• New and updated policies effective March 1, 2023

     

    Policy Title –March 1, 2023

    Policy#

    Status

    1

    Charged-Particle (Proton or Helium Ion) Radiotherapy for Neoplastic Conditions

    BSC8.04

    Major Update

    2

    Germline and Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment and Immunotherapy in Breast Cancer

    2.04.151

    Major Update

    3

    Negative Pressure Wound Therapy in the Outpatient Setting

    1.01.16

    Major Update

     4

    Tumor-Informed Circulating Tumor DNA Testing for Cancer Management

    BSC2.18

    Major Update

    5

    Facet Joint Denervation

    7.01.116

    New

    6

    Adipose-Derived Stem Cells in Autologous Fat Grafting to the Breast

    7.01.153

    Minor Update

    7

    Ambulatory Event Monitors and Mobile Cardiac Outpatient Telemetry 

    2.02.08

    Admin Update

    8

    Amniotic Membrane and Amniotic Fluid

    7.01.149

    Admin Update

    9

    Autologous Platelet-Derived Growth Factors for Wound Healing and Other Non-Orthopedic Conditions

    2.01.16

    Minor Update

    10

    Bioengineered Skin and Soft Tissue Substitutes

    7.01.113 

    Minor Update

    11

    Bioimpedance Devices for Detection and Management of Lymphedema

    2.01.82

    Minor Update

    12

    Blepharoplasty, Blepharoptosis Repair (Levator Resection) and Brow Lift (Repair of Brow Ptosis)

    BSC7.01

    Minor Update

    13

    Bone Turnover Markers for the Diagnosis and Management of Osteoporosis and Diseases Associated With High Bone Turnover

    2.04.15

    Minor Update

    14

    Catheter Ablation for Cardiac Arrhythmias

    BSC2.12

    Admin Update

    15

    Corneal Collagen Cross-Linking

    9.03.28

    Admin Update

    16

    Cranial Electrotherapy Stimulation and Auricular Electrostimulation

    8.01.58

    Admin Update

    17

    Digital Health Therapies for Substance Use Disorders

    5.01.35

    Admin Update

    18

    Electrostimulation and Electromagnetic Therapy for Treating Wounds

    2.01.57

    Minor Update

    19

    Esophageal pH Monitoring

    2.01.20

    Admin Update

    20

    Evaluation of Biomarkers for Alzheimer Disease

    2.04.14

    Admin Update

    21

    Focal Treatments for Prostate Cancer

    8.01.61

    Admin Update

    22

    Gender Affirmation Surgery

    BSC7.02

    Minor Update

    23

    General Approach to Evaluating the Utility of Genetic Panels

    2.04.92

    Admin Update

    24

    Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer

    2.04.33

    Admin Update

    25

    Genetic Testing for Alzheimer Disease

    2.04.13

    Admin Update

    26

    Genetic Testing for Cardiac Ion Channelopathies

    2.04.43

    Minor Update

    27

    Genetic Testing for Diagnosis and Management of Mental Health Condition

    2.04.110

    Admin Update

    28

    Genetic Testing for FLT3, NPM1, and CEBPA Variants in Cytogenetically Normal Acute Myeloid Leukemia

    2.04.124

    Minor Update

    29

    Genetic Testing: Exome and Genome Sequencing For The Diagnosis Of Genetic Disorders

    BSC_CON_2.02

    Admin Update

    30

    Hyperbaric Oxygen Therapy

    2.01.04

    Minor Update

    31

    Identification of Microorganisms Using Nucleic Acid Probes

    2.04.10

    Admin Update

    32

    Implantable Bone-Conduction and Bone-Anchored Hearing Aids

    7.01.03

    Admin Update

    33

    Ingestible pH and Pressure Capsule

    BSC2.17

    Minor Update

    34

    Interferential Current Stimulation

    1.01.24

    Admin Update

    35

    Lumbar Spine Surgery

    BSC_NIA_CG_304

    Admin Update

    36

    Lysis of Epidural Adhesions

    BSC8.05

    Minor Update

    37

    Manipulation Under Anesthesia 

    8.01.40

    Admin Update

    38

    Noncontact Ultrasound Treatment for Wounds

    2.01.79

    Minor Update

    39

    Oncology: Cancer Screening

    BSC_CON_2.09

    Admin Update

    40

    Orthopedic Applications of Stem Cell Therapy (Including Allografts and Bone Substitutes Used With Autologous Bone Marrow)

    8.01.52

    Minor Update

    41

    Orthoptic Training for the Treatment of Vision or Learning Disabilities

    9.03.03

    Admin Update

    42

    Percutaneous Vertebroplasty and Sacroplasty

    6.01.25

    Admin Update

    43

    Pharmacogenomic and Metabolite Markers for Patients Treated With Thiopurines

    2.04.19

    Admin Update

    44

    Reduction Mammaplasty

    7.01.21

    Admin Update

    45

    Retinal Prosthesis

    9.03.15

    Admin Update

    46

    Scintimammography and Gamma Imaging of the Breast and Axilla

    6.01.18

    Admin Update

    47

    Surgical Treatment of Gynecomastia

    BSC7.13

    Minor Update

    48

    Vagus Nerve Blocking Therapy for Treatment of Obesity

    BSC7.17

    Admin Update

     

    Please note:

     

    California Senate Bill 535 (“SB 535”) mandates that health plans are not to require prior authorization for either of the following services:

    • Biomarker testing for an enrollee or insured with advanced metastatic stage 3 or 4 cancer, or
    • Biomarker testing for cancer progression or recurrence in the enrollee or insured with advanced or metastatic stage 3 or 4 cancer.

    Blue Shield of California has removed prior authorization for Biomarker testing services. Compliance with SB 535 is required for Blue Shield’s delegated provider organizations, in cases where the organization is financially responsible for those services.

    For more coverage information, we encourage you to review our applicable medical or medication policies and benefits online at blueshieldca.com/provider.

     

     

  • New and updated policies effective February 1, 2023

     

    Policy Title – February 1, 2023

    Policy#

    Status

    Vendor

    1

    Intensity-Modulated Radiotherapy of the Breast and Lung

    8.01.46

    Major Update

    No

    2

    Intensity-Modulated Radiotherapy of the Prostate

    8.01.47

    Major Update

    No

    3

    Intensity-Modulated Radiotherapy: Abdomen, Pelvis and Chest

    8.01.49

    Major Update

    No

    4

    Intensity-Modulated Radiotherapy: Cancer of the Head and Neck or Thyroid

    8.01.48

    Major Update

    No

    5

    Intensity-Modulated Radiotherapy: Central Nervous System Tumors

    8.01.59

    Major Update

    No

    6

    Radiation Oncology

    BSC8.06

    Major Update

    No

    7

    Somatic (Tumor) Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment and Immunotherapy in Non-Small-Cell Lung Cancer (EGFR, ALK, BRAF, ROS1, RET, MET, KRAS, HER2, PD-L1, TMB)

    2.04.45

    Major Update

    No

    8

    Stereotactic Radiosurgery and Stereotactic Body Radiotherapy

    6.01.10

    Major Update

    No

    9

    Axillary Reverse Mapping for Prevention of Breast Cancer-Related Lymphedema

    7.01.173

    New

    No

    10

    Genetic Testing: Prenatal and Preconception Carrier Screening

    BSC_CON_2.07

    New

    No

    11

    Genetic Testing: Prenatal Diagnosis (Via Amniocentesis, CVS, or PUBS) and Pregnancy Loss

    BSC_CON_2.06

    New

    No

    12

    Oncology: Cancer Screening

    BSC_CON_2.09

    New

    No

    13

    Temporarily Implanted Nitinol Device (iTind) for Benign Prostatic Hyperplasia

    7.01.175

    New

    No

    14

    Bariatric Surgery

    7.01.47

    Minor Update

    No

    15

    Cardiovascular Risk Panels

    2.04.100

    Minor Update

    No

    16

    Carrier Screening for Genetic Diseases

    2.04.107

    ARCHIVED

    No

    17

    Dermatologic Applications of Photodynamic Therapy

    2.01.44

    Minor Update

    No

    18

    Fecal Analysis in the Diagnosis of Intestinal Dysbiosis

    2.04.26

    Minor Update

    No

    19

    Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer

    2.04.33

    Minor Update

    No

    20

    Immune Cell Function Assay

    2.04.56

    Minor Update

    No

    21

    Invasive Prenatal (Fetal) Diagnostic Testing

    2.04.116

    ARCHIVED

    No

    22

    Laser Interstitial Thermal Therapy for Neurological Conditions

    7.01.170

    Minor Update

    No

    23

    Measurement of Lipoprotein-Associated Phospholipase A2 in the Assessment of Cardiovascular Risk

    2.04.32

    Minor Update

    No

    24

    Multimarker Serum Testing Related to Ovarian Cancer

    2.04.62

    Minor Update

    No

    25

    Nonpharmacologic Treatment of Rosacea

    2.01.71

    Minor Update

    No

    26

    Novel Biomarkers in Risk Assessment and Management of Cardiovascular Disease

    2.04.65

    Minor Update

    No

    27

    Proteomic Testing for Targeted Therapy in Non-Small-Cell Lung Cancer

    2.04.125

    Minor Update

    No

    28

    Serum Biomarker Human Epididymis Protein 4

    2.04.66

    Minor Update

    No

    29

    Testing Serum Vitamin D Levels

    2.04.135

    Minor Update

    No

    30

    Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease

    2.01.38

    Minor Update

    No

    31

    Urinary Biomarkers for Cancer Screening, Diagnosis, and Surveillance

    2.04.07

    ARCHIVED

    No

    32

    Wireless Capsule Endoscopy for Gastrointestinal (GI) Disorders

    6.01.33

    Minor Update

    No

     

    Please note:

     

    California Senate Bill 535 (“SB 535”) mandates that health plans are not to require prior authorization for either of the following services:

    • Biomarker testing for an enrollee or insured with advanced metastatic stage 3 or 4 cancer, or
    • Biomarker testing for cancer progression or recurrence in the enrollee or insured with advanced or metastatic stage 3 or 4 cancer.

