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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 12/11/13 05/27/13 05/27/13
Acne Surgery 08/20/13 09/19/13 09/19/13
Acoustic Pharyngometers & SNAP Testing 10/06/08 10/06/08 11/05/08
Actigraphy 06/07/13 10/19/09 10/19/09
Acute and Maintenance Subcutaneous and Intravenous Tocolysis 12/31/13 01/09/12 01/09/12
Adjustable Cranial Orthoses for Positional Plagiocephaly and Craniosynostoses 08/06/13 09/05/13 09/05/13
Alcohol Injection Therapy for Morton’s Neuroma 04/26/13 06/03/11 06/03/11
Ambulatory Blood Pressure Monitoring 12/31/13 12/07/12 12/07/12
Ambulatory Event Monitors and Mobile Outpatient Cardiac Telemetry 09/03/14 09/03/14 09/03/14
Ampyra™ (dalfampridine) 07/29/14 08/28/14 08/28/14
Androgens and Anabolic Steroids 08/12/14 08/15/14 08/15/14
Anodyne® - Skin Contact Monochromatic Infrared Energy as a Technique to Treat Cutaneous Ulcers, Diabetic Neuropathy, and Miscellaneous Musculoskeletal Conditions
replaces Monochromatic Infrared Energy (Anodyne®)
09/30/14 03/13/13 03/13/13
Antidepressant Agents 09/17/14 09/17/14 09/17/14
Antihypertensive Medications 09/17/14 04/01/14 04/01/14
Aqueous Shunts and Stents for Glaucoma 12/31/13 01/30/14 01/30/14
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 09/25/13 09/25/13 09/25/13
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 09/05/13 08/01/11 08/01/11
Barrett's Esophagus Ablative Treatments 12/31/13 02/15/13 02/15/13
Benlysta® (belimumab) Prior Authorization 12/29/11 07/01/11 02/01/12
Bio-Engineered Skin and Soft Tissue Substitutes 12/31/13 01/01/14 01/01/14
Biologic Immunomodulators Therapy 09/03/14 10/01/14 10/01/14
Bone Mineral Density Studies 10/04/13 10/04/13 10/04/13
Botulinum Toxin (BT) 04/15/14 04/15/14 04/15/14
BRCA1 and BRCA2 Testing 07/29/14 08/28/14 08/28/14
Breast Reconstructive Surgery after Mastectomy 12/11/13 12/11/13 12/11/13
Bronchial Thermoplasty 12/11/13 02/10/11 03/14/11
Cardiac Computed Tomography (CT) 02/28/14 09/11/12 09/11/12
Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting 10/31/13 09/10/10 10/11/10
Cardiac Rehabilitation Programs 07/15/14 07/15/14 07/15/14
Cardiovascular Magnetic Resonance (CMR) 07/15/14 07/15/14 07/15/14
Cardioverter-Defibrillators 12/31/13 04/08/13 04/08/13
Charged-Particle (Proton or Helium Ion) Radiation Therapy 12/11/13 08/06/13 08/06/13
Chelation Therapy 02/28/14 03/31/14 03/31/14
Cochlear Implant 09/12/14 10/13/14 10/13/14
Computed Tomographic Angiography (CTA) and Magnetic Resonance Angiography (MRA) of the Chest (excluding the heart) 02/28/14 12/15/08 12/15/08
Computed Tomographic Angiography (CTA) and Magnetic Resonance Angiography (MRA) of the Head, Neck, Abdomen, Pelvis, and Extremities 02/05/14 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 09/05/13 10/04/13 10/04/13
Continuous Passive Motion for Home Use 09/17/13 03/07/12 03/08/10
Contrast-Enhanced Computed Tomography Angiography (CTA) for Coronary Artery Evaluation 12/31/13 12/09/11 12/09/11
Corneal Topography/Computer-Assisted Corneal Topography/Photokeratoscopy 07/12/13 12/09/11 12/09/11
COX-2 Inhibitor (Celebrex®) 09/17/14 10/17/14 10/17/14
