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Medical Review

Medical Policies

The medical policies listed below reflect medical criteria used/developed by Blue Cross and Blue Shield of Kansas. These medical policies do not guarantee benefits under BCBSKS member contracts.

A BCBSKS medical policy may apply to professional providers, to institutional providers or to both. That’s why the medical policy format shows separate effective dates for professional and institutional providers. It’s also why if you compare the list of professional medical policies to the list for institutional providers there could be a difference.

BCBSKS only displays the most current version of a medical policy. When updated policies become effective, prior versions are removed from this Web site.

These are the most recent policy updates.

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Medical Policies

Policy Title PDF Files Date Posted Professional Effective Date Institutional Effective Date
Accelerated Breast Irradiation after Breast-Conserving Surgery for Early Stage Breast Cancer and Breast Brachytherapy as Boost with Whole-Breast Irradiation 04/26/13 05/27/13 05/27/13
Acne Surgery 03/01/06 04/01/06 N/A
Acoustic Pharyngometers & SNAP Testing 10/06/08 10/06/08 11/05/08
Actigraphy 06/05/12 10/19/09 10/19/09
Acute and Maintenance Subcutaneous and Intravenous Tocolysis 12/09/11 01/09/12 01/09/12
Adjustable Cranial Orthoses for Positional Plagiocephaly and Craniosynostoses 10/11/11 10/11/11 10/11/11
Adult Growth Hormone 09/10/10 09/10/10 10/11/10
Alcohol Injection Therapy for Morton’s Neuroma 04/26/13 06/03/11 06/03/11
Ambulatory Blood Pressure Monitoring 02/26/13 12/07/12 12/07/12
Ambulatory Event Monitors and Mobile Outpatient Cardiac Telemetry 02/26/13 02/26/13 02/26/13
Ampyra™ (dalfampridine) Prior Authorization (and Quantity Limit) Criteria 04/10/12 12/01/11 12/01/11
Androgens and Anabolic Steroids Prior Authorization and Quantity Limit Criteria 10/24/12 01/01/13 01/01/13
Antidepressant Agents Prior Authorization Criteria (1-Step Edit) 07/31/12 08/30/12 08/30/12
Antihypertensive Medications 12/27/12 01/01/13 01/01/13
Aqueous Shunts and Stents for Glaucoma 05/07/13 06/07/13 06/07/13
Artificial Intervertebral Disc: Cervical Spine 03/08/13 09/23/08 10/23/08
Artificial Intervertebral Disc: Lumbar Spine 03/08/13 09/23/08 09/23/08
Automated Percutaneous and Endoscopic Discectomy 02/14/12 02/14/12 02/14/12
Automated Point-of-Care Devices for Nerve Conduction Testing 08/13/12 10/13/08 10/13/08
Axial Lumbosacral Interbody Fusion 01/15/13 01/15/13 01/15/13
Balloon Sinuplasty for Treatment of Chronic Sinusitis 09/24/12 08/01/11 08/01/11
Barrett's Esophagus Ablative Treatments 02/15/13 02/15/13 02/15/13
Benlysta® (belimumab) Prior Authorization 12/29/11 07/01/11 02/01/12
Biologic Immunomodulators Therapy 02/01/13 03/01/13 03/01/13
Bone Anchored Hearing Aids (BAHA) 06/01/06 07/01/06 07/01/06
Bone Mineral Density Studies 03/15/12 04/13/12 04/13/12
Botulinum Toxin (BT) 01/15/13 12/09/11 12/09/11
BRCA 1 and BRCA 2 Testing 02/26/13 02/26/13 02/26/13
Breast Reconstructive Surgery after Mastectomy 10/26/12 10/26/12 10/26/12
Bronchial Thermoplasty 10/09/12 02/10/11 03/14/11
Cardiac Computed Tomography (CT) 09/11/12 09/11/12 09/11/12
Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting 09/18/12 09/10/10 10/11/10