    Blue Shield of California has removed prior authorization for Biomarker testing services. Compliance with SB 535 is required for Blue Shield’s delegated provider organizations, in cases where the organization is financially responsible for those services.

    For more coverage information, we encourage you to review our applicable medical or medication policies and benefits online at blueshieldca.com/provider.

     

     

  • New and updated policies effective January 1, 2023

     

    Policy Title –January 1, 2023

    Policy#

    Status

    1

    Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer

    2.04.36

    Major Update

    2

    Epidural Spine Injections

    BSC_NIA_CG_300

    Major Update

    3

    Esophageal pH Monitoring

    2.01.20

    Major Update

    4

    Genetic Testing: Non-Invasive Prenatal Screening (NIPS)/ Non-Invasive Prenatal Testing (NIPT)

    BSC_CON_2.08

    New

    5

    Genetic Testing: Preimplantation Genetic Testing

    BSC_CON_2.03

    New

    6

    Bariatric Surgery

    7.01.47

    Minor Update

    7

    Cervical Spine Surgery

    BSC_NIA_CG_307

    Minor Update

    8

    Confocal Laser Endomicroscopy

    2.01.87

    Minor Update

    9

    Drug Testing in Pain Management and Substance Use Disorder Treatment 

    2.04.98

    Minor Update

    10

    Endoscopic Radiofrequency Ablation or Cryoablation for Barrett Esophagus

    2.01.80

    Minor Update

    11

    Gene Expression Profiling and Protein Biomarkers for Prostate Cancer Management

    2.04.111

    Minor Update

    12

    Lumbar Spinal Surgery

    BSC_NIA_CG_304

    Minor Update

    13

    Magnetic Esophageal Sphincter Augmentation to Treat Gastroesophageal Reflux Disease

    7.01.137

    Minor Update

    14

    Measurement of Serum Antibodies to Selected Biologic Agents

    2.04.84

    Minor Update

    15

    Monitored Anesthesia Care

    7.02.01

    Minor Update

    16

    Noninvasive Prenatal Screening for Fetal Aneuploidies, Microdeletions, Single-Gene Disorders, and Twin Zygosity Using Cell-Free Fetal DNA

    4.01.21

    Archived

    17

    Noninvasive Techniques for the Evaluation and Monitoring of Patients With Chronic Liver Disease

    2.04.41

    Minor Update

    18

    Paravertebral Facet Joint Injections or Blocks

    BSC_NIA_CG_301

    Minor Update

    19

    Pharmacogenetic Testing for Pain Management

    2.04.131 

    Minor Update

    20

    Pharmacogenomic and Metabolite Markers for Patients Treated With Thiopurines

    2.04.19

    Minor Update

    21

    Plugs for Anal Fistula Repair

    7.01.123

    Minor Update

    22

    Preimplantation Genetic Testing

    4.02.05

    Archived

    23

    Prolotherapy

    2.01.26

    Minor Update

    24

    Sacroiliac Joint Injections

    BSC_NIA_CG_305

    Minor Update

    25

    Thoracic Spine Surgery

    BSC_NIA_CG_308

    Minor Update

     

    Please note:

     

    California Senate Bill 535 (“SB 535”) mandates that health plans are not to require prior authorization for either of the following services:

    • Biomarker testing for an enrollee or insured with advanced metastatic stage 3 or 4 cancer, or
    • Biomarker testing for cancer progression or recurrence in the enrollee or insured with advanced or metastatic stage 3 or 4 cancer.

    Blue Shield of California is compliant with SB 535 and has removed prior authorization for Biomarker testing services. Compliance with SB 535 is required for Blue Shield’s delegated provider organizations, as well, in cases where the organization is financially responsible for those services.

    Please note that when prior authorization is not required for a service for which Blue Shield is financially responsible, this does not represent a guarantee of coverage or payment. A final coverage determination is made “post-service,” after the claim has been received and reviewed by Blue Shield. The review is based on member eligibility, medical necessity, such as medical or medication policy or site of service, and other limitations or exclusions in the member’s health coverage plan that may apply. For more coverage information, we encourage you to review our applicable medical or medication policies and benefits online at blueshieldca.com/provider.

     

     

  • New and updated policies effective December 1, 2022

     

    Policy Title –December 1, 2022

    Policy#

    Status

    1

    Comprehensive Genomic Profiling for Selecting Targeted Cancer Therapies

    2.04.115

    Major Update

    2

    Germline Genetic Testing for Hereditary Breast/Ovarian Cancer Syndrome and Other High-Risk Cancers (BRCA1, BRCA2, PALB2)

    2.04.02

    Major Update

    3

    Hip Arthroplasty for Adults

    BSC7.11

    Major Update

    4

    Knee Arthroplasty for Adults

    BSC7.10

    Major Update

    5

    Knee Arthroscopy in Knee Osteoarthritis

    BSC7.16

    Major Update

    6

    Laboratory Tests Post Transplant and for Heart Failure

    2.01.68

    Major Update

    7

    Germline and Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment and Immunotherapy in Ovarian Cancer (BRCA1, BRCA2, Homologous Recombination Deficiency, Tumor Mutational Burden, Microsatellite Instability/Mismatch Repair)

    2.04.156

    New

    8

    Germline and Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment and Immunotherapy in Prostate Cancer (BRCA1/2, Homologous Recombination Repair Gene Alterations, Microsatellite Instability/Mismatch Repair, Tumor Mutational Burden)

    2.04.155

    New

    9

    Absorbable Nasal Implant for Treatment of Nasal Valve Collapse

    7.01.163

    Minor Update

    10

    Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer

    2.04.36

    Admin Update

    11

    Bioengineered Skin and Soft Tissue Substitutes

    7.01.113

    Admin-Coding

    12

    Cranial Electrotherapy Stimulation and Auricular Electrostimulation

    8.01.58

    Admin-Coding

    13

    Elective Invasive Coronary Angiography (ICA)

    BSC2.13

    Admin Update

    14

    Elective Percutaneous Coronary Intervention (PCI)

    BSC6.02

    Admin Update

    15

    Evaluation of Biomarkers for Alzheimer Disease

    2.04.14

    Minor Update

    16

    Genetic Cancer Susceptibility Panels Using Next-Generation Sequencing

    2.04.93

    Minor Update

    17

    Genetic Testing for Alzheimer Disease

    2.04.13

    Minor Update

    18

    Genetic Testing for Cardiac Ion Channelopathies

    2.04.43

    Admin Update

    19

    Genetic Testing for Developmental Delay/Intellectual Disability, Autism Spectrum Disorder, and Congenital Anomalies

    2.04.59

    Minor Update

    20

    Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes

    2.04.08

    Admin Update

    21

    Genetic Testing for Mitochondrial Disorders

    2.04.117

    Admin-Coding

    22

    Genetic Testing for Predisposition to Inherited Hypertrophic Cardiomyopathy

    2.02.28

    Admin Update

    23

    Genetic Testing: Exome and Genome Sequencing For The Diagnosis Of Genetic Disorders

    BSC_CON_2.02

    Admin Update

    24

    Germline Genetic Testing for Gene Variants Associated With Breast Cancer in Individuals at High Breast Cancer Risk (CHEK2, ATM, and BARD1)

    2.04.126

    Admin Update

    25

    Germline Genetic Testing for Pancreatic Cancer Susceptibility Genes

    2.04.148

    Admin-Coding

    26

    Hysterectomy Surgery for Benign Conditions

    BSC7.09

    Admin Update

    27

    Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence

    7.01.19

    Minor Update

    28

    Magnetic Resonance Spectroscopy

    6.01.24

    Minor Update

    29

    Microwave and Locoregional Laser Tumor Ablation

    7.01.133

    Minor Update

    30

    Miscellaneous (Noncardiac, Nononcologic) Applications of Fluorine 18 Fluorodeoxyglucose Positron Emission Tomography

    6.01.06

    Minor Update

    31

    Quantitative Electroencephalography as a Diagnostic Aid for Attention-Deficit/Hyperactivity Disorder

    3.01.03

    Minor Update

    32

    Radiofrequency Ablation of the Renal Sympathetic Nerves as a Treatment for Resistant or Uncontrolled Hypertension

    7.01.136

    Minor Update

    33

    Selected Positron Emission Tomography Technologies for Evaluation of Alzheimer Disease

    6.01.55

    Minor Update

    34

    Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders

    2.01.50

    Minor Update

     

    Please note:

     

    California Senate Bill 535 (“SB 535”) mandates that health plans are not to require prior authorization for either of the following services:

    • Biomarker testing for an enrollee or insured with advanced metastatic stage 3 or 4 cancer, or
    • Biomarker testing for cancer progression or recurrence in the enrollee or insured with advanced or metastatic stage 3 or 4 cancer.

