Medical policy updates | Blue Shield of CA Provider

New and updated policies effective March 1, 2023

	Policy Title –March 1, 2023	Policy#	Status
1	Charged-Particle (Proton or Helium Ion) Radiotherapy for Neoplastic Conditions	BSC8.04	Major Update
2	Germline and Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment and Immunotherapy in Breast Cancer	2.04.151	Major Update
3	Negative Pressure Wound Therapy in the Outpatient Setting	1.01.16	Major Update
4	Tumor-Informed Circulating Tumor DNA Testing for Cancer Management	BSC2.18	Major Update
5	Facet Joint Denervation	7.01.116	New
6	Adipose-Derived Stem Cells in Autologous Fat Grafting to the Breast	7.01.153	Minor Update
7	Ambulatory Event Monitors and Mobile Cardiac Outpatient Telemetry	2.02.08	Admin Update
8	Amniotic Membrane and Amniotic Fluid	7.01.149	Admin Update
9	Autologous Platelet-Derived Growth Factors for Wound Healing and Other Non-Orthopedic Conditions	2.01.16	Minor Update
10	Bioengineered Skin and Soft Tissue Substitutes	7.01.113	Minor Update
11	Bioimpedance Devices for Detection and Management of Lymphedema	2.01.82	Minor Update
12	Blepharoplasty, Blepharoptosis Repair (Levator Resection) and Brow Lift (Repair of Brow Ptosis)	BSC7.01	Minor Update
13	Bone Turnover Markers for the Diagnosis and Management of Osteoporosis and Diseases Associated With High Bone Turnover	2.04.15	Minor Update
14	Catheter Ablation for Cardiac Arrhythmias	BSC2.12	Admin Update
15	Corneal Collagen Cross-Linking	9.03.28	Admin Update
16	Cranial Electrotherapy Stimulation and Auricular Electrostimulation	8.01.58	Admin Update
17	Digital Health Therapies for Substance Use Disorders	5.01.35	Admin Update
18	Electrostimulation and Electromagnetic Therapy for Treating Wounds	2.01.57	Minor Update
19	Esophageal pH Monitoring	2.01.20	Admin Update
20	Evaluation of Biomarkers for Alzheimer Disease	2.04.14	Admin Update
21	Focal Treatments for Prostate Cancer	8.01.61	Admin Update
22	Gender Affirmation Surgery	BSC7.02	Minor Update
23	General Approach to Evaluating the Utility of Genetic Panels	2.04.92	Admin Update
24	Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer	2.04.33	Admin Update
25	Genetic Testing for Alzheimer Disease	2.04.13	Admin Update
26	Genetic Testing for Cardiac Ion Channelopathies	2.04.43	Minor Update
27	Genetic Testing for Diagnosis and Management of Mental Health Condition	2.04.110	Admin Update
28	Genetic Testing for FLT3, NPM1, and CEBPA Variants in Cytogenetically Normal Acute Myeloid Leukemia	2.04.124	Minor Update
29	Genetic Testing: Exome and Genome Sequencing For The Diagnosis Of Genetic Disorders	BSC_CON_2.02	Admin Update
30	Hyperbaric Oxygen Therapy	2.01.04	Minor Update
31	Identification of Microorganisms Using Nucleic Acid Probes	2.04.10	Admin Update
32	Implantable Bone-Conduction and Bone-Anchored Hearing Aids	7.01.03	Admin Update
33	Ingestible pH and Pressure Capsule	BSC2.17	Minor Update
34	Interferential Current Stimulation	1.01.24	Admin Update
35	Lumbar Spine Surgery	BSC_NIA_CG_304	Admin Update
36	Lysis of Epidural Adhesions	BSC8.05	Minor Update
37	Manipulation Under Anesthesia	8.01.40	Admin Update
38	Noncontact Ultrasound Treatment for Wounds	2.01.79	Minor Update
39	Oncology: Cancer Screening	BSC_CON_2.09	Admin Update
40	Orthopedic Applications of Stem Cell Therapy (Including Allografts and Bone Substitutes Used With Autologous Bone Marrow)	8.01.52	Minor Update
41	Orthoptic Training for the Treatment of Vision or Learning Disabilities	9.03.03	Admin Update
42	Percutaneous Vertebroplasty and Sacroplasty	6.01.25	Admin Update
43	Pharmacogenomic and Metabolite Markers for Patients Treated With Thiopurines	2.04.19	Admin Update
44	Reduction Mammaplasty	7.01.21	Admin Update
45	Retinal Prosthesis	9.03.15	Admin Update
46	Scintimammography and Gamma Imaging of the Breast and Axilla	6.01.18	Admin Update
47	Surgical Treatment of Gynecomastia	BSC7.13	Minor Update
48	Vagus Nerve Blocking Therapy for Treatment of Obesity	BSC7.17	Admin Update

Please note:

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

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

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

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

New and updated policies effective February 1, 2023

	Policy Title – February 1, 2023	Policy#	Status	Vendor
1	Intensity-Modulated Radiotherapy of the Breast and Lung	8.01.46	Major Update	No
2	Intensity-Modulated Radiotherapy of the Prostate	8.01.47	Major Update	No
3	Intensity-Modulated Radiotherapy: Abdomen, Pelvis and Chest	8.01.49	Major Update	No
4	Intensity-Modulated Radiotherapy: Cancer of the Head and Neck or Thyroid	8.01.48	Major Update	No
5	Intensity-Modulated Radiotherapy: Central Nervous System Tumors	8.01.59	Major Update	No
6	Radiation Oncology	BSC8.06	Major Update	No
7	Somatic (Tumor) Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment and Immunotherapy in Non-Small-Cell Lung Cancer (EGFR, ALK, BRAF, ROS1, RET, MET, KRAS, HER2, PD-L1, TMB)	2.04.45	Major Update	No
8	Stereotactic Radiosurgery and Stereotactic Body Radiotherapy	6.01.10	Major Update	No
9	Axillary Reverse Mapping for Prevention of Breast Cancer-Related Lymphedema	7.01.173	New	No
10	Genetic Testing: Prenatal and Preconception Carrier Screening	BSC_CON_2.07	New	No
11	Genetic Testing: Prenatal Diagnosis (Via Amniocentesis, CVS, or PUBS) and Pregnancy Loss	BSC_CON_2.06	New	No
12	Oncology: Cancer Screening	BSC_CON_2.09	New	No
13	Temporarily Implanted Nitinol Device (iTind) for Benign Prostatic Hyperplasia	7.01.175	New	No
14	Bariatric Surgery	7.01.47	Minor Update	No
15	Cardiovascular Risk Panels	2.04.100	Minor Update	No
16	Carrier Screening for Genetic Diseases	2.04.107	ARCHIVED	No
17	Dermatologic Applications of Photodynamic Therapy	2.01.44	Minor Update	No
18	Fecal Analysis in the Diagnosis of Intestinal Dysbiosis	2.04.26	Minor Update	No
19	Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer	2.04.33	Minor Update	No
20	Immune Cell Function Assay	2.04.56	Minor Update	No
21	Invasive Prenatal (Fetal) Diagnostic Testing	2.04.116	ARCHIVED	No
22	Laser Interstitial Thermal Therapy for Neurological Conditions	7.01.170	Minor Update	No
23	Measurement of Lipoprotein-Associated Phospholipase A2 in the Assessment of Cardiovascular Risk	2.04.32	Minor Update	No
24	Multimarker Serum Testing Related to Ovarian Cancer	2.04.62	Minor Update	No
25	Nonpharmacologic Treatment of Rosacea	2.01.71	Minor Update	No
26	Novel Biomarkers in Risk Assessment and Management of Cardiovascular Disease	2.04.65	Minor Update	No
27	Proteomic Testing for Targeted Therapy in Non-Small-Cell Lung Cancer	2.04.125	Minor Update	No
28	Serum Biomarker Human Epididymis Protein 4	2.04.66	Minor Update	No
29	Testing Serum Vitamin D Levels	2.04.135	Minor Update	No
30	Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease	2.01.38	Minor Update	No
31	Urinary Biomarkers for Cancer Screening, Diagnosis, and Surveillance	2.04.07	ARCHIVED	No
32	Wireless Capsule Endoscopy for Gastrointestinal (GI) Disorders	6.01.33	Minor Update	No