Cryosurgical Ablation of Primary or Metastatic Liver Tumors 03/26/13 05/10/12 05/10/12
Cytochrome p450 Genotyping 02/28/14 03/31/14 03/31/14
Cytoreduction and Hyperthermic Intraperitoneal Chemotherapy for the Treatment of Peritoneal Carcinomatosis of Gastrointestinal Origin 02/28/14 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 09/17/13 09/17/13 09/17/13
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 10/08/13 01/30/12 01/30/12
Diagnosis and Treatment of Sacroiliac Joint Pain 08/12/14 09/11/14 09/11/14
Digital Breast Tomosynthesis 09/17/13 10/11/12 10/11/12
Dynamic Posturography 12/31/13 01/30/14 01/30/14
Electrical Bone Growth Stimulation of the Appendicular Skeleton 02/05/14 03/07/14 03/07/14
Electrical Stimulation Devices for Home Use 10/06/14 11/05/14 11/05/14
Electrical Stimulation Devices for Home Use 12/31/13 12/31/13 12/31/13
Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures 10/30/13 10/30/13 10/30/13
Electromyography (EMG), Nerve Conduction Studies (NCS), and Other Electrodiagnostic (EDX) Related Services 07/29/14 04/12/13 04/12/13
Enhanced External Counterpulsation (EECP) 02/05/14 11/01/07 11/01/07
Epidermal Growth Factor Receptor Mutation Analysis for Patients with Non-Small Cell Lung Cancer 08/29/14 09/28/14 09/28/14
Equipment for Cold Therapy 05/07/13 10/04/12 10/04/12
Esophageal pH Monitoring 09/17/13 10/11/11 10/11/11
Extracorporeal Shock Wave Therapy (ESWT) for Plantar Fasciitis and Other Musculoskeletal Conditions 04/15/14 04/15/14 04/15/14
Extracranial Carotid Angioplasty/Stenting 12/31/13 07/01/07 07/01/07
Eye Movement Desensitization and Reprocessing (EMDR) for Acute Stress Disorder and Post Traumatic Stress Disorder (PTSD) 08/21/13 11/01/07 11/01/07
Facet Joint Denervation (Cervical and Lumbar) 10/31/13 12/02/13 12/02/13
Fetal Fibronectin 09/25/13 10/25/13 10/25/13
First-Trimester Detection of Down Syndrome Using Fetal Ultrasound Markers Combined with Maternal Serum Assessment 09/12/13 06/07/12 06/07/12
Foot Care Services 12/31/13 06/07/13 06/07/13
Functional Neuromuscular Electrical Stimulation for Home Use 06/07/13 06/07/13 06/07/13
Fundus Photography 12/11/13 07/25/12 07/25/12
Gastric Electrical Stimulation 10/31/13 12/02/13 12/02/13
Gene-Based Tests for Screening, Detection, and/or Management of Prostate Cancer 08/20/13 02/11/11 02/11/11
Gene Expression Assay for Breast Cancer Treatment 02/25/14 03/27/14 03/27/14
General Approach to Evaluating the Utility of Genetic Panels 01/08/14 02/07/14 02/07/14
General Approach to Genetic Testing 01/08/14 02/07/14 02/07/14
Genetic Cancer Susceptibility Panels Using Next Generation Sequencing 01/08/14 02/07/14 02/07/14
Genetic Testing for Cardiac Ion Channelopathies
replaces Genetic Testing for Congenital Long QT Syndrome
02/28/14 03/31/14 03/31/14
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 08/21/13 03/26/13 03/26/13
Genetic Testing for Predisposition to Inherited Hypertrophic Cardiomyopathy 12/31/13 04/08/13 04/08/13
Genetic Testing for Tamoxifen Treatment 09/25/13 10/26/10 11/29/10
Genetic Testing for the Diagnosis of Inherited Peripheral Neuropathies 07/24/13 08/23/13 08/23/13
