• New and updated policies effective February 1, 2024

     

    Policy Title – February 1, 2024

    Policy#

    Status

    1

    Genetic Testing: General Approach to Genetic and Molecular Testing

    BSC_CON_2.27

    Major Update

    2

    Genetic Testing: Prenatal and Preconception Carrier Screening

    BSC_CON_2.07

    Major Update

    3

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

    BSC_CON_2.06

    Major Update

    4

    Testing Serum Vitamin D Levels

    2.04.135

    Major Update

    5

    Biofeedback as a Treatment of Chronic Pain

    2.01.30

    New

    6

    Biofeedback as a Treatment of Fecal Incontinence or Constipation

    2.01.64

    New

    7

    Biofeedback as a Treatment of Headache

    2.01.29

    New

    8

    Biofeedback for Miscellaneous Indications

    2.01.53

    New

    9

    Chromoendoscopy as an Adjunct to Colonoscopy

    2.01.84

    New

    10

    Fecal Microbiota Transplantation

    2.01.92

    New

    11

    Genetic Testing: Dermatologic Conditions

    BSC_CON_2.25

    New

    12

    Genetic Testing: Hearing Loss

    BSC_CON_2.16

    New

    13

    Genetic Testing: Pharmacogenetics

    BSC_CON_2.12

    New

    14

    Human Leukocyte Antigen Testing for Celiac Disease

    2.04.95

    New

    15

    Intravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric Disorders

    5.01.16

    New

    16

    Laser Treatment of Onychomycosis

    2.01.89

    New

    17

    Nerve Fiber Density Measurement

    2.04.58

    New

    18

    Neural Therapy

    2.01.85

    New

    19

    Nutrient/Nutritional Panel Testing

    2.04.136

    New

    20

    Peroral Endoscopic Myotomy for Treatment of Esophageal Achalasia and Gastroparesis

    2.01.91

    New

    21

    Sphenopalatine Ganglion Block for Headache

    7.01.159

    New

    22

    Transanal Endoscopic Microsurgery

    7.01.112

    New

    23

    Transcutaneous Electrical Nerve Stimulation

    1.01.09

    New

    24

    Biomarker Testing in Risk Assessment and Management of Cardiovascular Disease

    2.04.65

    Minor Update

    25

    Cardiovascular Risk Panels

    2.04.100

    Minor Update

    26

    Cytochrome P450 Genotype-Guided Treatment Strategy

    2.04.38

    Archived

    27

    Dermatologic Applications of Photodynamic Therapy

    2.01.44

    Minor Update

    28

    Fecal Analysis in the Diagnosis of Intestinal Dysbiosis

    2.04.26

    Minor Update

    29

    Genetic Testing for Diagnosis and Management of Mental Health Conditions

    2.04.110

    Archived

    30

    Genetic Testing for Hereditary Hearing Loss

    2.04.87

    Archived

    31

    Genotype-Guided Tamoxifen Treatment

    2.04.51

    Archived

    32

    Genotype-Guided Warfarin Dosing

    2.04.48

    Archived

    33

    Immune Cell Function Assay

    2.04.56

    Minor Update

    34

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

    2.04.68

    Archived

    35

    Laser Interstitial Thermal Therapy for Neurological Conditions

    7.01.170

    Minor Update

    36

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

    2.04.32

    Minor Update

    37

    Multitarget Polymerase Chain Reaction Testing for Diagnosis of Bacterial Vaginosis

    2.04.127

    Minor Update

    38

    Nonpharmacologic Treatment of Rosacea

    2.01.71

    Minor Update

    39

    Oncologic Applications of Positron Emission Tomography Scanning (Genitourinary)

    6.01.26

    Archived

    40

    Oncology: Cancer Screening

    BSC_CON_2.09

    Minor Update

    41

    Pharmacogenetic Testing for Pain Management

    2.04.131

    Archived

    42

    Pharmacogenomic and Metabolite Markers for Patients Treated with Thiopurines

    2.04.19

    Archived

    43

    Positional Magnetic Resonance Imaging

    6.01.48

    Archived

    44

    Serum Biomarker Human Epididymis Protein 4

    2.04.66

    Minor Update

    45

    Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease

    2.01.38

    Minor Update

    46

    Wireless Capsule Endoscopy for Gastrointestinal (GI) Disorders

    6.01.33

    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 January 1, 2024

     

