• New and updated policies effective September 1, 2023

     

    Policy Title –September 1, 2023

    Policy#

    Status

    1

    Oncology: Molecular Analysis Of Solid Tumors And Hematologic Malignancies

    BSC_CON_2.04

    Major Update

    2

    Automated Ambulatory Blood Pressure Monitoring for Diagnosis of Hypertension in Patients with Elevated Office Blood Pressure

    1.01.02

    New

    3

    Electromagnetic Navigational Bronchoscopy

    7.01.122

    New

    4

    Hyperthermic Intraperitoneal Chemotherapy for Select Intra-Abdominal and Pelvic Malignancies

    2.03.07

    New

    5

    Multicancer Early Detection Testing

    2.04.158

    New

    6

    Neurofeedback

    2.01.28

    New

    7

    Percutaneous Electrical Nerve Stimulation, Percutaneous Neuromodulation Therapy, and Restorative Neurostimulation Therapy

    7.01.29

    New

    8

    Proteogenomic Testing for Patients With Cancer

    2.04.140

    New

    9

    Risk-Reducing Mastectomy

    7.01.09

    New

    10

    Tumor Treating Fields Therapy

    1.01.29

    New

    11

    Brachytherapy for Clinically Localized Prostate Cancer Using Permanently Implanted Seeds

    8.01.14

    Minor Update

    12

    Cellular Immunotherapy for Prostate Cancer

    8.01.53

    Minor Update

    13

    Continuous Glucose Monitoring

    1.01.20

    Admin Coding

    14

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

    7.01.92

    Minor Update

    15

    Elective Invasive Coronary Angiography (ICA)

    BSC2.13

    Minor Update

    16

    Elective Percutaneous Coronary Intervention (PCI)

    BSC6.02

    Minor Update

    17

    Electronic Brachytherapy for Nonmelanoma Skin Cancer

    8.01.62

    Minor Update

    18

    Endobronchial Brachytherapy

    8.03.11

    Minor Update

    19

    Genetic Testing for Diagnosis and Management of Mental Health Conditions

    2.04.110

    Minor Update

    20

    Genotype-Guided Tamoxifen Treatment

    2.04.51

    Minor Update

    21

    Intensity-Modulated Radiotherapy of the Breast and Lung

    8.01.46

    Admin Coding

    22

    Intensity-Modulated Radiotherapy of the Prostate

    8.01.47

    Admin Coding

    23

    Intensity-Modulated Radiotherapy: Abdomen, Pelvis and Chest

    8.01.49

    Admin Coding

    24

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

    8.01.48

    Admin Coding

    25

    Intensity-Modulated Radiotherapy: Central Nervous System Tumors

    8.01.59

    Admin Coding

    26

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

    8.01.45

    Minor Update

    27

    Intraoperative Radiotherapy

    8.01.08

    Minor Update

    28

    Magnetic Resonance-Guided Focused Ultrasound

    7.01.109

    Minor Update

    29

    Oncologic Applications of Photodynamic Therapy, Including Barrett Esophagus

    8.01.06

    Minor Update

    30

    Radioembolization for Primary and Metastatic Tumors of the Liver

    8.01.43

    Minor Update

    31

    Radiofrequency Ablation of Primary or Metastatic Liver Tumors

    7.01.91

    Minor Update

    32

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

    7.01.121

    Minor Update

    33

    Serologic Genetic and Molecular Screening for Colorectal Cancer

    2.04.150

    Minor Update

    34

    Stereotactic Radiosurgery and Stereotactic Body Radiotherapy

    6.01.10

    Admin Coding

    35

    Transcatheter Arterial Chemoembolization to Treat Primary or Metastatic Liver Malignancies

    8.01.11

    Minor Update

    36

    Treatment of Varicose Veins/Venous Insufficiency

    7.01.124

    Admin Coding

    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 August 1, 2023

     