Genetic Testing for Warfarin Dose 03/19/13 10/26/10 11/29/10
Glucose Test Strips/Disks and Meters 12/02/13 01/01/14 01/01/14
Hepatitis B / Oncology and Hepatitis C Agents (Pegasys®/Pegasys Proclick®/peginterferon alfa-2a, PegIntron®/peginterferon alfa-2b, Incivek™/telaprevir, Olysio™ (simeprevir), Sovaldi™/sofosbuvir, and Victrelis™/boceprevir) 08/12/14 06/15/14 06/15/14
Hepatitis C Second Generation Antivirals – Through Preferred Pegylated Interferon (2014) (ledipasvir/sofosbuvir, paritaprevir/ritonavir/ombitasvir + dasabuvir, and Sovaldi [sofosbuvir]) 10/02/14 10/01/14 10/01/14
Hereditary Angioedema (Berinert, Cinryze, Firazyr, Kalbitor) 04/24/14 04/01/14 04/01/14
High-Sensitivity C-Reactive Protein 10/31/13 01/30/12 01/30/12
Home Phototherapy 12/11/13 04/01/07 04/01/07
Home Prothrombin Time Monitoring 08/20/13 09/18/09 10/19/09
Home Uterine Activity Monitoring 12/07/12 03/08/10 04/07/10
Homocysteine Testing 03/31/14 08/17/10 09/16/10
H.P. Acthar Gel (repository corticotropin) 05/22/13 05/22/13 05/22/13
Human Growth Hormone
replaces Adult Growth Hormone
replaces Pediatric Growth Hormone
12/31/13 01/30/14 01/30/14
Hyperbaric Oxygen Pressurization (HBO) 02/25/14 03/27/14 03/27/14
Identification of Microorganisms Using Nucleic Acid Probes 11/12/13 11/12/13 11/12/13
Image-Guided Minimally Invasive Lumbar Decompression (IG-MLD) for Spinal Stenosis 07/12/13 09/30/10 05/23/11
Implantable Bone-Conduction and Bone-Anchored Hearing Aids 08/15/14 08/15/14 08/15/14
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 08/20/13 03/28/12 04/27/12
Insulin Pump 01/21/14 12/14/12 N/A
Intensity Modulated Radiation Therapy (IMRT) 12/11/13 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 03/25/14 05/01/14 05/01/14
Intravenous and Subcutaneous Immune Globulin Therapy 09/12/14 09/12/14 09/12/14
Intravenous Antibiotic Therapy and Associated Diagnostic Testing for Lyme Disease 02/28/14 04/12/12 04/12/12
In Vitro Chemoresistance and Chemosensitivity Assays 09/25/13 09/20/11 10/20/11
Kalydeco™ (ivacaftor) 08/12/14 08/12/14 08/12/14
Keratoprosthesis 02/05/14 11/19/12 11/19/12
Ketogenic Diet as a Treatment of Refractory Epilepsy 02/28/14 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 10/16/13 10/16/13 10/16/13
Laser Assisted Uvulopalatopharyngoplasty (LAUP) 12/30/05 02/01/06 02/01/06
LASIK (laser in situ keratomileusis) 02/05/14 02/15/07 12/01/07
Low-Level Laser Therapy 03/12/13 03/12/13 03/12/13
Lumbar Spinal Fusion
replaces Lumbar Spine Fusion Surgery
10/01/14 10/31/14 10/31/14
Lumbar Spine Fusion Surgery 06/07/13 07/08/13 07/08/13
Lysis of Epidural Adhesions 08/15/14 02/08/10 02/08/10
Magnetic Resonance Imaging (MRI) Breast 09/12/13 12/07/12 12/07/12
Magnetic Resonance Spectroscopy 09/17/14 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 10/31/13 03/13/09 03/13/09
Measurement of Serum Antibodies to Infliximab 06/07/13 06/07/13 07/08/13
Meniscal Allografts and Other Meniscus Implants 09/17/13 09/17/13 09/17/13
Microarray-Based Gene Expression Testing for Cancers of Unknown Primary 01/21/14 01/15/09 10/06/11
Molecular Panel Testing of Cancers to Identify Targeted Therapies 08/06/14 09/05/14 09/05/14