Please note:

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

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

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

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

New and updated policies effective January 1, 2023

	Policy Title –January 1, 2023	Policy#	Status
1	Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer	2.04.36	Major Update
2	Epidural Spine Injections	BSC_NIA_CG_300	Major Update
3	Esophageal pH Monitoring	2.01.20	Major Update
4	Genetic Testing: Non-Invasive Prenatal Screening (NIPS)/ Non-Invasive Prenatal Testing (NIPT)	BSC_CON_2.08	New
5	Genetic Testing: Preimplantation Genetic Testing	BSC_CON_2.03	New
6	Bariatric Surgery	7.01.47	Minor Update
7	Cervical Spine Surgery	BSC_NIA_CG_307	Minor Update
8	Confocal Laser Endomicroscopy	2.01.87	Minor Update
9	Drug Testing in Pain Management and Substance Use Disorder Treatment	2.04.98	Minor Update
10	Endoscopic Radiofrequency Ablation or Cryoablation for Barrett Esophagus	2.01.80	Minor Update
11	Gene Expression Profiling and Protein Biomarkers for Prostate Cancer Management	2.04.111	Minor Update
12	Lumbar Spinal Surgery	BSC_NIA_CG_304	Minor Update
13	Magnetic Esophageal Sphincter Augmentation to Treat Gastroesophageal Reflux Disease	7.01.137	Minor Update
14	Measurement of Serum Antibodies to Selected Biologic Agents	2.04.84	Minor Update
15	Monitored Anesthesia Care	7.02.01	Minor Update
16	Noninvasive Prenatal Screening for Fetal Aneuploidies, Microdeletions, Single-Gene Disorders, and Twin Zygosity Using Cell-Free Fetal DNA	4.01.21	Archived
17	Noninvasive Techniques for the Evaluation and Monitoring of Patients With Chronic Liver Disease	2.04.41	Minor Update
18	Paravertebral Facet Joint Injections or Blocks	BSC_NIA_CG_301	Minor Update
19	Pharmacogenetic Testing for Pain Management	2.04.131	Minor Update
20	Pharmacogenomic and Metabolite Markers for Patients Treated With Thiopurines	2.04.19	Minor Update
21	Plugs for Anal Fistula Repair	7.01.123	Minor Update
22	Preimplantation Genetic Testing	4.02.05	Archived
23	Prolotherapy	2.01.26	Minor Update
24	Sacroiliac Joint Injections	BSC_NIA_CG_305	Minor Update
25	Thoracic Spine Surgery	BSC_NIA_CG_308	Minor Update

Please note:

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

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

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

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

New and updated policies effective December 1, 2022

	Policy Title –December 1, 2022	Policy#	Status
1	Comprehensive Genomic Profiling for Selecting Targeted Cancer Therapies	2.04.115	Major Update
2	Germline Genetic Testing for Hereditary Breast/Ovarian Cancer Syndrome and Other High-Risk Cancers (BRCA1, BRCA2, PALB2)	2.04.02	Major Update
3	Hip Arthroplasty for Adults	BSC7.11	Major Update
4	Knee Arthroplasty for Adults	BSC7.10	Major Update
5	Knee Arthroscopy in Knee Osteoarthritis	BSC7.16	Major Update
6	Laboratory Tests Post Transplant and for Heart Failure	2.01.68	Major Update
7	Germline and Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment and Immunotherapy in Ovarian Cancer (BRCA1, BRCA2, Homologous Recombination Deficiency, Tumor Mutational Burden, Microsatellite Instability/Mismatch Repair)	2.04.156	New
8	Germline and Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment and Immunotherapy in Prostate Cancer (BRCA1/2, Homologous Recombination Repair Gene Alterations, Microsatellite Instability/Mismatch Repair, Tumor Mutational Burden)	2.04.155	New
9	Absorbable Nasal Implant for Treatment of Nasal Valve Collapse	7.01.163	Minor Update
10	Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer	2.04.36	Admin Update
11	Bioengineered Skin and Soft Tissue Substitutes	7.01.113	Admin-Coding
12	Cranial Electrotherapy Stimulation and Auricular Electrostimulation	8.01.58	Admin-Coding
13	Elective Invasive Coronary Angiography (ICA)	BSC2.13	Admin Update
14	Elective Percutaneous Coronary Intervention (PCI)	BSC6.02	Admin Update
15	Evaluation of Biomarkers for Alzheimer Disease	2.04.14	Minor Update
16	Genetic Cancer Susceptibility Panels Using Next-Generation Sequencing	2.04.93	Minor Update
17	Genetic Testing for Alzheimer Disease	2.04.13	Minor Update
18	Genetic Testing for Cardiac Ion Channelopathies	2.04.43	Admin Update
19	Genetic Testing for Developmental Delay/Intellectual Disability, Autism Spectrum Disorder, and Congenital Anomalies	2.04.59	Minor Update
20	Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes	2.04.08	Admin Update
21	Genetic Testing for Mitochondrial Disorders	2.04.117	Admin-Coding
22	Genetic Testing for Predisposition to Inherited Hypertrophic Cardiomyopathy	2.02.28	Admin Update
23	Genetic Testing: Exome and Genome Sequencing For The Diagnosis Of Genetic Disorders	BSC_CON_2.02	Admin Update
24	Germline Genetic Testing for Gene Variants Associated With Breast Cancer in Individuals at High Breast Cancer Risk (CHEK2, ATM, and BARD1)	2.04.126	Admin Update
25	Germline Genetic Testing for Pancreatic Cancer Susceptibility Genes	2.04.148	Admin-Coding
26	Hysterectomy Surgery for Benign Conditions	BSC7.09	Admin Update
27	Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence	7.01.19	Minor Update
28	Magnetic Resonance Spectroscopy	6.01.24	Minor Update
29	Microwave and Locoregional Laser Tumor Ablation	7.01.133	Minor Update
30	Miscellaneous (Noncardiac, Nononcologic) Applications of Fluorine 18 Fluorodeoxyglucose Positron Emission Tomography	6.01.06	Minor Update
31	Quantitative Electroencephalography as a Diagnostic Aid for Attention-Deficit/Hyperactivity Disorder	3.01.03	Minor Update
32	Radiofrequency Ablation of the Renal Sympathetic Nerves as a Treatment for Resistant or Uncontrolled Hypertension	7.01.136	Minor Update
33	Selected Positron Emission Tomography Technologies for Evaluation of Alzheimer Disease	6.01.55	Minor Update
34	Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders	2.01.50	Minor Update

Please note:

