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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
2
Automated Ambulatory Blood Pressure Monitoring for Diagnosis of Hypertension in Patients with Elevated Office Blood Pressure
1.01.02
3
Electromagnetic Navigational Bronchoscopy
7.01.122
4
Hyperthermic Intraperitoneal Chemotherapy for Select Intra-Abdominal and Pelvic Malignancies
2.03.07
5
Multicancer Early Detection Testing
2.04.158
6
Neurofeedback
2.01.28
7
Percutaneous Electrical Nerve Stimulation, Percutaneous Neuromodulation Therapy, and Restorative Neurostimulation Therapy
7.01.29
8
Proteogenomic Testing for Patients With Cancer
2.04.140
9
Risk-Reducing Mastectomy
7.01.09
10
Tumor Treating Fields Therapy
1.01.29
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.
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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
2
Autonomic Nervous System Testing
2.01.96
3
Closure Devices for Patent Foramen Ovale and Atrial Septal Defects
2.02.09
4
Electromyography and Nerve Conduction Studies
2.01.95
5
Endovascular Stent Grafts for Abdominal Aortic Aneurysms
7.01.67
6
Gene Expression Profiling for Cutaneous Melanoma
2.04.146
7
Genetic Testing for Alpha Thalassemia
2.04.104
8
Genetic Testing for Rett Syndrome
2.04.81
9
Home Cardiorespiratory Monitoring
1.01.06
10
Low Level Laser Therapy
2.01.56
11
Oncology: Algorithmic (Genetic Expression) Testing
BSC_CON_2.05
12
Percutaneous Left Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation
2.02.26
13
Polysomnography for Non-Respiratory Sleep Disorders
2.01.99
14
Progenitor Cell Therapy for the Treatment of Damaged Myocardium Due to Ischemia
2.02.18
15
Serum Biomarker Panel Testing for Systemic Lupus Erythematosus and Other Connective Tissue Diseases
2.04.123
16
Transurethral Water Vapor Thermal Therapy and Transurethral Water Jet Ablation (Aquablation) for Benign Prostatic Hypertrophy
2.01.49
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.
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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
5
Dry Needling of Trigger Points for Myofascial Pain
2.01.100
6
Electrical Bone Growth Stimulation of the Appendicular Skeleton
7.01.07
7
Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures
7.01.85
8
Genetic Testing for Hereditary Hemochromatosis
2.04.80
9
Genetic Testing for Limb-Girdle Muscular Dystrophies
2.04.132
10
Immediate and Delayed Lymphatic Reconstruction Surgery
BSC7.18
11
Interventions for Progressive Scoliosis
2.01.83
12
Intradialytic Parenteral Nutrition
8.01.44
13
Leadless Cardiac Pacemakers
2.02.32
14
Meniscal Allografts and Other Meniscal Implants
7.01.15
15
Percutaneous Electrical Nerve Field Stimulation for Irritable Bowel Syndrome
2.01.106
16
Spinal Cord and Dorsal Root Ganglion Stimulation
7.01.25
17
Transcatheter Mitral Valve Repair
2.02.30
18
Allograft Injection for Degenerative Disc Disease
7.01.166
Minor Update
19
Ambulatory Event Monitors and Mobile Cardiac Outpatient Telemetry
2.02.08
Minor Update
20
Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions
7.01.78
Minor Update
21
Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions
7.01.48
Minor Update
22
Baroreflex Stimulation Devices
8.01.57
Minor Update
23
Cardiac Rehabilitation in the Outpatient Setting
8.03.08
Admin Update
24
Catheter Ablation as Treatment for Atrial Fibrillation
2.02.19
Minor Update
25
Endovascular Therapies for Extracranial Vertebral Artery Disease
7.01.148
Minor Update
26
Enhanced External Counterpulsation
2.02.06
Minor Update
27
Extracorporeal Membrane Oxygenation for Adult Conditions
8.01.60
Minor Update
28
Extracranial Carotid Artery Stenting
7.01.68
Minor Update
29
Genetic Testing for Inherited Thrombophilia
2.04.82
Minor Update
30
Genetic Testing for Lactase Insufficiency
2.04.94
Minor Update
31
Inhaled Nitric Oxide
8.01.37
Minor Update
32
Lower Limb Prostheses
BSC1.01
Minor Update
33
Myocardial Strain Imaging
2.02.31
Minor Update
34
Neuropsychological Testin+14:22g
BSC2.06
Minor Update
35
Oncology: Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy)
BSC_CON_2.10
Admin Update
36
Open and Thoracoscopic Approaches to Treat Atrial Fibrillation and Atrial Flutter (Maze and Related Procedures)
7.01.14
Minor Update
37
Phrenic Nerve Stimulation for Central Sleep Apnea
2.02.33
Minor Update
38
Power Wheelchairs and Power Operated Vehicles for Permanent Use
BSC1.02
Minor Update
39
Speech Therapy
BSC8.02
Minor Update
40
Surgical Treatments for Breast Cancer-Related Lymphedema
7.01.162
Archived
41
Treatment of Varicose Veins/Venous Insufficiency
7.01.124
Minor Update
42
Tumor-Informed Circulating Tumor DNA Testing for Cancer Management
BSC2.18
Archived
43
Ultrasonographic Measurement of Carotid Intimal-Medial Thickness as an Assessment of Subclinical Atherosclerosis
2.02.16
Minor Update
44
Wearable Cardioverter Defibrillators
2.02.15
Minor Update
Please Note:
California Senate Bill 535 (“SB 535”) mandates that health plans are not to require prior authorization for either of the following services:
- Biomarker testing for an enrollee or insured with advanced metastatic stage 3 or 4 cancer, or
- Biomarker testing for cancer progression or recurrence in the enrollee or insured with advanced or metastatic stage 3 or 4 cancer.
