Medical policy updates

	Policy Title	Policy#	Status
1	Baroreflex Stimulation Devices	8.01.57	Major Update
2	Liposuction for Lipedema and Lymphedema	7.01.169	Major Update
3	Carrier Screening for Genetic Diseases	2.04.107	New
4	Chromosomal Microarray Testing for the Evaluation of Pregnancy Loss	2.04.122	New
5	Gene Expression Profile Testing and Circulating Tumor DNA Testing for Predicting Recurrence in Colon Cancer	2.04.61	New
6	Gene Expression Profiling for Cutaneous Melanoma	2.04.146	New
7	Genetic Testing for Duchenne and Becker Muscular Dystrophy	2.04.86	New
8	Genetic Testing for FMR1 Variants (Including Fragile X Syndrome)	2.04.83	New
9	Genetic Testing for Hereditary Hearing Loss	2.04.87	New
10	Genetic Testing for Heterozygous Familial Hypercholesterolemia	2.04.139	New
11	Genetic Testing for Marfan Syndrome, Thoracic Aortic Aneurysms and Dissections, and Related Disorders	2.04.129	New
12	Genetic Testing for Statin-Induced Myopathy	2.04.96	New
13	Germline Genetic Testing for Hereditary Breast/Ovarian Cancer Syndrome and Other High-Risk Cancers (BRCA1, BRCA2, PALB2)	2.04.02	New
14	Molecular Testing in the Management of Pulmonary Nodules	2.04.142	New
15	Multibiomarker Disease Activity Blood Test for Rheumatoid Arthritis	2.04.119	New
16	Noninvasive Techniques for the Evaluation and Monitoring of Patients With Chronic Liver Disease	2.04.41	New
17	Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment in Non-Small-Cell Lung Cancer (EGFR, ALK, BRAF, ROS1, RET, MET, KRAS, NTRK)	2.04.45	New
18	Use of Common Genetic Variants (Single Nucleotide Variants) to Predict Risk of Nonfamilial Breast Cancer	2.04.63	New
19	Ablation of Peripheral Nerves to Treat Pain	7.01.154	Minor Update
20	Allogeneic Pancreas Transplant	7.03.02	Minor Update
21	Balloon Dilation of the Eustachian Tube	7.01.158	Minor Update
22	Bone Mineral Density Studies	6.01.01	Minor Update
23	Cardiac Applications of Positron Emission Tomography Scanning	6.01.20	Minor Update
24	Composite Tissue Allotransplantation of the Hand and Face	7.03.13	Minor Update
25	Cryoablation of Tumors Located in the Kidney, Lung, Breast, Pancreas, or Bone	7.01.92	Admin Update
26	Cryosurgical Ablation of Primary or Metastatic Liver Tumors	7.01.75	Minor Update
27	Dynamic Spinal Visualization and Vertebral Motion Analysis	6.01.46	Minor Update
28	Elective Invasive Coronary Angiography (ICA)	BSC2.13	Minor Update
29	Elective Percutaneous Coronary Intervention (PCI)	BSC6.02	Minor Update
30	Endobronchial Ultrasound for Diagnosis and Staging of Lung Cancer	6.01.58	Minor Update
31	Endovascular Stent Grafts for Disorders of the Thoracic Aorta	7.01.86	Minor Update
32	Focal Treatments for Prostate Cancer	8.01.61	Minor Update
33	Heart Transplant	7.03.09	Minor Update
34	Heart/Lung Transplant	7.03.08	Minor Update
35	Hip Arthroplasty for Adults	BSC7.11	Minor Update
36	Hyperbaric Oxygen Therapy	2.01.04	Minor Update
37	Intensity-Modulated Radiotherapy of the Breast and Lung	8.01.46	Minor Update
38	Islet Transplantation for Chronic Pancreatitis and Donislecel-jujn for Type 1 Diabetes	7.03.12	Minor Update
39	Isolated Small Bowel Transplant	7.03.04	Minor Update
40	Kidney Transplant	7.03.01	Minor Update
41	Liver Transplant and Combined Liver-Kidney Transplant	7.03.06	Minor Update
42	Low-Level Laser Therapy	2.01.56	Admin Update
43	Lung and Lobar Lung Transplant	7.03.07	Minor Update
44	Magnetoencephalography/Magnetic Source Imaging	BSC6.05	Minor Update
45	Myocardial Sympathetic Innervation Imaging in Individuals With Heart Failure	6.01.56	Minor Update
46	Non-emergency Ground Ambulance	BSC10.02	Minor Update
47	Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Conditions	1.01.15	Minor Update
48	Ovarian and Internal Iliac Vein Endovascular Occlusion as a Treatment of Pelvic Congestion Syndrome	4.01.18	Minor Update
49	Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence	1.01.17	Minor Update
50	Percutaneous Electrical Nerve Field Stimulation for Irritable Bowel Syndrome	2.01.106	Minor Update
51	Periureteral Bulking Agents as a Treatment of Vesicoureteral Reflux	7.01.102	Minor Update
52	Photodynamic Therapy for Choroidal Neovascularization	9.03.08	Admin Update
53	Prostatic Urethral Lift	7.01.151	Minor Update
54	Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors	7.01.95	Minor Update
55	Reproductive Techniques	4.02.04	Minor Update
56	Risk-Reducing Mastectomy	7.01.09	Minor Update
57	Scintimammography and Gamma Imaging of the Breast and Axilla	6.01.18	Minor Update
58	Small Bowel/Liver and Multivisceral Transplant	7.03.05	Minor Update
59	Surgical Left Atrial Appendage Occlusion Devices for Stroke Prevention in Atrial Fibrillation	7.01.172	Minor Update
60	Uterus Transplantation for Absolute Uterine Factor Infertility	4.02.06	Minor Update
61	Virtual Colonoscopy/Computed Tomography Colonography	6.01.32	Minor Update
62	Whole Body Dual X-Ray Absorptiometry to Determine Body Composition	6.01.40	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.