Cardiac Rehabilitation Programs 09/24/12 09/24/12 09/24/12
Cardiovascular Magnetic Resonance (CMR) 02/15/13 02/15/13 02/15/13
Cardioverter-Defibrillators 03/08/13 04/08/13 04/08/13
Charged-Particle (Proton or Helium Ion) Radiation Therapy 09/06/11 10/06/11 10/06/11
Chelation Therapy 11/19/12 11/19/12 12/19/12
Cochlear Implant 03/19/10 03/19/10 04/19/10
Computed Tomographic Angiography (CTA) and Magnetic Resonance Angiography (MRA) of the Head, Neck, Abdomen, Pelvis, and Extremities 12/29/11 12/15/08 12/15/08
Computed Tomography (CT) to Detect Coronary Artery Calcification 11/06/12 11/14/08 11/14/08
Computer-Aided Evaluation of Malignancy with Magnetic Resonance Imaging of the Breast 04/26/13 11/02/09 11/02/09
Continuous or Intermittent Monitoring of Glucose in Interstitial Fluid 03/25/11 09/09/09 09/09/09
Continuous Passive Motion for Home Use 03/07/12 03/07/12 03/08/10
Contrast-Enhanced Computed Tomography Angiography (CTA) for Coronary Artery Evaluation 02/26/13 12/09/11 12/09/11
Corneal Topography/Computer-Assisted Corneal Topography/Photokeratoscopy 12/09/11 12/09/11 12/09/11
COX-2 Inhibitor (Celebrex®) Prior Authorization Criteria 06/01/12 07/01/12 07/01/12
Cryosurgical Ablation of Primary or Metastatic Liver Tumors 03/26/13 05/10/12 05/10/12
CTA and MRA of the Chest (excluding the Heart) 07/23/09 12/15/08 12/15/08
Cytochrome p450 Genotyping 12/27/12 10/26/10 11/29/10
Cytoreduction and Hyperthermic Intraperitoneal Chemotherapy for the Treatment of Peritoneal Carcinomatosis of Gastrointestinal Origin 03/07/11 10/19/09 10/19/09
Decompression of the Intervertebral Disc Using Laser Energy (Laser Discectomy) or Radiofrequency Coblation (Nucleoplasty) 11/06/12 02/08/10 02/08/10
Deep Brain Stimulation 05/13/11 06/13/11 06/13/11
Denosumab (Prolia and Xgeva) 03/12/13 03/12/13 03/12/13
Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome 12/27/12 08/30/12 08/30/12
Diagnosis and Treatment of Chronic Cerebrospinal Venous Insufficiency in Multiple Sclerosis 09/18/12 01/30/12 01/30/12
Diagnosis and Treatment of Sacroiliac Joint Pain 06/05/12 06/05/12 07/05/12
Digital Breast Tomosynthesis 09/11/12 10/11/12 10/11/12
Electrical Bone Growth Stimulation of the Appendicular Skeleton 05/07/13 05/07/13 06/07/13
Electrical Bone Growth Stimulation of the Appendicular Skeleton 03/26/13 03/26/13 03/26/13
Electrical Stimulation Devices for Home Use 04/04/11 04/04/11 04/04/11
Electromyography (EMG), Nerve Conduction Studies (NCS), and Other Electrodiagnostic (EDX) Related Services 04/12/13 04/12/13 04/12/13
Enhanced External Counterpulsation (EECP) 11/01/07 11/01/07 11/01/07
Equipment for Cold Therapy 05/07/13 10/04/12 10/04/12
Esophageal pH Monitoring 10/11/11 10/11/11 10/11/11
Extracorporeal Shock Wave Therapy (ESWT) for Plantar Fasciitis and Other Musculoskeletal Conditions 05/07/13 10/26/12 10/26/12
Extracranial Carotid Angioplasty/Stenting (CAS) 12/09/11 07/01/07 07/01/07
Eye Movement Desensitization and Reprocessing (EMDR) for Acute Stress Disorder and Post Traumatic Stress Disorder (PTSD) 05/07/13 11/01/07 11/01/07
Facet Joint Denervation 12/29/11 02/08/10 02/08/10
Fetal Fibronectin 05/01/07 05/01/07 05/01/07
First-Trimester Detection of Down Syndrome Using Fetal Ultrasound Markers Combined with Maternal Serum Assessment 12/27/12 06/07/12 06/07/12
Foot Care Services 12/01/11 01/03/12 01/03/12
