The application of each Blue Shield of California medical policy is subject to regulatory requirements and/or plan specific benefits and limitations (Evidence of Coverage - EOC).

Goals of medical policy include:

  • Ensuring safe and effective technologies
  • Supporting an evidence-based approach to technology
  • Providing current and pertinent information regarding technologies (devices, procedures for medical and behavioral health)
  • Improving the quality of care and services provided through Blue Shield

Use medical policy information to provide Blue Shield members with the highest standard of evidence-based medical care that is safe and effective.

Medical policy index

Use this alphabetical index to find Blue Shield medical policies, and review requirements and criteria for new technologies, devices and procedures. The policies are updated frequently - see latest updates.

Find a medical policy for your patients who are out-of-area Blue plan members

Preventive Health Guidelines (PDF, 148KB)
 

Medical policy list
Ablation of Peripheral Nerves to Treat Pain
Absorbable Nasal Implant for Treatment of Nasal Valve Collapse
Actigraphy
Adipose-Derived Stem Cells in Autologous Fat Grafting to the Breast
Alcohol Injections for Treatment of Peripheral Neuromas
Allogeneic Hematopoietic Cell Transplantation for Genetic Diseases and Acquired Anemias
Allogeneic Hematopoietic Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms
Allogeneic Pancreas Transplant
Ambulatory Event Monitors and Mobile Cardiac Outpatient Telemetry
Ambulatory Surgery Center
Amniotic Membrane and Amniotic Fluid
Aqueous Shunts and Stents for Glaucoma
Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer
Auditory Brainstem Implant
Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions
Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions
Autologous Platelet-Derived Growth Factors for Wound Healing and Other Non‒Orthopedic Conditions
Automated Point-of-Care Nerve Conduction Tests
Balloon Dilation of the Eustachian Tube
Balloon Ostial Dilation for Treatment of Chronic and Recurrent Acute Rhinosinusitis
Bariatric Surgery
Baroreflex Stimulation Devices
Behavioral Health Treatment for Autism Spectrum Disorders
Beta-Amyloid Imaging with Positron Emission Tomography for Alzheimer’s Disease
Bioengineered Skin and Soft Tissue Substitutes
Biofeedback as a Treatment of Urinary Incontinence in Adults
Bioimpedance Devices for Detection and Management of Lymphedema
Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment and Immunotherapy in Breast Cancer
Biventricular Pacemakers (Cardiac Resynchronization Therapy) for the Treatment of Heart Failure
Blepharoplasty, Blepharoptosis Repair (Levator Resection) and Brow Lift (Repair of Brow Ptosis)
Bone Mineral Density Studies
Bone Turnover Markers for the Diagnosis and Management of Osteoporosis and Diseases Associated With High Bone Turnover
Brachytherapy for Clinically Localized Prostate Cancer Using Permanently Implanted Seeds
Breast Implant Management
Bronchial Thermoplasty
Bronchial Valves
Cardiac Applications of Positron Emission Tomography Scanning
Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting
Cardiovascular Risk Panels
Carrier Screening for Genetic Diseases
Catheter Ablation as Treatment for Atrial Fibrillation
Catheter Ablation for Cardiac Arrhythmias
Cellular Immunotherapy for Prostate Cancer
Cervical Spine Surgery
Charged-Particle (Proton or Helium Ion) Radiotherapy for Neoplastic Conditions
Chelation Therapy for Off-Label Uses
Chronic Intermittent Intravenous Insulin Therapy
Circulating Tumor DNA and Circulating Tumor Cells for Cancer Management (Liquid Biopsy)
Circulating Tumor DNA for Management of Non-Small-Cell Lung Cancer (Liquid Biopsy)
Cleft Palate - Dental Related Services
Comprehensive Genomic Profiling for Selecting Targeted Cancer Therapies
Computed Tomography Perfusion Imaging of the Brain
Computed Tomography to Detect Coronary Artery Calcification
Computer-Aided Evaluation of Malignancy With Magnetic Resonance Imaging of the Breast
Computer-Assisted Navigation for Orthopedic Procedure
Confocal Laser Endomicroscopy
Continuous Passive Motion in the Home Setting
Continuous or Intermittent Monitoring of Glucose in the Interstitial Fluid
Contrast-Enhanced Coronary Computed Tomography Angiography for Coronary Artery Evaluation
Corneal Collogen Cross-Linking
Cranial Electrotherapy Stimulation and Auricular Electrostimulation
Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate, or Dermatologic Tumors
Cryosurgical Ablation of Primary or Metastatic Liver Tumors
Cytochrome P450 Genotype-Guided Treatment Strategy
DNA-Based Testing for Adolescent Idiopathic Scoliosis
Dental Anesthesia
Dermatologic Applications of Photodynamic Therapy
Diabetes Prevention Program
Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome
Drug Testing in Pain Management and Substance Use Disorder Treatment
Dynamic Posturography
Dynamic Spinal Visualization and Vertebral Motion Analysis
Elective Invasive Coronary Angiography (ICA)
Elective Percutaneous Coronary Intervention (PCI)
Electrical and Electromagnetic Stimulation for the Treatment of Arthritis
Electronic Brachytherapy for Nonmelanoma Skin Cancer
Electrostimulation and Electromagnetic Therapy for Treating Wounds
Endobronchial Brachytherapy
Endobronchial Valves
Endoscopic Radiofrequency Ablation or Cryoablation for Barrett Esophagus
Endothelial Keratoplasty
Endovascular Procedures for Intracranial Arterial Disease (Atherosclerosis and Aneurysms)
Endovascular Stent Grafts for Disorders of the Thoracic Aorta
Endovascular Therapies for Extracranial Vertebral Artery Disease
Enhanced External Counterpulsation
Epidural Spine Injections
Esophageal pH Monitoring
Evaluation of Biomarkers for Alzheimer Disease
External Insulin Infusion Pump
Extracorporeal Membrane Oxygenation for Adult Conditions
Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions
Extracranial Carotid Artery Stenting
Eyelid Thermal Pulsation for the Treatment of Dry Eye Syndrome
Facet Arthroplasty
Fecal Analysis in the Diagnosis of Intestinal Dysbiosis
Focal Treatments for Prostate Cancer
Functional Magnetic Resonance Imaging of the Brain
Functional Neuromuscular Electrical Stimulation
Gastric Electrical Stimulation
Gender Reassignment Surgery
Gene Expression Profiling and Protein Biomarkers for Prostate Cancer Management
Gene Expression-Based Assays for Cancers of Unknown Primary
Gene Variants Associated With Breast Cancer in Individuals at High Breast Cancer Risk
General Approach to Evaluating the Utility of Genetic Panels
General Approach to Genetic Testing
Genetic Cancer Susceptibility Panels Using Next-Generation Sequencing
Genetic Testing for Alzheimer Disease
Genetic Testing for BRCA1 or BRCA2 for Hereditary Breast/Ovarian Cancer Syndrome and Other High-Risk Cancers
Genetic Testing for Cardiac Ion Channelopathies
Genetic Testing for Developmental Delay/Intellectual Disability, Autism Spectrum Disorder, and Congenital Anomalies
Genetic Testing for Diagnosis and Management of Mental Health Conditions
Genetic Testing for FLT3, NPM1, and CEBPA Variants in Cytogenetically Normal Acute Myeloid Leukemia
Genetic Testing for Familial Cutaneous Malignant Melanoma
Genetic Testing for Inherited Thrombophilia
Genetic Testing for Lactase Insufficiency
Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes
Genetic Testing for Macular Degeneration
Genetic Testing for Predisposition to Inherited Hypertrophic Cardiomyopathy
Genetic Testing of Mitochondrial Disorders
Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer
Genotype-Guided Tamoxifen Treatment
Genotype-Guided Warfarin Dosing
Germline Genetic Testing for Pancreatic Cancer Susceptibility Genes
Handheld Radiofrequency Spectroscopy for Intraoperative Assessment of Surgical Margins During Breast-Conserving Surgery
Heart Transplant
Heart-Lung Transplant
Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia
Hematopoietic Cell Transplantation for Acute Myeloid Leukemia
Hematopoietic Cell Transplantation for Autoimmune Diseases
Hematopoietic Cell Transplantation for Central Nervous System Embryonal Tumors and Ependymoma
Hematopoietic Cell Transplantation for Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma
Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia
Hematopoietic Cell Transplantation for Hodgkin Lymphoma
Hematopoietic Cell Transplantation for Non-Hodgkin Lymphomas
Hematopoietic Cell Transplantation for Plasma Cell Dyscrasias, Including Multiple Myeloma and POEMS Syndrome
Hematopoietic Cell Transplantation for Primary Amyloidosis
Hematopoietic Cell Transplantation for Solid Tumors of Childhood
Hematopoietic Cell Transplantation for Waldenstrom Macroglobulinemia
Hematopoietic Cell Transplantation in the Treatment of Germ Cell Tumors
Hepatitis C Positive Organs for Transplantation to Non-Viremic Patients