    Blue Shield of California is compliant with SB 535 and has removed prior authorization for Biomarker testing services. Compliance with SB 535 is required for Blue Shield’s delegated provider organizations, as well, in cases where the organization is financially responsible for those services.

    Please note that when prior authorization is not required for a service for which Blue Shield is financially responsible, this does not represent a guarantee of coverage or payment. A final coverage determination is made “post-service,” after the claim has been received and reviewed by Blue Shield. The review is based on member eligibility, medical necessity, such as medical or medication policy or site of service, and other limitations or exclusions in the member’s health coverage plan that may apply. For more coverage information, we encourage you to review our applicable medical or medication policies and benefits online at blueshieldca.com/provider.

     

     

  • New and updated policies effective November 1, 2022

     

    Policy Title – November 1, 2022

    Policy#

    Status

    1

    Elective Invasive Coronary Angiography (ICA)

    BSC2.13

    Major Update

    2

    Elective Percutaneous Coronary Intervention (PCI)

    BSC6.02

    Major Update

    3

    Germline Genetic Testing for Hereditary Diffuse Gastric Cancer (CDH1, CTNNA1)

    2.04.154

    New

    4

    Ablation of Peripheral Nerves to Treat Pain

    7.01.154

    Minor Update

    5

    Aqueous Shunts and Stents for Glaucoma

    9.03.21

    Minor Update

    6

    Balloon Dilation of the Eustachian Tube

    7.01.158

    Minor Update

    7

    Bone Mineral Density Studies

    6.01.01

    Minor Update

    8

    Cardiac Applications of Positron Emission Tomography Scanning

    6.01.20  

    Minor Update

    9

    Carrier Screening for Genetic Diseases

    2.04.107

    Minor Update

    10

    Circulating Tumor DNA and Circulating Tumor Cells for Cancer Management (Liquid Biopsy)

    2.04.141

    Admin Coding

    11

    Comprehensive Genomic Profiling for Selecting Targeted Cancer Therapies

    2.04.115

    Admin Coding

    12

    Computed Tomography Perfusion Imaging of the Brain

    6.01.49

    Minor Update

    13

    Computed Tomography to Detect Coronary Artery Calcification

    6.01.03

    Minor Update

    14

    Contrast-Enhanced Computed Tomographic Angiography for Coronary Artery Evaluation

    6.01.43

    Minor Update

    15

    Cryosurgical Ablation of Primary or Metastatic Liver Tumors

    7.01.75

    Minor Update

    16

    Dynamic Spinal Visualization and Vertebral Motion Analysis

    6.01.46

    Minor Update

    17

    Evaluation of Biomarkers for Alzheimer Disease

    2.04.14

    Admin Coding

    18

    Focal Treatments for Prostate Cancer 

    8.01.61

    Minor Update

    19

    Functional Magnetic Resonance Imaging of the Brain

    6.01.47

    Minor Update

    20

    General Approach to Genetic Testing

    2.04.91

    Admin Coding

    21

    Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer

    2.04.33

    Admin Coding

    22

    Genetic Testing for Developmental Delay/Intellectual Disability, Autism Spectrum Disorder, and Congenital Anomalies

    2.04.59

    Admin Coding

    23

    Genetic Testing for Diagnosis and Management of Mental Health Conditions

    2.04.110

    Admin Coding

    24

    Genetic Testing for FLT3, NPM1, and CEBPA Variants in Cytogenetically Normal Acute Myeloid Leukemia

    2.04.124

    Admin Coding

    25

    Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes

    2.04.08

    Minor Update

    26

    Genetic Testing for Mitochondrial Disorders

    2.04.117

    Minor Update

    27

    Genetic Testing: Exome and Genome Sequencing For The Diagnosis Of Genetic Disorders

    BSC_CON_2.02

    Admin Coding

    28

    Identification of Microorganisms Using Nucleic Acid Probes

    2.04.10

    Admin Coding

    29

    Interim Positron Emission Tomography Scanning in Oncology to Detect Early Response During Treatment

    6.01.51

    Minor Update

    30

    Invasive Prenatal (Fetal) Diagnostic Testing

    2.04.116

    Admin Coding

    31

    Magnetic Resonance Imaging for Detection and Diagnosis of Breast Cancer

    6.01.29

    Minor Update

    32

    Magnetoencephalography/Magnetic Source Imaging

    BSC6.05

    Minor Update

    33

    Myocardial Sympathetic Innervation Imaging in Patients With Heart Failure 

    6.01.56  

    Minor Update

    34

    Noninvasive Techniques for the Evaluation and Monitoring of Patients with Chronic Liver Disease

    2.04.41

    Admin Coding

    35

    Oncologic Applications of Positron Emission Tomography Scanning

    6.01.26  

    Minor Update

    36

    Pharmacogenetic Testing for Pain Management

    2.04.131

    Admin Coding

    37

    Positional Magnetic Resonance Imaging

    6.01.48

    Minor Update

    38

    Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors

    7.01.95

    Minor Update

    39

    Reproductive Techniques

    4.02.04

    Minor Update

    40

    Scintimammography and Gamma Imaging of the Breast and Axilla

    6.01.18

    Minor Update

    41

    Surgical Treatments for Breast Cancer-Related Lymphedema

    7.01.162

    Minor Update

    42

    Tumor-Informed Circulating Tumor DNA Testing for Cancer Management

    2.04.153

    Admin Coding

    43

    Vertebral Fracture Assessment with Densitometry

    6.01.44

    Minor Update

    44

    Virtual Colonoscopy/Computed Tomography Colonography

    6.01.32 

    Minor Update

     

    Please note:

     

    California Senate Bill 535 (“SB 535”) mandates that health plans are not to require prior authorization for either of the following services:

    • Biomarker testing for an enrollee or insured with advanced metastatic stage 3 or 4 cancer, or
    • Biomarker testing for cancer progression or recurrence in the enrollee or insured with advanced or metastatic stage 3 or 4 cancer.

    Blue Shield of California is compliant with SB 535 and has removed prior authorization for Biomarker testing services. Compliance with SB 535 is required for Blue Shield’s delegated provider organizations, as well, in cases where the organization is financially responsible for those services.

    Please note that when prior authorization is not required for a service for which Blue Shield is financially responsible, this does not represent a guarantee of coverage or payment. A final coverage determination is made “post-service,” after the claim has been received and reviewed by Blue Shield. The review is based on member eligibility, medical necessity, such as medical or medication policy or site of service, and other limitations or exclusions in the member’s health coverage plan that may apply. For more coverage information, we encourage you to review our applicable medical or medication policies and benefits online at blueshieldca.com/provider.

     

     

  • New and updated policies effective October 1, 2022

     

    Policy Title – October 1, 2022

    Policy#

    Status

    1

    Diagnosis of Obstructive Sleep Apnea Syndrome

    2.01.18

    Major Update

    2

    Germline Genetic Testing for Gene Variants Associated With Breast Cancer in Individuals at High Breast Cancer Risk (CHEK2, ATM, and BARD1)

    2.04.126

    Major Update

    3

    Germline Genetic Testing for Hereditary Breast/Ovarian Cancer Syndrome and Other High-Risk Cancers (BRCA1, BRCA2, PALB2)

    2.04.02

    Major Update

    4

    Germline Genetic Testing for Ovarian Cancer Risk (BRIP1, RAD51C, RAD51D, NBN)

    2.04.149

    Major Update

    5

    Kidney Transplant

    7.03.01

    Major Update

    6

    Noninvasive Prenatal Screening for Fetal Aneuploidies, Microdeletions, Single-Gene Disorders, and Twin Zygosity Using Cell-Free Fetal DNA

    4.01.21

    Major Update

    7

    Small Bowel/Liver and Multivisceral Transplant

    7.03.05

    Major Update

    8

    Medical Management of Obstructive Sleep Apnea Syndrome

    8.01.67  

    New

    9

    Surgical Left Atrial Appendage Occlusion Devices for Stroke Prevention in Atrial Fibrillation

    7.01.172

    New

    10

    Allogeneic Pancreas Transplant

    7.03.02

    Minor Update

    11

    Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer

    2.04.36

    Admin Update

    12

    Biofeedback as a Treatment of Urinary Incontinence in Adults

    2.01.27

    Minor Update

    13

    Circulating Tumor DNA and Circulating Tumor Cells for Cancer Management (Liquid Biopsy)

    2.04.141

    Minor Update

    14

    Gender Affirmation Surgery

    BSC7.02

    Admin Update

    15

    Gene Expression Profile Testing and Circulating Tumor DNA Testing for Predicting Recurrence in Colon Cancer

    2.04.61

    Minor Update

    16

    Gene Expression-Based Assays for Cancers of Unknown Primary

    2.04.54

    Admin Update

    17

    General Approach to Evaluating the Utility of Genetic Panels

    2.04.92

    Admin Update

    18

    General Approach to Genetic Testing

    2.04.91

    Admin Update

    19

    Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes

    2.04.08

    Admin Update

    20

    Genetic Testing for Predisposition to Inherited Hypertrophic Cardiomyopathy

    2.02.28

    Admin Update

    21

    Genotype-Guided Tamoxifen Treatment

    2.04.51

    Minor Update

    22

    Heart Transplant

    7.03.09

    Minor Update

    23

    Heart/Lung Transplant

    7.03.08

    Minor Update

    24

    Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia

    8.01.32

    Admin Update

    25

    Hematopoietic Cell Transplantation for Acute Myeloid Leukemia

    8.01.26

    Admin Update

    26

    Hematopoietic Cell Transplantation for Autoimmune Diseases

    8.01.25

    Admin Update

    27

    Hematopoietic Cell Transplantation for Central Nervous System Embryonal Tumors and Ependymoma