Blue Shield of California has removed prior authorization for Biomarker testing services. Compliance with SB 535 is required for Blue Shield’s delegated provider organizations, in cases where the organization is financially responsible for those services.
For more coverage information, we encourage you to review our applicable medical or medication policies and benefits online at blueshieldca.com/provider.
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New and updated policies effective June 1, 2023
Policy Title –June 1, 2023
Policy#
Status
1
Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes
2.04.08
2
Germline and Somatic Biomarker Testing for Targeted Treatment and Immunotherapy in Breast Cancer
2.04.151
3
Germline and Somatic Biomarker Testing for Targeted Treatment and Immunotherapy in Ovarian Cancer
(BRCA1, BRCA2, Homologous Recombination Deficiency, Tumor Mutational Burden, Microsatellite Instability/Mismatch Repair)2.04.156
4
Germline and Somatic Biomarker Testing for Targeted Treatment and Immunotherapy in Prostate Cancer
(BRCA1/2, Homologous Recombination Repair Gene Alterations, Microsatellite Instability/Mismatch Repair, Tumor Mutational Burden)2.04.155
5
Intensity-Modulated Radiotherapy of the Prostate
8.01.47
6
Adjustable Cranial Orthoses for Positional Plagiocephaly and Craniosynostoses
1.01.11
7
Bone Morphogenetic Protein
7.01.100
8
Cardiac Rehabilitation in the Outpatient Setting
8.03.08
9
Cognitive Rehabilitation
8.03.10
10
Cooling Devices Used in the Outpatient Setting
1.01.26
11
Corneal Topography/Computer-Assisted Corneal Topography/Photokeratoscopy
9.03.05
12
Deep Brain Stimulation
7.01.63
13
Digital Health Technologies: Therapeutic Applications
3.03.02
14
Genetic Testing for Duchenne and Becker Muscular Dystrophy
2.04.86
15
Genetic Testing for Hereditary Hearing Loss
2.04.87
16
Genetic Testing of CADASIL Syndrome
2.04.75
17
Keratoprosthesis
9.03.01
18
Intraocular Radiotherapy for Age-Related Macular Degeneration
9.03.20
19
Multitarget Polymerase Chain Reaction Testing for Diagnosis of Bacterial Vaginosis
2.04.127
20
Nerve Graft with Radical Prostatectomy
7.01.81
21
Occipital Nerve Stimulation
7.01.125
22
Oncology: Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy)
BSC_CON_2.10
23
Oncology: Molecular Analysis Of Solid Tumors And Hematologic Malignancies
BSC_CON_2.04
24
Outpatient Pulmonary Rehabilitation
8.03.05
25
Percutaneous Balloon Kyphoplasty, Radiofrequency Kyphoplasty, and Mechanical Vertebral Augmentation
6.01.38
26
Peripheral Subcutaneous Field Stimulation
7.01.139
27
Photodynamic Therapy for Choroidal Neovascularization
9.03.08
28
Responsive Neurostimulation for the Treatment of Refractory Focal Epilepsy
7.01.143
29
Retinal Telescreening for Diabetic Retinopathy
9.03.13
30
Sacral Nerve Neuromodulation/Stimulation
7.01.69
31
Vertical Expandable Prosthetic Titanium Rib
7.01.110
32
Viscocanalostomy and Canaloplasty
9.03.26
33
Behavioral Health Treatment for Autism Spectrum Disorders
BSC3.01
Minor Update
34
Bioengineered Skin and Soft Tissue Substitutes
7.01.113
Admin Coding
35
Cardiovascular Risk Panels
2.04.100
Admin Coding
36
Catheter Ablation for Cardiac Arrhythmias
BSC2.12
Minor Update
37
Circulating Tumor DNA and Circulating Tumor Cells for Cancer Management (Liquid Biopsy)
2.04.141
Archived
38
Comprehensive Genomic Profiling for Selecting Targeted Cancer Therapies
2.04.115
Archived
39
