TRASTUZUMAB-DKST (Ogivri)	Capital BC Medicare Part B ST	1, 4, 5
Q5120	PEGFILGRASTIM-BMEZ (Ziextenzo)	Capital BC Medicare Part B ST	1, 4, 5
Q5121	INFLIXIMAB-AXXQ (Avsola)	Capital BC Medicare Part B ST	1, 4, 5
Q5122	PEGFILGRASTIM-APGF (Nyvepria)	Capital BC Medicare Part B ST	1, 4, 5
Q5123	RITUXIMAB-ARRX (Riabni)	Capital BC Medicare Part B ST	1, 4, 5
Q5124	RANIBIZUMAB-NUNA (Byooviz)	Capital BC Medicare Part B ST	1, 4, 5
Q5125	FILGRASTIM-AYOW (Releuko)	Capital BC Medicare Part B ST	1, 4, 5
Q5126	BEVACIZUMAB-MALY (Alymsys)	Capital BC Medicare Part B ST	1, 4, 5
Q5127	PEGFILGRASTIM-FPGK (Stimufend/Pegfilgrastim-FPGK)	Capital BC Medicare Part B ST	1, 4, 5
Q5128	RANIBIZUMAB-EQRN (Cimerli)	Capital BC Medicare Part B ST	1, 4, 5
Q5129	BEVACIZUMAB-ADCD (Vegzelma)	Capital BC Medicare Part B ST	1, 4, 5
Q5130	PEGFILGRASTIM-PBBK (Fylnetra)	Capital BC Medicare Part B ST	1, 4, 5
Q5146	TRASTUZUMAB-STRF (Hercessi)	Capital BC Medicare Part B ST	1, 4, 5
Q5148	FILGRASTIM-TXID (Nypozi)	Capital BC Medicare Part B ST	1, 4, 5
Q5150	AFLIBERCEPT-MRBB (Ahzantive)	Capital BC Medicare Part B ST	1, 4, 5
Q5151	ECULIZUMAB-AAGH (Epysqli/Eculizumab-AAGH)	Capital BC Medicare Part B ST	1, 4, 5
Q5152	ECULIZUMAB-AEEB (Bkemv)	Capital BC Medicare Part B ST	1, 4, 5
Q5153	AFLIBERCEPT-YSZY (Opuviz)	Capital BC Medicare Part B ST	1, 4, 5
Q5155	AFLIBERCEPT-JBVF (Yesafili)	Capital BC Medicare Part B ST	1, 4, 5
E2102	CONTINUOUS GLUCOSE MONITOR RECEIVER ADJUNCTIVE NON-IMPLANTED	CBC Part B CGM PA	2, 4, 5
E2103	CONTINUOUS GLUCOSE MONITOR RECEIVER/READER NON-ADJUNCTIVE NON-IMPLANTED	CBC Part B CGM PA	2, 4, 5
E2104	HOME BLOOD GLUCOSE MONITOR FOR USE WITH INTEGRATED LANCING/BLOOD SAMPLE TESTING CARTRIDGE (EX. POGO METER)	CBC Part B DTS PA	2, 4, 5
E0607	DIABETIC TESTING MONITORS	CBC Part B DTS PA	2, 4, 5
A4238	CONTINUOUS GLUCOSE MONITOR SENSOR/TRANSMITTER ADJUNCTIVE NON-IMPLANTED	CBC Part B CGM PA	2, 4, 5
A4239	CONTINUOUS GLUCOSE MONITOR SENSOR/TRANSMITTER NON-ADJUNCTIVE NON-IMPLANTED	CBC Part B CGM PA	2, 4, 5
A4253	DIABETIC TESTING STRIPS	CBC Part B DTS PA	2, 4, 5
A4271	INTEGRATED LANCING AND BLOOD SAMPLE TESTING CARTRIDGES FOR HOME BLOOD GLUCOSE MONITOR (EX. POGO TEST CARTRIDGE)	CBC Part B DTS PA	2, 4, 5