    8.01.28

    Admin Update

    28

    Hematopoietic Cell Transplantation for Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma

    8.01.15

    Admin Update

    29

    Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia

    8.01.30

    Admin Update

    30

    Hematopoietic Cell Transplantation for Hodgkin Lymphoma

    8.01.29

    Admin Update

    31

    Hematopoietic Cell Transplantation for Non-Hodgkin Lymphomas

    8.01.20

    Admin Update

    32

    Hematopoietic Cell Transplantation for Plasma Cell Dyscrasias, Including Multiple Myeloma and POEMS Syndrome

    8.01.17

    Admin Update

    33

    Hematopoietic Cell Transplantation for Primary Amyloidosis 

    8.01.42  

    Admin Update

    34

    Hematopoietic Cell Transplantation for Solid Tumors of Childhood

    8.01.34

    Admin Update

    35

    Hematopoietic Cell Transplantation in the Treatment of Germ Cell Tumors

    8.01.35  

    Admin Update

    36

    Hepatitis C Viremic Organs for Transplantation to Non-Viremic Patients

    7.03.14

    Archived

    37

    Invasive Prenatal (Fetal) Diagnostic Testing

    2.04.116

    Minor Update

    38

    Islet Transplantation

    7.03.12

    Minor Update

    39

    Isolated Small Bowel Transplant

    7.03.04

    Minor Update

    40

    JAK2, MPL, and CALR Testing for Myeloproliferative Neoplasms

    2.04.60

    Minor Update

    41

    Liver Transplant and Combined Liver-Kidney Transplant

    7.03.06

    Minor Update

    42

    Lung and Lobar Lung Transplant

    7.03.07

    Minor Update

    43

    Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence

    1.01.17

    Minor Update

    44

    Placental and Umbilical Cord Blood as a Source of Stem Cells

    7.01.50  

    Admin Update

    45

    Preimplantation Genetic Testing

    4.02.05

    Minor Update

    46

    Reconstructive Services

    BSC7.08

    Admin Update

    47

    Total Artificial Hearts and Implantable Ventricular Assist Devices

    7.03.11

    Minor Update

    48

    Whole Gland Cryoablation of Prostate Cancer

    7.01.79

    Minor Update

     

    Please note:

     

    California Senate Bill 535 (“SB 535”) mandates that health plans are not to require prior authorization for either of the following services:

    • Biomarker testing for an enrollee or insured with advanced metastatic stage 3 or 4 cancer, or
    • Biomarker testing for cancer progression or recurrence in the enrollee or insured with advanced or metastatic stage 3 or 4 cancer.

    Blue Shield of California is compliant with SB 535 and has removed prior authorization for Biomarker testing services. Compliance with SB 535 is required for Blue Shield’s delegated provider organizations, as well, in cases where the organization is financially responsible for those services.

    Please note that when prior authorization is not required for a service for which Blue Shield is financially responsible, this does not represent a guarantee of coverage or payment. A final coverage determination is made “post-service,” after the claim has been received and reviewed by Blue Shield. The review is based on member eligibility, medical necessity, such as medical or medication policy or site of service, and other limitations or exclusions in the member’s health coverage plan that may apply. For more coverage information, we encourage you to review our applicable medical or medication policies and benefits online at blueshieldca.com/provider.

     

     

  • New and updated policies effective September 1, 2022

     

    Policy Title – September 1, 2022

    Policy#

    Status

    1

    Digital Health Technologies: Diagnostic Applications

    3.03.01

    New

    2

    Minimally Invasive Ablation Procedures for Morton and Other Peripheral Neuromas

    7.01.147

    New

    3

    Reconstructive Breast Surgery/Management of Breast Implants

    7.01.22

    New

    4

    Alcohol Injections for Treatment of Peripheral Morton Neuromas

    2.01.97

    Archived

    5

    Brachytherapy for Clinically Localized Prostate Cancer Using Permanently Implanted Seeds

    8.01.14

    Admin Update

    6

    Breast Implant Management

    BSC7.12

    Archived

    7

    Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting

    2.02.24

    Minor Update

    8

    Cellular Immunotherapy for Prostate Cancer

    8.01.53

    Minor Update

    9

    Computer-Assisted Navigation for Orthopedic Procedure

    7.01.96

    Archived

    10

    Continuous Glucose Monitoring

    1.01.20

    Minor Update

    11

    Cryoablation of Tumors Located in the Kidney, Lung, Breast, Pancreas, or Bone

    7.01.92

    Minor Update

    12

    Digital Health Therapies for Attention Deficit/Hyperactivity Disorder

    3.03.03

    Minor Update

    13

    Digital Health Therapies for Substance Use Disorders

    5.01.35

    Minor Update

    14

    Electronic Brachytherapy for Nonmelanoma Skin Cancer

    8.01.62

    Admin Update

    15

    Endobronchial Brachytherapy

    8.03.11

    Admin Update

    16

    Genetic Testing for Diagnosis and Management of Mental Health Condition

    2.04.110

    Minor Update

    17

    Hip Arthroplasty for Adults

    BSC7.11

    Admin Update

    18

    Hydrogel Spacer use During Radiotherapy for Prostate Cancer

    7.01.164

    Archived

    19

    Intensity-Modulated Radiotherapy of the Breast and Lung

    8.01.46

    Admin Update

    20

    Intensity-Modulated Radiotherapy of the Prostate

    8.01.47

    Admin Update

    21

    Intensity-Modulated Radiotherapy: Abdomen, Pelvis and Chest

    8.01.49

    Admin Update

    22

    Intensity-Modulated Radiotherapy: Cancer of the Head and Neck or Thyroid

    8.01.48

    Admin Update

    23

    Intensity-Modulated Radiotherapy: Central Nervous System Tumors

    8.01.59

    Admin Update

    24

    Intracavitary Balloon Catheter Brain Brachytherapy for Malignant Gliomas or Metastasis to the Brain

    8.01.45

    Admin Update

    25

    Intraoperative Radiotherapy

    8.01.08

    Admin Update

    26

    Knee Arthroplasty for Adults

    BSC7.10

    Admin Update

    27

    Magnetic Resonance-Guided Focused Ultrasound

    7.01.109

    Minor Update

    28

    Molecular Analysis (Including Liquid Biopsy) for Targeted Therapy or Immunotherapy

    2.04.45

    Admin Update

    29

    Oncologic Applications of Photodynamic Therapy, Including Barrett Esophagus

    8.01.06

    Minor Update

    30

    Patient-Specific Instrumentation (e.g., Cutting Guides) for Joint Arthroplasty

    7.01.144

    Archived

    31

    Radiation Oncology

    BSC8.06

    Admin Update

    32

    Radioembolization for Primary and Metastatic Tumors of the Liver

    8.01.43

    Admin Update

    33

    Radiofrequency Ablation of Primary or Metastatic Liver Tumors

    7.01.91

    Minor Update

    34

    Saturation Biopsy for Diagnosis, Staging, and Management of Prostate Cancer

    7.01.121

    Minor Update

    35

    Serologic Genetic and Molecular Screening for Colorectal Cancer

    2.04.150

    Minor Update

    36

    Stereotactic Radiosurgery and Stereotactic Body Radiotherapy

    6.01.10

    Admin Update

    37

    Subtalar Arthroereisis

    7.01.104

    Admin Update

    38

    Synthetic Cartilage Implants for Joint Pain

    7.01.160

    Minor Update

    39

    Transcatheter Arterial Chemoembolization to Treat Primary or Metastatic Liver Malignancies

    8.01.11

    Minor Update

     

    Please note:

     

    California Senate Bill 535 (“SB 535”) mandates that health plans are not to require prior authorization for either of the following services:

    • Biomarker testing for an enrollee or insured with advanced metastatic stage 3 or 4 cancer, or
    • Biomarker testing for cancer progression or recurrence in the enrollee or insured with advanced or metastatic stage 3 or 4 cancer.

    Blue Shield of California is compliant with SB 535 and has removed prior authorization for Biomarker testing services. Compliance with SB 535 is required for Blue Shield’s delegated provider organizations, as well, in cases where the organization is financially responsible for those services.

    Please note that when prior authorization is not required for a service for which Blue Shield is financially responsible, this does not represent a guarantee of coverage or payment. A final coverage determination is made “post-service,” after the claim has been received and reviewed by Blue Shield. The review is based on member eligibility, medical necessity, such as medical or medication policy or site of service, and other limitations or exclusions in the member’s health coverage plan that may apply. For more coverage information, we encourage you to review our applicable medical or medication policies and benefits online at blueshieldca.com/provider.