    Policy Title –August 1, 2023

    Policy#

    Status

    1

    Cytochrome P450 Genotype-Guided Treatment Strategy

    2.04.38

    Major Update

    2

    Autonomic Nervous System Testing

    2.01.96

    New

    3

    Closure Devices for Patent Foramen Ovale and Atrial Septal Defects

    2.02.09

    New

    4

    Electromyography and Nerve Conduction Studies

    2.01.95

    New

    5

    Endovascular Stent Grafts for Abdominal Aortic Aneurysms

    7.01.67

    New

    6

    Gene Expression Profiling for Cutaneous Melanoma          

    2.04.146    

    New

    7

    Genetic Testing for Alpha Thalassemia

    2.04.104

    New

    8

    Genetic Testing for Rett Syndrome

    2.04.81

    New

    9

    Home Cardiorespiratory Monitoring

    1.01.06

    New

    10

    Low Level Laser Therapy

    2.01.56

    New

    11

    Oncology: Algorithmic (Genetic Expression) Testing

    BSC_CON_2.05

    New

    12

    Percutaneous Left Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation

    2.02.26

    New

    13

    Polysomnography for Non-Respiratory Sleep Disorders

    2.01.99

    New

    14

    Progenitor Cell Therapy for the Treatment of Damaged Myocardium Due to Ischemia

    2.02.18

    New

    15

    Serum Biomarker Panel Testing for Systemic Lupus Erythematosus and Other Connective Tissue Diseases

    2.04.123

    New

    16

    Transurethral Water Vapor Thermal Therapy and Transurethral Water Jet Ablation (Aquablation) for Benign Prostatic Hypertrophy

    2.01.49

    New

    17

    Actigraphy

    2.01.73

    Minor Update

    18

    Amniotic Membrane and Amniotic Fluid

    7.01.149

    Admin Coding

    19

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

    2.04.36

    Archived

    20

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

    2.01.16

    Admin Coding

    21

    Bariatric Surgery

    7.01.47

    Minor Update

    22

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

    2.02.10

    Admin Coding

    23

    Bronchial Thermoplasty

    7.01.127

    Minor Update

    24

    Bronchial Valves

    7.01.128

    Minor Update

    25

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

    2.02.24

    Minor Update

    26

    Cardiovascular Risk Panels

    2.04.100

    Admin Coding

    27

    Cognitive Rehabilitation

    8.03.10

    Admin Coding

    28

    Diagnosis of Obstructive Sleep Apnea Syndrome

    2.01.18

    Minor Update

    29

    Drug Testing in Pain Management and Substance Use Disorder Treatment

    2.04.98

    Admin Coding

    30

    Dry Hydrotherapy for Chronic Pain Conditions

    2.01.105

    Minor Update

    31

    Endovascular Stent Grafts for Disorders of the Thoracic Aorta

    7.01.86

    Minor Update

    32

    Evaluation of Biomarkers for Alzheimer Disease

    2.04.14

    Admin Coding

    33

    External Insulin Infusion Pump

    BSC1.03

    Minor Update

    34

    Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions

    2.01.40

    Minor Update

    35

    Gene Expression Profiling and Protein Biomarkers for Prostate Cancer Management

    2.04.111

    Archived

    36

    Gene Expression-Based Assays for Cancers of Unknown Primary

    2.04.54

    Archived

    37

    General Approach to Genetic Testing

    2.04.91

    Admin Coding

    38

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

    2.04.33

    Archived

    39

    Genetic Testing: Preimplantation Genetic Testing

    BSC_CON_2.03

    Admin Coding

    40

    Genetic Testing: Prenatal and Preconception Carrier Screening

    BSC_CON_2.07

    Admin Coding

    41

    Genotype-Guided Warfarin Dosing

    2.04.48

    Minor Update

    42

    Hyperbaric Oxygen Therapy

    2.01.04

    Minor Update

    43

    Identification of Microorganisms Using Nucleic Acid Probes 

    2.04.10

    Minor Update

    44

    Interferential Current Stimulation

    1.01.24

    Minor Update

    45

    Lung Volume Reduction Surgery for Severe Emphysema

    7.01.71

    Minor Update

    46

    Maternal Serum Biomarkers for Prediction of Adverse Obstetric Outcomes

    2.04.152

    Admin Coding

    47

    Medical Cannabis for the Treatment of Pain and Spasticity

    5.01.32

    Minor Update

    48

    Medical Management of Obstructive Sleep Apnea Syndrome

    8.01.67

    Minor Update

    49

    Minimally Invasive Ablation Procedures for Morton and Other Peripheral Neuromas

    7.01.147

    Minor Update

    50

    Molecular Testing in the Management of Pulmonary Nodules

    2.04.142

    Archived

    51

    Multibiomarker Disease Activity Blood Test for Rheumatoid Arthritis

    2.04.119

    Minor Update

    52

    Multimarker Serum Testing Related to Ovarian Cancer

    2.04.62

    Archived

    53

    Navigated Transcranial Magnetic Stimulation

    2.01.90

    Minor Update

    54

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

    1.01.15

    Minor Update

    55

    Paraspinal Surface Electromyography to Evaluate and Monitor Back Pain

    2.01.35

    Minor Update

    56

    Quantitative Sensory Testing

    2.01.39       

    Minor Update

    57

    Reconstructive Breast Surgery/Management of Breast

    7.01.22

    Minor Update

    58

    Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome

    7.01.101

    Minor Update

    59

    Transcatheter Pulmonary Valve Implantation

    7.01.131

    Minor Update

    60

    Treatment of Hyperhidrosis

    8.01.19

    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 July 1, 2023
     
     
     
