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.


Medical Policy Information for Out-of-Area Members

To view the out-of-area Blue Plan's medical policy information, enter the first three letters of the member's identification number on the Blue Cross Blue Shield ID card, and click "GO."

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If you experience difficulties or need additional information, please contact 800-676-BLUE.


Medical Policies

To search all medical policies by keyword or CPT code, use this search tool.

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You can also filter medical policies by the first letter of the policy title using the dropdown below.

Policy Title Date Posted Professional Effective Date Institutional Effective Date
Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures
Electromyography and Nerve Conduction Studies
Elevidys® (delandistrogene moxeparvovec-rokl) (Intravenous)
Endoscopic Radiofrequency Ablation or Cryoablation for Barrett Esophagus
Esketamine Nasal Spray for Depression
Esophageal pH Monitoring
Extracorporeal Shock Wave Therapy (ESWT) for Plantar Fasciitis and Other Musculoskeletal Conditions
Extracranial Carotid Artery Stenting
Facet Joint Denervation
Filsuvez (birch triterpenes) Medical Drug Criteria
Fundus Photography
Gastric Electrical Stimulation
Gene Expression Profile Testing and Circulating Tumor DNA Testing for Predicting Recurrence in Colon Cancer
Gene Expression Profiling and Protein Biomarkers for Prostate Cancer Management
Gene Expression Profiling for Cutaneous Melanoma
Gene Expression Profiling for Uveal Melanoma
Gene Expression-Based Assays for Cancers of Unknown Primary
Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer
Genetic Cancer Susceptibility Panels Using Next Generation Sequencing
Genetic Testing for Cardiac Ion Channelopathies
Genetic Testing for Diagnosis and Management of Mental Health Conditions
Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes
Genetic Testing for Marfan Syndrome, Thoracic Aortic Aneurysms and Dissections, and Related Disorders
Genetic Testing for Predisposition to Inherited Hypertrophic Cardiomyopathy
Genetic Testing for the Diagnosis of Inherited Peripheral Neuropathies
Germline and Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment in Breast Cancer (BRCA1, BRCA2, PIK3CA, Ki-67, RET, BRAF, ESR1)
Germline Genetic Testing for Hereditary Breast/Ovarian Cancer Syndrome and Other High-Risk Cancers (BRCA1, BRCA2, PALB2)
Hemophilia A Gene Therapy Medical Drug Criteria Program Summary
Hemophilia A Gene Therapy Medical Drug Criteria Program Summary
Hemophilia B Gene Therapy Medical Drug Criteria Program Summary
Home Non-invasive Positive Airway Pressure Devices for the Treatment of Respiratory Insufficiency and Failure
Homocysteine Testing
Human Growth Hormone
Hydrogel Spacer use During Radiotherapy for Prostate Cancer
Hyperthermic Intraperitoneal Chemotherapy for Select Intra-Abdominal and Pelvic Malignancies
Identification of Microorganisms Using Nucleic Acid Testing
Immunoglobulin Therapy
Implantable Bone-Conduction and Bone-Anchored Hearing Aids
Implantable Cardioverter Defibrillators
Implanted Peripheral Nerve Stimulator (PNS) for Pain Control
Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence
Intensity Modulated Radiotherapy (IMRT)
Interventions for Progressive Scoliosis
Interventions for Progressive Scoliosis
Intra-Articular Hyaluronan Injections for Osteoarthritis
Intravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric Disorders
Intravenous Antibiotic Therapy and Associated Diagnostic Testing for Lyme Disease
Laboratory Tests Post Transplant and for Heart Failure
Leadless Cardiac Pacemakers
Lenmeldy

Dental Policies

The dental policies listed below do not contain coding information. An Availity login is required to access the dental policies with full coding information. Access Availity for dental policies with full coding information here.

Archived Policies

No review or update is scheduled on these Medical Policies. If there are questions about coverage of this service, please contact Blue Cross and Blue Shield of Kansas customer service, your professional or institutional relations representative, or submit a predetermination request.