	Policy Title	Policy#	Status
1	Behavioral Health Treatment for Autism Spectrum Disorder or Pervasive Developmental Disorder	BSC3.01	Major Update
2	Corneal Collagen Cross-Linking	9.03.28	Admin Update
3	Diagnosis of Obstructive Sleep Apnea Syndrome	2.01.18	Minor Update
4	Repetitive Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders	BSC2.19	Minor Update
5	Total Artificial Hearts and Implantable Ventricular Assist Devices	7.03.11	Minor Update
6	Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer	2.04.36	New
7	Circulating Tumor DNA and Circulating Tumor Cells for Cancer Management (Liquid Biopsy)	2.04.141	New
8	Comprehensive Genomic Profiling for Selecting Targeted Cancer Therapies	2.04.115	New
9	Gene Expression Profiling, Protein Biomarkers, and Multimodal Artificial Intelligence for Prostate Cancer Management	2.04.111	New
10	General Approach to Evaluating the Utility of Genetic Panels	2.04.92	New
11	General Approach to Genetic Testing	2.04.91	New
12	Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer	2.04.33	New
13	Genetic Cancer Susceptibility Panels Using Next-Generation Sequencing	2.04.93	New
14	Genetic Testing for Alzheimer Disease	2.04.13	New
15	Genetic Testing for Cardiac Ion Channelopathies	2.04.43	New
16	Genetic Testing for Developmental Delay/Intellectual Disability, Autism Spectrum Disorder, and Congenital Anomalies	2.04.59	New
17	Genetic Testing for Diagnosis and Management of Mental Health Conditions	2.04.110	New
18	Genetic Testing for Epilepsy	2.04.109	New
19	Genetic Testing for Idiopathic Dilated Cardiomyopathy	2.04.114	New
20	Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes	2.04.08	New
21	Genetic Testing for Macular Degeneration	2.04.103	New
22	Genetic Testing for Mitochondrial Disorders	2.04.117	New
23	Genetic Testing for Predisposition to Inherited Hypertrophic Cardiomyopathy	2.02.28	New
24	Genetic Testing for the Diagnosis of Inherited Peripheral Neuropathies	2.04.89	New
25	Germline and Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment in Breast Cancer (BRCA1, BRCA2, PIK3CA, Ki-67, RET, BRAF, ESR1, NTRK)	2.04.151	New
26	Germline and Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment in Ovarian Cancer (BRCA1, BRCA2, Homologous Recombination Deficiency, NTRK)	2.04.156	New
27	Germline and Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment in Prostate Cancer (BRCA1/2, Homologous Recombination Repair Gene Alterations, NTRK Gene Fusion)	2.04.155	New
28	Invasive Prenatal (Fetal) Diagnostic Testing	2.04.116	New
29	Laboratory Testing Investigational Services	2.04.159	New
30	Laboratory Tests Post Transplant and for Heart Failure	2.01.68	New
31	Molecular Genomic Profiling for Cancers of Unknown Primary	2.04.54	New
32	Molecular Markers in Fine Needle Aspiration of the Thyroid	2.04.78	New
33	Multimarker Serum Testing Related to Ovarian Cancer	2.04.62	New
34	Noninvasive Prenatal Screening for Fetal Aneuploidies, Microdeletions, Single-Gene Disorders, and Twin Zygosity Using Cell-Free Fetal DNA	4.01.21	New
35	Pharmacogenetic Testing for Pain Management	2.04.131	New
36	Preimplantation Genetic Testing	4.02.05	New
37	Serologic Genetic and Molecular Screening for Colorectal Cancer	2.04.150	New
38	Tumor-Informed Circulating Tumor DNA Testing for Cancer Management	2.04.153	New
39	Urinary Biomarkers for Cancer Screening, Diagnosis, and Surveillance	2.04.07	New
40	Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders	2.04.102	New
41	Genetic Testing: Aortopathies and Connective Tissue Disorders	BSC_CON_2.19	Archived
42	Genetic Testing: Cardiac Disorders	BSC_CON_2.18	Archived
43	Genetic Testing: Dermatologic Conditions	BSC_CON_2.25	Archived
44	Genetic Testing: Epilepsy, Neurodegenerative, and Neuromuscular Disorders	BSC_CON_2.14	Archived
45	Genetic Testing: Exome and Genome Sequencing for the Diagnosis of Genetic Disorders	BSC_CON_2.02	Archived
46	Genetic Testing: Eye Disorders	BSC_CON_2.20	Archived
47	Genetic Testing: Gastroenterologic Disorders (Non-Cancerous)	BSC_CON_2.17	Archived
48	Genetic Testing: General Approach to Genetic and Molecular Testing	BSC_CON_2.27	Archived
49	Genetic Testing: Hearing Loss	BSC_CON_2.16	Archived
50	Genetic Testing: Hematologic Conditions (Non-Cancerous)	BSC_CON_2.15	Archived
51	Genetic Testing: Hereditary Cancer Susceptibility	BSC_CON_2.01	Archived
52	Genetic Testing: Immune, Autoimmune, and Rheumatoid Disorders	BSC_CON_2.21	Archived
53	Genetic Testing: Kidney Disorders	BSC_CON_2.22	Archived
54	Genetic Testing: Lung Disorders	BSC_CON_2.23	Archived
55	Genetic Testing: Metabolic, Endocrine, And Mitochondrial Disorders	BSC_CON_2.24	Archived
56	Genetic Testing: Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay	BSC_CON_2.13	Archived
57	Genetic Testing: Pharmacogenetics	BSC_CON_2.12	Archived
58	Genetic Testing: Preimplantation Genetic Testing	BSC_CON_2.03	Archived
59	Genetic Testing: Prenatal and Preconception Carrier Screening	BSC_CON_2.07	Archived
60	Genetic Testing: Prenatal Cell-Free DNA Testing	BSC_CON_2.08	Archived
61	Genetic Testing: Prenatal Diagnosis (via Amniocentesis, CVS, or PUBS) and Pregnancy Loss	BSC_CON_2.06	Archived
62	Genetic Testing: Skeletal Dysplasia and Rare Bone Disorders	BSC_CON_2.26	Archived
63	Oncology: Algorithmic Testing	BSC_CON_2.05	Archived
64	Oncology: Cancer Screening	BSC_CON_2.09	Archived
65	Oncology: Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy)	BSC_CON_2.10	Archived
66	Oncology: Cytogenetic Testing	BSC_CON_2.11	Archived
67	Oncology: Molecular Analysis of Solid Tumors and Hematologic Malignancies	BSC_CON_2.04	Archived

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.