     

     

  • New and updated policies effective August 1, 2022

     

    Policy Title - August 1, 2022

    Policy#

    Status

    1

    Cytochrome P450 Genotype-Guided Treatment Strategy

    2.04.38

    Major Update

    2

    Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome

    7.01.101

    Major Update

    3

    Treatment of Hyperhidrosis

    8.01.19

    Major Update

    4

    Dry Hydrotherapy for chronic pain conditions

    2.01.105

    New

    5

    Actigraphy

    2.01.73

    Minor Update

    6

    Amniotic Membrane and Amniotic Fluid

    7.01.149

    Admin coding

    7

    Bioengineered Skin and Soft Tissue Substitutes

    7.01.113

    Admin coding

    8

    Brachytherapy for Clinically Localized Prostate Cancer Using Permanently Implanted Seeds

    8.01.14

    Minor Update

    9

    Bronchial Thermoplasty

    7.01.127

    Minor Update

    10

    Bronchial Valves

    7.01.128

    Minor Update

    11

    Circulating Tumor DNA and Circulating Tumor Cells for Cancer Management (Liquid Biopsy)

    2.04.141

    Admin coding

    12

    Comprehensive Genomic Profiling for Selecting Targeted Cancer Therapies

    2.04.115

    Admin coding

    13

    Corneal Collagen Cross-Linking

    9.03.28

    Admin coding

    14

    Electronic Brachytherapy for Nonmelanoma Skin Cancer

    8.01.62

    Minor Update

    15

    Endobronchial Brachytherapy

    8.03.11

    Minor Update

    16

    Endovascular Stent Grafts for Disorders of the Thoracic Aorta

    7.01.86

    Minor Update

    17

    External Insulin Infusion Pump

    BSC1.03

    Minor Update

    18

    Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions

    2.01.40

    Minor Update

    19

    Genotype-Guided Warfarin Dosing

    2.04.48

    Minor Update

    20

    Identification of Microorganisms Using Nucleic Acid Probes

    2.04.10

    Minor Update

    21

    Intensity-Modulated Radiotherapy of the Breast and Lung

    8.01.46

    Minor Update

     

    Policy Title-August 1, 2022

    Policy#

    Status

    22

    Intensity-Modulated Radiotherapy of the Prostate

    8.01.47

    Minor Update

    23

    Intensity-Modulated Radiotherapy: Abdomen and Pelvis

    8.01.49

    Minor Update

    24

    Intensity-Modulated Radiotherapy: Cancer of the Head and Neck or Thyroid

    8.01.48

    Minor Update

    25

    Intensity-Modulated Radiotherapy: Central Nervous System Tumors

    8.01.59

    Minor Update

    26

    Interferential Current Stimulation

    1.01.24

    Minor Update

    27

    Intracavitary Balloon Catheter Brain Brachytherapy for Malignant Gliomas or Metastasis to the Brain

    8.01.45

    Minor Update

    28

    Intraoperative Radiotherapy

    8.01.08

    Minor Update

    29

    Knee Arthroscopy in Knee Osteoarthritis

    BSC7.16

    Minor Update

    30

    Lung Volume Reduction Surgery for Severe Emphysema

    7.01.71

    Minor Update

    31

    Medical Cannabis for the Treatment of Pain and Spasticity

    5.01.32

    Minor Update

    32

    Multibiomarker Disease Activity Blood Test for Rheumatoid Arthritis

    2.04.119

    Minor Update

    33

    Navigated Transcranial Magnetic Stimulation

    2.01.90

    Minor Update

    34

    Noninvasive Prenatal Screening for Fetal Aneuploidies, Microdeletions, and Twin Zygosity Using Cell-Free Fetal DNA

    4.01.21

    Admin coding

    35

    Oncologic Applications of Positron Emission Tomography Scanning

    6.01.26

    Admin coding

    36

    Orthopedic Applications of Stem Cell Therapy (including Allografts and Bone Substitutes with Autologous Bone Marrow

    8.01.52

    Admin coding

    37

    Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Conditions

    1.01.15

    Minor Update

    38

    Paraspinal Surface Electromyography to Evaluate and Monitor Back Pain

    2.01.35

    Minor Update

    39

    Quantitative Sensory Testing

    2.01.39

    Minor Update

    40

    Radiation Oncology

    BSC8.06

    Minor Update

     

    Policy Title-August 1, 2022

    Policy#

    Status

    41

    Radioembolization for Primary and Metastatic Tumors of the Liver

    8.01.43

    Minor Update

    42

    Stereotactic Radiosurgery and Stereotactic Body Radiotherapy

    6.01.10

    Minor Update

    43

    Transcatheter Pulmonary Valve Implantation

    7.01.131

    Minor Update

     

    Please note:

     

    California Senate Bill 535 (“SB 535”) mandates that health plans are not to require prior authorization for either of the following services:

    • Biomarker testing for an enrollee or insured with advanced metastatic stage 3 or 4 cancer, or
    • Biomarker testing for cancer progression or recurrence in the enrollee or insured with advanced or metastatic stage 3 or 4 cancer.

    Blue Shield of California is compliant with SB 535 and has removed prior authorization for Biomarker testing services. Compliance with SB 535 is required for Blue Shield’s delegated provider organizations, as well, in cases where the organization is financially responsible for those services.

    Please note that when prior authorization is not required for a service for which Blue Shield is financially responsible, this does not represent a guarantee of coverage or payment. A final coverage determination is made “post-service,” after the claim has been received and reviewed by Blue Shield. The review is based on member eligibility, medical necessity, such as medical or medication policy or site of service, and other limitations or exclusions in the member’s health coverage plan that may apply. For more coverage information, we encourage you to review our applicable medical or medication policies and benefits online at blueshieldca.com/provider.

     

     

  • New and updated policies effective July 1, 2022

     

    Policy Title – July 1, 2022

    Policy#

    Status

    1

    Catheter Ablation as Treatment for Atrial Fibrillation

    7.01.124

    Major Update

    2

    Temporomandibular Joint Disorder

    2.01.21

    Major Update

    3

    Remote Electrical Neuromodulation for Migraine

    7.01.171

    New

    4

    Allograft Injection for Degenerative Disc Disease

    BSC2.11

    Minor Update

    5

    Ambulatory Event Monitors and Mobile Cardiac Outpatient Telemetry

    2.02.08

    Minor Update

    6

    Baroreflex Stimulation Devices

    BSC1.01

    Minor Update

    7

    Biventricular Pacemakers (Cardiac Resynchronization Therapy) for the Treatment of Heart Failure

    7.01.14

    Minor Update

    8

    Catheter Ablation for Cardiac Arrhythmias

    2.02.19

    Minor Update

    9

    Diabetes Prevention Program

    2.04.94

    Minor Update

    10

    Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome

    2.01.18

    Admin Coding

    11

    Endovascular Therapies for Extracranial Vertebral Artery Disease

    2.02.15

    Minor Update

    12

    Enhanced External Counterpulsation

    2.02.31

    Minor Update

    13

    Extracorporeal Membrane Oxygenation for Adult Conditions

    8.01.60

    Minor Update

    14

    Extracranial Carotid Artery Stenting

    7.01.68

    Minor Update

    15

    Facet Arthroplasty

    7.01.166

    Minor Update

    16

    Genetic Testing for Inherited Thrombophilia

    8.01.57

    Minor Update

    17

    Genetic Testing for Lactase Insufficiency

    2.04.142

    Minor Update

    18

    Germline Genetic Testing for Pancreatic Cancer Susceptibility Genes

    2.04.148

    Minor Update

    19

    Implantable Cardioverter Defibrillators

    7.01.44

    Minor Update

    20

    Inhaled Nitric Oxide

    8.01.37

    Minor Update

    21

    Knee Arthroplasty for Adults

    BSC7.10

    Minor Update

    22

    Lipid Apheresis

    BSC8.07

    Minor Update

    23

    Lower Limb Prostheses

    BSC2.12

    Minor Update

    24

    Molecular Testing in the Management of Pulmonary Nodules

    2.02.10

    Minor Update

    25

    Myocardial Strain Imaging

    2.02.06

    Minor Update

    26

    Neuropsychological Testing

    BSC2.06

    Minor Update

    27

    Open and Thoracoscopic Approaches to Treat Atrial Fibrillation and Atrial Flutter (Maze and Related Procedures)

    7.01.120

    Minor Update

    28

    Phrenic Nerve Stimulation for Central Sleep Apnea

    2.02.33

    Minor Update

    29

    Power Wheelchairs and Power Operated Vehicles for Permanent Use

    BSC1.02

    Minor Update

    30

    Speech Therapy

    BSC8.02

    Minor Update

    31

    Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome

    7.01.101

    Admin Coding

    32

    Treatment of Varicose Veins/Venous Insufficiency

    7.01.148

    Minor Update

    33

    Ultrasonographic Measurement of Carotid Intimal-Medial Thickness as an Assessment of Subclinical Atherosclerosis

    2.02.16

    Minor Update

    34

    Wearable Cardioverter Defibrillators

    2.04.82

    Minor Update

     

    Please note:

    California Senate Bill 535 (“SB 535”) mandates that health plans are not to require prior authorization for either of the following services:

     

    • Biomarker testing for an enrollee or insured with advanced metastatic stage 3 or 4 cancer, or
    • Biomarker testing for cancer progression or recurrence in the enrollee or insured with advanced or metastatic stage 3 or 4 cancer.

     

    Blue Shield of California has removed prior authorization for Biomarker testing services. Compliance with SB 535 is required for Blue Shield’s delegated provider organizations, in cases where the organization is financially responsible for those services. For more coverage information, we encourage you to review our applicable medical or medication policies and benefits online at blueshieldca.com/provider.

