Medical policy list
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
Medical policy list
- Medical Policy Name
- 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
- Adjunctive Techniques for Screening, Surveillance, and Risk Classification of Barrett Esophagus and Esophageal Dysplasia
- Adjustable Cranial Orthoses for Positional Plagiocephaly and Craniosynostoses
- 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
- 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 Ambulatory Blood Pressure Monitoring for Diagnosis of Hypertension in Patients with Elevated Office Blood Pressure
- Autonomic Nervous System Testing
- Axillary Reverse Mapping for Prevention of Breast Cancer-Related Lymphedema
- Balloon Dilation of the Eustachian Tube
- Balloon Ostial Dilation for Treatment of Chronic and Recurrent Acute Rhinosinusitis
- Balloon Spacers for Treatment of Irreparable Rotator Cuffs of the Shoulder
- Bariatric Surgery
- Baroreflex Stimulation Devices
- Behavioral Health Treatment for Autism Spectrum Disorders
- Bioengineered Skin and Soft Tissue Substitutes
- Biofeedback as a Treatment of Chronic Pain
- Biofeedback as a Treatment of Fecal Incontinence or Constipation
- Biofeedback as a Treatment of Headache
- Biofeedback as a Treatment of Urinary Incontinence in Adults
- Biofeedback for Miscellaneous Indications
- Bioimpedance Devices for Detection and Management of Lymphedema
- Biomarker Testing in Risk Assessment and Management of Cardiovascular Disease
- 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 Morphogenetic Protein
- Bone Turnover Markers for Diagnosis and Management of Osteoporosis and Diseases Associated with High Bone Turnover
- Brachytherapy for Clinically Localized Prostate Cancer Using Permanently Implanted Seeds
- Bronchial Thermoplasty
- Bronchial Valves
- Cardiac Applications of Positron Emission Tomography Scanning
- Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting
- Cardiac Rehabilitation in the Outpatient Setting
- 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
- Chemical Peels
- Chromoendoscopy as an Adjunct to Colonoscopy
- Chronic Intermittent Intravenous Insulin Therapy
- Cleft Palate - Dental Related Services
- Closure Devices for Patent Foramen Ovale and Atrial Septal Defects
- Cochlear Implant
- Cognitive Rehabilitation
- Composite Tissue Allotransplantation of the Hand and Face
- Confocal Laser Endomicroscopy
- Continuous Glucose Monitoring
- Continuous Passive Motion in the Home Setting
- Cooling Devices Used in the Outpatient Setting
- Corneal Collagen 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
- Deep Brain Stimulation
- Dental Anesthesia
- Dermatologic Applications of Photodynamic Therapy
- Diabetes Prevention Program
- Diagnosis of Obstructive Sleep Apnea Syndrome
- Digital Health Technologies for Attention Deficit/Hyperactivity Disorder
- Digital Health Technologies: Diagnostic Applications
- Digital Health Technologies: Therapeutic Applications
- Dopamine Transporter Single-Photon Emission Computed Tomography
- Drug Testing in Pain Management and Substance Use Disorder Treatment
- Dry Hydrotherapy for Chronic Pain Conditions
- Dry Needling of Trigger Points for Myofascial Pain
- 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
- Electrical Bone Growth Stimulation of the Appendicular Skeleton
- Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures
- Electroconvulsive Therapy
- Electromagnetic Navigational Bronchoscopy
- Electromyography and Nerve Conduction Studies
- Electronic Brachytherapy for Nonmelanoma Skin Cancer
- Electrostimulation and Electromagnetic Therapy for Treating Wounds
- Endobronchial Brachytherapy
- Endobronchial Ultrasound for Diagnosis and Staging of Lung Cancer
- Endoscopic Radiofrequency Ablation or Cryoablation for Barrett Esophagus
- Endothelial Keratoplasty
- Endovascular Procedures for Intracranial Arterial Disease (Atherosclerosis and Aneurysms)
- Endovascular Stent Grafts for Abdominal Aortic 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