    Policy Title – January 1, 2024

    Policy#

    Status

    1

    Genetic Testing: Preimplantation Genetic Testing

    BSC_CON_2.03

    Major Update

    2

    Dopamine Transporter Single-Photon Emission Computed Tomography

    6.01.54

    New

    3

    Extracorporeal Photopheresis

    8.01.36

    New

    4

    Genetic Testing: Aortopathies and Connective Tissue Disorders

    BSC_CON_2.19

    New

    5

    Genetic Testing: Cardiac Disorders

    BSC_CON_2.18

    New

    6

    Axillary Reverse Mapping for Prevention of Breast Cancer-Related Lymphedema

    7.01.173

    Minor Update

    7

    Cervical Spine Surgery

    BSC_NIA_CG_307

    Minor Update

    8

    Computed Tomography to Detect Coronary Artery Calcification

    6.01.03 

    Archived

    9

    Confocal Laser Endomicroscopy

    2.01.87

    Minor Update

    10

    Contrast-Enhanced Coronary Computed Tomography Angiography for Coronary Artery Evaluation

    6.01.43  

    Archived

    11

    Coronary Computed Tomography Angiography With Selective Noninvasive Fractional Flow Reserve

    6.01.59 

    Archived

    12

    Drug Testing in Pain Management and Substance Use Disorder Treatment 

    2.04.98

    Minor Update

    13

    Dry Hydrotherapy for Chronic Pain Conditions

    2.01.105

    Minor Update

    14

    Endoscopic Radiofrequency Ablation or Cryoablation for Barrett Esophagus

    2.01.80

    Minor Update

    15

    Epidural Spine Injections

    BSC_NIA_CG_300

    Minor Update

    16

    Esophageal pH Monitoring

    2.01.20

    Minor Update

    17

    Genetic Testing for Cardiac Ion Channelopathies

    2.04.43

    Archived

    18

    Genetic Testing for Predisposition to Inherited Hypertrophic Cardiomyopathy

    2.02.28

    Archived

    19

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

    BSC_CON_2.08

    Minor Update

    20

    Lumbar Spine Surgery

    BSC_NIA_CG_304

    Minor Update

    21

    Magnetic Esophageal Sphincter Augmentation to Treat Gastroesophageal Reflux Disease

    7.01.137

    Minor Update

    22

    Measurement of Serum Antibodies to Selected Biologic Agents

    2.04.84

    Minor Update

    23

    Monitored Anesthesia Care

    7.02.01

    Minor Update

    24

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

    2.04.41

    Minor Update

    25

    Paravertebral Facet Joint Injections or Blocks

    BSC_NIA_CG_301

    Minor Update

    26

    Pharmacogenetic Testing for Pain Management

    2.04.131

    Minor Update

    27

    Pharmacogenomic and Metabolite Markers for Patients Treated with Thiopurines

    2.04.19

    Minor Update

    28

    Plugs for Anal Fistula Repair

    7.01.123

    Minor Update

    29

    Prolotherapy

    2.01.26

    Minor Update

    30

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

    2.04.125

    Minor Update

    31

    Sacroiliac Joint Injections

    BSC_NIA_CG_305         

    Minor Update

    32

    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 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 December 1, 2023

     

    Policy Title – December 1, 2023

    Policy#

    Status

    1

    Genetic Testing: Eye Disorders 

    BSC_CON_2.20

    New

    2

    Genetic Testing: General Approach to Genetic and Molecular Testing

    BSC_CON_2.27

    New

    3

    Genetic Testing: Immune, Autoimmune, and Rheumatoid Disorders

    BSC_CON_2.21

    New

    4

    Genetic Testing: Lung Disorders

    BSC_CON_2.23

    New

    5

    Genetic Testing: Skeletal Dysplasia and Rare Bone Disorders

    BSC_CON_2.26

    New

    6

    Oncology: Cytogenetic Testing

    BSC_CON_2.11

    New

    7

    Suture Button Suspensionplasty Fixation System for Thumb Carpometacarpal Osteoarthritis

    7.01.176

    New

    8

    Home Non-Invasive Positive Airway Pressure Devices for the Treatment of Respiratory Insufficiency and Failure