Monitored and General Anesthesia Services 02/05/14 09/10/10 10/11/10
Multiple Sclerosis Agents 07/15/14 04/01/14 04/01/14
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 09/25/13 07/30/12 07/30/12
Optical Coherence Tomography (OCT) of the Anterior Eye Segment 04/26/13 03/28/11 03/28/11
Oral Immunotherapy Agents (Grastek®, Oralair®, Ragwitek™)
replaces Sublingual Immunotherapy as a Technique of Allergen-Specific Therapy
10/02/14 11/01/14 11/01/14
Orthopedic Applications of Stem-Cell Therapy 08/20/13 09/19/13 09/19/13
Oscillatory Devices for the Treatment of Cystic Fibrosis and other Respiratory Disorders 12/31/13 05/15/12 05/15/12
Outpatient Pulmonary Rehabilitation Programs 07/12/13 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
Pachymetry 12/11/13 07/30/13 07/30/13
Panniculectomy and Abdominoplasty 02/28/14 03/07/11 03/07/11
Percutaneous Intradiscal Electrothermal (IDET) Annuloplasty and Percutaneous Intradiscal Radiofrequency Annuloplasty 11/06/12 02/08/10 02/08/10
Percutaneous Left-Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation 11/22/13 12/23/13 12/23/13
Percutaneous Vertebroplasty, Kyphoplasty and Sacroplasty 12/31/13 12/31/13 12/31/13
Periureteral Bulking Agents as a Treatment of Vesicoureteral Reflux (VUR) 12/31/13 08/17/10 09/16/10
Periurethral Bulking Agents for the Treatment of Urinary and Fecal Incontinence 12/31/13 08/19/13 08/19/13
Pharmacogenomic and Metabolite Markers for Patients Treated with Thiopurines 02/28/14 11/29/10 11/29/10
Plugs for Fistula Repair 10/31/13 12/31/09 12/31/09
Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers (for Home Use) 06/07/13 06/07/13 07/08/13
Positron Emission Tomography (PET) Scanning: Cardiac Applications 10/30/13 10/30/13 10/30/13
Positron Emission Tomography (PET) Scanning: In Oncology to Detect Early Response during Treatment 10/16/13 09/24/12 09/24/12
Positron Emission Tomography (PET) Scanning: Miscellaneous (Non-cardiac, Non-oncologic) Applications 12/31/13 10/30/13 10/30/13
Positron Emission Tomography (PET) Scanning: Oncologic Applications 10/30/13 10/30/13 10/30/13
Posterior Tibial Nerve Stimulation 10/06/14 10/06/14 10/06/14
Progesterone Therapy as a Technique to Reduce Preterm Birth in High-Risk Pregnancies 02/28/14 03/31/14 03/31/14
Prophylactic Mastectomy 10/30/13 11/29/13 11/29/13
Radioembolization for Primary and Metastatic Tumors of the Liver 11/12/13 12/12/13 12/12/13
Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors 12/11/13 04/01/11 04/01/11
Radiofrequency Ablation of Primary or Metastatic Liver Tumors 08/21/13 05/10/12 05/10/12
Radiofrequency Catheter Ablation of the Pulmonary Veins as Treatment for Atrial Fibrillation 06/14/13 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 02/05/14 06/05/12 06/05/12
Regional Nerve Block and General Anesthesia 02/05/14 11/01/05 11/01/05
Rhinomanometry & Acoustic/Optical Rhinometry 09/25/13 10/06/08 11/05/08
Sacral Nerve Neuromodulation / Stimulation for Pelvic Floor Dysfunction 09/17/14 10/16/13 10/16/13
Scanning Computerized Ophthalmic Diagnostic Imaging Devices 07/30/13 07/30/13 07/30/13
Scintimammography/Breast-Specific Gamma Imaging/Molecular Breast Imaging 09/17/13 01/28/11 02/28/11