Hip Resurfacing
Hippotherapy
Hydrogel Spacer Use During Radiotherapy for Prostate Cancer
Hyperbaric Oxygen Therapy
Hysterectomy Surgery for Benign Conditions
Identification of Microorganisms Using Nucleic Acid Probes
Image-Guided Minimally Invasive Decompression for Spinal Stenosis
Immune Cell Function Assay
Implantable Bone-Conduction and Bone-Anchored Hearing Aids
Implantable Cardioverter Defibrillators
Implantation of Intrastromal Corneal Ring Segments
In Vitro Chemoresistance and Chemosensitivity Assays
Ingestible pH and Pressure Capsule
Inhaled Nitric Oxide
Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence
Injectable Clostridial Collagenase for Fibroproliferative Disorders
Intensity-Modulated Radiotherapy Abdomen and Pelvis
Intensity-Modulated Radiotherapy of the Breast and Lung
Intensity-Modulated Radiotherapy of the Prostate
Intensity-Modulated Radiotherapy: Cancer of the Head and Neck or Thyroid
Intensity-Modulated Radiotherapy: Central Nervous System Tumors
Interferential Current Stimulation
Interim Positron Emission Tomography Scanning in Oncology to Detect Early Response During Treatment
Intracavitary Balloon Catheter Brain Brachytherapy for Malignant Gliomas or Metastasis to the Brain
Intraoperative Neurophysiologic Monitoring
Intraoperative Radiotherapy
Invasive Prenatal (Fetal) Diagnostic Testing
Islet Transplantation
Isolated Small Bowel Transplant
JAK2, MPL, and CALR Testing for Myeloproliferative Neoplasms
Kidney Transplant
Knee Arthroplasty for Adults
Knee Arthroscopy in Knee Osteoarthritis
Knee Braces (Custom)
Laboratory Tests Post Transplant and for Heart Failure
Laboratory and Genetic Testing for Use of 5-Fluorouracil in Patients with Cancer
Laparoscopic and Percutaneous Techniques for the Myolysis of Uterine Fibroids
Lifestyle Modification Program for Reversing Heart Disease
Light Therapy for Psoriasis
Lipid Apheresis
Liver Transplant and Combined Liver-Kidney Transplant
Lower Limb Prostheses
Lumbar Spine Surgery
Lung Volume Reduction Surgery for Severe Emphysema
Lung and Lobar Lung Transplant
Lysis of Epidural Adhesions
Magnetic Esophageal Sphincter Augmentation to Treat Gastroesophageal Reflux Disease
Magnetic Resonance Imaging for Detection and Diagnosis of Breast Cancer
Magnetic Resonance Imaging to Monitor the Integrity of Silicone Gel-Filled Breast Implants
Magnetic Resonance Spectroscopy
Magnetic Resonance-Guided Focused Ultrasound
Magnetoencephalography/Magnetic Source Imaging
Manipulation Under Anesthesia
Measurement of Lipoprotein-Associated Phospholipase A2 in the Assessment of Cardiovascular Risk
Measurement of Serum Antibodies to Selected Biologic Agents
Medical Cannabis for the Treatment of Chronic Pain and Spasticity
Microprocessor-Controlled Prostheses for the Lower Limb
Microwave and Locoregional Laser Tumor Ablation
Miscellaneous (Noncardiac, Nononcologic) Applications of Fluorine 18 Fluorodeoxyglucose Positron Emission Tomography
Molecular Analysis for Targeted Therapy or Immunotherapy of Non- Small-Cell Lung Cancer
Molecular Testing for Variants Associated with Hereditary Ovarian Cancer
Molecular Testing in the Management of Pulmonary Nodules
Monitored Anesthesia Care
Multibiomarker Disease Activity Blood Test for Rheumatoid Arthritis
Multimarker Serum Testing Related to Ovarian Cancer
Myocardial Strain Imaging
Myocardial Sympathetic Innervation Imaging in Patients With Heart Failure
Myoelectric Prosthetic and Orthotic Components for the Upper Limb
Navigated Transcranial Magnetic Stimulation
Negative Pressure Wound Therapy in the Outpatient Setting
Neuropsychological Testing
Noncontact Ultrasound Treatment for Wounds
Noninvasive Prenatal Screening for Fetal Aneuploidies, Microdeletions, and Twin Zygosity Using Cell-Free Fetal DNA
Noninvasive Techniques for the Evaluation and Monitoring of Patients With Chronic Liver Disease
Nonpharmacologic Treatment of Rosacea
Novel Biomarkers in Risk Assessment and Management of Cardiovascular Disease
Oncologic Applications of Photodynamic Therapy, Including Barrett Esophagus
Oncologic Applications of Positron Emission Tomography Scanning
Open and Thoracoscopic Approaches to Treat Atrial Fibrillation and Atrial Flutter (Maze and Related Procedures)
Ophthalmologic Techniques That Evaluate the Posterior Segment for Glaucoma
Optical Coherence Tomography of the Anterior Eye Segment
Orthognathic Surgery
Orthopedic Applications of Platelet-Rich Plasma