	Policy Title	Policy#	Status
1	Compression Pumps for Treatment of Lymphedema and Venous Ulcers	1.01.18	Major Update
2	Power Wheelchairs and Power Operated Vehicles for Permanent Use	BSC1.02	Major Update
3	Amniotic Membrane and Amniotic Fluid	7.01.149	Minor Update
4	Automated Ambulatory Blood Pressure Monitoring for Diagnosis of Hypertension in Patients with Elevated Office Blood Pressure	1.01.02	Minor Update
5	Bioengineered Skin and Soft Tissue Substitutes	7.01.113	Minor Update
6	Brachytherapy for Clinically Localized Prostate Cancer Using Permanently Implanted Seeds	8.01.14	Minor Update
7	Cellular Immunotherapy for Prostate Cancer	8.01.53	Minor Update
8	Cryoablation of Tumors Located in the Kidney, Lung, Breast, Pancreas, or Bone	7.01.92	Minor Update
9	Digital Health Technologies for Attention Deficit/Hyperactivity Disorder	3.03.03	Minor Update
10	Digital Health Technologies: Diagnostic Applications	3.03.01	Minor Update
11	Digital Health Technologies: Therapeutic Applications	3.03.02	Minor Update
12	Electromagnetic Navigational Bronchoscopy	7.01.122	Minor Update
13	Electronic Brachytherapy for Nonmelanoma Skin Cancer	8.01.62	Minor Update
14	Endobronchial Brachytherapy	8.03.11	Archived
15	External Insulin Infusion Pump	BSC1.03	Minor Update
16	High Intensity Laser Therapy for Chronic Musculoskeletal Pain Conditions and Bell's Palsy	2.01.108	Minor Update
17	Hyperthermic Intraperitoneal Chemotherapy for Select Intra-Abdominal and Pelvic Malignancies	2.03.07	Minor Update
18	Immediate and Delayed Lymphatic Reconstruction Surgery	BSC7.18	Minor Update
19	Implantable Peripheral Nerve Stimulation for Chronic Pain Conditions	1.01.31	Minor Update
20	Intensity-Modulated Radiotherapy: Abdomen, Pelvis and Chest	8.01.49	Minor Update
21	Intensity-Modulated Radiotherapy: Cancer of the Head and Neck or Thyroid	8.01.48	Minor Update
22	Intracavitary Balloon Catheter Brain Brachytherapy for Malignant Gliomas or Metastasis to the Brain	8.01.45	Minor Update
23	Intraoperative Radiotherapy	8.01.08	Minor Update
24	Lower Limb Prostheses	BSC1.01	Minor Update
25	Magnetic Resonance-Guided Focused Ultrasound	7.01.109	Minor Update
26	Oncologic Applications of Photodynamic Therapy, Including Barrett Esophagus	8.01.06	Minor Update
27	Radioembolization for Primary and Metastatic Tumors of the Liver	8.01.43	Minor Update
28	Radiofrequency Ablation of Primary or Metastatic Liver Tumors	7.01.91	Minor Update
29	Reconstructive Breast Surgery/Management of Breast Implants	7.01.22	Minor Update
30	Saturation Biopsy for Diagnosis, Staging, and Management of Prostate Cancer	7.01.121	Minor Update
31	Speech Therapy	BSC8.02	Minor Update
32	Synthetic Cartilage Implants for Joint Pain	7.01.160	Minor Update
33	Transcatheter Arterial Chemoembolization to Treat Primary or Metastatic Liver Malignancies	8.01.11	Minor Update
34	Transurethral Water Vapor Thermal Therapy and Transurethral Water Jet Ablation (Aquablation) for Benign Prostatic Hypertrophy	2.01.49	Minor Update
35	Treatment of Hyperhidrosis	8.01.19	Minor Update
36	Tumor Treating Fields Therapy	1.01.29	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.

	Policy Title	Policy#	Status
1	Electroconvulsive Therapy	BSC8.09	Major Update
2	Leadless Cardiac Pacemakers	2.02.32	Major Update
3	Repetitive Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders	BSC2.19	Major Update
4	Actigraphy	2.01.73	Minor Update
5	Amniotic Membrane and Amniotic Fluid	7.01.149	Admin Update
6	Autonomic Nervous System Testing	2.01.96	Minor Update
7	Bronchial Thermoplasty	7.01.127	Minor Update
8	Bronchial Valves	7.01.128	Minor Update
9	Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting	2.02.24	Minor Update
10	Diagnosis of Obstructive Sleep Apnea Syndrome	2.01.18	Minor Update
11	Electromagnetic Navigational Bronchoscopy	7.01.122	Minor Update
12	Electromyography and Nerve Conduction Studies	2.01.95	Minor Update
13	Endothelial Keratoplasty	9.03.22	Archived
14	Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions	2.01.40	Minor Update
15	Gender Affirmation Surgery	BSC7.02	Minor Update
16	Home Cardiorespiratory Monitoring	1.01.06	Minor Update
17	Identification of Microorganisms Using Nucleic Acid Probes	2.04.10	Minor Update
18	Implantable Cardioverter Defibrillators	7.01.44	Admin Update
19	Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence	7.01.19	Admin Update
20	Interferential Current Stimulation	1.01.24	Minor Update
21	Low-Level Laser Therapy	2.01.56	Minor Update
22	Lung Volume Reduction Surgery for Severe Emphysema	7.01.71	Minor Update
23	Measurement of Exhaled Nitric Oxide and Exhaled Breath Condensate in the Diagnosis and Management of Respiratory Disorders	2.01.61	Minor Update
24	Medical Management of Obstructive Sleep Apnea Syndrome	8.01.67	Minor Update
25	Minimally Invasive Ablation Procedures for Morton and Other Peripheral Neuromas	7.01.147	Minor Update
26	Multicancer Early Detection Testing	2.04.158	Minor Update
27	Multitarget Polymerase Chain Reaction Testing for Diagnosis of Bacterial Vaginosis	2.04.127	Admin Update
28	Occipital Nerve Stimulation	7.01.125	Minor Update
29	Paraspinal Surface Electromyography to Evaluate and Monitor Back Pain	2.01.35	Minor Update
30	Percutaneous Electrical Nerve Stimulation, Percutaneous Neuromodulation Therapy, and Restorative Neurostimulation Therapy	7.01.29	Minor Update
31	Polysomnography for Non-Respiratory Sleep Disorders	2.01.99	Minor Update
32	Proteogenomic Testing for Patients With Cancer	2.04.140	Minor Update
33	Quantitative Sensory Testing	2.01.39	Minor Update
34	Responsive Neurostimulation for the Treatment of Refractory Focal Epilepsy	7.01.143	Admin Update
35	Retinal Telescreening for Diabetic Retinopathy	9.03.13	Archived
36	Semi-Implantable and Fully Implantable Middle Ear Hearing Aids	7.01.84	Admin Update
37	Serum Biomarker Panel Testing for Systemic Lupus Erythematosus and Other Connective Tissue Diseases	2.04.123	Minor Update
38	Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome	7.01.101	Minor Update
39	Transcatheter Pulmonary Valve Implantation	7.01.131	Minor Update
40	Wireless Capsule Endoscopy for Gastrointestinal Disorders	6.01.33	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.