  • New and updated policies effective June 1, 2022

     

    Policy Title – June 1, 2022

    Policy#

    Status

    1

    Continuous Glucose Monitoring

    1.01.20

    Major Update

    2

    Intraoperative Neurophysiologic Monitoring

    7.01.58

    Major Update

    3

    Laparoscopic, Percutaneous, and Transcervical Techniques for Uterine Fibroid Myolysis

    4.01.19

    Major Update

    4

    Myoelectric Prosthetic and Orthotic Components for the Upper Limb

    1.04.04

    Major Update

    5

    Digital Health Therapies for Attention Deficit/Hyperactivity Disorder

    3.03.03

    New

    6

    Digital Health Therapies for Substance Abuse

    5.01.35

    New

    7

    Genetic Testing: Exome and Genome Sequencing For The Diagnosis Of Genetic Disorders

    BSC_CON_2.02

    New

    8

    Tumor-Informed Circulating Tumor DNA Testing for Cancer Management

    2.04.153

    New

    9

    Uterus Transplantation for Absolute Uterine Factor Infertility

    4.02.06

    New

    10

    Amniotic Membrane and Amniotic Fluid

    7.01.149

    Coding Vote

    11

    Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions

    7.01.78

    Minor Update

    12

    Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions

    7.01.48

    Minor Update

    13

    Behavioral Health Treatment for Autism Spectrum Disorders

    BSC3.01

    Minor Update

    14

    Bioengineered Skin and Soft Tissue Substitutes

    7.01.113

    Coding Vote

    15

    Blepharoplasty, Blepharoptosis Repair (Levator Resection) and Brow Lift (Repair of Brow Ptosis)

    BSC7.01

    Admin Update

    16

    Breast Implant Management

    BSC7.12

    Admin Update

    17

    Cleft Palate - Dental Related Services

    BSC2.01

    Minor Update

    18

    Computer-Assisted Navigation for Orthopedic Procedure

    7.01.96

    Minor Update

    19

    Electrical and Electromagnetic Stimulation for the Treatment of Arthritis

    1.01.27

    Minor Update

    20

    Endothelial Keratoplasty

    9.03.22

    Minor Update

    21

    Endovascular Procedures for Intracranial Arterial Disease (Atherosclerosis and Aneurysms)

    2.01.54

    Minor Update

    22

    Functional Neuromuscular Electrical Stimulation

    8.03.01

    Minor Update

    23

    Genetic Testing for Familial Cutaneous Malignant Melanoma

    2.04.44

    Minor Update

    24

    Hip Arthroplasty for Adults

    BSC7.11

    Minor Update

    25

    Hip Femoroacetabular Impingement (FAI) Surgical Treatment

    7.01.118

    Minor Update

    26

    Hip Resurfacing

    7.01.80

    Minor Update

    27

    Hippotherapy

    8.03.12

    Minor Update

    28

    Image-Guided Minimally Invasive Decompression for Spinal Stenosis

    7.01.126

    Minor Update

    29

    Knee Braces (Custom)

    BSC1.05

    Minor Update

    30

    Lifestyle Modification Program for Reversing Heart Disease

    BSC8.01

    Minor Update

    31

    Manipulation Under Anesthesia 

    8.01.40

    Minor Update

    32

    Non-Invasive Positive Airway Pressure for Chronic Obstructive Pulmonary Disease

    8.01.64

    Minor Update

    33

    Orthognathic Surgery

    BSC7.03

    Minor Update

    34

    Orthopedic Applications of Platelet-Rich Plasma

    2.01.98

    Minor Update

    35

    Panniculectomy, Abdominoplasty, and Surgical Management of Diastasis Recti

    BSC7.04

    Minor Update

    36

    Partial Thickness Rotator Cuff Tears and Acromioplasty/ Subacromial Decompression

    BSC7.14

    Minor Update

    37

    Patient-Controlled End Range of Motion Stretching Devices

    1.03.05

    Minor Update

    38

    Patient-Specific Instrumentation (eg, Cutting Guides) for Joint Arthroplasty

    7.01.144

    Minor Update

    39

    Percutaneous Vertebroplasty and Sacroplasty

    6.01.25

    Minor Update

    40

    Personalized Breast Cancer Screening Clinical Trial

    BSC2.08

    Minor Update

    41

    Physical Therapy

    BSC8.03

    Minor Update

    42

    Power Morcellation for the Treatment of Uterine Fibroids

    BSC7.06

    Minor Update

    43

    Powered Exoskeleton for Ambulation in Patients With Lower-Limb Disabilities

    1.03.04

    Minor Update

    44

    Reconstructive Services

    BSC7.08

    Minor Update

    45

    Subtalar Arthroereisis

    7.01.104

    Minor Update

    46

    Surgical Treatment of Gynecomastia

    BSC7.13

    Admin Update

    47

    Trigger Point and Tender Point Injections

    2.01.103

    Minor Update

    48

    Vertebral Axial Decompression

    8.03.09

    Minor Update

    49

    Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders

    2.04.102

    Archived

     

  • New and updated policies effective May 1, 2022

     

    Policy Title – May1, 2022

    Policy#

    Status

    1

    Cryoablation, Radiofrequency Ablation, and Laser Ablation for Treatment of Chronic Rhinitis

    7.01.168

    Major Update

    2

    Low Intensity Pulsed Ultrasound Fracture Healing Device

    1.01.05

    Major Update

    3

    Orthoptic Training for the Treatment of Vision or Learning Disabilities

    9.03.03

    Major Update

    4

    Ambulatory Surgery Center

    BSC10.01

    Minor Update

    5

    Amniotic Membrane and Amniotic Fluid

    7.01.149

    Minor Update

    6

    Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer

    2.04.36

    Admin Update

    7

    Bariatric Surgery

    7.01.47

    Minor Update

    8

    Charged-Particle (Proton or Helium Ion) Radiotherapy for Neoplastic Conditions

    BSC8.04

    Minor Update

    9

    Continuous Passive Motion in the Home Setting

    1.01.10

    Minor Update

    10

    Corneal Collagen Cross-Linking

    9.03.28

    Minor Update

    11

    Cranial Electrotherapy Stimulation and Auricular Electrostimulation

    8.01.58

    Minor Update

    12

    Dental Anesthesia

    BSC2.02

    Minor Update

    13

    DNA-Based Testing for Adolescent Idiopathic Scoliosis

    2.04.74

    Archived

    14

    Elective Invasive Coronary Angiography (ICA)

    BSC2.13

    Minor Update

    15

    Elective Percutaneous Coronary Intervention (PCI)

    BSC6.02

    Minor Update

    16

    Eyelid Thermal Pulsation for the Treatment of Dry Eye Syndrome

    9.03.29

    Minor Update

    17

    Gastric Electrical Stimulation

    7.01.73

    Minor Update

    18

    Gene Expression Profile Testing and Circulating Tumor DNA Testing for Predicting Recurrence in Colon Cancer

    2.04.61

    Admin Update

    19

    Gene Expression-Based Assays for Cancers of Unknown Primary

    2.04.54

    Minor Update

    20

    Gene Variants (PALB2, CHEK2 and ATM) Associated with Breast Cancer in Individuals at High Breast Cancer Risk

    2.04.126

    Admin Update

    21

    Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes

    2.04.08

    Admin Update

    22

    Genetic Testing for Macular Degeneration

    2.04.103

    Minor Update

    23

    Genetic Testing for Predisposition to Inherited Hypertrophic Cardiomyopathy

    2.02.28

    Minor Update

    24

    Hysterectomy Surgery for Benign Conditions

    BSC7.09

    Minor Update

    25

    Implantable Bone-Conduction and Bone-Anchored Hearing Aids

    7.01.03

    Minor Update

    26

    Implantation of Intrastromal Corneal Ring Segments

    9.03.14

    Archived

    27

    JAK2, MPL, and CALR Testing for Myeloproliferative Neoplasms

    2.04.60

    Admin Update

    28

    Laboratory and Genetic Testing for Use of 5-Fluorouracil in Patients With Cancer

    2.04.68

    Minor Update

    29

    Microprocessor-Controlled Prostheses for the Lower Limb

    1.04.05

    Minor Update

    30

    Ophthalmologic Techniques That Evaluate the Posterior Segment for Glaucoma

    9.03.06

    Minor Update

    31

    Optical Coherence Tomography of the Anterior Eye Segment

    9.03.18

    Minor Update

    32

    Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers

    1.01.18

    Minor Update

    33

    Retinal Prosthesis

    9.03.15

    Minor Update

    34

    Semi-Implantable and Fully Implantable Middle Ear Hearing Aids

    7.01.84

    Minor Update

    35

    Steroid-Eluting Sinus Stents and Implants

    7.01.134

    Minor Update

    36

    Surgical Deactivation of Headache Trigger Sites

    7.01.135

    Minor Update

  • New and updated policies effective April 1, 2022

     

    Policy Title – April 1, 2022

    Policy#

    Status

    1

    Molecular Analysis (Including Liquid Biopsy) for Targeted Therapy or Immunotherapy of Non-Small-Cell Lung Cancer