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

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

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

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

New and updated policies effective November 1, 2022

	Policy Title – November 1, 2022	Policy#	Status
1	Elective Invasive Coronary Angiography (ICA)	BSC2.13	Major Update
2	Elective Percutaneous Coronary Intervention (PCI)	BSC6.02	Major Update
3	Germline Genetic Testing for Hereditary Diffuse Gastric Cancer (CDH1, CTNNA1)	2.04.154	New
4	Ablation of Peripheral Nerves to Treat Pain	7.01.154	Minor Update
5	Aqueous Shunts and Stents for Glaucoma	9.03.21	Minor Update
6	Balloon Dilation of the Eustachian Tube	7.01.158	Minor Update
7	Bone Mineral Density Studies	6.01.01	Minor Update
8	Cardiac Applications of Positron Emission Tomography Scanning	6.01.20	Minor Update
9	Carrier Screening for Genetic Diseases	2.04.107	Minor Update
10	Circulating Tumor DNA and Circulating Tumor Cells for Cancer Management (Liquid Biopsy)	2.04.141	Admin Coding
11	Comprehensive Genomic Profiling for Selecting Targeted Cancer Therapies	2.04.115	Admin Coding
12	Computed Tomography Perfusion Imaging of the Brain	6.01.49	Minor Update
13	Computed Tomography to Detect Coronary Artery Calcification	6.01.03	Minor Update
14	Contrast-Enhanced Computed Tomographic Angiography for Coronary Artery Evaluation	6.01.43	Minor Update
15	Cryosurgical Ablation of Primary or Metastatic Liver Tumors	7.01.75	Minor Update
16	Dynamic Spinal Visualization and Vertebral Motion Analysis	6.01.46	Minor Update
17	Evaluation of Biomarkers for Alzheimer Disease	2.04.14	Admin Coding
18	Focal Treatments for Prostate Cancer	8.01.61	Minor Update
19	Functional Magnetic Resonance Imaging of the Brain	6.01.47	Minor Update
20	General Approach to Genetic Testing	2.04.91	Admin Coding
21	Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer	2.04.33	Admin Coding
22	Genetic Testing for Developmental Delay/Intellectual Disability, Autism Spectrum Disorder, and Congenital Anomalies	2.04.59	Admin Coding
23	Genetic Testing for Diagnosis and Management of Mental Health Conditions	2.04.110	Admin Coding
24	Genetic Testing for FLT3, NPM1, and CEBPA Variants in Cytogenetically Normal Acute Myeloid Leukemia	2.04.124	Admin Coding
25	Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes	2.04.08	Minor Update
26	Genetic Testing for Mitochondrial Disorders	2.04.117	Minor Update
27	Genetic Testing: Exome and Genome Sequencing For The Diagnosis Of Genetic Disorders	BSC_CON_2.02	Admin Coding
28	Identification of Microorganisms Using Nucleic Acid Probes	2.04.10	Admin Coding
29	Interim Positron Emission Tomography Scanning in Oncology to Detect Early Response During Treatment	6.01.51	Minor Update
30	Invasive Prenatal (Fetal) Diagnostic Testing	2.04.116	Admin Coding
31	Magnetic Resonance Imaging for Detection and Diagnosis of Breast Cancer	6.01.29	Minor Update
32	Magnetoencephalography/Magnetic Source Imaging	BSC6.05	Minor Update
33	Myocardial Sympathetic Innervation Imaging in Patients With Heart Failure	6.01.56	Minor Update
34	Noninvasive Techniques for the Evaluation and Monitoring of Patients with Chronic Liver Disease	2.04.41	Admin Coding
35	Oncologic Applications of Positron Emission Tomography Scanning	6.01.26	Minor Update
36	Pharmacogenetic Testing for Pain Management	2.04.131	Admin Coding
37	Positional Magnetic Resonance Imaging	6.01.48	Minor Update
38	Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors	7.01.95	Minor Update
39	Reproductive Techniques	4.02.04	Minor Update
40	Scintimammography and Gamma Imaging of the Breast and Axilla	6.01.18	Minor Update
41	Surgical Treatments for Breast Cancer-Related Lymphedema	7.01.162	Minor Update
42	Tumor-Informed Circulating Tumor DNA Testing for Cancer Management	2.04.153	Admin Coding
43	Vertebral Fracture Assessment with Densitometry	6.01.44	Minor Update
44	Virtual Colonoscopy/Computed Tomography Colonography	6.01.32	Minor Update

Please note:

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

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

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

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

New and updated policies effective October 1, 2022

	Policy Title – October 1, 2022	Policy#	Status
1	Diagnosis of Obstructive Sleep Apnea Syndrome	2.01.18	Major Update
2	Germline Genetic Testing for Gene Variants Associated With Breast Cancer in Individuals at High Breast Cancer Risk (CHEK2, ATM, and BARD1)	2.04.126	Major Update
3	Germline Genetic Testing for Hereditary Breast/Ovarian Cancer Syndrome and Other High-Risk Cancers (BRCA1, BRCA2, PALB2)	2.04.02	Major Update
4	Germline Genetic Testing for Ovarian Cancer Risk (BRIP1, RAD51C, RAD51D, NBN)	2.04.149	Major Update
5	Kidney Transplant	7.03.01	Major Update
6	Noninvasive Prenatal Screening for Fetal Aneuploidies, Microdeletions, Single-Gene Disorders, and Twin Zygosity Using Cell-Free Fetal DNA	4.01.21	Major Update
7	Small Bowel/Liver and Multivisceral Transplant	7.03.05	Major Update
8	Medical Management of Obstructive Sleep Apnea Syndrome	8.01.67	New
9	Surgical Left Atrial Appendage Occlusion Devices for Stroke Prevention in Atrial Fibrillation	7.01.172	New
10	Allogeneic Pancreas Transplant	7.03.02	Minor Update
11	Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer	2.04.36	Admin Update
12	Biofeedback as a Treatment of Urinary Incontinence in Adults	2.01.27	Minor Update
13	Circulating Tumor DNA and Circulating Tumor Cells for Cancer Management (Liquid Biopsy)	2.04.141	Minor Update
14	Gender Affirmation Surgery	BSC7.02	Admin Update
15	Gene Expression Profile Testing and Circulating Tumor DNA Testing for Predicting Recurrence in Colon Cancer	2.04.61	Minor Update
16	Gene Expression-Based Assays for Cancers of Unknown Primary	2.04.54	Admin Update
17	General Approach to Evaluating the Utility of Genetic Panels	2.04.92	Admin Update
18	General Approach to Genetic Testing	2.04.91	Admin Update
19	Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes	2.04.08	Admin Update
20	Genetic Testing for Predisposition to Inherited Hypertrophic Cardiomyopathy	2.02.28	Admin Update
21	Genotype-Guided Tamoxifen Treatment	2.04.51	Minor Update
22	Heart Transplant	7.03.09	Minor Update
23	Heart/Lung Transplant	7.03.08	Minor Update
24	Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia	8.01.32	Admin Update
25	Hematopoietic Cell Transplantation for Acute Myeloid Leukemia	8.01.26	Admin Update
26	Hematopoietic Cell Transplantation for Autoimmune Diseases	8.01.25	Admin Update
27	Hematopoietic Cell Transplantation for Central Nervous System Embryonal Tumors and Ependymoma	8.01.28	Admin Update
28	Hematopoietic Cell Transplantation for Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma	8.01.15	Admin Update
29	Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia	8.01.30	Admin Update
30	Hematopoietic Cell Transplantation for Hodgkin Lymphoma	8.01.29	Admin Update
31	Hematopoietic Cell Transplantation for Non-Hodgkin Lymphomas	8.01.20	Admin Update
32	Hematopoietic Cell Transplantation for Plasma Cell Dyscrasias, Including Multiple Myeloma and POEMS Syndrome	8.01.17	Admin Update
33	Hematopoietic Cell Transplantation for Primary Amyloidosis	8.01.42	Admin Update
34	Hematopoietic Cell Transplantation for Solid Tumors of Childhood	8.01.34	Admin Update
35	Hematopoietic Cell Transplantation in the Treatment of Germ Cell Tumors	8.01.35	Admin Update
36	Hepatitis C Viremic Organs for Transplantation to Non-Viremic Patients	7.03.14	Archived
37	Invasive Prenatal (Fetal) Diagnostic Testing	2.04.116	Minor Update
38	Islet Transplantation	7.03.12	Minor Update
39	Isolated Small Bowel Transplant	7.03.04	Minor Update
40	JAK2, MPL, and CALR Testing for Myeloproliferative Neoplasms	2.04.60	Minor Update
41	Liver Transplant and Combined Liver-Kidney Transplant	7.03.06	Minor Update
42	Lung and Lobar Lung Transplant	7.03.07	Minor Update
43	Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence	1.01.17	Minor Update
44	Placental and Umbilical Cord Blood as a Source of Stem Cells	7.01.50	Admin Update
45	Preimplantation Genetic Testing	4.02.05	Minor Update
46	Reconstructive Services	BSC7.08	Admin Update
47	Total Artificial Hearts and Implantable Ventricular Assist Devices	7.03.11	Minor Update
48	Whole Gland Cryoablation of Prostate Cancer	7.01.79	Minor Update