	Policy Title	Policy#	Status
1	Balloon Spacers for Treatment of Irreparable Rotator Cuffs of the Shoulder	7.01.180	New
2	Liposuction for Lipedema	BSC7.20	New
3	Transcatheter Tricuspid Valve Repair or Replacement	2.02.34	New
4	Tibial Nerve Stimulation	7.01.106	Major Update
5	Allograft Injection for Degenerative Disc Disease	7.01.166	Minor Update
6	Ambulatory Event Monitors and Mobile Cardiac Outpatient Telemetry	2.02.08	Minor Update
7	Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions	7.01.78	Minor Update
8	Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions	7.01.48	Minor Update
9	Baroreflex Stimulation Devices	8.01.57	Minor Update
10	Biventricular Pacemakers (Cardiac Resynchronization Therapy) for the Treatment of Heart Failure	2.02.10	Minor Update
11	Cervical Spine Surgery	BSC_EVO_1759	Minor Update
12	Closure Devices for Patent Foramen Ovale and Atrial Septal Defects	2.02.09	Minor Update
13	Cognitive Rehabilitation	8.03.10	Minor Update
14	Continuous Passive Motion in the Home Setting	1.01.10	Minor Update
15	Electrical Bone Growth Stimulation of the Appendicular Skeleton	7.01.07	Minor Update
16	Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures	7.01.85	Minor Update
17	Endovascular Stent Grafts for Abdominal Aortic Aneurysms	7.01.67	Minor Update
18	Endovascular Therapies for Extracranial Vertebral Artery Disease	7.01.148	Minor Update
19	Enhanced External Counterpulsation	2.02.06	Minor Update
20	Epidural Spine Injections	BSC_EVO_1750	Minor Update
21	Extracorporeal Membrane Oxygenation for Adult Conditions	8.01.60	Minor Update
22	Extracranial Carotid Artery Stenting	7.01.68	Minor Update
23	Implantable Cardioverter Defibrillators	7.01.44	Minor Update
24	Inhaled Nitric Oxide	8.01.37	Minor Update
25	Leadless Cardiac Pacemakers	2.02.32	Minor Update
26	Low Intensity Pulsed Ultrasound Fracture Healing Device	1.01.05	Minor Update
27	Lumbar Spine Surgery	BSC_EVO_1766	Minor Update
28	Myocardial Strain Imaging	2.02.31	Minor Update
29	Nerve Graft with Radical Prostatectomy	7.01.81	Archived
30	Paravertebral Facet Joint Injections or Blocks	BSC_EVO_1753	Minor Update
31	Percutaneous Left Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation	2.02.26	Minor Update
32	Phrenic Nerve Stimulation for Central Sleep Apnea	2.02.33	Minor Update
33	Sacroiliac Joint Injections	BSC_EVO_1756	Minor Update
34	Thoracic Spine Surgery	BSC_EVO_1772	Minor Update
35	Transcatheter Aortic-Valve Implantation for Aortic Stenosis	7.01.132	Minor Update
36	Transcatheter Mitral Valve Repair or Replacement	7.01.132	Minor Update
37	Treatment of Varicose Veins/Venous Insufficiency	7.01.124	Minor Update
38	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.

	Policy Title	Policy#	Status
1	Deep Brain Stimulation	7.01.63	Major Update
2	Investigational or Experimental Services	BSC9.01	New
3	Bone Morphogenetic Protein	7.01.100	Minor Update
4	Catheter Ablation for Cardiac Arrhythmias	BSC2.12	Minor Update
5	Diabetes Prevention Program	BSC2.11	Minor Update
6	Dry Needling of Trigger Points for Myofascial Pain	2.01.100	Minor Update
7	Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures	7.01.85	Minor Update
8	Endovascular Procedures for Intracranial Arterial Disease (Atherosclerosis and Aneurysms)	2.01.54	Minor Update
9	Facet Arthroplasty	7.01.120	Minor Update
10	Hip Resurfacing	7.01.80	Minor Update
11	Image-Guided Minimally Invasive Decompression for Spinal Stenosis	7.01.126	Minor Update
12	Interventions for Progressive Scoliosis	2.01.83	Minor Update
13	Intraoperative Neurophysiologic Monitoring	7.01.58	Minor Update
14	Manipulation Under Anesthesia	8.01.40	Minor Update
15	Meniscal Allografts and Other Meniscal Implants	7.01.15	Minor Update
16	Minimally Invasive Approaches to Vertebral Fractures and Osteolytic Lesions of the Spine	6.01.25	Minor Update
17	Nerve Graft with Radical Prostatectomy	7.01.81	Minor Update
18	Occipital Nerve Stimulation	7.01.125	Minor Update
19	Orthopedic Applications of Platelet-Rich Plasma	2.01.98	Minor Update
20	Peripheral Subcutaneous Field Stimulation	7.01.139	Minor Update
21	Physical Therapy	BSC8.03	Minor Update
22	Power Morcellation for the Treatment of Uterine Fibroids	BSC7.06	Minor Update
23	Reconstructive Services	BSC7.08	Minor Update
24	Responsive Neurostimulation for the Treatment of Refractory Focal Epilepsy	7.01.143	Minor Update
25	Sacral Nerve Neuromodulation/Stimulation	7.01.69	Minor Update
26	Spinal Cord and Dorsal Root Ganglion Stimulation	7.01.25	Minor Update
27	Subtalar Arthroereisis	7.01.104	Minor Update
28	Surgical Treatment of Femoroacetabular Impingement	7.01.118	Minor Update
29	Trigger Point and Tender Point Injections	2.01.103	Minor Update
30	Vertebral Axial Decompression	8.03.09	Minor Update
31	Vertical Expandable Prosthetic Titanium Rib	7.01.110	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.