Cranial Electrotherapy Stimulation and Auricular Electrostimulation
8.01.58
Admin Coding
40
Diabetes Prevention Program
BSC2.11
Minor Update
41
Endovascular Procedures for Intracranial Arterial Disease (Atherosclerosis and Aneurysms)
2.01.54
Minor Update
42
Facet Arthroplasty
7.01.120
Minor Update
43
General Approach to Genetic Testing
2.04.91
Admin Coding
44
Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer
2.04.33
Admin Coding
45
Genetic Testing for FLT3, NPM1, and CEBPA Variants in Cytogenetically Normal Acute Myeloid Leukemia
2.04.124
Archived
46
Genetic Testing: Exome and Genome Sequencing For The Diagnosis Of Genetic Disorders
BSC_CON_2.02
Minor Update
47
Hip Femoroacetabular Impingement (FAI) Surgical Treatment
7.01.118
Minor Update
48
Hip Resurfacing
7.01.80
Minor Update
49
Identification of Microorganisms Using Nucleic Acid Probes
2.04.10
Admin Coding
50
Image-Guided Minimally Invasive Decompression for Spinal Stenosis
7.01.126
Minor Update
51
Intensity-Modulated Radiotherapy of the Breast and Lung
8.01.46
Admin Coding
52
Intensity-Modulated Radiotherapy: Abdomen, Pelvis and Chest
8.01.49
Admin Coding
53
Intensity-Modulated Radiotherapy: Cancer of the Head and Neck or Thyroid
8.01.48
Admin Coding
54
Intensity-Modulated Radiotherapy: Central Nervous System Tumors
8.01.59
Admin Coding
55
Intraoperative Neurophysiologic Monitoring
7.01.58
Minor Update
56
JAK2, MPL, and CALR Testing for Myeloproliferative Neoplasms
2.04.60
Archived
57
Lipid Apheresis
BSC8.07
Minor Update
58
Manipulation Under Anesthesia
8.01.40
Minor Update
59
Measurement of Lipoprotein-Associated Phospholipase A2 in the Assessment of Cardiovascular Risk
2.04.32
Admin Coding
60
Medical Management of Obstructive Sleep Apnea Syndrome
8.01.67
Admin Coding
61
Multimarker Serum Testing Related to Ovarian Cancer
2.04.62
Admin Coding
62
Orthopedic Applications of Platelet-Rich Plasma
2.01.98
Minor Update
63
Percutaneous Vertebroplasty and Sacroplasty
6.01.25
Minor Update
64
Physical Therapy
BSC8.03
Minor Update
65
Power Morcellation for the Treatment of Uterine Fibroids
BSC7.06
Minor Update
66
Reconstructive Services
BSC7.08
Minor Update
67
Somatic (Tumor) Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment and Immunotherapy in Non-Small-Cell Lung Cancer (EGFR, ALK, BRAF, ROS1, RET, MET, KRAS, HER2, PD-L1, TMB)
2.04.45
Archived
68
Subtalar Arthroereisis
7.01.104
Minor Update
69
Trigger Point and Tender Point Injections
2.01.103
Minor Update
70
Uterus Transplantation for Absolute Uterine Factor Infertility
4.02.06
Minor Update
71
Vertebral Axial Decompression
8.03.09
Minor Update
Please Note:
California Senate Bill 535 (“SB 535”) mandates that health plans are not to require prior authorization for either of the following services:
- Biomarker testing for an enrollee or insured with advanced metastatic stage 3 or 4 cancer, or
- Biomarker testing for cancer progression or recurrence in the enrollee or insured with advanced or metastatic stage 3 or 4 cancer.
Blue Shield of California has removed prior authorization for Biomarker testing services. Compliance with SB 535 is required for Blue Shield’s delegated provider organizations, in cases where the organization is financially responsible for those services.
For more coverage information, we encourage you to review our applicable medical or medication policies and benefits online at blueshieldca.com/provider.
-
New and updated policies effective May 1, 2023
