-
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
2
Germline and Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment and Immunotherapy in Breast Cancer
2.04.151
3
Negative Pressure Wound Therapy in the Outpatient Setting
1.01.16
4
Tumor-Informed Circulating Tumor DNA Testing for Cancer Management
BSC2.18
5
Facet Joint Denervation
7.01.116
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
No
2
Intensity-Modulated Radiotherapy of the Prostate
8.01.47
No
3
Intensity-Modulated Radiotherapy: Abdomen, Pelvis and Chest
8.01.49
No
4
Intensity-Modulated Radiotherapy: Cancer of the Head and Neck or Thyroid
8.01.48
No
5
Intensity-Modulated Radiotherapy: Central Nervous System Tumors
8.01.59
No
6
Radiation Oncology
BSC8.06
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
No
8
Stereotactic Radiosurgery and Stereotactic Body Radiotherapy
6.01.10
No
9
Axillary Reverse Mapping for Prevention of Breast Cancer-Related Lymphedema
7.01.173
No
10
Genetic Testing: Prenatal and Preconception Carrier Screening
BSC_CON_2.07
No
11
Genetic Testing: Prenatal Diagnosis (Via Amniocentesis, CVS, or PUBS) and Pregnancy Loss
BSC_CON_2.06
No
12
Oncology: Cancer Screening
BSC_CON_2.09
No
13
Temporarily Implanted Nitinol Device (iTind) for Benign Prostatic Hyperplasia
7.01.175
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
2
Epidural Spine Injections
BSC_NIA_CG_300
3
Esophageal pH Monitoring
2.01.20
4
Genetic Testing: Non-Invasive Prenatal Screening (NIPS)/ Non-Invasive Prenatal Testing (NIPT)
BSC_CON_2.08
5
Genetic Testing: Preimplantation Genetic Testing
BSC_CON_2.03
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
2
Germline Genetic Testing for Hereditary Breast/Ovarian Cancer Syndrome and Other High-Risk Cancers (BRCA1, BRCA2, PALB2)
2.04.02
3
Hip Arthroplasty for Adults
BSC7.11
4
Knee Arthroplasty for Adults
BSC7.10
5
Knee Arthroscopy in Knee Osteoarthritis
BSC7.16
6
Laboratory Tests Post Transplant and for Heart Failure
2.01.68
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
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
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
2
Elective Percutaneous Coronary Intervention (PCI)
BSC6.02
3
Germline Genetic Testing for Hereditary Diffuse Gastric Cancer (CDH1, CTNNA1)
2.04.154
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
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
3
Germline Genetic Testing for Hereditary Breast/Ovarian Cancer Syndrome and Other High-Risk Cancers (BRCA1, BRCA2, PALB2)
2.04.02
4
Germline Genetic Testing for Ovarian Cancer Risk (BRIP1, RAD51C, RAD51D, NBN)
2.04.149
5
Kidney Transplant
7.03.01
6
Noninvasive Prenatal Screening for Fetal Aneuploidies, Microdeletions, Single-Gene Disorders, and Twin Zygosity Using Cell-Free Fetal DNA
4.01.21
7
Small Bowel/Liver and Multivisceral Transplant
7.03.05
8
Medical Management of Obstructive Sleep Apnea Syndrome
8.01.67
9
Surgical Left Atrial Appendage Occlusion Devices for Stroke Prevention in Atrial Fibrillation
7.01.172
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
2
Minimally Invasive Ablation Procedures for Morton and Other Peripheral Neuromas
7.01.147
3
Reconstructive Breast Surgery/Management of Breast Implants
7.01.22
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
2
Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome
7.01.101
3
Treatment of Hyperhidrosis
8.01.19
4
Dry Hydrotherapy for chronic pain conditions
2.01.105
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
2
Temporomandibular Joint Disorder
2.01.21
3
Remote Electrical Neuromodulation for Migraine
7.01.171
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
2
Intraoperative Neurophysiologic Monitoring
7.01.58
3
Laparoscopic, Percutaneous, and Transcervical Techniques for Uterine Fibroid Myolysis
4.01.19
4
Myoelectric Prosthetic and Orthotic Components for the Upper Limb
1.04.04
5
Digital Health Therapies for Attention Deficit/Hyperactivity Disorder
3.03.03
6
Digital Health Therapies for Substance Abuse
5.01.35
7
Genetic Testing: Exome and Genome Sequencing For The Diagnosis Of Genetic Disorders
BSC_CON_2.02
8
Tumor-Informed Circulating Tumor DNA Testing for Cancer Management
2.04.153
9
Uterus Transplantation for Absolute Uterine Factor Infertility
4.02.06
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
2
Low Intensity Pulsed Ultrasound Fracture Healing Device
1.01.05
3
Orthoptic Training for the Treatment of Vision or Learning Disabilities
9.03.03
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
2
Maternal Serum Biomarkers for Prediction of Adverse Obstetric Outcomes
2.04.152
3
Non-Invasive Positive Airway Pressure for Chronic Obstructive Pulmonary Disease
8.01.64
4
Postsurgical Home Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis
1.01.28
5
Vagus Nerve Blocking Therapy for Treatment of Obesity
BSC7.17
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
2
Germline Genetic Testing for BRCA1 or BRCA2 for Hereditary Breast/Ovarian Cancer Syndrome and Other High-Risk Cancers
2.04.02
3
Low Intensity Pulsed Ultrasound Fracture Healing Device
1.01.05
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
2
Continuous Glucose Monitoring
1.01.20
3
Gene Expression Profiling and Protein Biomarkers for Prostate Cancer Management
2.04.111
4
Wireless Capsule Endoscopy for Gastrointestinal (GI) Disorders
6.01.33
5
Laser Interstitial Thermal Therapy for Neurological Conditions
7.01.170
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
2
Lumbar Spine Surgery
BSC_NIA_CG_304
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
2
Genetic Testing for Alzheimer Disease
2.04.13
3
Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes
2.04.08
4
Selected Positron Emission Tomography Technologies for Evaluation of Alzheimer Disease
6.01.55
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
2
Cryoablation for Chronic Rhinitis
7.01.168
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