Please note:

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

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

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

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

New and updated policies effective September 1, 2022

	Policy Title – September 1, 2022	Policy#	Status
1	Digital Health Technologies: Diagnostic Applications	3.03.01	New
2	Minimally Invasive Ablation Procedures for Morton and Other Peripheral Neuromas	7.01.147	New
3	Reconstructive Breast Surgery/Management of Breast Implants	7.01.22	New
4	Alcohol Injections for Treatment of Peripheral Morton Neuromas	2.01.97	Archived
5	Brachytherapy for Clinically Localized Prostate Cancer Using Permanently Implanted Seeds	8.01.14	Admin Update
6	Breast Implant Management	BSC7.12	Archived
7	Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting	2.02.24	Minor Update
8	Cellular Immunotherapy for Prostate Cancer	8.01.53	Minor Update
9	Computer-Assisted Navigation for Orthopedic Procedure	7.01.96	Archived
10	Continuous Glucose Monitoring	1.01.20	Minor Update
11	Cryoablation of Tumors Located in the Kidney, Lung, Breast, Pancreas, or Bone	7.01.92	Minor Update
12	Digital Health Therapies for Attention Deficit/Hyperactivity Disorder	3.03.03	Minor Update
13	Digital Health Therapies for Substance Use Disorders	5.01.35	Minor Update
14	Electronic Brachytherapy for Nonmelanoma Skin Cancer	8.01.62	Admin Update
15	Endobronchial Brachytherapy	8.03.11	Admin Update
16	Genetic Testing for Diagnosis and Management of Mental Health Condition	2.04.110	Minor Update
17	Hip Arthroplasty for Adults	BSC7.11	Admin Update
18	Hydrogel Spacer use During Radiotherapy for Prostate Cancer	7.01.164	Archived
19	Intensity-Modulated Radiotherapy of the Breast and Lung	8.01.46	Admin Update
20	Intensity-Modulated Radiotherapy of the Prostate	8.01.47	Admin Update
21	Intensity-Modulated Radiotherapy: Abdomen, Pelvis and Chest	8.01.49	Admin Update
22	Intensity-Modulated Radiotherapy: Cancer of the Head and Neck or Thyroid	8.01.48	Admin Update
23	Intensity-Modulated Radiotherapy: Central Nervous System Tumors	8.01.59	Admin Update
24	Intracavitary Balloon Catheter Brain Brachytherapy for Malignant Gliomas or Metastasis to the Brain	8.01.45	Admin Update
25	Intraoperative Radiotherapy	8.01.08	Admin Update
26	Knee Arthroplasty for Adults	BSC7.10	Admin Update
27	Magnetic Resonance-Guided Focused Ultrasound	7.01.109	Minor Update
28	Molecular Analysis (Including Liquid Biopsy) for Targeted Therapy or Immunotherapy	2.04.45	Admin Update
29	Oncologic Applications of Photodynamic Therapy, Including Barrett Esophagus	8.01.06	Minor Update
30	Patient-Specific Instrumentation (e.g., Cutting Guides) for Joint Arthroplasty	7.01.144	Archived
31	Radiation Oncology	BSC8.06	Admin Update
32	Radioembolization for Primary and Metastatic Tumors of the Liver	8.01.43	Admin Update
33	Radiofrequency Ablation of Primary or Metastatic Liver Tumors	7.01.91	Minor Update
34	Saturation Biopsy for Diagnosis, Staging, and Management of Prostate Cancer	7.01.121	Minor Update
35	Serologic Genetic and Molecular Screening for Colorectal Cancer	2.04.150	Minor Update
36	Stereotactic Radiosurgery and Stereotactic Body Radiotherapy	6.01.10	Admin Update
37	Subtalar Arthroereisis	7.01.104	Admin Update
38	Synthetic Cartilage Implants for Joint Pain	7.01.160	Minor Update
39	Transcatheter Arterial Chemoembolization to Treat Primary or Metastatic Liver Malignancies	8.01.11	Minor Update

Please note:

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

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

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

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

New and updated policies effective August 1, 2022

	Policy Title - August 1, 2022	Policy#	Status
1	Cytochrome P450 Genotype-Guided Treatment Strategy	2.04.38	Major Update
2	Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome	7.01.101	Major Update
3	Treatment of Hyperhidrosis	8.01.19	Major Update
4	Dry Hydrotherapy for chronic pain conditions	2.01.105	New
5	Actigraphy	2.01.73	Minor Update
6	Amniotic Membrane and Amniotic Fluid	7.01.149	Admin coding
7	Bioengineered Skin and Soft Tissue Substitutes	7.01.113	Admin coding
8	Brachytherapy for Clinically Localized Prostate Cancer Using Permanently Implanted Seeds	8.01.14	Minor Update
9	Bronchial Thermoplasty	7.01.127	Minor Update
10	Bronchial Valves	7.01.128	Minor Update
11	Circulating Tumor DNA and Circulating Tumor Cells for Cancer Management (Liquid Biopsy)	2.04.141	Admin coding
12	Comprehensive Genomic Profiling for Selecting Targeted Cancer Therapies	2.04.115	Admin coding
13	Corneal Collagen Cross-Linking	9.03.28	Admin coding
14	Electronic Brachytherapy for Nonmelanoma Skin Cancer	8.01.62	Minor Update
15	Endobronchial Brachytherapy	8.03.11	Minor Update
16	Endovascular Stent Grafts for Disorders of the Thoracic Aorta	7.01.86	Minor Update
17	External Insulin Infusion Pump	BSC1.03	Minor Update
18	Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions	2.01.40	Minor Update
19	Genotype-Guided Warfarin Dosing	2.04.48	Minor Update
20	Identification of Microorganisms Using Nucleic Acid Probes	2.04.10	Minor Update
21	Intensity-Modulated Radiotherapy of the Breast and Lung	8.01.46	Minor Update
	Policy Title-August 1, 2022	Policy#	Status
22	Intensity-Modulated Radiotherapy of the Prostate	8.01.47	Minor Update
23	Intensity-Modulated Radiotherapy: Abdomen and Pelvis	8.01.49	Minor Update
24	Intensity-Modulated Radiotherapy: Cancer of the Head and Neck or Thyroid	8.01.48	Minor Update
25	Intensity-Modulated Radiotherapy: Central Nervous System Tumors	8.01.59	Minor Update
26	Interferential Current Stimulation	1.01.24	Minor Update
27	Intracavitary Balloon Catheter Brain Brachytherapy for Malignant Gliomas or Metastasis to the Brain	8.01.45	Minor Update
28	Intraoperative Radiotherapy	8.01.08	Minor Update
29	Knee Arthroscopy in Knee Osteoarthritis	BSC7.16	Minor Update
30	Lung Volume Reduction Surgery for Severe Emphysema	7.01.71	Minor Update
31	Medical Cannabis for the Treatment of Pain and Spasticity	5.01.32	Minor Update
32	Multibiomarker Disease Activity Blood Test for Rheumatoid Arthritis	2.04.119	Minor Update
33	Navigated Transcranial Magnetic Stimulation	2.01.90	Minor Update
34	Noninvasive Prenatal Screening for Fetal Aneuploidies, Microdeletions, and Twin Zygosity Using Cell-Free Fetal DNA	4.01.21	Admin coding
35	Oncologic Applications of Positron Emission Tomography Scanning	6.01.26	Admin coding
36	Orthopedic Applications of Stem Cell Therapy (including Allografts and Bone Substitutes with Autologous Bone Marrow	8.01.52	Admin coding
37	Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Conditions	1.01.15	Minor Update
38	Paraspinal Surface Electromyography to Evaluate and Monitor Back Pain	2.01.35	Minor Update
39	Quantitative Sensory Testing	2.01.39	Minor Update
40	Radiation Oncology	BSC8.06	Minor Update
	Policy Title-August 1, 2022	Policy#	Status
41	Radioembolization for Primary and Metastatic Tumors of the Liver	8.01.43	Minor Update
42	Stereotactic Radiosurgery and Stereotactic Body Radiotherapy	6.01.10	Minor Update
43	Transcatheter Pulmonary Valve Implantation	7.01.131	Minor Update