    2.04.45

    Major Update

    2

    Maternal Serum Biomarkers for Prediction of Adverse Obstetric Outcomes

    2.04.152

    New

    3

    Non-Invasive Positive Airway Pressure for Chronic Obstructive Pulmonary Disease

    8.01.64

    New

    4

    Postsurgical Home Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis

    1.01.28

    New

    5

    Vagus Nerve Blocking Therapy for Treatment of Obesity

    BSC7.17

    New

    6

    Allogeneic Hematopoietic Cell Transplantation for Genetic Diseases and Acquired Anemias

    8.01.22

    Archived

    7

    Allogeneic Hematopoietic Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms

    8.01.21

    Minor Update

    8

    Auditory Brainstem Implant

    7.01.83

    Minor Update

    9

    Automated Point-of-Care Nerve Conduction Tests

    2.01.77

    Archived

    10

    Balloon Ostial Dilation for Treatment of Chronic and Recurrent Acute Rhinosinusitis

    7.01.105

    Minor Update

    11

    Blepharoplasty, Blepharoptosis Repair (Levator Resection) and Brow Lift (Repair of Brow Ptosis)

    BSC7.01

    Minor Update

    12

    Breast Implant Management

    BSC7.12

    Minor Update

    13

    Chelation Therapy for Off-Label Uses

    8.01.02

    Minor Update

    14

    Chronic Intermittent Intravenous Insulin Therapy

    2.01.43

    Minor Update

    15

    Circulating Tumor DNA for Management of Non-Small-Cell Lung Cancer (Liquid Biopsy)

    2.04.143

    Archived

    16

    Dynamic Posturography

    2.01.02

    Minor Update

    17

    Gender Affirmation Surgery

    BSC7.02

    Minor Update

    18

    General Approach to Evaluating the Utility of Genetic Panels

    2.04.92

    Minor Update

    19

    General Approach to Genetic Testing

    2.04.91

    Minor Update

    20

    Handheld Radiofrequency Spectroscopy for Intraoperative Assessment of Surgical Margins During Breast-Conserving Surgery

    7.01.140

    Minor Update

    21

    Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia

    8.01.32

    Minor Update

    22

    Hematopoietic Cell Transplantation for Acute Myeloid Leukemia

    8.01.26

    Minor Update

    23

    Hematopoietic Cell Transplantation for Autoimmune Diseases

    8.01.25

    Minor Update

    24

    Hematopoietic Cell Transplantation for Central Nervous System Embryonal Tumors and Ependymoma

    8.01.28

    Minor Update

    25

    Hematopoietic Cell Transplantation for Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma

    8.01.15

    Minor Update

    26

    Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia

    8.01.30

    Minor Update

    27

    Hematopoietic Cell Transplantation for Hodgkin Lymphoma

    8.01.29

    Minor Update

    28

    Hematopoietic Cell Transplantation for Non-Hodgkin Lymphomas

    8.01.20

    Minor Update

    29

    Hematopoietic Cell Transplantation for Plasma Cell Dyscrasias, Including Multiple Myeloma and POEMS Syndrome

    8.01.17

    Minor Update

    30

    Hematopoietic Cell Transplantation for Primary Amyloidosis

    8.01.42

    Minor Update

    31

    Hematopoietic Cell Transplantation for Solid Tumors of Childhood

    8.01.34

    Minor Update

    32

    Hematopoietic Cell Transplantation for Waldenström Macroglobulinemia

    8.01.54

    Archived

    33

    Hematopoietic Cell Transplantation in the Treatment of Germ Cell Tumors

    8.01.35

    Minor Update

    34

    Orthopedic Applications of Stem Cell Therapy (Including
    Allografts and Bone Substitutes Used with Autologous Bone Marrow)

    8.01.52

    Minor Update

    35

    Placental and Umbilical Cord Blood as a Source of Stem Cells

    7.01.50

    Minor Update

    36

    Reduction Mammaplasty

    7.01.21

    Minor Update

    37

    Stem Cell Therapy for Peripheral Arterial Disease

    8.01.55

    Minor Update

    38

    Surgical Treatment of Gynecomastia

    BSC7.13

    Minor Update

    39

    Surgical Ventricular Restoration

    7.01.103

    Minor Update

    40

    Temporomandibular Joint Disorder

    2.01.21

    Minor Update

    41

    Transcatheter Aortic-Valve Implantation for Aortic Stenosis

    7.01.132

    Minor Update

  • New and updated policies effective March 1, 2022

    Policy Title – March 1, 2022

    Policy#

    Status

    1

    Germline and Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment and Immunotherapy in Breast Cancer

    2.04.151

    Major Update

    2

    Germline Genetic Testing for BRCA1 or BRCA2 for Hereditary Breast/Ovarian Cancer Syndrome and Other High-Risk Cancers

    2.04.02

    Major Update

    3

    Low Intensity Pulsed Ultrasound Fracture Healing Device

    1.01.05

    New

    4

    Adipose-Derived Stem Cells in Autologous Fat Grafting to the Breast

    7.01.153

    Minor Update

    5

    Ambulatory Event Monitors and Mobile Cardiac Outpatient Telemetry

    2.02.08

    Coding Update

    6

    Amniotic Membrane and Amniotic Fluid

    7.01.149

    Coding Update

    7

    Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer

    2.04.36

    Coding Update

    8

    Auditory Brainstem Implant

    7.01.83

    Coding Update

    9

    Autologous Platelet-Derived Growth Factors for Wound Healing and Other Non-Orthopedic Conditions

    2.01.16

    Minor Update

    10

    Bioengineered Skin and Soft Tissue Substitutes

    7.01.113

    Minor Update

    11

    Bioimpedance Devices for Detection and Management of Lymphedema

    2.01.82

    Minor Update

    12

    Bone Turnover Markers for the Diagnosis and Management of Osteoporosis and Diseases Associated with High Bone Turnover

    2.04.15

    Minor Update

    13

    Circulating Tumor DNA for Management of Non-Small-Cell Lung Cancer (Liquid Biopsy)

    2.04.143

    Minor Update

    14

    Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome

    2.01.18

    Coding Update

    15

    Electrostimulation and Electromagnetic Therapy for Treating Wounds

    2.01.57

    Minor Update

    16

    General Approach to Evaluating the Utility of Genetic Panels

    2.04.92

    Coding Update

    17

    Genetic Testing for Alzheimer Disease

    2.04.13

    Coding Update

    18

    Genetic Testing for Cardiac Ion Channelopathies

    2.04.43

    Minor Update

    19

    Genetic Testing for Developmental Delay/Intellectual Disability, Autism Spectrum Disorder, and Congenital Anomalies

    2.04.59

    Coding Update

    20

    Genetic Testing for Diagnosis and Management of Mental Health Conditions

    2.04.110

    Coding Update

    21

    Genetic Testing for FLT3, NPM1, and CEBPA Variants in Cytogenetically Normal Acute Myeloid Leukemia

    2.04.124

    Minor Update

    22

    Hyperbaric Oxygen Therapy

    2.01.04

    Minor Update

    23

    Immune Cell Function Assay

    2.04.56

    Coding Update

    24

    Ingestible pH and Pressure Capsule

    BSC2.17

    Minor Update

    25

    Lysis of Epidural Adhesions

    BSC8.05

    Minor Update

    26

    Molecular Analysis for Targeted Therapy or Immunotherapy of Non- Small-Cell Lung Cancer

    2.04.45

    Minor Update

  • New and updated policies effective February 1, 2022

     

    Policy Title – February 1, 2022

    Policy#

    Status

    1

    Carrier Screening for Genetic Diseases

    2.04.107

    Major Update

    2

    Continuous Glucose Monitoring

    1.01.20

    Major Update

    3

    Gene Expression Profiling and Protein Biomarkers for Prostate Cancer Management

    2.04.111

    Major Update

    4

    Wireless Capsule Endoscopy for Gastrointestinal (GI) Disorders

    6.01.33

    Major Update

    5

    Laser Interstitial Thermal Therapy for Neurological Conditions

    7.01.170

    New

    6

    Light Therapy for Psoriasis

    2.01.47

    Archived

    7

    Aqueous Shunts and Stents for Glaucoma

    9.03.21

    Coding Update

    8

    Bariatric Surgery

    7.01.47

    Coding Update

    9

    Bone Mineral Density Studies

    6.01.01

    Coding Update

    10

    Cardiovascular Risk Panels

    2.04.100

    Minor Update

    11

    Catheter Ablation as Treatment for Atrial Fibrillation

    2.02.19

    Coding Update

    12

    Catheter Ablation for Cardiac Arrhythmias

    BSC2.12

    Coding Update

    13

    Cleft Palate - Dental Related Services

    BSC2.01

    Coding Update

    14

    Comprehensive Genomic Profiling for Selecting Targeted Cancer Therapies

    2.04.115

    Coding Update

    15

    Computed Tomography to Detect Coronary Artery Calcification

    6.01.03

    Coding Update

    16

    Contrast-Enhanced Computed Tomographic Angiography for Coronary Artery Evaluation