     
     
     

     

     
     
     
     

    Policy Title – July 1, 2023

     
     
     
     

    Policy# 

     
     
     
     

    Status 

     
     
     
     

    1 

     
     

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

     
     

    2.02.10 

     
     
     
     
     
     

    2 

     
     

    Implantable Cardioverter Defibrillators 

     
     

    7.01.44 

     
     
     
     
     
     

    3 

     
     

    Oncology: Molecular Analysis of Solid Tumors and Hematologic Malignancies 

     
     

    BSC_CON_2.04 

     
     
     
     
     
     

    4 

     
     

    Coronary Computed Tomography Angiography with Selective Noninvasive Fractional Flow Reserve 

     
     

    6.01.59 

     
     

    New 

     
     
     
     

    5 

     
     

    Dry Needling of Trigger Points for Myofascial Pain 

     
     

    2.01.100 

     
     

    New 

     
     
     
     

    6 

     
     

    Electrical Bone Growth Stimulation of the Appendicular Skeleton  

     
     

    7.01.07 

     
     

    New 

     
     
     
     

    7 

     
     

    Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures 

     
     

    7.01.85 

     
     

    New 

     
     
     
     

    8 

     
     

    Genetic Testing for Hereditary Hemochromatosis 

     
     

    2.04.80 

     
     

    New 

     
     
     
     

    9 

     
     

    Genetic Testing for Limb-Girdle Muscular Dystrophies 

     
     

    2.04.132 

     
     

    New 

     
     
     
     

    10 

     
     

    Immediate and Delayed Lymphatic Reconstruction Surgery 

     
     

    BSC7.18 

     
     

    New 

     
     
     
     

    11 

     
     

    Interventions for Progressive Scoliosis 

     
     

    2.01.83 

     
     

    New 

     
     
     
     

    12 

     
     

    Intradialytic Parenteral Nutrition 

     
     

    8.01.44 

     
     

    New 

     
     
     
     

    13 

     
     

    Leadless Cardiac Pacemakers 

     
     

    2.02.32 

     
     

    New 

     
     
     
     

    14 

     
     

    Meniscal Allografts and Other Meniscal Implants 

     
     

    7.01.15 

     
     

    New 

     
     
     
     

    15 

     
     

    Percutaneous Electrical Nerve Field Stimulation for Irritable Bowel Syndrome 

     
     

    2.01.106 

     
     

    New 

     
     
     
     

    16 

     
     

    Spinal Cord and Dorsal Root Ganglion Stimulation 

     
     

    7.01.25 

     
     

    New 

     
     
     
     

    17 

     
     

    Transcatheter Mitral Valve Repair 

     
     

    2.02.30 

     
     

    New 

     
     
     
     

    18 

     
     

    Allograft Injection for Degenerative Disc Disease 

     
     

    7.01.166 

     
     

    Minor Update 

     
     
     
     

    19 

     
     

    Ambulatory Event Monitors and Mobile Cardiac Outpatient Telemetry 

     
     

    2.02.08 

     
     

    Minor Update 

     
     
     
     

    20 

     
     

    Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions 

     
     

    7.01.78 

     
     

    Minor Update 

     
     
     
     

    21 

     
     

    Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions 

     
     

    7.01.48 

     
     

    Minor Update 

     
     
     
     

    22 

     
     

    Baroreflex Stimulation Devices 

     
     

    8.01.57 

     
     

    Minor Update 

     
     
     
     

    23 

     
     

    Cardiac Rehabilitation in the Outpatient Setting 

     
     

    8.03.08 

     
     

    Admin Update 

     
     
     
     

    24 

     
     

    Catheter Ablation as Treatment for Atrial Fibrillation 

     
     

    2.02.19 

     
     

    Minor Update 

     
     
     
     

    25 

     
     

    Endovascular Therapies for Extracranial Vertebral Artery Disease 

     
     

    7.01.148 

     
     

    Minor Update 

     
     
     
     

    26 

     
     

    Enhanced External Counterpulsation 

     
     

    2.02.06 

     
     

    Minor Update 

     
     
     
     

    27 

     
     

    Extracorporeal Membrane Oxygenation for Adult Conditions 

     
     