Please note:

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

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

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

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

New and updated policies effective July 1, 2022

	Policy Title – July 1, 2022	Policy#	Status
1	Catheter Ablation as Treatment for Atrial Fibrillation	7.01.124	Major Update
2	Temporomandibular Joint Disorder	2.01.21	Major Update
3	Remote Electrical Neuromodulation for Migraine	7.01.171	New
4	Allograft Injection for Degenerative Disc Disease	BSC2.11	Minor Update
5	Ambulatory Event Monitors and Mobile Cardiac Outpatient Telemetry	2.02.08	Minor Update
6	Baroreflex Stimulation Devices	BSC1.01	Minor Update
7	Biventricular Pacemakers (Cardiac Resynchronization Therapy) for the Treatment of Heart Failure	7.01.14	Minor Update
8	Catheter Ablation for Cardiac Arrhythmias	2.02.19	Minor Update
9	Diabetes Prevention Program	2.04.94	Minor Update
10	Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome	2.01.18	Admin Coding
11	Endovascular Therapies for Extracranial Vertebral Artery Disease	2.02.15	Minor Update
12	Enhanced External Counterpulsation	2.02.31	Minor Update
13	Extracorporeal Membrane Oxygenation for Adult Conditions	8.01.60	Minor Update
14	Extracranial Carotid Artery Stenting	7.01.68	Minor Update
15	Facet Arthroplasty	7.01.166	Minor Update
16	Genetic Testing for Inherited Thrombophilia	8.01.57	Minor Update
17	Genetic Testing for Lactase Insufficiency	2.04.142	Minor Update
18	Germline Genetic Testing for Pancreatic Cancer Susceptibility Genes	2.04.148	Minor Update
19	Implantable Cardioverter Defibrillators	7.01.44	Minor Update
20	Inhaled Nitric Oxide	8.01.37	Minor Update
21	Knee Arthroplasty for Adults	BSC7.10	Minor Update
22	Lipid Apheresis	BSC8.07	Minor Update
23	Lower Limb Prostheses	BSC2.12	Minor Update
24	Molecular Testing in the Management of Pulmonary Nodules	2.02.10	Minor Update
25	Myocardial Strain Imaging	2.02.06	Minor Update
26	Neuropsychological Testing	BSC2.06	Minor Update
27	Open and Thoracoscopic Approaches to Treat Atrial Fibrillation and Atrial Flutter (Maze and Related Procedures)	7.01.120	Minor Update
28	Phrenic Nerve Stimulation for Central Sleep Apnea	2.02.33	Minor Update
29	Power Wheelchairs and Power Operated Vehicles for Permanent Use	BSC1.02	Minor Update
30	Speech Therapy	BSC8.02	Minor Update
31	Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome	7.01.101	Admin Coding
32	Treatment of Varicose Veins/Venous Insufficiency	7.01.148	Minor Update
33	Ultrasonographic Measurement of Carotid Intimal-Medial Thickness as an Assessment of Subclinical Atherosclerosis	2.02.16	Minor Update
34	Wearable Cardioverter Defibrillators	2.04.82	Minor Update

Please note:

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

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

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

New and updated policies effective June 1, 2022

	Policy Title – June 1, 2022	Policy#	Status
1	Continuous Glucose Monitoring	1.01.20	Major Update
2	Intraoperative Neurophysiologic Monitoring	7.01.58	Major Update
3	Laparoscopic, Percutaneous, and Transcervical Techniques for Uterine Fibroid Myolysis	4.01.19	Major Update
4	Myoelectric Prosthetic and Orthotic Components for the Upper Limb	1.04.04	Major Update
5	Digital Health Therapies for Attention Deficit/Hyperactivity Disorder	3.03.03	New
6	Digital Health Therapies for Substance Abuse	5.01.35	New
7	Genetic Testing: Exome and Genome Sequencing For The Diagnosis Of Genetic Disorders	BSC_CON_2.02	New
8	Tumor-Informed Circulating Tumor DNA Testing for Cancer Management	2.04.153	New
9	Uterus Transplantation for Absolute Uterine Factor Infertility	4.02.06	New
10	Amniotic Membrane and Amniotic Fluid	7.01.149	Coding Vote
11	Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions	7.01.78	Minor Update
12	Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions	7.01.48	Minor Update
13	Behavioral Health Treatment for Autism Spectrum Disorders	BSC3.01	Minor Update
14	Bioengineered Skin and Soft Tissue Substitutes	7.01.113	Coding Vote
15	Blepharoplasty, Blepharoptosis Repair (Levator Resection) and Brow Lift (Repair of Brow Ptosis)	BSC7.01	Admin Update
16	Breast Implant Management	BSC7.12	Admin Update
17	Cleft Palate - Dental Related Services	BSC2.01	Minor Update
18	Computer-Assisted Navigation for Orthopedic Procedure	7.01.96	Minor Update
19	Electrical and Electromagnetic Stimulation for the Treatment of Arthritis	1.01.27	Minor Update
20	Endothelial Keratoplasty	9.03.22	Minor Update
21	Endovascular Procedures for Intracranial Arterial Disease (Atherosclerosis and Aneurysms)	2.01.54	Minor Update
22	Functional Neuromuscular Electrical Stimulation	8.03.01	Minor Update
23	Genetic Testing for Familial Cutaneous Malignant Melanoma	2.04.44	Minor Update
24	Hip Arthroplasty for Adults	BSC7.11	Minor Update
25	Hip Femoroacetabular Impingement (FAI) Surgical Treatment	7.01.118	Minor Update
26	Hip Resurfacing	7.01.80	Minor Update
27	Hippotherapy	8.03.12	Minor Update
28	Image-Guided Minimally Invasive Decompression for Spinal Stenosis	7.01.126	Minor Update
29	Knee Braces (Custom)	BSC1.05	Minor Update
30	Lifestyle Modification Program for Reversing Heart Disease	BSC8.01	Minor Update
31	Manipulation Under Anesthesia	8.01.40	Minor Update
32	Non-Invasive Positive Airway Pressure for Chronic Obstructive Pulmonary Disease	8.01.64	Minor Update
33	Orthognathic Surgery	BSC7.03	Minor Update
34	Orthopedic Applications of Platelet-Rich Plasma	2.01.98	Minor Update
35	Panniculectomy, Abdominoplasty, and Surgical Management of Diastasis Recti	BSC7.04	Minor Update
36	Partial Thickness Rotator Cuff Tears and Acromioplasty/ Subacromial Decompression	BSC7.14	Minor Update
37	Patient-Controlled End Range of Motion Stretching Devices	1.03.05	Minor Update
38	Patient-Specific Instrumentation (eg, Cutting Guides) for Joint Arthroplasty	7.01.144	Minor Update
39	Percutaneous Vertebroplasty and Sacroplasty	6.01.25	Minor Update
40	Personalized Breast Cancer Screening Clinical Trial	BSC2.08	Minor Update
41	Physical Therapy	BSC8.03	Minor Update
42	Power Morcellation for the Treatment of Uterine Fibroids	BSC7.06	Minor Update
43	Powered Exoskeleton for Ambulation in Patients With Lower-Limb Disabilities	1.03.04	Minor Update
44	Reconstructive Services	BSC7.08	Minor Update
45	Subtalar Arthroereisis	7.01.104	Minor Update
46	Surgical Treatment of Gynecomastia	BSC7.13	Admin Update
47	Trigger Point and Tender Point Injections	2.01.103	Minor Update
48	Vertebral Axial Decompression	8.03.09	Minor Update
49	Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders	2.04.102	Archived

