Availity Login

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."

Type of information being requested

Please select one at a time

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


Search Newsletters and Medical Review

Medical Policies

Policy Title PDF Files Date Posted Professional Effective Date Institutional Effective Date
ACA Prevention Copay Waiver Criteria – Individual Marketplace, Commercial 12/01/18 12/01/18 12/01/18
Accelerated Breast Irradiation and Brachytherapy Boost After Breast-Conserving Surgery for Early Stage Breast Cancer 09/12/18 10/12/18 10/12/18
Actigraphy 08/15/18 07/10/15 07/10/15
Actimmune (interferon gamma-1b) 09/12/18 06/10/16 06/10/16
Adjustable Cranial Orthoses for Positional Plagiocephaly and Craniosynostoses 04/11/18 09/05/13 09/05/13
Alcohol Injection Therapy for Morton’s Neuroma 08/15/18 06/03/11 06/03/11
Ambulatory Event Monitors and Mobile Cardiac Outpatient Telemetry 01/01/19 07/23/18 07/23/18
Amniotic Membrane and Amniotic Fluid 02/18/19 02/18/19 02/18/19
Analysis of Human DNA in Stool Samples as a Technique for Colorectal Cancer Screening 01/04/19 01/01/17 01/01/17
Anodyne® - Skin Contact Monochromatic Infrared Energy as a Technique to Treat Cutaneous Ulcers, Diabetic Neuropathy, and Miscellaneous Musculoskeletal Conditions 03/01/18 03/13/13 03/13/13
Aqueous Shunts and Stents for Glaucoma 07/01/17 11/09/16 11/09/16
Artificial Intervertebral Disc: Cervical Spine 05/23/18 10/12/16 10/12/16
Artificial Intervertebral Disc: Lumbar Spine 05/23/18 09/23/08 09/23/08
Artificial Pancreas Device Systems 01/04/19 11/07/18 11/07/18
Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer 01/04/19 02/01/19 02/01/19
Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions 06/06/18 07/06/18 07/06/18
Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions 05/23/18 05/10/17 05/10/17
Automated Ambulatory Blood Pressure Monitoring for the Diagnosis of Hypertension in Patients With Elevated Office Blood Pressure 09/12/18 12/07/12 12/07/12
Automated Percutaneous and Percutaneous Endoscopic Discectomy 01/30/19 06/09/17 06/09/17
Automated Point-of-Care Devices for Nerve Conduction Testing 10/26/18 10/26/18 10/26/18
Balloon Sinuplasty for Treatment of Chronic Sinusitis 03/14/18 11/11/16 11/11/16
Bio-Engineered Skin and Soft Tissue Substitutes 01/01/19 01/01/19 01/01/19
Bone Mineral Density Studies 02/01/19 03/04/19 03/04/19
Botulinum Toxin (BT) 11/20/18 11/20/18 11/20/18
BRCA1 and BRCA2 Testing 03/13/19 04/12/19 04/12/19
BRCA1 and BRCA2 Testing 01/01/19 03/17/18 03/17/18
Breast Reconstructive Surgery After Mastectomy 01/16/19 02/15/18 02/15/18
Bronchial Thermoplasty 08/15/18 02/10/11 03/14/11
Cardiac Computed Tomography (CT) 10/01/16 09/11/12 09/11/12
Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting 01/01/19 09/03/16 09/03/16
Cardiac Rehabilitation in the Outpatient Setting 04/11/18 08/18/17 08/18/17
Cardiovascular Magnetic Resonance (CMR) 10/01/18 07/15/14 07/15/14
Catheter Ablation as Treatment for Atrial Fibrillation
replaces Radiofrequency Catheter Ablation of the Pulmonary Veins as Treatment for Atrial Fibrillation
06/22/18 10/27/15 10/27/15
Charged-Particle (Proton or Helium Ion) Radiotherapy for Neoplastic Conditions 08/29/18 04/12/17 04/12/17
Chelation Therapy for Off-Label Uses 04/11/18 08/19/16 08/19/16
Chronic Intermittent Intravenous Insulin Therapy 03/28/18 12/09/16 12/09/16
Circulating Tumor DNA Management of Non-Small-Cell Lung Cancer (Liquid Biopsy) 11/20/18 12/21/18 12/21/18
Cochlear Implant 03/28/18 03/15/17 03/15/17
Computed Tomographic Angiography (CTA) and Magnetic Resonance Angiography (MRA) of the Head, Neck, Abdomen, Pelvis, and Lower Extremities 10/01/18 01/13/16 01/13/16
Computed Tomography (CT) to Detect Coronary Artery Calcification 11/15/17 11/14/08 11/14/08
Continuous or Intermittent Monitoring of Glucose in Interstitial Fluid 01/16/19 05/11/18 05/11/18
Continuous Passive Motion in the Home Setting 04/11/18 09/16/16 09/16/16