    8.01.60 

     
     

    Minor Update 

     
     
     
     

    28 

     
     

    Extracranial Carotid Artery Stenting 

     
     

    7.01.68 

     
     

    Minor Update 

     
     
     
     

    29 

     
     

    Genetic Testing for Inherited Thrombophilia 

     
     

    2.04.82 

     
     

    Minor Update 

     
     
     
     

    30 

     
     

    Genetic Testing for Lactase Insufficiency 

     
     

    2.04.94 

     
     

    Minor Update 

     
     
     
     

    31 

     
     

    Inhaled Nitric Oxide 

     
     

    8.01.37 

     
     

    Minor Update 

     
     
     
     

    32 

     
     

    Lower Limb Prostheses 

     
     

    BSC1.01 

     
     

    Minor Update 

     
     
     
     

    33 

     
     

    Myocardial Strain Imaging 

     
     

    2.02.31 

     
     

    Minor Update 

     
     
     
     

    34 

     
     

    Neuropsychological Testin+14:22g 

     
     

    BSC2.06 

     
     

    Minor Update 

     
     
     
     

    35 

     
     

    Oncology: Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy) 

     
     

    BSC_CON_2.10 

     
     

    Admin Update 

     
     
     
     

    36 

     
     

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

     
     

    7.01.14 

     
     

    Minor Update 

     
     
     
     

    37 

     
     

    Phrenic Nerve Stimulation for Central Sleep Apnea 

     
     

    2.02.33 

     
     

    Minor Update 

     
     
     
     

    38 

     
     

    Power Wheelchairs and Power Operated Vehicles for Permanent Use 

     
     

    BSC1.02 

     
     

    Minor Update 

     
     
     
     

    39 

     
     

    Speech Therapy 

     
     

    BSC8.02 

     
     

    Minor Update 

     
     
     
     

    40 

     
     

    Surgical Treatments for Breast Cancer-Related Lymphedema 

     
     

    7.01.162 

     
     

    Archived 

     
     
     
     

    41 

     
     

    Treatment of Varicose Veins/Venous Insufficiency 

     
     

    7.01.124 

     
     

    Minor Update 

     
     
     
     

    42 

     
     

    Tumor-Informed Circulating Tumor DNA Testing for Cancer Management 

     
     

    BSC2.18                 

     
     

    Archived 

     
     
     
     

    43 

     
     

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

     
     

    2.02.16 

     
     

    Minor Update 

     
     
     
     

    44 

     
     

    Wearable Cardioverter Defibrillators 

     
     

    2.02.15 

     
     

    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, 2023

     

    Policy Title –June 1, 2023

    Policy#

    Status

    1

    Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes

    2.04.08

    Major Update

    2

    Germline and Somatic Biomarker Testing for Targeted Treatment and Immunotherapy in Breast Cancer

    2.04.151

    Major Update

    3

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

    2.04.156

    Major Update

    4

    Germline and Somatic Biomarker Testing 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

    Major Update

    5

    Intensity-Modulated Radiotherapy of the Prostate

    8.01.47

    Major Update

    6

    Adjustable Cranial Orthoses for Positional Plagiocephaly and Craniosynostoses

    1.01.11

    New

    7

    Bone Morphogenetic Protein

    7.01.100

    New

    8

    Cardiac Rehabilitation in the Outpatient Setting

    8.03.08

    New

    9

    Cognitive Rehabilitation

    8.03.10

    New

    10

    Cooling Devices Used in the Outpatient Setting

    1.01.26

    New

    11

    Corneal Topography/Computer-Assisted Corneal Topography/Photokeratoscopy

    9.03.05

    New

    12

    Deep Brain Stimulation 

    7.01.63

    New

    13

    Digital Health Technologies: Therapeutic Applications

    3.03.02

    New

    14

    Genetic Testing for Duchenne and Becker Muscular Dystrophy

    2.04.86

    New

    15

    Genetic Testing for Hereditary Hearing Loss

    2.04.87

    New

    16

    Genetic Testing of CADASIL Syndrome

    2.04.75

    New

    17

    Keratoprosthesis

    9.03.01

    New

    18

    Intraocular Radiotherapy for Age-Related Macular Degeneration

    9.03.20

    New

    19

    Multitarget Polymerase Chain Reaction Testing for Diagnosis of Bacterial Vaginosis

    2.04.127

    New

    20

    Nerve Graft with Radical Prostatectomy

    7.01.81

    New

    21

    Occipital Nerve Stimulation

    7.01.125

    New

    22

    Oncology: Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy)