New and updated policies effective May 1, 2022

	Policy Title – May1, 2022	Policy#	Status
1	Cryoablation, Radiofrequency Ablation, and Laser Ablation for Treatment of Chronic Rhinitis	7.01.168	Major Update
2	Low Intensity Pulsed Ultrasound Fracture Healing Device	1.01.05	Major Update
3	Orthoptic Training for the Treatment of Vision or Learning Disabilities	9.03.03	Major Update
4	Ambulatory Surgery Center	BSC10.01	Minor Update
5	Amniotic Membrane and Amniotic Fluid	7.01.149	Minor Update
6	Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer	2.04.36	Admin Update
7	Bariatric Surgery	7.01.47	Minor Update
8	Charged-Particle (Proton or Helium Ion) Radiotherapy for Neoplastic Conditions	BSC8.04	Minor Update
9	Continuous Passive Motion in the Home Setting	1.01.10	Minor Update
10	Corneal Collagen Cross-Linking	9.03.28	Minor Update
11	Cranial Electrotherapy Stimulation and Auricular Electrostimulation	8.01.58	Minor Update
12	Dental Anesthesia	BSC2.02	Minor Update
13	DNA-Based Testing for Adolescent Idiopathic Scoliosis	2.04.74	Archived
14	Elective Invasive Coronary Angiography (ICA)	BSC2.13	Minor Update
15	Elective Percutaneous Coronary Intervention (PCI)	BSC6.02	Minor Update
16	Eyelid Thermal Pulsation for the Treatment of Dry Eye Syndrome	9.03.29	Minor Update
17	Gastric Electrical Stimulation	7.01.73	Minor Update
18	Gene Expression Profile Testing and Circulating Tumor DNA Testing for Predicting Recurrence in Colon Cancer	2.04.61	Admin Update
19	Gene Expression-Based Assays for Cancers of Unknown Primary	2.04.54	Minor Update
20	Gene Variants (PALB2, CHEK2 and ATM) Associated with Breast Cancer in Individuals at High Breast Cancer Risk	2.04.126	Admin Update
21	Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes	2.04.08	Admin Update
22	Genetic Testing for Macular Degeneration	2.04.103	Minor Update
23	Genetic Testing for Predisposition to Inherited Hypertrophic Cardiomyopathy	2.02.28	Minor Update
24	Hysterectomy Surgery for Benign Conditions	BSC7.09	Minor Update
25	Implantable Bone-Conduction and Bone-Anchored Hearing Aids	7.01.03	Minor Update
26	Implantation of Intrastromal Corneal Ring Segments	9.03.14	Archived
27	JAK2, MPL, and CALR Testing for Myeloproliferative Neoplasms	2.04.60	Admin Update
28	Laboratory and Genetic Testing for Use of 5-Fluorouracil in Patients With Cancer	2.04.68	Minor Update
29	Microprocessor-Controlled Prostheses for the Lower Limb	1.04.05	Minor Update
30	Ophthalmologic Techniques That Evaluate the Posterior Segment for Glaucoma	9.03.06	Minor Update
31	Optical Coherence Tomography of the Anterior Eye Segment	9.03.18	Minor Update
32	Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers	1.01.18	Minor Update
33	Retinal Prosthesis	9.03.15	Minor Update
34	Semi-Implantable and Fully Implantable Middle Ear Hearing Aids	7.01.84	Minor Update
35	Steroid-Eluting Sinus Stents and Implants	7.01.134	Minor Update
36	Surgical Deactivation of Headache Trigger Sites	7.01.135	Minor Update

New and updated policies effective April 1, 2022

	Policy Title – April 1, 2022	Policy#	Status
1	Molecular Analysis (Including Liquid Biopsy) for Targeted Therapy or Immunotherapy of Non-Small-Cell Lung Cancer	2.04.45	Major Update
2	Maternal Serum Biomarkers for Prediction of Adverse Obstetric Outcomes	2.04.152	New
3	Non-Invasive Positive Airway Pressure for Chronic Obstructive Pulmonary Disease	8.01.64	New
4	Postsurgical Home Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis	1.01.28	New
5	Vagus Nerve Blocking Therapy for Treatment of Obesity	BSC7.17	New
6	Allogeneic Hematopoietic Cell Transplantation for Genetic Diseases and Acquired Anemias	8.01.22	Archived
7	Allogeneic Hematopoietic Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms	8.01.21	Minor Update
8	Auditory Brainstem Implant	7.01.83	Minor Update
9	Automated Point-of-Care Nerve Conduction Tests	2.01.77	Archived
10	Balloon Ostial Dilation for Treatment of Chronic and Recurrent Acute Rhinosinusitis	7.01.105	Minor Update
11	Blepharoplasty, Blepharoptosis Repair (Levator Resection) and Brow Lift (Repair of Brow Ptosis)	BSC7.01	Minor Update
12	Breast Implant Management	BSC7.12	Minor Update
13	Chelation Therapy for Off-Label Uses	8.01.02	Minor Update
14	Chronic Intermittent Intravenous Insulin Therapy	2.01.43	Minor Update
15	Circulating Tumor DNA for Management of Non-Small-Cell Lung Cancer (Liquid Biopsy)	2.04.143	Archived
16	Dynamic Posturography	2.01.02	Minor Update
17	Gender Affirmation Surgery	BSC7.02	Minor Update
18	General Approach to Evaluating the Utility of Genetic Panels	2.04.92	Minor Update
19	General Approach to Genetic Testing	2.04.91	Minor Update
20	Handheld Radiofrequency Spectroscopy for Intraoperative Assessment of Surgical Margins During Breast-Conserving Surgery	7.01.140	Minor Update
21	Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia	8.01.32	Minor Update
22	Hematopoietic Cell Transplantation for Acute Myeloid Leukemia	8.01.26	Minor Update
23	Hematopoietic Cell Transplantation for Autoimmune Diseases	8.01.25	Minor Update
24	Hematopoietic Cell Transplantation for Central Nervous System Embryonal Tumors and Ependymoma	8.01.28	Minor Update
25	Hematopoietic Cell Transplantation for Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma	8.01.15	Minor Update
26	Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia	8.01.30	Minor Update
27	Hematopoietic Cell Transplantation for Hodgkin Lymphoma	8.01.29	Minor Update
28	Hematopoietic Cell Transplantation for Non-Hodgkin Lymphomas	8.01.20	Minor Update
29	Hematopoietic Cell Transplantation for Plasma Cell Dyscrasias, Including Multiple Myeloma and POEMS Syndrome	8.01.17	Minor Update
30	Hematopoietic Cell Transplantation for Primary Amyloidosis	8.01.42	Minor Update
31	Hematopoietic Cell Transplantation for Solid Tumors of Childhood	8.01.34	Minor Update
32	Hematopoietic Cell Transplantation for Waldenström Macroglobulinemia	8.01.54	Archived
33	Hematopoietic Cell Transplantation in the Treatment of Germ Cell Tumors	8.01.35	Minor Update
34	Orthopedic Applications of Stem Cell Therapy (Including Allografts and Bone Substitutes Used with Autologous Bone Marrow)	8.01.52	Minor Update
35	Placental and Umbilical Cord Blood as a Source of Stem Cells	7.01.50	Minor Update
36	Reduction Mammaplasty	7.01.21	Minor Update
37	Stem Cell Therapy for Peripheral Arterial Disease	8.01.55	Minor Update
38	Surgical Treatment of Gynecomastia	BSC7.13	Minor Update
39	Surgical Ventricular Restoration	7.01.103	Minor Update
40	Temporomandibular Joint Disorder	2.01.21	Minor Update
41	Transcatheter Aortic-Valve Implantation for Aortic Stenosis	7.01.132	Minor Update