Screening for Lung Cancer Using CT Scanning 10/01/14 10/01/14 10/01/14
Self Administered Oncology Agents 07/29/14 08/28/14 08/28/14
Sensorimotor and Neurobehavioral Status Exams for Optometric Providers 09/05/13 01/01/06 N/A
Sequencing-based Tests to Determine Trisomy 21 from Maternal Plasma DNA 12/31/13 06/10/13 06/10/13
Serologic Diagnosis of Celiac Disease 07/12/13 03/28/12 03/28/12
Serum Antibodies for the Diagnosis of Inflammatory Bowel Disease 10/31/13 03/28/11 03/28/11
Serum Tumor Markers for Breast and Gastrointestinal Malignancies
replaces Tumor Markers CA-15-3 and CA-27.29
02/25/14 03/27/14 03/27/14
Small Bowel/Liver and Multivisceral Transplant 02/28/14 02/10/11 02/10/11
Spinal Cord Stimulation 04/26/13 03/28/12 04/27/12
Statin Therapy 12/02/13 01/01/14 01/01/14
Stereotactic Radiosurgery and Radiotherapy 02/25/14 03/27/14 03/27/14
Sublingual Immunotherapy as a Technique of Allergen-Specific Therapy 07/18/14 08/18/14 08/18/14
Subtalar Arthroeresis 12/27/12 01/27/09 02/26/09
Surgical Treatment of Femoroacetabular Impingement 10/15/14 11/15/14 11/15/14
Surgical Treatment of Gynecomastia 12/31/13 03/15/12 03/15/12
Synagis 09/09/14 10/09/14 10/09/14
Temporomandibular Joint (TMJ) Dysfunction 10/01/14 10/01/14 10/01/14
Testing for Vitamin D Deficiency 02/05/14 02/05/14 02/05/14
Total Ankle Replacement 02/05/14 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 11/12/13 05/10/12 05/10/12
Transcranial Magnetic Stimulation (TMS) as a Treatment of Depression and Other Psychiatric Disorders 10/15/14 10/15/14 10/15/14
Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease 12/31/13 01/03/12 01/03/12
Transplantation for Chondral Defects 02/25/14 03/27/14 03/27/14
Transtympanic Micropressure Applications as a Treatment of Meniere's Disease 08/12/11 08/12/11 09/12/11
Treatment of Hyperhidrosis 02/28/14 03/31/14 03/31/14
Treatment of Tinnitus 11/12/13 08/30/12 08/30/12
Tysabri (natalizumab) 12/02/13 01/01/14 01/01/14
Ultrafiltration in Decompensated Heart Failure 09/03/14 09/03/14 09/03/14
Ultrasonographic Measurement of Carotid Intimal-Medial Thickness as an Assessment of Subclinical Atherosclerosis 09/18/12 02/27/07 09/23/09
Ultraviolet Light Therapy for Skin Conditions 08/29/14 09/28/14 09/28/14
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 06/26/13 08/24/12 08/24/12
Varicose Veins 03/08/13 09/11/12 10/11/12
Vertebral Fracture Assessment with Densitometry 10/30/13 11/29/13 11/29/13
Video EEG Monitoring 01/21/14 02/20/14 02/20/14
Virtual Colonoscopy/CT Colonography 09/17/13 10/08/10 11/08/10
Wireless Capsule Endoscopy as a Diagnostic Technique in Disorders of the Small Bowel, Esophagus, and Colon 12/11/13 01/10/14 01/10/14
Xolair® (omalizumab) 08/12/14 08/15/14 08/15/14

Dental Policies

Policy Title PDF Files Date Posted Professional Effective Date Institutional Effective Date
Cone Beam Computed Tomography (CBCT) 12/31/13 05/14/13 05/14/13
Identification of Periodontal Microorganisms 12/31/13 05/14/13 06/13/13
Periodontal Soft Tissue Grafting 12/31/13 06/27/11 06/27/11
Temporomandibular Joint (TMJ) Dysfunction 10/01/14 10/01/14 10/01/14