Functional Neuromuscular Electrical Stimulation for Home Use 01/15/13 04/04/11 04/04/11
Fundus Photography 03/13/13 07/25/12 07/25/12
Gene-Based Tests for Screening, Detection, and/or Management of Prostate Cancer 12/27/12 02/11/11 02/11/11
Gene Expression Assay for Breast Cancer Treatment 03/13/13 04/12/13 04/12/13
Genetic Testing for Congenital Long QT Syndrome 12/07/12 10/26/10 11/29/10
Genetic Testing for Helicobacter pylori Treatment 01/15/13 10/26/10 11/29/10
Genetic Testing for Inherited Susceptibility to Colon Cancer, Including Microsatellite Instability Testing 03/26/13 03/26/13 03/26/13
Genetic Testing for Predisposition to Inherited Hypertrophic Cardiomyopathy 03/08/13 04/08/13 04/08/13
Genetic Testing for Tamoxifen Treatment 01/15/13 10/26/10 11/29/10
Genetic Testing for Warfarin Dose 03/19/13 10/26/10 11/29/10
Glucose Test Strips/Disks and Meters 12/27/12 01/01/13 01/01/13
Hepatitis B / Oncology and Hepatitis C Agents (Pegasys®/Pegasys Proclick®/peginterferon alfa-2a, PegIntron®/peginterferon alfa-2b, Incivek™/telaprevir, and Victrelis™/boceprevir) 11/30/12 01/01/13 01/01/13
High Dose Rate (HDR) Breast Brachytherapy with HDR Radioactive Source via MammoSite Catheter 06/29/10 07/01/07 07/01/07
High-Sensitivity C-Reactive Protein 12/29/11 01/30/12 01/30/12
Home Phototherapy 03/01/07 04/01/07 04/01/07
Home Prothrombin Time Monitoring 06/29/12 09/18/09 10/19/09
Home Uterine Activity Monitoring 12/07/12 03/08/10 04/07/10
Homocysteine Testing 06/29/12 08/17/10 09/16/10
H.P. Acthar Gel (repository corticotropin) Prior Authorization Criteria 06/01/12 07/01/12 07/01/12
Hyperbaric Oxygen Pressurization (HBO) 01/30/12 10/11/11 10/11/11
Identification of Microorganisms Using Nucleic Acid Probes 01/15/13 01/15/13 01/15/13
Image-Guided Minimally Invasive Lumbar Decompression (IG-MLD) for Spinal Stenosis 07/17/12 09/30/10 05/23/11
Implanted Peripheral Nerve Stimulator (PNS) for Pain Control 03/13/13 03/13/13 03/13/13
Influenza Virus Diagnostic Testing and Treatment in the Outpatient Setting 07/17/12 03/28/12 04/27/12
Insulin Pump 11/15/12 12/14/12 N/A
Intensity Modulated Radiation Therapy (IMRT) 10/15/12 10/15/12 10/15/12
Interspinous Distraction Devices (Spacers) 03/19/13 02/08/10 02/08/10
Intra-articular Hyaluronan Injections for Osteoarthritis 10/26/12 09/24/12 09/24/12
Intravenous and Subcutaneous Immune Globulin Therapy 03/15/12 04/13/12 04/13/12
Intravenous Antibiotic Therapy and Associated Diagnostic Testing for Lyme Disease 12/07/12 04/12/12 04/12/12
In Vitro Chemoresistance and Chemosensitivity Assays 06/29/12 09/20/11 10/20/11
Kalydeco™ (ivacaftor) 02/01/13 03/01/13 03/01/13
Keratoprosthesis 11/19/12 11/19/12 11/19/12
Ketogenic Diet as a Treatment of Refractory Epilepsy 03/08/10 01/12/09 02/11/09
KIF6 Genotyping for Predicting Cardiovascular Risk and/or Effectiveness of Statin Therapy 05/10/13 03/10/11 04/11/11
Laboratory Tests for Heart Transplant Rejection 03/12/13 03/12/13 03/12/13
Laser Assisted Uvulopalatopharyngoplasty (LAUP) 12/30/05 02/01/06 02/01/06
LASIK (laser in situ keratomileusis) 11/01/07 02/15/07 12/01/07
Low-Level Laser Therapy 03/12/13 03/12/13 03/12/13
Lysis of Epidural Adhesions 03/13/13 02/08/10 02/08/10
Magnetic Resonance Imaging (MRI) Breast 12/07/12 12/07/12 12/07/12
Magnetic Resonance Spectroscopy 03/26/13 02/14/05 07/16/09