New and updated policies effective March 1, 2022

Policy Title – March 1, 2022		Policy#	Status
1	Germline and Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment and Immunotherapy in Breast Cancer	2.04.151	Major Update
2	Germline Genetic Testing for BRCA1 or BRCA2 for Hereditary Breast/Ovarian Cancer Syndrome and Other High-Risk Cancers	2.04.02	Major Update
3	Low Intensity Pulsed Ultrasound Fracture Healing Device	1.01.05	New
4	Adipose-Derived Stem Cells in Autologous Fat Grafting to the Breast	7.01.153	Minor Update
5	Ambulatory Event Monitors and Mobile Cardiac Outpatient Telemetry	2.02.08	Coding Update
6	Amniotic Membrane and Amniotic Fluid	7.01.149	Coding Update
7	Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer	2.04.36	Coding Update
8	Auditory Brainstem Implant	7.01.83	Coding Update
9	Autologous Platelet-Derived Growth Factors for Wound Healing and Other Non-Orthopedic Conditions	2.01.16	Minor Update
10	Bioengineered Skin and Soft Tissue Substitutes	7.01.113	Minor Update
11	Bioimpedance Devices for Detection and Management of Lymphedema	2.01.82	Minor Update
12	Bone Turnover Markers for the Diagnosis and Management of Osteoporosis and Diseases Associated with High Bone Turnover	2.04.15	Minor Update
13	Circulating Tumor DNA for Management of Non-Small-Cell Lung Cancer (Liquid Biopsy)	2.04.143	Minor Update
14	Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome	2.01.18	Coding Update
15	Electrostimulation and Electromagnetic Therapy for Treating Wounds	2.01.57	Minor Update
16	General Approach to Evaluating the Utility of Genetic Panels	2.04.92	Coding Update
17	Genetic Testing for Alzheimer Disease	2.04.13	Coding Update
18	Genetic Testing for Cardiac Ion Channelopathies	2.04.43	Minor Update
19	Genetic Testing for Developmental Delay/Intellectual Disability, Autism Spectrum Disorder, and Congenital Anomalies	2.04.59	Coding Update
20	Genetic Testing for Diagnosis and Management of Mental Health Conditions	2.04.110	Coding Update
21	Genetic Testing for FLT3, NPM1, and CEBPA Variants in Cytogenetically Normal Acute Myeloid Leukemia	2.04.124	Minor Update
22	Hyperbaric Oxygen Therapy	2.01.04	Minor Update
23	Immune Cell Function Assay	2.04.56	Coding Update
24	Ingestible pH and Pressure Capsule	BSC2.17	Minor Update
25	Lysis of Epidural Adhesions	BSC8.05	Minor Update
26	Molecular Analysis for Targeted Therapy or Immunotherapy of Non- Small-Cell Lung Cancer	2.04.45	Minor Update

New and updated policies effective February 1, 2022

	Policy Title – February 1, 2022	Policy#	Status
1	Carrier Screening for Genetic Diseases	2.04.107	Major Update
2	Continuous Glucose Monitoring	1.01.20	Major Update
3	Gene Expression Profiling and Protein Biomarkers for Prostate Cancer Management	2.04.111	Major Update
4	Wireless Capsule Endoscopy for Gastrointestinal (GI) Disorders	6.01.33	Major Update
5	Laser Interstitial Thermal Therapy for Neurological Conditions	7.01.170	New
6	Light Therapy for Psoriasis	2.01.47	Archived
7	Aqueous Shunts and Stents for Glaucoma	9.03.21	Coding Update
8	Bariatric Surgery	7.01.47	Coding Update
9	Bone Mineral Density Studies	6.01.01	Coding Update
10	Cardiovascular Risk Panels	2.04.100	Minor Update
11	Catheter Ablation as Treatment for Atrial Fibrillation	2.02.19	Coding Update
12	Catheter Ablation for Cardiac Arrhythmias	BSC2.12	Coding Update
13	Cleft Palate - Dental Related Services	BSC2.01	Coding Update
14	Comprehensive Genomic Profiling for Selecting Targeted Cancer Therapies	2.04.115	Coding Update
15	Computed Tomography to Detect Coronary Artery Calcification	6.01.03	Coding Update
16	Contrast-Enhanced Computed Tomographic Angiography for Coronary Artery Evaluation	6.01.43	Coding Update
17	Dermatologic Applications of Photodynamic Therapy	2.01.44	Minor Update
18	Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions	2.01.40	Coding Update
19	Fecal Analysis in the Diagnosis of Intestinal Dysbiosis	2.04.26	Minor Update
20	General Approach to Genetic Testing	2.04.91	Coding Update
21	Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer	2.04.33	Minor Update
22	Identification of Microorganisms Using Nucleic Acid Probes	2.04.10	Coding Update
23	Image-Guided Minimally Invasive Decompression for Spinal Stenosis	7.01.126	Coding Update
24	Immune Cell Function Assay	2.04.56	Minor Update
25	Implantable Bone-Conduction and Bone-Anchored Hearing Aids	7.01.03	Coding Update
26	Invasive Prenatal (Fetal) Diagnostic Testing	2.04.116	Coding Update
27	Lumbar Spine Surgery	BSC_NIA_CG_304	Coding Update
28	Measurement of Lipoprotein-Associated Phospholipase A2 in the Assessment of Cardiovascular Risk	2.04.32	Minor Update
29	Measurement of Serum Antibodies to Selected Biologic Agents	2.04.84	Minor Update
30	Monitored Anesthesia Care	7.02.01	Coding Update
31	Multimarker Serum Testing Related to Ovarian Cancer	2.04.62	Minor Update
32	Nonpharmacologic Treatment of Rosacea	2.01.71	Minor Update
33	Oncologic Applications of Positron Emission Tomography Scanning	6.01.26	Coding Update
34	Orthoptic Training for the Treatment of Vision or Learning Disabilities	9.03.03	Coding Update
35	Preimplantation Genetic Testing	4.02.05	Coding Update
36	Proteomic Testing for Targeted Therapy in Non-Small-Cell Lung Cancer	2.04.125	Minor Update
37	Serum Biomarker Human Epididymis Protein 4	2.04.66	Minor Update
38	Testing Serum Vitamin D Levels	2.04.135	Minor Update
39	Thoracic Spine Surgery	BSC_NIA_CG_308	Coding Update
40	Total Artificial Hearts and Implantable Ventricular Assist Devices	7.03.11	Coding Update
41	Transcatheter Aortic-Valve Implantation for Aortic Stenosis	7.01.132	Coding Update
42	Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease	2.01.38	Minor Update
43	Urinary Biomarkers for Cancer Screening, Diagnosis, and Surveillance	2.04.07	Minor Update