Orthopedic Applications of Stem Cell Therapy (Including Allografts and Bone Substitutes Used with Autologous Bone Marrow)
Orthoptic Training for the Treatment of Vision or Learning Disabilities
Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Conditions
Panniculectomy, Abdominoplasty, and Surgical Management of Diastasis Recti
Paraspinal Surface Electromyography to Evaluate and Monitor Back Pain
Paravertebral Facet Joint Injections or Blocks (no U/S)
Partial Thickness Rotator Cuff Tears and Acromioplasty/Subacromial Decompression
Patient-Controlled End of Range Motion Stretching Devices
Patient-Specific Instrumentation (e.g., Cutting Guides) for Joint Arthroplasty
Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence
Percutaneous Vertebroplasty and Sacroplasty
Personalized Breast Cancer Screening Clinical Trial
Pharmacogenetic Testing for Pain Management
Pharmacogenomic and Metabolite Markers for Patients Treated with Thiopurines
Phrenic Nerve Stimulation For Central Sleep Apnea
Physical Therapy
Placental and Umbilical Cord Blood as a Source of Stem Cells
Plugs for Anal Fistula Repair
Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers
Positional Magnetic Resonance Imaging
Positron Emission Mammography
Power Morcellation for the Treatment of Uterine Fibroids
Power Wheelchairs and Power Operated Vehicles for Permanent Use
Powered Exoskeleton for Ambulation in Patients With Lower-Limb Disabilities
Preimplantation Genetic Testing
Prolotherapy
Proteomic Testing for Targeted Therapy in Non-Small-Cell Lung Cancer
Quantitative Electroencephalography as a Diagnostic Aid for Attention-Deficit/Hyperactivity Disorder
Quantitative Sensory Testing
Radiation Oncology
Radioembolization for Primary and Metastatic Tumors of the Liver
Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors
Radiofrequency Ablation of Primary or Metastatic Liver Tumors
Radiofrequency Ablation of the Renal Sympathetic Nerves as a Treatment for Resistant Hypertension
Radioimmunoscintigraphy (Monoclonal Antibody Imaging) With Indium 111 Capromab Pendetide for Prostate Cancer
Reconstructive Services
Reduction Mammaplasty
Reproductive Techniques
Retinal Prosthesis
Sacroiliac Joint Injections (with image guidance [fluoroscopy or CT])
Saturation Biopsy for Diagnosis, Staging, and Management of Prostate Cancer
Scintimammography and Gamma Imaging of the Breast and Axilla
Semi-Implantable and Fully Implantable Middle Ear Hearing Aids
Sensory Integration Therapy and Auditory Integration Therapy
Serum Biomarker Human Epididymis Protein 4
Small Bowel/Liver and Multivisceral Transplant
Speech Therapy
Spine Surgery and Pain Management (summary of changes effective January 1, 2017)
Stem Cell Therapy for Peripheral Arterial Disease
Stereotactic Radiosurgery and Stereotactic Body Radiotherapy
Steroid-Eluting Sinus Stents and Implants
Subtalar Arthroereisis
Surgical Deactivation of Headache Trigger Sites
Surgical Treatment of Femoroacetabular Impingement
Surgical Treatment of Gynecomastia
Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome
Surgical Treatments for Breast Cancer-Related Lymphedema
Surgical Ventricular Restoration
Synthetic Cartilage Implants for Joint Pain
Temporomandibular Joint Disorder
Testing Serum Vitamin D Levels
Thoracic Spine Surgery
Total Artificial Hearts and Implantable Ventricular Assist Devices
Total Hip Arthroplasty for Adults
Transcatheter Aortic-Valve Implantation for Aortic Stenosis
Transcatheter Arterial Chemoembolization to Treat Primary or Metastatic Liver Malignancies
Transcatheter Pulmonary Valve Implantation
Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders
Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease
Treatment of Hyperhidrosis
Treatment of Varicose Veins/Venous Insufficiency
Trigger Point and Tender Point Injections
Ultrasonographic Measurement of Carotid Intima-Medial Thickness as an Assessment of Subclinical Atherosclerosis
Urinary Biomarkers for Cancer Screening, Diagnosis, and Surveillance
Vagus Nerve Blocking Therapy for Treatment of Obesity
Vertebral Axial Decompression
Vertebral Fracture Assessment With Densitometry
Virtual Colonoscopy/Computed Tomography Colonography
Wearable Cardioverter-Defibrillator
Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders
Whole Gland Cryoablation of Prostate Cancer
Wireless Capsule Endoscopy to DiagNose Disorders of the Small Bowel, Esophagus, and Colon