    6.01.43

    Coding Update

    17

    Dermatologic Applications of Photodynamic Therapy

    2.01.44

    Minor Update

    18

    Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions

    2.01.40

    Coding Update

    19

    Fecal Analysis in the Diagnosis of Intestinal Dysbiosis

    2.04.26

    Minor Update

    20

    General Approach to Genetic Testing

    2.04.91

    Coding Update

    21

    Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer

    2.04.33

    Minor Update

    22

    Identification of Microorganisms Using Nucleic Acid Probes

    2.04.10

    Coding Update

    23

    Image-Guided Minimally Invasive Decompression for Spinal Stenosis

    7.01.126

    Coding Update

    24

    Immune Cell Function Assay

    2.04.56

    Minor Update

    25

    Implantable Bone-Conduction and Bone-Anchored Hearing Aids

    7.01.03

    Coding Update

    26

    Invasive Prenatal (Fetal) Diagnostic Testing

    2.04.116

    Coding Update

    27

    Lumbar Spine Surgery

    BSC_NIA_CG_304

    Coding Update

    28

    Measurement of Lipoprotein-Associated Phospholipase A2 in the Assessment of Cardiovascular Risk

    2.04.32

    Minor Update

    29

    Measurement of Serum Antibodies to Selected Biologic Agents

    2.04.84

    Minor Update

    30

    Monitored Anesthesia Care

    7.02.01

    Coding Update

    31

    Multimarker Serum Testing Related to Ovarian Cancer

    2.04.62

    Minor Update

    32

    Nonpharmacologic Treatment of Rosacea

    2.01.71

    Minor Update

    33

    Oncologic Applications of Positron Emission Tomography Scanning

    6.01.26

    Coding Update

    34

    Orthoptic Training for the Treatment of Vision or Learning Disabilities

    9.03.03

    Coding Update

    35

    Preimplantation Genetic Testing

    4.02.05

    Coding Update

    36

    Proteomic Testing for Targeted Therapy in Non-Small-Cell Lung Cancer

    2.04.125

    Minor Update

    37

    Serum Biomarker Human Epididymis Protein 4

    2.04.66

    Minor Update

    38

    Testing Serum Vitamin D Levels

    2.04.135

    Minor Update

    39

    Thoracic Spine Surgery

    BSC_NIA_CG_308

    Coding Update

    40

    Total Artificial Hearts and Implantable Ventricular Assist Devices

    7.03.11

    Coding Update

    41

    Transcatheter Aortic-Valve Implantation for Aortic Stenosis

    7.01.132

    Coding Update

    42

    Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease

    2.01.38

    Minor Update

    43

    Urinary Biomarkers for Cancer Screening, Diagnosis, and Surveillance

    2.04.07

    Minor Update

  • New and updated policies effective January 1, 2022

     

    Policy Title – January 1, 2022

    Policy#

    Status

    1

    Laboratory Tests Post Transplant and for Heart Failure

    2.01.68

    Major Update

    2

    Lumbar Spine Surgery

    BSC_NIA_CG_304

    Major Update

    3

    Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer

    2.04.36

    Minor Update

    4

    Cervical Spine Surgery

    BSC_NIA_CG_307

    Minor Update

    5

    Confocal Laser Endomicroscopy

    2.01.87

    Minor Update

    6

    Drug Testing in Pain Management and Substance Use Disorder Treatment 

    2.04.98

    Minor Update

    7

    Endoscopic Radiofrequency Ablation or Cryoablation for Barrett Esophagus

    2.01.80

    Minor Update

    8

    Epidural Spine Injections

    BSC_NIA_CG_300

    Minor Update

    9

    Esophageal pH Monitoring

    2.01.20

    Minor Update

    10

    Germline Genetic Testing for BRCA1 or BRCA2 for Hereditary Breast/Ovarian Cancer Syndrome and Other High-Risk Cancers

    2.04.02

    Minor Update

    11

    Magnetic Esophageal Sphincter Augmentation to Treat Gastroesophageal Reflux Disease

    7.01.137

    Minor Update

    12

    Monitored Anesthesia Care

    7.02.01

    Minor Update

    13

    Noninvasive Techniques for the Evaluation and Monitoring of Patients With Chronic Liver Disease

    2.04.41

    Minor Update

    14

    Paravertebral Facet Joint Injections or Blocks (no U/S)

    BSC_NIA_CG_301

    Minor Update

    15

    Pharmacogenetic Testing for Pain Management

    2.04.131

    Minor Update

    16

    Pharmacogenomic and Metabolite Markers for Patients Treated With Thiopurines

    2.04.19

    Minor Update

    17

    Plugs for Anal Fistula Repair

    7.01.123

    Minor Update

    18

    Prolotherapy

    2.01.26

    Minor Update

    19

    Sacroiliac Joint Injections (with image guidance [fluoroscopy or CT])

    BSC_NIA_CG_305

    Minor Update

    20

    Thoracic Spine Surgery

    BSC_NIA_CG_308

    Minor Update

  • New and updated policies effective December 1, 2021

     

    Policy Title – December 1, 2021

      Policy#

    Status

    1

    Evaluation of Biomarkers for Alzheimer Disease

    2.04.14

    Major Update

    2

    Genetic Testing for Alzheimer Disease

    2.04.13

    Major Update

    3

    Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes

    2.04.08

    Major Update

    4

    Selected Positron Emission Tomography Technologies for Evaluation of Alzheimer Disease

    6.01.55

    Major Update

    5

    Absorbable Nasal Implant for Treatment of Nasal Valve Collapse

    7.01.163

    Minor Update

    6

    Automated Point-of-Care Nerve Conduction Tests

    2.01.77

    Minor Update

    7

    Brachytherapy for Clinically Localized Prostate Cancer Using Permanently Implanted Seeds

    8.01.14

    Admin Update

    8

    Charged-Particle (Proton or Helium Ion) Radiotherapy for Neoplastic Conditions

    BSC8.04

    Admin Update

    9

    Comprehensive Genomic Profiling for Selecting Targeted Cancer Therapies

    2.04.115

    Minor Update

    10

    Dynamic Spinal Visualization and Vertebral Motion Analysis

    6.01.46

    Minor Update

    11

    Electronic Brachytherapy for Nonmelanoma Skin Cancer

    8.01.62

    Admin Update

    12

    Endobronchial Brachytherapy

    8.03.11

    Admin Update

    13

    Gene Expression Profiling and Protein Biomarkers for Prostate Cancer Management

    2.04.111

    Admin Update

    14

    Genetic Cancer Susceptibility Panels Using Next-Generation Sequencing

    2.04.93

    Minor Update

    15

    Genetic Testing for Developmental Delay/Intellectual Disability, Autism Spectrum Disorder, and Congenital Anomalies

    2.04.59

    Minor Update

    16

    In Vitro Chemoresistance and Chemosensitivity Assays

    2.03.01

    Archived

    17

    Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence

    7.01.19 

    Minor Update

    18

    Intensity-Modulated Radiotherapy of the Breast and Lung

    8.01.46

    Admin Update

    19

    Intensity-Modulated Radiotherapy of the Prostate

    8.01.47

    Admin Update

    20

    Intensity-Modulated Radiotherapy: Abdomen and Pelvis

    8.01.49

    Admin Update

    21

    Intensity-Modulated Radiotherapy: Cancer of the Head and Neck or Thyroid

    8.01.48

    Admin Update

    22

    Intensity-Modulated Radiotherapy: Central Nervous System Tumors

    8.01.59

    Admin Update

    23

    Intracavitary Balloon Catheter Brain Brachytherapy for Malignant Gliomas or Metastasis to the Brain

    8.01.45

    Admin Update

    24

    Laboratory Tests Post Transplant and for Heart Failure

    2.01.68

    Coding Update

    25

    Magnetic Resonance Spectroscopy

    6.01.24

    Minor Update

    26

    Microwave and Locoregional Laser Tumor Ablation

    7.01.133

    Minor Update

    27

    Miscellaneous (Noncardiac, Nononcologic) Applications of Fluorine 18 Fluorodeoxyglucose Positron Emission Tomography

    6.01.06

    Minor Update

    28

    Quantitative Electroencephalography as a Diagnostic Aid for Attention-Deficit/Hyperactivity Disorder

    3.01.03

    Minor Update

    29

    Radiation Oncology

    BSC8.06

    Admin Update

    30

    Radioembolization for Primary and Metastatic Tumors of the Liver

    8.01.43 

    Admin Update

    31

    Stereotactic Radiosurgery and Stereotactic Body Radiotherapy

    6.01.10

    Admin Update

    32

    Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders

    2.01.50

    Minor Update

  • New and updated policies effective Nov 1, 2021

     

    Policy Title – November 1, 2021

    Policy#

    Status

    1

    Oncologic Applications of Positron Emission Tomography Scanning

    6.01.26

    Major Update

    2

    Cryoablation for Chronic Rhinitis

    7.01.168

    New

    3

    Ablation of Peripheral Nerves to Treat Pain

    7.01.154

    Minor Update

    4

    Amniotic Membrane and Amniotic Fluid

    7.01.149

    Coding Update

    5

    Aqueous Shunts and Stents for Glaucoma

    9.03.21

    Minor Update

    6

    Balloon Dilation of the Eustachian Tube

    7.01.15

    Minor Update

    7

    Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment and Immunotherapy in Breast Cancer

    2.04.151

    Coding Update

    8

    Bone Mineral Density Studies

    6.01.01

    Minor Update

    9

    Cardiac Applications of Positron Emission Tomography Scanning

    6.01.20

    Minor Update

    10

    Carrier Screening for Genetic Diseases

    2.04.107

    Minor Update

    11

    Computed Tomography Perfusion Imaging of the Brain

    6.01.49

    Minor Update

    12

    Computed Tomography to Detect Coronary Artery Calcification

    6.01.03

    Minor Update