    BSC_CON_2.10

    New

    23

    Oncology: Molecular Analysis Of Solid Tumors And Hematologic Malignancies

    BSC_CON_2.04

    New

    24

    Outpatient Pulmonary Rehabilitation

    8.03.05

    New

    25

    Percutaneous Balloon Kyphoplasty, Radiofrequency Kyphoplasty, and Mechanical Vertebral Augmentation

    6.01.38

    New

    26

    Peripheral Subcutaneous Field Stimulation

    7.01.139

    New

    27

    Photodynamic Therapy for Choroidal Neovascularization

    9.03.08

    New

    28

    Responsive Neurostimulation for the Treatment of Refractory Focal Epilepsy

    7.01.143

    New

    29

    Retinal Telescreening for Diabetic Retinopathy

    9.03.13

    New

    30

    Sacral Nerve Neuromodulation/Stimulation

    7.01.69

    New

    31

    Vertical Expandable Prosthetic Titanium Rib

    7.01.110

    New

    32

    Viscocanalostomy and Canaloplasty

    9.03.26

    New

    33

    Behavioral Health Treatment for Autism Spectrum Disorders

    BSC3.01

    Minor Update

    34

    Bioengineered Skin and Soft Tissue Substitutes

    7.01.113

    Admin Coding

    35

    Cardiovascular Risk Panels

    2.04.100

    Admin Coding

    36

    Catheter Ablation for Cardiac Arrhythmias

    BSC2.12

    Minor Update

    37

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

    2.04.141

    Archived

    38

    Comprehensive Genomic Profiling for Selecting Targeted Cancer Therapies

    2.04.115

    Archived

    39

    Cranial Electrotherapy Stimulation and Auricular Electrostimulation

    8.01.58

    Admin Coding

    40

    Diabetes Prevention Program

    BSC2.11

    Minor Update

    41

    Endovascular Procedures for Intracranial Arterial Disease (Atherosclerosis and Aneurysms)

    2.01.54

    Minor Update

    42

    Facet Arthroplasty

    7.01.120

    Minor Update

    43

    General Approach to Genetic Testing

    2.04.91

    Admin Coding

    44

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

    2.04.33

    Admin Coding

    45

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

    2.04.124

    Archived

    46

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

    BSC_CON_2.02

    Minor Update

    47

    Hip Femoroacetabular Impingement (FAI) Surgical Treatment

    7.01.118

    Minor Update

    48

    Hip Resurfacing

    7.01.80

    Minor Update

    49

    Identification of Microorganisms Using Nucleic Acid Probes

    2.04.10

    Admin Coding

    50

    Image-Guided Minimally Invasive Decompression for Spinal Stenosis

    7.01.126

    Minor Update

    51

    Intensity-Modulated Radiotherapy of the Breast and Lung

    8.01.46

    Admin Coding

    52

    Intensity-Modulated Radiotherapy: Abdomen, Pelvis and Chest

    8.01.49

    Admin Coding

    53

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

    8.01.48

    Admin Coding

    54

    Intensity-Modulated Radiotherapy: Central Nervous System Tumors

    8.01.59

    Admin Coding

    55

    Intraoperative Neurophysiologic Monitoring

    7.01.58

    Minor Update

    56

    JAK2, MPL, and CALR Testing for Myeloproliferative Neoplasms

    2.04.60

    Archived

    57

    Lipid Apheresis

    BSC8.07

    Minor Update

    58

    Manipulation Under Anesthesia 

    8.01.40

    Minor Update

    59

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

    2.04.32

    Admin Coding

    60

    Medical Management of Obstructive Sleep Apnea Syndrome

    8.01.67

    Admin Coding

    61

    Multimarker Serum Testing Related to Ovarian Cancer

    2.04.62

    Admin Coding

    62

    Orthopedic Applications of Platelet-Rich Plasma

    2.01.98

     Minor Update

    63

    Percutaneous Vertebroplasty and Sacroplasty

    6.01.25

    Minor Update

    64

    Physical Therapy

    BSC8.03

    Minor Update

    65

    Power Morcellation for the Treatment of Uterine Fibroids

    BSC7.06

    Minor Update

    66

    Reconstructive Services

    BSC7.08

    Minor Update

    67

    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

    Archived

    68

    Subtalar Arthroereisis

    7.01.104

    Minor Update

    69

    Trigger Point and Tender Point Injections

    2.01.103

    Minor Update

    70

    Uterus Transplantation for Absolute Uterine Factor Infertility

    4.02.06

    Minor Update

    71

    Vertebral Axial Decompression

    8.03.09

    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 May 1, 2023