- External Insulin Infusion Pump
- Extracorporeal Membrane Oxygenation for Adult Conditions
- Extracorporeal Photopheresis
- 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
- Fecal Calprotectin Testing
- Fecal Microbiota Transplantation
- Focal Treatments for Prostate Cancer
- Fractional Carbon Dioxide (CO2) Laser Ablation Treatment of Hypertrophic Scars or Keloids
- Functional Endoscopic Sinus Surgery for Chronic Rhinosinusitis
- Functional Neuromuscular Electrical Stimulation
- Gastric Electrical Stimulation
- Gender Affirmation Surgery
- Genetic Testing: Aortopathies and Connective Tissue Disorders
- Genetic Testing: Cardiac Disorders
- Genetic Testing: Dermatologic Conditions
- Genetic Testing: Epilepsy, Neurodegenerative, and Neuromuscular Disorders
- Genetic Testing: Exome and Genome Sequencing For The Diagnosis Of Genetic Disorders
- Genetic Testing: Eye Disorders
- Genetic Testing: Gastroenterologic Disorders (Non-Cancerous)
- Genetic Testing: General Approach to Genetic and Molecular Testing
- Genetic Testing: Hearing Loss
- Genetic Testing: Hematologic Conditions (Non-Cancerous)
- Genetic Testing: Hereditary Cancer Susceptibility
- Genetic Testing: Immune, Autoimmune, and Rheumatoid Disorders
- Genetic Testing: Kidney Disorders
- Genetic Testing: Lung Disorders
- Genetic Testing: Metabolic, Endocrine, And Mitochondrial Disorders
- Genetic Testing: Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay
- Genetic Testing: Pharmacogenetics
- Genetic Testing: Preimplantation Genetic Testing
- Genetic Testing: Prenatal and Preconception Carrier Screening
- Genetic Testing: Prenatal Cell-Free DNA Testing
- Genetic Testing: Prenatal Diagnosis (via Amniocentesis, CVS, or PUBS) and Pregnancy Loss
- Genetic Testing: Skeletal Dysplasia and Rare Bone Disorders
- 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 Epithelial Ovarian Cancer
- Hematopoietic Cell Transplantation for Hodgkin Lymphoma
- Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors in Adults
- 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
- High Intensity Laser Therapy for Chronic Musculoskeletal Pain Conditions and Bell's Palsy
- Hip Arthroplasty for Adults
- Hip Resurfacing
- Hippotherapy
- Home Cardiorespiratory Monitoring
- Home Non-Invasive Positive Airway Pressure Devices for the Treatment of Respiratory Insufficiency and Failure
- Homocysteine Testing in the Screening, Diagnosis, and Management of Cardiovascular Disease and Venous Thromboembolic Disease
- Hyperbaric Oxygen Therapy
- Hyperthermic Intraperitoneal Chemotherapy for Select Intra-Abdominal and Pelvic Malignancies
- Hysterectomy Surgery for Benign Conditions
- Identification of Microorganisms Using Nucleic Acid Probes
- Image-Guided Minimally Invasive Decompression for Spinal Stenosis
- Immediate and Delayed Lymphatic Reconstruction Surgery
- Immune Cell Function Assay
- Implantable Bone-Conduction and Bone-Anchored Hearing Aids
- Implantable Cardioverter Defibrillators
- Implantable Peripheral Nerve Stimulation for Chronic Pain Conditions
- Ingestible pH and Pressure Capsule
- Inhaled Nitric Oxide
- Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence
- Intensity-Modulated Radiotherapy of the Breast and Lung
- Intensity-Modulated Radiotherapy of the Prostate
- Intensity-Modulated Radiotherapy: Abdomen and Pelvis and Chest
- Intensity-Modulated Radiotherapy: Cancer of the Head and Neck or Thyroid
- Intensity-Modulated Radiotherapy: Central Nervous System Tumors
- Interferential Current Stimulation
- Interventions for Progressive Scoliosis
- Intracavitary Balloon Catheter Brain Brachytherapy for Malignant Gliomas or Metastasis to the Brain
- Intracellular Micronutrient Analysis
- Intraocular Radiotherapy for Age-Related Macular Degeneration
- Intraoperative Neurophysiologic Monitoring
- Intraoperative Radiotherapy
- Irreversible Electroporation of Tumors Located in the Liver, Pancreas, Kidney, or Lung
- Islet Transplantation for Chronic Pancreatitis and Donislecel-jujn for Type 1 Diabetes
