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 Benefit Drug Policy
View medical benefit drug policy in our Medication Policy section:
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 Myelodysplastic Syndromes and Myeloproliferative Neoplasms
- Allogeneic Pancreas Transplant
- Allograft Injection for Degenerative Disc Disease
- 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
- 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
- Bioengineered Skin and Soft Tissue Substitutes
- Biofeedback as a Treatment of Urinary Incontinence in Adults
- Bioimpedance Devices for Detection and Management of Lymphedema
- 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)
- 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 Glucose Monitoring
- Continuous Passive Motion in the Home Setting
- Contrast-Enhanced Coronary Computed Tomography Angiography for Coronary Artery Evaluation
- Corneal Collogen Cross-Linking
- Cranial Electrotherapy Stimulation and Auricular Electrostimulation
- Cryoablation of Tumors Located in the Kidney, Lung, Breast, Pancreas, or Bone
- Cryoablation, Radiofrequency Ablation, and Laser Ablation for Treatment of Chronic Rhinitis
- Cryosurgical Ablation of Primary or Metastatic Liver Tumors
- Cytochrome P450 Genotype-Guided Treatment Strategy
- 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 Affirmation Surgery
- Gene Expression Profile Testing and Circulating Tumor DNA Testing for Predicting Recurrence in Colon Cancer
- Gene Expression Profiling and Protein Biomarkers for Prostate Cancer Management
- Gene Expression-Based Assays for Cancers of Unknown Primary
- Gene Variants (PALB2, CHEK2 and ATM) 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 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 BRCA1 or BRCA2 for Hereditary Breast/Ovarian Cancer Syndrome and Other High-Risk Cancers
- Germline Genetic Testing for Pancreatic Cancer Susceptibility Genes
- Germline and Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment and Immunotherapy in Breast Cancer
- 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 in the Treatment of Germ Cell Tumors
- Hepatitis C Viremic 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
- 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
- Laser Interstitial Thermal Therapy for Neurological Conditions
- Lifestyle Modification Program for Reversing Heart Disease
- Lipid Apheresis
- Liver Transplant and Combined Liver-Kidney Transplant
- Low Intensity Pulsed Ultrasound Fracture Healing Device
- 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 Spectroscopy
- Magnetic Resonance-Guided Focused Ultrasound
- Magnetoencephalography/Magnetic Source Imaging
- Manipulation Under Anesthesia
- Maternal Serum Biomarkers for Prediction of Adverse Obstetric Outcomes
- 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 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 (Including Liquid Biopsy) for Targeted Therapy or Immunotherapy of Non-Small-Cell Lung Cancer
- Molecular Testing for Germline BRIP1, RAD51C, and RAD51D Variants Associated with 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
- Non-Invasive Positive Airway Pressure for Chronic Obstructive Pulmonary Disease
- 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
- Postsurgical Home Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis
- 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
- 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
- Selected Positron Emission Tomography Technologies for Evaluation of Alzheimer Disease
- Semi-Implantable and Fully Implantable Middle Ear Hearing Aids
- Sensory Integration Therapy and Auditory Integration Therapy
- Serologic Genetic and Molecular Screening for Colorectal Cancer
- 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 for Gastrointestinal (GI) Disorders