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 MB)

 Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer (PDF, 897 KB)

 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)

 Circulating Tumor DNA and Circulating Tumor Cells for Cancer Management (Liquid Biopsy) (PDF, 449 KB)

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

 Comprehensive Genomic Profiling for Selecting Targeted Cancer Therapies (PDF, 685 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)

 Gene Expression Profiling for Cutaneous Melanoma (PDF, 584 KB)

 Gene Expression Profiling, Protein Biomarkers, and Multimodal Artificial Intelligence for Prostate Cancer Management (PDF, 935 KB)

 General Approach to Evaluating the Utility of Genetic Panels (PDF, 422 KB)

 General Approach to Genetic Testing (PDF, 693 KB)

 Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer (PDF, 663 KB)

 Genetic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment in Advanced Cancer (PDF, 813 KB)

 Genetic Testing for Alzheimer Disease (PDF, 423 KB)

 Genetic Testing for Cardiac Ion Channelopathies (PDF, 527 KB)

 Genetic Testing for Developmental Delay/Intellectual Disability, Autism Spectrum Disorder, and Congenital Anomalies (PDF, 450 KB)

 Genetic Testing for Diagnosis and Management of Mental Health Conditions (PDF, 580 KB)

 Genetic Testing for Epilepsy (PDF, 550 KB)

 Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes (PDF, 444 KB)

 Genetic Testing for Mitochondrial Disorders (PDF, 293 KB)

 Germline Genetic Testing for Hereditary Breast/Ovarian Cancer Syndrome and Other High-Risk Cancers (BRCA1, BRCA2, PALB2) (PDF, 526 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)

 Identification of Microorganisms Using Nucleic Acid Probes (PDF, 675 MB)

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

 Low-Level Laser Therapy (PDF, 739 KB)

 Molecular Genomic Profiling for Cancers of Unknown Primary (PDF, 289 KB)

 Multimarker Serum Testing Related to Ovarian Cancer (PDF, 339 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)

 Tumor Treating Fields Therapy (PDF, 393 KB)

 Tumor-Informed Circulating Tumor DNA Testing for Cancer Management (PDF, 605 KB)

 Use of Common Genetic Variants (Single Nucleotide Variants) to Predict Risk of Nonfamilial Breast Cancer (PDF, 389 KB)

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

 Vertical Expandable Prosthetic Titanium Rib (PDF, 196 KB)

 Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders (PDF, 679 KB)