	Policy Title	Policy#	Status
1	Electroconvulsive Therapy	BSC8.09	New
2	Nasal Septoplasty	BSC7.19	New
3	Peripheral Nerve Injury Repair Using Synthetic Conduits or Processed Nerve Allografts	7.01.177	New
4	Radiofrequency Volumetric Tissue Reduction for Nasal Obstruction	7.01.156	New
5	Adjustable Cranial Orthoses for Positional Plagiocephaly and Craniosynostoses	1.01.11	Minor Update
6	Amniotic Membrane and Amniotic Fluid	7.01.149	Minor Update
7	Bioengineered Skin and Soft Tissue Substitutes	7.01.113	Minor Update
8	Biomarker Testing in Risk Assessment and Management of Cardiovascular Disease	2.04.65	Admin Update
9	Cardiac Applications of Positron Emission Tomography Scanning	6.01.20	Admin Update
10	Cardiac Rehabilitation in the Outpatient Setting	8.03.08	Minor Update
11	Catheter Ablation as Treatment for Atrial Fibrillation	2.02.19	Minor Update
12	Continuous Glucose Monitoring	1.01.20	Minor Update
13	Cooling Devices Used in the Outpatient Setting	1.01.26	Minor Update
14	Corneal Collagen Cross-Linking	9.03.28	Minor Update
15	Dental Anesthesia	BSC2.02	Minor Update
16	Electrical and Electromagnetic Stimulation for the Treatment of Arthritis	1.01.27	Minor Update
17	Endothelial Keratoplasty	9.03.22	Minor Update
18	Eyelid Thermal Pulsation for the Treatment of Dry Eye Syndrome	9.03.29	Minor Update
19	Functional Neuromuscular Electrical Stimulation	8.03.01	Minor Update
20	Genetic Testing: Cardiac Disorders	BSC_CON_2.18	Admin Update
21	Genetic Testing: Exome and Genome Sequencing For The Diagnosis Of Genetic Disorders	BSC_CON_2.02	Admin Update
22	Genetic Testing: Kidney Disorders	BSC_CON_2.22	Admin Update
23	Genetic Testing: Lung Disorders	BSC_CON_2.23	Admin Update
24	Genetic Testing: Pharmacogenetics	BSC_CON_2.12	Admin Update
25	Genetic Testing: Prenatal Cell-Free DNA Testing	BSC_CON_2.08	Admin Update
26	Genetic Testing: Prenatal Diagnosis (Via Amniocentesis, CVS, or PUBS) And Pregnancy Loss	BSC_CON_2.06	Admin Update
27	Hippotherapy	BSC8.10	Minor Update
28	Home Non-Invasive Positive Airway Pressure Devices for the Treatment of Respiratory Insufficiency and Failure	8.01.64	Minor Update
29	Identification of Microorganisms Using Nucleic Acid Probes	2.04.10	Admin Update
30	Intraocular Radiotherapy for Age-Related Macular Degeneration	9.03.20	Minor Update
31	Keratoprosthesis	9.03.01	Minor Update
32	Knee Braces (Custom)	BSC1.05	Minor Update
33	Lifestyle Modification Program for Reversing Heart Disease	BSC8.01	Minor Update
34	Low Intensity Pulsed Ultrasound Fracture Healing Device	1.01.05	Minor Update
35	Microprocessor-Controlled Prostheses for the Lower Limb	1.04.05	Minor Update
36	Myoelectric Prosthetic and Orthotic Components for the Upper Limb	1.04.04	Minor Update
37	Oncology: Algorithmic Testing	BSC_CON_2.05	Admin Update
38	Oncology: Cancer Screening	BSC_CON_2.09	Admin Update
39	Oncology: Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy)	BSC_CON_2.10	Admin Update
40	Oncology: Molecular Analysis Of Solid Tumors And Hematologic Malignancies	BSC_CON_2.04	Admin Update
41	Open and Thoracoscopic Approaches to Treat Atrial Fibrillation and Atrial Flutter (Maze and Related Procedures)	7.01.14	Minor Update
42	Ophthalmologic Techniques That Evaluate Posterior Segment for Glaucoma	9.03.06	Minor Update
43	Optical Coherence Tomography of the Anterior Eye Segment	9.03.18	Minor Update
44	Orthognathic Surgery	BSC7.03	Minor Update
45	Outpatient Pulmonary Rehabilitation	8.03.05	Minor Update
46	Panniculectomy, Abdominoplasty, and Surgical Management of Diastasis Recti	BSC7.04	Minor Update
47	Partial Thickness Rotator Cuff Tears and Acromioplasty/Subacromial Decompression	BSC7.14	Minor Update
48	Patient-Controlled End Range of Motion Stretching Devices	1.03.05	Minor Update
49	Personalized Breast Cancer Screening Clinical Trial	BSC2.08	Minor Update
50	Photodynamic Therapy for Choroidal Neovascularization	9.03.08	Minor Update
51	Postsurgical Home Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis	1.01.28	Minor Update
52	Power Wheelchairs and Power Operated Vehicles for Permanent Use	BSC1.02	Admin Update
53	Powered Exoskeleton for Ambulation in Patients With Lower-Limb Disabilities	1.03.04	Minor Update
54	Radioembolization for Primary and Metastatic Tumors of the Liver	8.01.43	Admin Update
55	Repetitive Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders	BSC2.19	Minor Update
56	Retinal Telescreening for Diabetic Retinopathy	9.03.13	Minor Update
57	Sensory Integration Therapy and Auditory Integration Therapy	8.03.13	Minor Update
58	Transcatheter Aortic-Valve Implantation for Aortic Stenosis	7.01.132	Minor Update
59	Viscocanalostomy and Canaloplasty	9.03.26	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.