New and updated policies effective January 1, 2022

	Policy Title – January 1, 2022	Policy#	Status
1	Laboratory Tests Post Transplant and for Heart Failure	2.01.68	Major Update
2	Lumbar Spine Surgery	BSC_NIA_CG_304	Major Update
3	Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer	2.04.36	Minor Update
4	Cervical Spine Surgery	BSC_NIA_CG_307	Minor Update
5	Confocal Laser Endomicroscopy	2.01.87	Minor Update
6	Drug Testing in Pain Management and Substance Use Disorder Treatment	2.04.98	Minor Update
7	Endoscopic Radiofrequency Ablation or Cryoablation for Barrett Esophagus	2.01.80	Minor Update
8	Epidural Spine Injections	BSC_NIA_CG_300	Minor Update
9	Esophageal pH Monitoring	2.01.20	Minor Update
10	Germline Genetic Testing for BRCA1 or BRCA2 for Hereditary Breast/Ovarian Cancer Syndrome and Other High-Risk Cancers	2.04.02	Minor Update
11	Magnetic Esophageal Sphincter Augmentation to Treat Gastroesophageal Reflux Disease	7.01.137	Minor Update
12	Monitored Anesthesia Care	7.02.01	Minor Update
13	Noninvasive Techniques for the Evaluation and Monitoring of Patients With Chronic Liver Disease	2.04.41	Minor Update
14	Paravertebral Facet Joint Injections or Blocks (no U/S)	BSC_NIA_CG_301	Minor Update
15	Pharmacogenetic Testing for Pain Management	2.04.131	Minor Update
16	Pharmacogenomic and Metabolite Markers for Patients Treated With Thiopurines	2.04.19	Minor Update
17	Plugs for Anal Fistula Repair	7.01.123	Minor Update
18	Prolotherapy	2.01.26	Minor Update
19	Sacroiliac Joint Injections (with image guidance [fluoroscopy or CT])	BSC_NIA_CG_305	Minor Update
20	Thoracic Spine Surgery	BSC_NIA_CG_308	Minor Update

New and updated policies effective December 1, 2021

	Policy Title – December 1, 2021	Policy#	Status
1	Evaluation of Biomarkers for Alzheimer Disease	2.04.14	Major Update
2	Genetic Testing for Alzheimer Disease	2.04.13	Major Update
3	Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes	2.04.08	Major Update
4	Selected Positron Emission Tomography Technologies for Evaluation of Alzheimer Disease	6.01.55	Major Update
5	Absorbable Nasal Implant for Treatment of Nasal Valve Collapse	7.01.163	Minor Update
6	Automated Point-of-Care Nerve Conduction Tests	2.01.77	Minor Update
7	Brachytherapy for Clinically Localized Prostate Cancer Using Permanently Implanted Seeds	8.01.14	Admin Update
8	Charged-Particle (Proton or Helium Ion) Radiotherapy for Neoplastic Conditions	BSC8.04	Admin Update
9	Comprehensive Genomic Profiling for Selecting Targeted Cancer Therapies	2.04.115	Minor Update
10	Dynamic Spinal Visualization and Vertebral Motion Analysis	6.01.46	Minor Update
11	Electronic Brachytherapy for Nonmelanoma Skin Cancer	8.01.62	Admin Update
12	Endobronchial Brachytherapy	8.03.11	Admin Update
13	Gene Expression Profiling and Protein Biomarkers for Prostate Cancer Management	2.04.111	Admin Update
14	Genetic Cancer Susceptibility Panels Using Next-Generation Sequencing	2.04.93	Minor Update
15	Genetic Testing for Developmental Delay/Intellectual Disability, Autism Spectrum Disorder, and Congenital Anomalies	2.04.59	Minor Update
16	In Vitro Chemoresistance and Chemosensitivity Assays	2.03.01	Archived
17	Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence	7.01.19	Minor Update
18	Intensity-Modulated Radiotherapy of the Breast and Lung	8.01.46	Admin Update
19	Intensity-Modulated Radiotherapy of the Prostate	8.01.47	Admin Update
20	Intensity-Modulated Radiotherapy: Abdomen and Pelvis	8.01.49	Admin Update
21	Intensity-Modulated Radiotherapy: Cancer of the Head and Neck or Thyroid	8.01.48	Admin Update
22	Intensity-Modulated Radiotherapy: Central Nervous System Tumors	8.01.59	Admin Update
23	Intracavitary Balloon Catheter Brain Brachytherapy for Malignant Gliomas or Metastasis to the Brain	8.01.45	Admin Update
24	Laboratory Tests Post Transplant and for Heart Failure	2.01.68	Coding Update
25	Magnetic Resonance Spectroscopy	6.01.24	Minor Update
26	Microwave and Locoregional Laser Tumor Ablation	7.01.133	Minor Update
27	Miscellaneous (Noncardiac, Nononcologic) Applications of Fluorine 18 Fluorodeoxyglucose Positron Emission Tomography	6.01.06	Minor Update
28	Quantitative Electroencephalography as a Diagnostic Aid for Attention-Deficit/Hyperactivity Disorder	3.01.03	Minor Update
29	Radiation Oncology	BSC8.06	Admin Update
30	Radioembolization for Primary and Metastatic Tumors of the Liver	8.01.43	Admin Update
31	Stereotactic Radiosurgery and Stereotactic Body Radiotherapy	6.01.10	Admin Update
32	Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders	2.01.50	Minor Update

New and updated policies effective Nov 1, 2021

	Policy Title – November 1, 2021	Policy#	Status
1	Oncologic Applications of Positron Emission Tomography Scanning	6.01.26	Major Update
2	Cryoablation for Chronic Rhinitis	7.01.168	New
3	Ablation of Peripheral Nerves to Treat Pain	7.01.154	Minor Update
4	Amniotic Membrane and Amniotic Fluid	7.01.149	Coding Update
5	Aqueous Shunts and Stents for Glaucoma	9.03.21	Minor Update
6	Balloon Dilation of the Eustachian Tube	7.01.15	Minor Update
7	Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment and Immunotherapy in Breast Cancer	2.04.151	Coding Update
8	Bone Mineral Density Studies	6.01.01	Minor Update
9	Cardiac Applications of Positron Emission Tomography Scanning	6.01.20	Minor Update
10	Carrier Screening for Genetic Diseases	2.04.107	Minor Update
11	Computed Tomography Perfusion Imaging of the Brain	6.01.49	Minor Update
12	Computed Tomography to Detect Coronary Artery Calcification	6.01.03	Minor Update