Measurement of Exhaled Nitric Oxide and Exhaled Breath Condensate in the Diagnosis and Management of Asthma and Other Respiratory Disorders 03/19/13 03/13/12 03/13/12
Measurement of Lipoprotein-Associated Phospholipase A2 (Lp-PLA2) in the Assessment of Cardiovascular Risk 08/13/12 03/13/09 03/13/09
Meniscal Allografts and Collagen Meniscus Implants 08/13/12 07/21/11 07/21/11
Microarray-Based Gene Expression Testing for Cancers of Unknown Primary 03/08/13 01/15/09 10/06/11
Monitored and General Anesthesia Services 01/28/11 09/10/10 10/11/10
Monochromatic Infrared Energy (Anodyne®) 03/13/13 03/13/13 03/13/13
Multiple Sclerosis Agents Prior Authorization (Through Preferred) Program Summary 09/24/12 11/01/12 11/01/12
Novel Lipid Risk Factors in Risk Assessment and Management of Cardiovascular Disease 09/18/12 02/10/11 02/10/11
Off-Label, Approved Orphan, and Expanded Access (Compassionate Use) Drugs 06/29/12 07/30/12 07/30/12
Optical Coherence Tomography (OCT) of the Anterior Eye Segment 04/26/13 03/28/11 03/28/11
Oscillatory Devices for the Treatment of Cystic Fibrosis and other Respiratory Disorders 05/15/12 05/15/12 05/15/12
Outpatient Pulmonary Rehabilitation Programs 05/08/12 06/07/12 06/07/12
Outpatient Use of Limb Pneumatic Compression Devices for Venous Thromboembolism Prophylaxis 04/09/13 04/09/13 05/09/13
Oxycodone Extended Release (ER) 05/10/13 06/10/13 06/10/13
Oxycodone Extended Release (ER) Quantity Limit Criteria 06/01/12 07/01/12 07/01/12
Pachymetry 12/30/05 02/01/06 N/A
Panniculectomy and Abdominoplasty 03/07/11 03/07/11 03/07/11
Pediatric Growth Hormone 08/19/11 11/29/10 11/29/10
Percutaneous Intradiscal Electrothermal (IDET) Annuloplasty and Percutaneous Intradiscal Radiofrequency Annuloplasty 11/06/12 02/08/10 02/08/10
Percutaneous Vertebroplasty, Kyphoplasty and Sacroplasty 12/29/11 07/23/09 07/23/09
Periureteral Bulking Agents as a Treatment of Vesicoureteral Reflux (VUR) 01/28/11 08/17/10 09/16/10
Periurethral Bulking Agents for the Treatment of Urinary Incontinence 04/10/12 01/21/11 05/10/12
Pharmacogenomic and Metabolite Markers for Patients Treated with Thiopurines 01/15/13 11/29/10 11/29/10
Plugs for Fistula Repair 06/29/12 12/31/09 12/31/09
Positron Emission Tomography (PET) 02/08/13 09/24/12 09/24/12
Progesterone Therapy as a Technique to Reduce Preterm Birth in High-Risk Pregnancies 02/14/12 10/06/11 10/06/11
Prophylactic Mastectomy 07/13/12 10/28/11 10/28/11
Radioembolization for Primary and Metastatic Tumors of the Liver 05/10/12 05/10/12 05/10/12
Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors 03/03/11 04/01/11 04/01/11
Radiofrequency Ablation of Primary or Metastatic Liver Tumors 05/10/12 05/10/12 05/10/12
Radiofrequency Catheter Ablation of the Pulmonary Veins as Treatment for Atrial Fibrillation 01/15/13 10/08/10 11/08/10
Real-Time Intra-Fraction Target Tracking during Radiation Therapy 03/19/13 01/01/11 04/11/11
Recombinant and Autologous Platelet-Derived Growth Factors as a Treatment of Wound Healing and Other Conditions 06/05/12 06/05/12 06/05/12
Regional Nerve Blocks and General Anesthesia 09/30/05 11/01/05 11/01/05
Rhinomanometry & Acoustic/Optical Rhinometry 10/06/08 10/06/08 11/05/08
Sacral Nerve Neuromodulation / Stimulation for Pelvic Floor Dysfunction 01/15/13 03/28/12 03/28/12
Sacroiliac Joint Arthrography and Injection 01/09/12 07/27/11 07/27/11