	Policy Title	Policy#	Status
1	Charged-Particle (Proton or Helium Ion) Radiotherapy for Neoplastic Conditions	BSC8.04	Major Update
2	Identification of Microorganisms Using Nucleic Acid Probes	2.04.10	Major Update
3	Occupational Therapy	BSC8.08	New
4	Ambulatory Surgery Center	BSC10.01	Minor Update
5	Auditory Brainstem Implant	7.01.83	Minor Update
6	Balloon Ostial Dilation for Treatment of Chronic and Recurrent Acute Rhinosinusitis	7.01.105	Minor Update
7	Chelation Therapy for Off-Label Uses	8.01.02	Minor Update
8	Chronic Intermittent Intravenous Insulin Therapy	2.01.43	Minor Update
9	Cleft Palate - Dental Related Services	BSC2.01	Minor Update
10	Cochlear Implant	7.01.05	Minor Update
11	Cranial Electrotherapy Stimulation and Auricular Electrostimulation	8.01.58	Minor Update
12	Cryoablation, Radiofrequency Ablation, and Laser Ablation for Treatment of Chronic Rhinitis	7.01.168	Minor Update
13	Dynamic Posturography	2.01.02	Minor Update
14	Functional Endoscopic Sinus Surgery for Chronic Rhinosinusitis	7.01.155	Minor Update
15	Gastric Electrical Stimulation	7.01.73	Minor Update
16	Handheld Radiofrequency Spectroscopy for Intraoperative Assessment of Surgical Margins During Breast-Conserving Surgery	7.01.140	Minor Update
17	Hysterectomy Surgery for Benign Conditions	BSC7.09	Minor Update
18	Implantable Bone-Conduction and Bone-Anchored Hearing Aids	7.01.03	Minor Update
19	Ingestible pH and Pressure Capsule	BSC2.17	Minor Update
20	Intensity-Modulated Radiotherapy of the Breast and Lung	8.01.46	Minor Update
21	Intensity-Modulated Radiotherapy of the Prostate	8.01.47	Minor Update
22	Intensity-Modulated Radiotherapy: Abdomen, Pelvis and Chest	8.01.49	Minor Update
23	Intensity-Modulated Radiotherapy: Cancer of the Head and Neck or Thyroid	8.01.48	Minor Update
24	Intensity-Modulated Radiotherapy: Central Nervous System Tumors	8.01.59	Minor Update
25	Laparoscopic, Percutaneous, and Transcervical Techniques for Uterine Fibroid Myolysis	4.01.19	Minor Update
26	Lysis of Epidural Adhesions	BSC8.05	Minor Update
27	Maternal Serum Biomarkers for Prediction of Adverse Obstetric Outcomes	2.04.152	Minor Update
28	Physical Therapy	BSC8.03	Admin Update
29	Radiation Oncology	BSC8.06	Minor Update
30	Reconstructive Services	BSC7.08	Admin Update
31	Reduction Mammaplasty for Breast-Related Symptoms	7.01.21	Minor Update
32	Semi-Implantable and Fully Implantable Middle Ear Hearing Aids	7.01.84	Minor Update
33	Speech Therapy	BSC8.02	Admin Update
34	Stereotactic Radiosurgery and Stereotactic Body Radiotherapy	6.01.10	Minor Update
35	Steroid-Eluting Sinus Stents and Implants	7.01.134	Minor Update
36	Surgery for Groin Pain in Athletes	7.01.142	Minor Update
37	Surgical Deactivation of Headache Trigger Sites	7.01.135	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	Transmyocardial Revascularization	7.01.54	Minor Update
42	Treatment of Tinnitus	8.01.39	Minor Update
43	Vagus Nerve Stimulation	7.01.20	Minor Update
44	Vestibular Function Testing	2.01.104	Minor Update

Read about the latest medical policy changes.

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.

	Policy Title	Policy#	Status
1	Behavioral Health Treatment for Autism Spectrum Disorders and/or Other Neurodevelopmental Disorders	BSC3.01	Major Update
2	Repetitive Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders	BSC2.19	Major Update
3	Adipose-Derived Stem Cells in Autologous Fat Grafting to the Breast	7.01.153	Minor Update
4	Allogeneic Hematopoietic Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms	8.01.21	Minor Update
5	Autologous Platelet-Derived Growth Factors for Wound Healing and Other Non-Orthopedic Conditions	2.01.16	Minor Update
6	Bioimpedance Devices for Detection and Management of Lymphedema	2.01.82	Minor Update
7	Blepharoplasty, Blepharoptosis Repair (Levator Resection) and Brow Lift (Repair of Brow Ptosis)	BSC7.01	Minor Update
8	Bone Turnover Markers for Diagnosis and Management of Osteoporosis and Diseases Associated With High Bone Turnover	2.04.15	Minor Update
9	Electrostimulation and Electromagnetic Therapy for Treating Wounds	2.01.57	Minor Update
10	Fractional Carbon Dioxide (CO2) Laser Ablation Treatment of Hypertrophic Scars or Keloids for Functional Improvement	2.01.107	Minor Update
11	Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia	8.01.32	Minor Update
12	Hematopoietic Cell Transplantation for Acute Myeloid Leukemia	8.01.26	Minor Update
13	Hematopoietic Cell Transplantation for Autoimmune Diseases	8.01.25	Minor Update
14	Hematopoietic Cell Transplantation for Central Nervous System Embryonal Tumors and Ependymoma	8.01.28	Minor Update
15	Hematopoietic Cell Transplantation for Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma	8.01.15	Minor Update
16	Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia	8.01.30	Minor Update
17	Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer	8.01.23	Minor Update
18	Hematopoietic Cell Transplantation for Hodgkin Lymphoma	8.01.29	Minor Update
19	Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors in Adults	8.01.24	Minor Update
20	Hematopoietic Cell Transplantation for Non-Hodgkin Lymphomas	8.01.20	Minor Update
21	Hematopoietic Cell Transplantation for Plasma Cell Dyscrasias, Including Multiple Myeloma and POEMS Syndrome	8.01.17	Minor Update
22	Hematopoietic Cell Transplantation for Primary Amyloidosis	8.01.42	Minor Update
23	Hematopoietic Cell Transplantation for Solid Tumors of Childhood	8.01.34	Minor Update
24	Hematopoietic Cell Transplantation in the Treatment of Germ Cell Tumors	8.01.35	Minor Update
25	Negative Pressure Wound Therapy in the Outpatient Setting	1.01.16	Minor Update
26	Noncontact Ultrasound Treatment for Wounds	2.01.79	Minor Update
27	Orthopedic Applications of Stem Cell Therapy (Including Allografts and Bone Substitutes Used with Autologous Bone Marrow)	8.01.52	Minor Update
28	Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers	1.01.18	Minor Update
29	Stationary Ultrasonic Diathermy Devices	7.01.174	Minor Update
30	Stem Cell Therapy for Peripheral Arterial Disease	8.01.55	Minor Update
31	Treatment of Varicose Veins/Venous Insufficiency	7.01.124	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.

