Blue Cross Blue Shield of Massachusetts Utilization Management Updates

April 26, 2022

The BlueCard^® program gives BlueCross BlueShield of South Carolina members access to health care services when traveling or living in another Blue^® Plan service area. As a result, you may occasionally see patients who are enrolled in Blue Plans from other states. Therefore, we want to ensure our providers are aware of any changes made by other Blue Plans that could impact their practice.

Effective June 1, 2022, Blue Cross^® Blue Shield^® of Massachusetts (BCBSMA) is expanding utilization management to certain services for their commercial exclusive provider organization (EPO) and preferred provider organization (PPO) members.

The below services will require authorization beginning June 1, 2022, and members having these services will require an approved authorization for coverage for dates of services on or after June 1, 2022. BCBSMA will accept authorizations at least 30 days in advance of the requirement date.

Service	Applies to:	Providers can request authorization by:
Continuous glucose monitors (Codes: A9277, K0553, S1036)	Commercial EPO and PPO	Calling the preauthorization number on the back of the member's identification card. Note: Authorization is required on an annual basis.
Spine surgeries using InterQual SmartSheets for: Anterior Cervical Discectomy and Fusion (ACDF) Discectomy, Percutaneous, Lumbar Fusion (with Laminectomy), Cervical Fusion (with Laminectomy), Lumbar Fusion (with Laminectomy), Thoracic Fusion, Cervical Spine Fusion, Lumbar Spine Fusion, Thoracic Spine Hemilaminectomy (Laminotomy) +/- Discectomy, Cervical Hemilaminectomy (Laminotomy) +/- Discectomy, Lumbar Laminectomy (with Fusion), Cervical Laminectomy (with Fusion), Lumbar Laminectomy (with Fusion), Thoracic Laminectomy, Cervical Laminectomy, Lumbar Laminectomy, Thoracic	Commercial EPO and PPO	Calling the preauthorization number on the back of the member's identification card.
Other services (view here) Note: The links in the attachment will not be available until after June 1, 2022.	Commercial EPO and PPO	Calling the preauthorization number on the back of the member's identification card.

As always, check eligibility and benefits to verify the member’s benefits and any authorization requirements. Also, please note that all services must continue to meet medical necessity criteria. After June 1, 2022, the below medical policies will be available on BCBSMA’s website for review:

Medical Policy 107 – Continuous or Intermittent Monitoring of Glucose in Interstitial Fluid and Artificial Pancreas Device Systems Requirements
Medical Policy 072 – Outpatient Prior Authorization Code List

If you have any questions about these updates or other authorization requirements (except chiropractic, genetic testing, high-tech radiology and sleep studies), feel free to contact BCBSMA’s utilization management team at 800-327-6716.

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association.