- Isolated Small Bowel Transplant
- Keratoprosthesis
- Kidney Transplant
- Knee Arthroplasty for Adults
- Knee Arthroscopy in Knee Osteoarthritis
- Knee Braces (Custom)
- Laparoscopic, Percutaneous, and Transcervical Techniques for Uterine Fibroid Myolysis
- Laser Interstitial Thermal Therapy for Neurological Conditions
- Laser Treatment of Onychomycosis
- Leadless Cardiac Pacemakers
- Lifestyle Modification Program for Reversing Heart Disease
- Liposuction for Lipedema
- Liver Transplant and Combined Liver-Kidney Transplant
- Low Intensity Pulsed Ultrasound Fracture Healing Device
- Low-Dose Radiotherapy for Non-Oncologic Indications
- Lower Limb Prostheses
- Low-Level Laser Therapy
- Lumbar Spine Surgery
- Lung and Lobar Lung Transplant
- Lung Volume Reduction Surgery for Severe Emphysema
- Lysis of Epidural Adhesions
- Magnetic Esophageal Sphincter Augmentation to Treat Gastroesophageal Reflux Disease
- 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 Exhaled Nitric Oxide and Exhaled Breath Condensate in the Diagnosis and Management of Respiratory Disorders
- Measurement of Serum Antibodies to Selected Biologic Agents
- Medical Management of Obstructive Sleep Apnea Syndrome
- Meniscal Allografts and Other Meniscal Implants
- Microprocessor-Controlled Prostheses for the Lower Limb
- Microwave Tumor Ablation
- Minimally Invasive Ablation Procedures for Morton and Other Peripheral Neuromas
- Minimally Invasive Approaches to Vertebral Fractures and Osteolytic Lesions of the Spine
- Monitored Anesthesia Care
- Multicancer Early Detection Testing
- Multitarget Polymerase Chain Reaction Testing for Diagnosis of Bacterial Vaginosis
- Myocardial Strain Imaging
- Myocardial Sympathetic Innervation Imaging in Patients With Heart Failure
- Myoelectric Prosthetic and Orthotic Components for the Upper Limb
- Nasal Septoplasty
- Negative Pressure Wound Therapy in the Outpatient Setting
- Nerve Fiber Density Measurement
- Neural Therapy
- Neuropsychological Testing
- Noncontact Ultrasound Treatment for Wounds
- Non-emergency Ground Ambulance
- Nonpharmacologic Treatment of Rosacea
- Nutrient/Nutritional Panel Testing
- Occipital Nerve Stimulation
- Occupational Therapy
- Oncologic Applications of Photodynamic Therapy, Including Barrett Esophagus
- Oncology: Algorithmic Testing
- Oncology: Cancer Screening
- Oncology: Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy)
- Oncology: Cytogenetic Testing
- Oncology: Molecular Analysis of Solid Tumors and Hematologic Malignancies
- 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)
- Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Conditions
- Outpatient Pulmonary Rehabilitation
- Ovarian and Internal Iliac Vein Endovascular Occlusion as a Treatment of Pelvic Congestion Syndrome
- Panniculectomy, Abdominoplasty, and Surgical Management of Diastasis Recti
- Paraspinal Surface Electromyography to Evaluate and Monitor Back Pain
- Paravertebral Facet Joint Injections or Blocks
- Partial Thickness Rotator Cuff Tears and Acromioplasty/Subacromial Decompression
- Patient-Controlled End Range of Motion Stretching Devices
- Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence
- Percutaneous Electrical Nerve Field Stimulation for Irritable Bowel Syndrome
- Percutaneous Electrical Nerve Stimulation, Percutaneous Neuromodulation Therapy, and Restorative Neurostimulation Therapy
- Percutaneous Left-Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation
- Percutaneous Revascularization Procedures for Lower Extremity Peripheral Arterial Disease
- Peripheral Nerve Injury Repair Using Synthetic Conduits or Processed Nerve Allografts
- Peripheral Subcutaneous Field Stimulation
- Periureteral Bulking Agents as a Treatment of Vesicoureteral Reflux
- Peroral Endoscopic Myotomy for Treatment of Esophageal Achalasia and Gastroparesis
- Personalized Breast Cancer Screening Clinical Trial
- Photodynamic Therapy for Choroidal Neovascularization
- Phrenic Nerve Stimulation For Central Sleep Apnea
- Physical Therapy
- Plugs for Anal Fistula Repair
- Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers
- Polysomnography for Non-Respiratory Sleep Disorders
- 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
- Prolotherapy
- Prostatic Urethral Lift
- Proteogenomic Testing for Patients With Cancer
- Proteomic Testing for Targeted Therapy in Non-Small-Cell Lung Cancer
- Quantitative Electroencephalography as a Diagnostic Aid for Attention-Deficit/Hyperactivity Disorder, Cognitive Impairment, or Autism Spectrum 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 Uncontrolled Hypertension
- Radiofrequency Coblation Tenotomy for Musculoskeletal Conditions
- Radiofrequency Volumetric Tissue Reduction for Nasal Obstruction
- Reconstructive Breast Surgery/Management of Breast Implants
- Reconstructive Services
- Reduction Mammaplasty for Breast-Related Symptoms
- Remote Electrical Neuromodulation for Migraines
- Repetitive Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders
- Reproductive Techniques
- Responsive Neurostimulation for the Treatment of Refractory Focal Epilepsy
- Retinal Telescreening for Diabetic Retinopathy
- Risk-Reducing Mastectomy
- Sacral Nerve Neuromodulation/Stimulation
- Sacroiliac Joint Injections
- 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
- Serum Biomarker Panel Testing for Systemic Lupus Erythematosus and Other Connective Tissue Diseases
- Small Bowel/Liver and Multivisceral Transplant
- Speech Therapy
- Sphenopalatine Ganglion Block for Headache
- Spinal Cord and Dorsal Root Ganglion Stimulation
- Stationary Ultrasonic Diathermy Devices
- Stem Cell Therapy for Peripheral Arterial Disease
- Stereotactic Radiosurgery and Stereotactic Body Radiotherapy
- Steroid-Eluting Sinus Stents and Implants
- Subtalar Arthroereisis
- Surgery for Groin Pain in Athletes
- Surgical Deactivation of Headache Trigger Sites
- Surgical Left Atrial Appendage Occlusion Devices for Stroke Prevention in Atrial Fibrillation
- Surgical Treatment of Femoroacetabular Impingement
- Surgical Treatment of Gynecomastia
- Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome
- Surgical Ventricular Restoration
- Suture Button Suspensionplasty Fixation System for Thumb Carpometacarpal Osteoarthritis
- Synthetic Cartilage Implants for Joint Pain
- Targeted Phototherapy and Psoralen with Ultraviolet A for Vitiligo
- Temporarily Implanted Nitinol Device (iTind) for Benign Prostatic Hyperplasia
- Temporomandibular Joint Disorder
- Testing Serum Vitamin D Levels
- Thoracic Spine Surgery
- Tibial Nerve Stimulation
- Total Artificial Hearts and Implantable Ventricular Assist Devices
- Transanal Endoscopic Microsurgery
- Transcatheter Aortic-Valve Implantation for Aortic Stenosis
- Transcatheter Arterial Chemoembolization to Treat Primary or Metastatic Liver Malignancies
- Transcatheter Mitral Valve Repair or Replacement
- Transcatheter Pulmonary Valve Implantation
- Transcatheter Tricuspid Valve Repair or Replacement
- Transcutaneous Electrical Nerve Stimulation and Transcutaneous Afferent Patterned Stimulation
- Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease
- Transmyocardial Revascularization
- Transurethral Water Vapor Thermal Therapy and Transurethral Water Jet Ablation (Aquablation) for Benign Prostatic Hypertrophy
- Treatment of Hyperhidrosis
- Treatment of Tinnitus
- Treatment of Varicose Veins/Venous Insufficiency
- Trigger Point and Tender Point Injections
- Tumor Treating Fields Therapy
- Uterus Transplantation for Absolute Uterine Factor Infertility
- Vagus Nerve Stimulation
- Vertebral Axial Decompression
- Vertebral Fracture Assessment with Densitometry or Biomechanical Computed Tomography
- Vertical Expandable Prosthetic Titanium Rib
- Vestibular Function Testing
- Virtual Colonoscopy/Computed Tomography Colonography
- Viscocanalostomy and Canaloplasty
- Wearable Cardioverter Defibrillators
- Whole Body Dual X-Ray Absorptiometry to Determine Body Composition
- Wireless Capsule Endoscopy for Gastrointestinal Disorders
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