    8.01.64

    Major Update

    9

    Microwave Tumor Ablation

    7.01.133

    Major Update

    10

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

    2.01.50

    Major Update

    11

    Treatment of Varicose Veins/Venous Insufficiency

    7.01.124

    Major Update

    12

    Absorbable Nasal Implant for Treatment of Nasal Valve Collapse

    7.01.163

    Minor Update

    13

    Bioengineered Skin and Soft Tissue Substitutes

    7.01.113

    Admin Update

    14

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

    2.02.10

    Admin Update

    15

    Diagnosis of Obstructive Sleep Apnea Syndrome 2.01.18

    2.01.18

    Admin Update

    16

    Digital Health Therapies for Substance Use Disorders

    5.01.35

    Archived

    17

    Endovascular Stent Grafts for Disorders of the Thoracic Aorta

    7.01.86

    Minor Update

    18

    Evaluation of Biomarkers for Alzheimer Disease

    2.04.14

    Minor Update

    19

    General Approach to Evaluating the Utility of Genetic Panels

    2.04.92

    Archived

    20

    General Approach to Genetic Testing

    2.04.91

    Archived

    21

    Genetic Cancer Susceptibility Panels Using Next-Generation Sequencing

    2.04.93

    Minor Update

    22

    Genetic Testing for Alzheimer Disease

    2.04.13

    Minor Update

    23

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

    2.04.59

    Minor Update

    24

    Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes

    2.04.08

    Minor Update

    25

    Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence

    7.01.19

    Minor Update

    26

    Knee Arthroplasty for Adults

    BSC7.10

    Minor Update

    27

    Knee Arthroscopy in Knee Osteoarthritis

    BSC7.16

    Minor Update

    28

    Laboratory Tests Post Transplant and for Heart Failure

    2.01.68

    Minor Update

    29

    Magnetic Resonance Spectroscopy

    6.01.24

    Minor Update

    30

    Medical Management of Obstructive Sleep Apnea Syndrome

    8.01.67  

    Admin Update

    31

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

    6.01.06

    Minor Update

    32

    Multibiomarker Disease Activity Blood Test for Rheumatoid Arthritis

    2.04.119

    Archived

    33

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

    3.01.03

    Minor Update

    34

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

    7.01.136

    Minor Update

    35

    Remote Electrical Neuromodulation for Migraines

    7.01.171

    Minor Update

    36

    Selected Positron Emission Tomography Technologies for Evaluation of Alzheimer Disease

    6.01.55

    Minor Update

    37

    Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome

    7.01.101

    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 November 1, 2023

     

    Policy Title – November 1, 2023

    Policy#

    Status

    1

    Endobronchial Ultrasound for Diagnosis and Staging of Lung Cancer

    6.01.58

    New

    2

    Ovarian and Internal Iliac Vein Endovascular Occlusion as a Treatment of Pelvic Congestion Syndrome

    4.01.18

    New

    3

    Percutaneous and Subcutaneous Tibial Nerve Stimulation

    7.01.106

    New

    4

    Radioactive Seed Localization of Nonpalpable Breast Lesions

    6.01.57

    New

    5

    Thermography

    6.01.12

    New

    6

    Whole Body Dual X-Ray Absorptiometry to Determine Body Composition

    6.01.40

    New

    7

    Ablation of Peripheral Nerves to Treat Pain

    7.01.154

    Minor Update

    8

    Amniotic Membrane and Amniotic Fluid

    7.01.149

    Admin Coding

    9

    Aqueous Shunts and Stents for Glaucoma

    9.03.21

    Minor Update

    10

    Balloon Dilation of the Eustachian Tube

    7.01.158

    Minor Update

    11

    Bone Mineral Density Studies

    6.01.01

    Minor Update

    12

    Cardiac Applications of Positron Emission Tomography Scanning

    6.01.20

    Minor Update

    13

    Cardiovascular Risk Panels

    2.04.100

    Admin Coding

    14

    Computed Tomography Perfusion Imaging of the Brain

    6.01.49

    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

    Genetic Testing for Diagnosis and Management of Mental Health Conditions

    2.04.110

    Admin Coding

    21

    Genetic Testing for Mitochondrial Disorders

    2.04.117

    Minor Update

    22

    Germline and Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment in Ovarian Cancer (BRCA1, BRCA2, Homologous Recombination Deficiency)

    2.04.156

    Minor Update

    23

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

    2.04.02

    Minor Update

    24

    Identification of Microorganisms Using Nucleic Acid Probes

    2.04.10

    Admin Coding

    25

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

    6.01.51

    Minor Update

    26

    Islet Transplantation for Chronic Pancreatitis and Donislecel-jujn for Type 1 Diabetes