	Policy Title	Policy#	Status
1	Bariatric Surgery	7.01.47	Major Update
2	Genetic Testing: Gastroenterologic Disorders (Non-Cancerous)	BSC_CON_2.17	Major Update
3	Oncology: Molecular Analysis Of Solid Tumors And Hematologic Malignancies	BSC_CON_2.04	Major Update
4	Oncology: Circulating Tumor DNA and Circulating Tumor Cells (Liquid Biopsy)	BSC_CON_2.10	Major Update
5	Transcutaneous Electrical Nerve Stimulation and Transcutaneous Afferent Patterned Stimulation	1.01.09	Major Update
6	Ablation of Peripheral Nerves to Treat Pain	7.01.154	Admin 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	Bioengineered Skin and Soft Tissue Substitutes	7.01.113	Admin Update
10	Biomarker Testing in Risk Assessment and Management of Cardiovascular Disease	2.04.65	Minor Update
11	Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting	2.02.24	Admin Update
12	Catheter Ablation as Treatment for Atrial Fibrillation	2.02.19	Admin Update
13	Chemical Peels	8.01.16	Minor Update
14	Continuous Glucose Monitoring	1.01.20	Admin Update
15	Cranial Electrotherapy Stimulation and Auricular Electrostimulation	8.01.58	Admin Update
16	Dermatologic Applications of Photodynamic Therapy	2.01.44	Minor Update
17	Diabetes Prevention Program	BSC2.11	Admin Update
18	Digital Health Technologies for Attention Deficit/Hyperactivity Disorder	3.03.03	Admin Update
19	Digital Health Technologies: Therapeutic Applications	3.03.02	Admin Update
20	Elective Invasive Coronary Angiography (ICA)	BSC2.13	Admin Update
21	Evaluation of Biomarkers for Alzheimer Disease	2.04.14	Archived
22	Fecal Analysis in the Diagnosis of Intestinal Dysbiosis	2.04.26	Minor Update
23	Fecal Calprotectin Testing	2.04.69	Minor Update
24	Focal Treatments for Prostate Cancer	8.01.61	Admin Update
25	Genetic Testing: Hereditary Cancer Susceptibility	BSC_CON_2.01	Admin Update
26	Genetic Testing: Immune, Autoimmune, and Rheumatoid Disorders	BSC_CON-2.21	Admin Update
27	Genetic Testing: Pharmacogenetics	BSC_CON_2.12	Admin Update
28	Genetic Testing: Prenatal Cell-Free DNA Testing	BSC_CON_2.08	Admin Update
29	Homocysteine Testing in the Screening, Diagnosis, and Management of Cardiovascular Disease and Venous Thromboembolic Disorders	2.04.23	Minor Update
30	Identification of Microorganisms Using Nucleic Acid Probes	2.04.10	Admin Update
31	Immune Cell Function Assay	2.04.56	Minor Update
32	Implantable Cardioverter Defibrillators	7.01.44	Admin Update
33	Intracellular Micronutrient Analysis	2.04.73	Minor Update
34	Knee Arthroplasty for Adults	BSC7.10	Admin Update
35	Knee Braces (Custom)	BSC1.05	Admin Update
36	Laser Interstitial Thermal Therapy for Neurological Conditions	7.01.170	Minor Update
37	Laser Treatment of Onychomycosis	2.01.89	Minor Update
38	Magnetic Resonance-Guided Focused Ultrasound	7.01.109	Admin Update
39	Maternal Serum Biomarkers for Prediction of Adverse Obstetric Outcomes	2.04.152	Admin Update
40	Microwave Tumor Ablation	7.01.133	Admin Update
41	Multitarget Polymerase Chain Reaction Testing for Diagnosis of Bacterial Vaginosis	2.04.127	Minor Update
42	Nerve Fiber Density Measurement	2.04.58	Minor Update
43	Nonpharmacologic Treatment of Rosacea	2.01.71	Minor Update
44	Nutrient/Nutritional Panel Testing	2.04.136	Minor Update
45	Oncology: Algorithmic Testing	BSC_CON_2.05	Admin Update
46	Oncology: Cancer Screening	BSC_CON_2.09	Minor Update
47	Ophthalmologic Techniques That Evaluate the Posterior Segment for Glaucoma	9.03.06	Admin Update
48	Optical Coherence Tomography of the Anterior Eye Segment	9.03.18	Admin Update
49	Orthognathic Surgery	BSC7.03	Admin Update
50	Personalized Breast Cancer Screening Clinical Trial	BSC2.08	Admin Update
51	Prostatic Urethral Lift	7.01.151	Admin Update
52	Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumor	7.01.95	Admin Update
53	Radiofrequency Ablation of the Renal Sympathetic Nerves as a Treatment for Uncontrolled Hypertension	7.01.136	Minor Update
54	Radiofrequency Coblation Tenotomy for Musculoskeletal Conditions	7.01.165	Minor Update
55	Reconstructive Services	BSC7.08	Admin Update
56	Serum Biomarker Human Epididymis Protein 4	2.04.66	Minor Update
57	Spinal Cord and Dorsal Root Ganglion Stimulation	7.01.25	Admin Update
58	Stereotactic Radiosurgery and Stereotactic Body Radiotherapy	6.01.10	Admin Update
59	Targeted Phototherapy and Psoralen with Ultraviolet A for Vitiligo	2.01.86	Minor Update
60	Temporarily Implanted Nitinol Device (iTind) for Benign Prostatic Hyperplasia	7.01.175	Minor Update
61	Testing Serum Vitamin D Levels	2.04.135	Minor Update
62	Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease	2.01.38	Minor Update
63	Transurethral Water Vapor Thermal Therapy and Transurethral Water Jet Ablation (Aquablation) for Benign Prostatic Hypertrophy	2.01.49	Admin Update
64	Vagus Nerve Stimulation	7.01.20	Admin Update
65	Wireless Capsule Endoscopy for Gastrointestinal 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.