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Laboratory Services

Coverage criteria related to specialized laboratory services can be found in the following policies:

Policy number	Policy title	Clinical benefit(s)
G2159	B-Hemolytic Streptococcus Testing	2
G2022	Biomarker Testing for Autoimmune Rheumatic Disease	2, 4
G2150	Biomarkers For Myocardial Infarction and Chronic Heart Failure	2, 4
G2051	Bone Turnover Markers Testing	2
G2050	Cardiovascular Disease Risk Assessment	2, 4, 5
G2043	Celiac Disease Testing	2, 5
G2174	Coronavirus Testing in the Outpatient Setting	1, 2, 5
G2006	Diabetes Mellitus Testing	2, 5
G2056	Diagnosis of Idiopathic Environmental Intolerance	2, 4, 5
M2057	Diagnosis of Vaginitis including Multi-target PCR Testing	2
G2157	Diagnostic Testing of Common Sexually Transmitted Infections	2, 4, 5
G2119	Diagnostic Testing of Influenza	2, 5
G2011	Diagnostic Testing of Iron Homeostasis and Metabolism	2, 5
G2059	Epithelial Cell Cytology In Breast Cancer Risk Assessment	2
G2138	Evaluation of Dry Eyes	2, 5
G2060	Fecal Analysis in the Diagnosis of Intestinal Dysbiosis	2, 5
G2061	Fecal Calprotectin Testing	2
F2019	Flow Cytometry	2, 4, 5
G2154	Folate Testing	2
G2173	Gamma-Glutamyl Transferase (GGT)	2, 4, 5
G2155	General Inflammation Testing	2, 5
G2044	Helicobacter Pylori Testing	2, 4, 5
M2097	Identification Of Microorganisms Using Nucleic Acid Probes	2
G2098	Immune Cell Function Assay	2
G2100	In Vitro Chemoresistance and Chemosensitivity Assays	2
G2099	Intracellular Micronutrient Analysis	2
G2143	Lyme Disease Testing	2, 5
G2107	Measurement of Thromboxane Metabolites for ASA Resistance	2
M2112	Nerve Fiber Density Testing	5
M2172	Onychomycosis Testing	2, 5
G2113	Oral Cancer Screening and Testing	2, 5
G2153	Pancreatic Enzyme Testing for Acute Pancreatitis	2, 5
G2164	Parathyroid Hormone, Phosphorus, Calcium, and Magnesium Testing	2, 5
G2149	Pathogen Panel Testing	5
G2055	Prenatal Testing for Fetal Aneuploidy	2, 3, 5
T2015	Prescription Medication and Illicit Drug Testing in the Outpatient Setting	5
G2007	Prostate Biopsy Specimen Analysis	3
G2120	Salivary Hormone Testing	2, 5
G2151	Serum Testing For Evidence Of Mild Traumatic Brain Injury	2
G2123	Serum Biomarker Testing for Multiple Sclerosis and Related Neurologic Diseases	2
G2063	Testing for Diagnosis of Active or Latent Tuberculosis	2, 5
G2158	Testing for Vector-Borne Infections	2, 5
G2013	Testosterone	5
G2045	Thyroid Disease Testing	5
M2091	Transplant Rejection Testing	2, 5
G2125	Urinary Tumor Markers For Bladder Cancer	2, 5
G2156	Urine Culture Testing for Bacteria	5
G2014	Vitamin B12 and Methylmalonic Acid Testing	3
G2005	Vitamin D Testing	2, 5

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Dental Services

Dental’s Utilization Review Guidelines

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Updated October 1, 2025

Y0016_26WBST_M

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Medicare Medical Policies

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Capital Medical Policies

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Behavioral Health Services

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High tech Radiology, Select Cardiac Imaging, and Radiation Oncology Services

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Select Diagnostic and Surgical Cardiology Services

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Select Musculoskeletal Services Including Hip, Knee, Shoulder, and Spine Procedures

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Medical Drugs, Biologics and Diabetes Supplies

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Laboratory Services

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Dental Services

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