    7.03.12

    Minor Update

    27

    Lower Limb Prostheses

    BSC1.01

    Admin Coding

    28

    Magnetic Resonance Imaging for Detection and Diagnosis of Breast Cancer

    6.01.29

    Minor Update

    29

    Myocardial Sympathetic Innervation Imaging in Patients With Heart Failure

    6.01.56

    Minor Update

    30

    Oncologic Applications of Positron Emission Tomography Scanning

    6.01.26

    Minor Update

    31

    Oncology: Algorithmic (Genetic Expression) Testing

    BSC_CON_2.05

    Admin Coding

    32

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

    BSC_CON_2.10

    Admin Coding

    33

    Oncology: Molecular Analysis Of Solid Tumors And Hematologic Malignancies

    BSC_CON_2.04

    Admin Coding

    34

    Positional Magnetic Resonance Imaging

    6.01.48

    Minor Update

    35

    Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors

    7.01.95

    Minor Update

    36

    Scintimammography and Gamma Imaging of the Breast and Axilla

    6.01.18

    Minor Update

    37

    Stationary Ultrasonic Diathermy Devices

    7.01.174

    Admin Coding

    38

    Synthetic Cartilage Implants for Joint Pain

    7.01.160

    Minor Update

    39

    Vertebral Fracture Assessment with Densitometry

    6.01.44

    Minor Update

    40

    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 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 October 1, 2023

     

    Policy Title –October 1, 2023

    Policy#

    Status

    1

    Bariatric Surgery

    7.01.47   

    Major Update

    2

    Composite Tissue Allotransplantation of the Hand and Face

    7.03.13

    New

    3

    Magnetic Resonance Imaging-Targeted Biopsy of the Prostate

    7.01.152

    New

    4

    Periureteral Bulking Agents as a Treatment of Vesicoureteral Reflux

    7.01.102

    New

    5

    Prostatic Urethral Lift

    7.01.151

    New

    6

    Allogeneic Pancreas Transplant

    7.03.02

    Minor Update

    7

    Biofeedback as a Treatment of Urinary Incontinence in Adults

    2.01.27

    Minor Update

    8

    Digital Health Technologies for Attention Deficit/Hyperactivity Disorder

    3.03.03

    Minor Update

    9

    Digital Health Technologies: Diagnostic Applications

    3.03.01

    Minor Update

    10

    Facet Joint Denervation

    7.01.116

    Archived

    11

    Gender Affirmation Surgery

    BSC7.02

    Admin Coding

    12

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

    2.04.61

    Minor Update

    13

    Gene Expression Profiling for Cutaneous Melanoma

    2.04.146

    Archived

    14

    Genetic Testing for Macular Degeneration

    2.04.103

    Archived

    15

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

    2.04.126

    Minor Update

    16

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

    2.04.154

    Minor Update

    17

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

    2.04.149

    Minor Update

    18

    Heart Transplant

    7.03.09

    Minor Update

    19

    Heart/Lung Transplant

    7.03.08

    Minor Update

    20

    Hip Arthroplasty for Adults

    BSC7.11

    Minor Update

    21

    Isolated Small Bowel Transplant

    7.03.04

    Minor Update

    22

    Kidney Transplant

    7.03.01

    Minor Update

    23

    Liver Transplant and Combined Liver-Kidney Transplant

    7.03.06

    Minor Update

    24

    Lung and Lobar Lung Transplant

    7.03.07 

    Minor Update

    25

    Lung Volume Reduction Surgery for Severe Emphysema

    7.01.71

    Minor Update

    26

    Magnetoencephalography/Magnetic Source Imaging

    BSC6.05

    Minor Update

    27

    Medical Cannabis for the Treatment of Pain and Spasticity

    5.01.32

    Archived

    28

    Non-Invasive Positive Airway Pressure for Chronic Obstructive Pulmonary Disease

    8.01.64

    Minor Update

    29

    Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence

    1.01.17

    Minor Update

    30

    Remote Electrical Neuromodulation for Migraine

    7.01.171

    Minor Update

    31

    Reproductive Techniques

    4.02.04

    Minor Update

    32

    Small Bowel/Liver and Multivisceral Transplant

    7.03.05

    Minor Update

    33

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

    7.01.172

    Minor Update

    34

    Total Artificial Hearts and Implantable Ventricular Assist Devices

    7.03.11

    Minor Update

    35

    Uterus Transplantation for Absolute Uterine Factor Infertility

    4.02.06

    Minor Update

    36

    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 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 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