	Policy Title	Policy#	Status
1	Adjunctive Techniques for Screening, Surveillance, and Risk Classification of Barrett Esophagus and Esophageal Dysplasia	7.01.167	New
2	Irreversible Electroporation of Tumors Located in the Liver, Pancreas, Kidney, or Lung	6.01.68	New
3	Genetic Testing: Aortopathies and Connective Tissue Disorders	BSC_CON_2.19	Major Update
4	Genetic Testing: Cardiac Disorders	BSC_CON_2.18	Major Update
5	Genetic Testing: Dermatologic Conditions	BSC_CON_2.25	Major Update
6	Genetic Testing: Eye Disorders	BSC_CON_2.20	Major Update
7	Genetic Testing: General Approach to Genetic and Molecular Testing	BSC_CON_2.27	Major Update
8	Genetic Testing: Hearing Loss	BSC_CON_2.16	Major Update
9	Genetic Testing: Hematologic Conditions (Non-Cancerous)	BSC_CON_2.15	Major Update
10	Genetic Testing: Hereditary Cancer Susceptibility	BSC_CON_2.01	Major Update
11	Genetic Testing: Immune, Autoimmune, and Rheumatoid Disorders	BSC_CON_2.21	Major Update
12	Genetic Testing: Kidney Disorders	BSC_CON_2.22	Major Update
13	Genetic Testing: Lung Disorders	BSC_CON_2.23	Major Update
14	Genetic Testing: Metabolic, Endocrine, and Mitochondrial Disorders	BSC_CON_2.24	Major Update
15	Genetic Testing: Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay	BSC_CON_2.13	Major Update
16	Genetic Testing: Pharmacogenetics	BSC_CON_2.12	Major Update
17	Genetic Testing: Prenatal Diagnosis (Via Amniocentesis, CVS, or PUBS) and Pregnancy Loss	BSC_CON_2.06	Major Update
18	Genetic Testing: Prenatal Preconception Carrier Screening	BSC_CON_2.07	Major Update
19	Neuropsychological Testing	BSC2.06	Major Update
20	Oncology: Algorithmic Testing	BSC_CON_2.05	Major Update
21	Oncology: Cytogenetic Testing	BSC_CON_2.11	Major Update
22	Aqueous Shunts and Stents for Glaucoma	9.03.21	Minor Update
23	Axillary Reverse Mapping for Prevention of Breast Cancer-Related Lymphedema	7.01.173	Minor Update
24	Biofeedback as a Treatment of Chronic Pain	2.01.30	Minor Update
25	Biofeedback as a Treatment of Fecal Incontinence or Constipation	2.01.64	Minor Update
26	Biofeedback as a Treatment of Headache	2.01.29	Minor Update
27	Biofeedback for Miscellaneous Indications	2.01.53	Minor Update
28	Chromoendoscopy as an Adjunct to Colonoscopy	2.01.84	Minor Update
29	Computed Tomography Perfusion Imaging of the Brain	6.01.49	Archived
30	Confocal Laser Endomicroscopy	2.01.87	Minor Update
31	Drug Testing in Pain Management and Substance Use Disorder Treatment	2.04.98	Minor Update
32	Dry Hydrotherapy for Chronic Pain Conditions	2.01.105	Minor Update
33	Endoscopic Radiofrequency Ablation or Cryoablation for Barrett Esophagus	2.01.80	Minor Update
34	Esophageal pH Monitoring	2.01.20	Minor Update
35	Extracorporeal Photopheresis	8.01.36	Minor Update
36	Fecal Microbiota Transplantation	2.01.92	Minor Update
37	Genetic Testing: Epilepsy, Neurodegenerative, and Neuromuscular Disorders	BSC_CON_2.14	Minor Update
38	Genetic Testing: Exome and Genome Sequencing For The Diagnosis Of Genetic Disorders	BSC_CON_2.02	Minor Update
39	Genetic Testing: Preimplantation Genetic Testing	BSC_CON_2.03	Minor Update
40	Genetic Testing: Prenatal Cell-Free DNA Testing	BSC_CON_2.08	Minor Update
41	Genetic Testing: Skeletal Dysplasia and Rare Bone Disorders	BSC_CON_2.26	Minor Update
42	Interim Positron Emission Tomography Scanning in Oncology to Detect Early Response During Treatment	6.01.51	Archived
43	Magnetic Esophageal Sphincter Augmentation to Treat Gastroesophageal Reflux Disease	7.01.137	Minor Update
44	Magnetic Resonance Imaging for Detection and Diagnosis of Breast Cancer	6.01.29	Archived
45	Measurement of Serum Antibodies to Selected Biologic Agents	2.04.84	Minor Update
46	Miscellaneous (Noncardiac, Nononcologic) Applications of Fluorine 18 Fluorodeoxyglucose Positron Emission Tomography	6.01.06	Archived
47	Monitored Anesthesia Care	7.02.01	Minor Update
48	Neural Therapy	2.01.85	Minor Update
49	Peroral Endoscopic Myotomy for Treatment of Esophageal Achalasia and Gastroparesis	2.01.91	Minor Update
50	Plugs for Anal Fistula Repair	7.01.123	Minor Update
51	Prolotherapy	2.01.26	Minor Update
52	Proteomic Testing for Targeted Therapy in Non-Small-Cell Lung Cancer	2.04.125	Minor Update
53	Repetitive Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders	BSC2.19	Minor Update
54	Selected Positron Emission Tomography Technologies for Evaluation of Alzheimer Disease	6.01.55	Archived
55	Sphenopalatine Ganglion Block for Headache	7.01.159	Minor Update
56	Transanal Endoscopic Microsurgery	7.01.112	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.

	Policy Title	Policy#	Status
1	Low-Dose Radiotherapy for Non-Oncologic Indications	7.01.179	New
2	Percutaneous Revascularization Procedures for Lower Extremity Peripheral Arterial Disease	7.01.178	New
3	Quantitative Electroencephalography as a Diagnostic Aid for Attention-Deficit/Hyperactivity Disorder, Cognitive Impairment, or Autism Spectrum Disorder	3.01.03	Major Update
4	Absorbable Nasal Implant for Treatment of Nasal Valve Collapse	7.01.163	Minor Update
5	Biofeedback as a Treatment of Urinary Incontinence in Adults	2.01.27	Minor Update
6	Dopamine Transporter Single-Photon Emission Computed Tomography	6.01.54	Minor Update
7	Functional Magnetic Resonance Imaging of the Brain	6.01.47	Archived
8	Genetic Testing: Eye Disorders	BSC_CON_2.20	Minor Update
9	Genetic Testing: Skeletal Dysplasia and Rare Bone Disorders	BSC_CON_2.26	Minor Update
10	Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence	7.01.19	Minor Update
11	Knee Arthroplasty for Adults	BSC7.10	Minor Update
12	Knee Arthroscopy in Knee Osteoarthritis	BSC7.16	Minor Update
13	Magnetic Resonance Spectroscopy	6.01.24	Minor Update
14	Microwave Tumor Ablation	7.01.133	Minor Update
15	Miscellaneous (Noncardiac, Nononcologic) Applications of Fluorine 18 Fluorodeoxyglucose Positron Emission Tomography	6.01.06	Minor Update
16	Radioactive Seed Localization of Nonpalpable Breast Lesions	6.01.57	Archived
17	Radiofrequency Ablation of the Renal Sympathetic Nerves as a Treatment for Uncontrolled Hypertension	7.01.136	Minor Update
18	Remote Electrical Neuromodulation for Migraines	7.01.171	Minor Update
19	Suture Button Suspensionplasty Fixation System for Thumb Carpometacarpal Osteoarthritis	7.01.176	Minor Update
20	Thermography	6.01.12	Archived
21	Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders	2.01.50	Minor Update
22	Vertebral Fracture Assessment with Densitometry or Biomechanical Computed Tomography	6.01.44	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.

Eligibility & benefits

Authorizations

Claims

Guidelines & resources

News & education

New and updated policies effective November 1, 2025

New and updated policies effective October 1, 2025

New and updated policies effective September 1, 2025

New and updated policies effective August 1, 2025

New and updated policies effective July 1, 2025

New and updated policies effective June 1, 2025

New and updated policies effective May 1, 2025

New and updated policies effective April 1, 2025

New and updated policies effective March 1, 2025

New and updated policies effective February 1, 2025

New and updated policies effective January 1, 2025

New and updated policies effective December 1, 2024

Medical policy list

Technical evaluation and assessment