Blue Shield Promise medical policies

The application of each Blue Shield of California Promise Health Plan (Blue Shield Promise) medical policy is subject to state guidelines, regulatory requirements, and/or specific benefits and limitations stated in the plan Evidence of Coverage (EOC).

The goals of each medical policy include:

• Ensuring safe and effective technologies
• Supporting an evidence-based approach to technology
• Providing current and pertinent information regarding technologies (devices and procedures for medical and behavioral health)
• Improving the quality of care and services provided through Blue Shield Promise

Use medical policy information to provide Blue Shield Promise plan members with the highest standard of evidence-based medical care that is safe and effective.

Pharmacy services and drug formularies

Medi-Cal pharmacy benefits are managed by Medi-Cal Rx, which is administered by the Department of Health Care Services (DHCS). Find more information under the Pharmacy services and drug formularies section

Medical policy index

Use this alphabetical index to find Blue Shield Promise medical policies and to review requirements and criteria for new technologies, devices and procedures. 

 Actigraphy (PDF, 258 KB)

 Amniotic Membrane and Amniotic Fluid (PDF, 1.2 MB)

 Amniotic Membrane and Amniotic Fluid (PDF, 1 MB)

 Balloon Dilation of the Eustachian Tube (PDF, 633 KB)

 Balloon Ostial Dilation for Treatment of Chronic and Recurrent Acute Rhinosinusitis (PDF, 369 KB)

 Behavioral Health Treatment (PDF, 321 KB)

 Bioengineered Skin and Soft Tissue Substitutes (PDF, 710 KB)

 Bone Morphogenetic Protein (PDF, 401 KB)

 Bronchial Thermoplasty (PDF, 339 KB)

 Bronchial Valves (PDF, 539 KB)

 Closure Devices for Patent Foramen Ovale and Atrial Septal Defects (PDF, 509 KB)

 Cooling Devices Used in the Outpatient Setting (PDF, 415 KB)

 Cryoablation of Tumors Located in the Kidney, Lung, Breast, Pancreas, or Bone (PDF, 766 KB)

 Electromagnetic Navigational Bronchoscopy (PDF, 344 KB)

 Extracorporeal Shock Wave Treatment for Plantar Fasciitis (PDF, 813 KB)

 Gender Affirmation Surgery (PDF, 248 KB)

 High Intensity Laser Therapy for Chronic Musculoskeletal Pain Conditions and Bell's Palsy (PDF, 388 KB)

 Hip Resurfacing (PDF, 274 KB)

 Home Cardiorespiratory Monitoring (PDF, 202 KB)

 Hyperbaric Oxygen Therapy (PDF, 1 MB)

 Implantable Peripheral Nerve Stimulation for Chronic Pain Conditions (PDF, 290 KB)

 Low-Level Laser Therapy (PDF, 739 KB)

 Myocardial Strain Imaging (PDF, 218 KB)

 Orthopedic Applications of Platelet-Rich Plasma (PDF, 675 KB)

 Ovarian and Internal Iliac Vein Endovascular Occlusion as a Treatment of Pelvic Congestion Syndrome (PDF, 234 KB)

 Panniculectomy, Abdominoplasty, and Surgical Management of Diastasis Recti (PDF, 205 KB)

 Paraspinal Surface Electromyography to Evaluate and Monitor Back Pain (PDF, 173 KB)

 Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence (PDF, 267 KB)

 Percutaneous Electrical Nerve Field Stimulation for Irritable Bowel Syndrome (PDF, 191 KB)

 Photodynamic Therapy for Choroidal Neovascularization (PDF, 468 KB)

 Reconstructive Services (PDF, 173 KB)

 Saturation Biopsy for Diagnosis, Staging, and Management of Prostate Cancer (PDF, 198 KB)

 Subtalar Arthroereisis (PDF, 223 KB)

 Surgical Deactivation of Headache Trigger Sites (PDF, 207 KB)

 Surgical Treatment of Femoroacetabular Impingement (PDF, 312 KB)

 Synthetic Cartilage Implants for Joint Pain (PDF, 251 KB)

 Treatment of Varicose Veins/Venous Insufficiency (PDF, 608 KB)

 Vertical Expandable Prosthetic Titanium Rib (PDF, 196 KB)