Scanning Computerized Ophthalmic Diagnostic Imaging Devices 01/22/13 01/15/13 01/15/13
Scintimammography/Breast-Specific Gamma Imaging/Molecular Breast Imaging 01/28/11 01/28/11 02/28/11
Screening for Lung Cancer Using CT Scanning 04/26/13 04/26/13 04/26/13
Self Administered Oncology Agents 02/01/13 03/01/13 03/01/13
Sensorimotor and Neurobehavioral Status Exams for Optometric Providers 12/30/05 01/01/06 N/A
Sequencing-based Tests to Determine Trisomy 21 from Maternal Plasma DNA 05/10/13 06/10/13 06/10/13
Serologic Diagnosis of Celiac Disease 03/28/12 03/28/12 03/28/12
Serum Antibodies for the Diagnosis of Inflammatory Bowel Disease 02/25/11 03/28/11 03/28/11
Sleeve Gastrectomy 02/08/10 02/08/10 03/10/10
Small Bowel/Liver and Multivisceral Transplant 11/19/12 02/10/11 02/10/11
Spinal Cord Stimulation 04/26/13 03/28/12 04/27/12
Statin Prior Authorization 11/19/12 01/01/13 01/01/13
Stereotactic Radiosurgery and Radiotherapy 01/15/13 06/30/09 07/30/09
Sublingual Immunotherapy as a Technique of Allergen-Specific Therapy 05/07/13 06/07/13 06/07/13
Subtalar Arthroeresis 12/27/12 01/27/09 02/26/09
Surgical Treatment of Gynecomastia 02/26/13 03/15/12 03/15/12
Synagis (Respiratory Syncytial Virus [RSV]) Prior Authorization Criteria 10/26/12 12/07/09 12/07/09
Testing for Vitamin D Deficiency 12/21/11 09/29/11 09/29/11
Tissue-Engineered Skin Substitutes 01/15/13 01/15/13 01/15/13
Total Ankle Replacement 12/07/12 06/29/10 07/29/10
Total Body Plethysmography 12/29/11 07/16/09 07/16/09
Total Facet Arthroplasty 08/17/10 08/17/10 09/16/10
Transcatheter Arterial Chemoembolization (TACE) to Treat Primary or Metastatic Liver Malignancies 05/10/12 05/10/12 05/10/12
Transcranial Magnetic Stimulation (TMS) as a Treatment of Depression and Other Psychiatric Disorders 05/07/13 11/01/11 11/01/11
Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease 03/12/13 01/03/12 01/03/12
Transplantation for Chondral Defects 12/15/09 01/14/10 01/14/10
Transtympanic Micropressure Applications as a Treatment of Meniere's Disease 08/12/11 08/12/11 09/12/11
Treatment of Hyperhidrosis 01/26/10 01/26/10 01/26/10
Treatment of Tinnitus 01/15/13 08/30/12 08/30/12
Tumor Markers CA-15-3 and CA-27.29 07/01/05 07/01/03 08/01/05
Ultrafiltration in Decompensated Heart Failure 03/08/13 04/08/13 04/08/13
Ultrasonographic Measurement of Carotid Intimal-Medial Thickness as an Assessment of Subclinical Atherosclerosis 09/18/12 02/27/07 09/23/09
Uvulopalatopharyngoplasty (UPPP) and Tongue Base Reduction Surgery 03/23/09 01/01/07 01/01/07
Vacuum Assisted Wound Closure (VAC) 01/30/12 06/15/07 06/15/07
Vagus Nerve Stimulation 08/24/12 08/24/12 08/24/12
Varicose Veins 03/08/13 09/11/12 10/11/12
Video EEG Monitoring 12/29/06 02/01/07 02/01/07
Virtual Colonoscopy/CT Colonography 10/08/10 10/08/10 11/08/10
Wireless Capsule Endoscopy as a Diagnostic Technique in Disorders of the Small Bowel, Esophagus, and Colon 01/15/13 06/29/10 07/29/10
Xolair® (omalizumab) Prior Authorization Criteria 04/02/12 04/02/12 04/02/12

Dental Policies

Policy Title PDF Files Date Posted Professional Effective Date Institutional Effective Date
Cone Beam Computed Tomography (CBCT) 05/14/13 05/14/13 05/14/13
Identification of Periodontal Microorganisms 05/14/13 05/14/13 06/13/13
Periodontal Soft Tissue Grafting 12/27/12 06/27/11 06/27/11