Contrast-Enhanced Coronary Computed Tomography Angiography (CCTA) for Coronary Artery Evaluation
replaces Contrast-Enhanced Computed Tomography Angiography (CTA) for Coronary Artery Evaluation
11/07/18 12/21/16 12/21/16
Corneal Collagen Cross-Linking 01/01/19 08/01/18 08/01/18
Corneal Topography/Computer-Assisted Corneal Topography/Photokeratoscopy 04/11/18 12/09/11 12/09/11
Coronary Computed Tomography Angiography with Selective Noninvasive Fractional Flow Reserve 09/12/18 10/15/17 10/15/17
Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate, or Dermatologic Tumors 02/01/19 03/04/19 03/04/19
Cryosurgical Ablation of Primary or Metastatic Liver Tumors 09/12/18 06/12/15 06/12/15
Cytochrome p450 Genotyping 10/01/16 03/31/14 03/31/14
Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Select Intra-Abdominal and Pelvic Malignancies replaces Cytoreductive Surgery and Perioperative Intraperitoneal Chemotherapy for Select Intra-Abdominal and Pelvic Malignancies 03/13/19 04/12/19 04/12/19
Cytoreductive Surgery and Perioperative Intraperitoneal Chemotherapy for Select Intra-Abdominal and Pelvic Malignancies 08/15/17 09/15/16 09/15/16
Decompression of the Intervertebral Disc Using Laser Energy (Laser Discectomy) or Radiofrequency Coblation (Nucleoplasty) 05/23/18 02/08/10 02/08/10
Deep Brain Stimulation 01/01/19 05/24/17 05/24/17
Denosumab (Prolia and Xgeva) 05/10/17 05/10/17 05/10/17
Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome 09/16/15 08/30/12 08/30/12
Diagnosis and Treatment of Chronic Cerebrospinal Venous Insufficiency in Multiple Sclerosis 07/01/17 08/01/17 08/01/17
Diagnosis and Treatment of Sacroiliac Joint Pain 01/16/19 01/16/19 01/16/19
Drug Testing in Pain Management and Substance Use Disorder Treatment 01/01/19 02/15/18 02/15/18
Dry Needling of Myofascial Trigger Points 06/09/17 01/01/17 01/01/17
Dynamic Posturography 03/14/18 06/10/16 06/10/16
Electrical Bone Growth Stimulation of the Appendicular Skeleton 05/23/18 10/17/16 10/17/16
Electrical Stimulation Devices for Home Use 10/01/17 09/05/16 09/05/16
Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures 11/07/18 06/09/17 06/09/17
Electromyography (EMG), Nerve Conduction Studies (NCS), and Other Electrodiagnostic (EDX) Related Services 10/01/18 04/12/13 04/12/13
Electronic Brachytherapy for Nonmelanoma Skin Cancer 09/12/18 09/14/17 09/14/17
Endoscopic Radiofrequency Ablation or Cryoablation for Barrett Esophagus 02/18/19 04/25/16 04/25/16
Enhanced External Counterpulsation (EECP) 06/22/18 11/01/07 11/01/07
Equipment for Cold Therapy 07/11/17 07/11/17 07/11/17
Esophageal pH Monitoring 01/30/19 01/30/19 01/30/19
Eteplirsen (Exondys 51) for Duchenne Muscular Dystrophy 03/13/19 01/19/17 01/19/17
Expanded Molecular Panel Testing of Cancers to Identify Targeted Therapies 01/01/19 01/20/17 01/20/17
Extracorporeal Shock Wave Therapy (ESWT) for Plantar Fasciitis and Other Musculoskeletal Conditions 08/01/18 08/10/17 08/10/17
Extracranial Carotid Artery Stenting
replaces Extracranial Carotid Angioplasty/Stenting
07/18/18 10/25/17 10/25/17
Eye Movement Desensitization and Reprocessing (EMDR) for Acute Stress Disorder and Post Traumatic Stress Disorder (PTSD) 05/09/18 11/01/07 11/01/07
Facet Joint Denervation 01/04/19 06/11/18 06/11/18
Fetal Fibronectin 11/09/16 11/09/16 11/09/16
Foot Care Services 03/14/18 06/07/13 06/07/13
Fundus Photography 11/07/18 04/28/17 04/28/17
Gastric Electrical Stimulation 04/11/18 12/02/13 12/02/13
Gene Expression-Based Assays for Cancers of Unknown Primary 05/09/18 01/01/16 01/01/16
Gene Expression Profiling and Protein Biomarkers for Prostate Cancer Management 06/22/18 02/19/16 02/19/16
Gene Expression Profiling for Cutaneous Melanoma 02/01/19 07/23/18 07/23/18
Gene Expression Profiling for Uveal Melanoma 01/01/19 03/15/17 03/15/17
General Approach to Evaluating the Utility of Genetic Panels 10/01/17 03/25/16 03/25/16
General Approach to Genetic Testing 12/29/16 03/25/16 03/25/16
Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer
replaces Gene-Based Tests for Screening, Detection, and/or Management of Prostate Cancer
02/27/19 02/27/19 02/27/19
Genetic Cancer Susceptibility Panels Using Next Generation Sequencing 11/07/18 02/07/14 02/07/14
Genetic Testing for Cardiac Ion Channelopathies 12/29/16 03/31/14 03/31/14
Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes 02/18/19 02/18/19 02/18/19
Genetic Testing for Marfan Syndrome, Thoracic Aortic Aneurysms and Dissections, and Related Disorders 03/28/18 03/28/18 03/28/18
Genetic Testing for Predisposition to Inherited Hypertrophic Cardiomyopathy 04/11/18 05/11/18 05/11/18
Genetic Testing for the Diagnosis of Inherited Peripheral Neuropathies 12/29/17 02/15/18 02/15/18
Genetic Testing for Warfarin Dose 09/01/17 10/26/10 11/29/10
Genotype-Guided Tamoxifen Treatment
replaces Genetic Testing for Tamoxifen Treatment
09/12/18 11/09/16 11/09/16
High-Sensitivity C-Reactive Protein 12/01/16 01/30/12 01/30/12
Home Prothrombin Time Monitoring 12/01/16 09/18/09 10/19/09
Homocysteine Testing 10/01/17 08/17/10 09/16/10
Human Growth Hormone 12/05/18 08/18/17 08/18/17
Hyperbaric Oxygen Therapy (HBOT) 02/15/18 11/12/15 11/12/15
Identification of Microorganisms Using Nucleic Acid Testing
replaces Identification of Microorganisms Using Nucleic Acid Probes
10/01/17 03/20/17 03/20/17
Image-Guided Minimally Invasive Decompression for Spinal Stenosis 05/23/18 07/10/17 07/10/17
Implantable Bone-Conduction and Bone-Anchored Hearing Aids 03/28/18 03/01/18 03/01/18
Implantable Cardioverter Defibrillators 07/18/18 07/11/17 07/11/17
Implanted Peripheral Nerve Stimulator (PNS) for Pain Control 05/09/18 04/01/16 04/01/16
Influenza Virus Diagnostic Testing and Treatment in the Outpatient Setting 01/16/19 03/04/16 03/04/16
Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence 10/01/18 11/01/18 11/01/18
Insulin Pump 01/16/19 03/31/16 N/A
Intensity Modulated Radiotherapy (IMRT) 10/01/18 10/13/15 10/13/15
Interspinous and Interlaminar Stabilization / Distraction Devices (Spacers) 02/01/19 02/01/19 02/01/19
Interspinous Fixation (Fusion) Devices 06/06/18 01/23/15 01/23/15
Intra-Articular Hyaluronan Injections for Osteoarthritis 01/01/19 07/22/16 07/22/16
Intravenous and Subcutaneous Immune Globulin Therapy 11/07/18 08/20/15 08/20/15
Intravenous Antibiotic Therapy and Associated Diagnostic Testing for Lyme Disease 11/20/18 02/01/17 02/01/17
In Vitro Chemoresistance and Chemosensitivity Assays 09/12/18 09/12/18 09/12/18
Keratoprosthesis 10/01/17 08/20/15 08/20/15
KIF6 Genotyping for Predicting Cardiovascular Risk and/or Effectiveness of Statin Therapy 08/01/18 03/10/11 04/11/11
KRAS, NRAS, and BRAF Variant Analysis in Metastatic Colorectal Cancer 08/29/18 01/30/18 01/30/18
Laboratory Tests for Heart and Kidney Transplant Rejection 11/20/18 12/20/18 12/20/18
Laboratory Tests for Heart Transplant Rejection 09/12/18 09/12/18 09/12/18
LASIK (laser assisted in situ keratomileusis) 06/08/16 02/15/07 12/01/07
Low-Level Laser Therapy 11/12/18 11/12/18 11/12/18
Lumbar Spinal Fusion 08/15/18 08/15/18 08/15/18
Lysis of Epidural Adhesions 01/16/19 02/08/10 02/08/10
Magnetic Resonance Imaging (MRI) of the Breast 01/01/19 07/08/15 07/08/15
Magnetic Resonance Spectroscopy 12/19/18 02/14/05 07/16/09
Measurement of Exhaled Nitric Oxide and Exhaled Breath Condensate in the Diagnosis and Management of Respiratory Disorders 03/13/19 03/13/19 03/13/19
Measurement of Lipoprotein-Associated Phospholipase A2 in the Assessment of Cardiovascular Risk 03/13/19 03/13/09 03/13/09
Measurement of Serum Antibodies to Infliximab and Adalimumab 02/27/19 01/23/15 01/23/15
Meniscal Allografts and Other Meniscus Implants 05/23/18 03/04/15 03/04/15
Microwave Tumor Ablation 01/01/19 01/01/18 02/15/18
Miscellaneous Genetic and Molecular Diagnostic Tests 01/01/19 10/12/18 10/12/18
Molecular Analysis for Targeted Therapy of Non-Small-Cell Lung Cancer 01/04/19 02/01/19 02/01/19
Molecular Markers in Fine Needle Aspirates of the Thyroid 01/01/19 09/14/18 09/14/18
Molecular Testing for the Management of Pancreatic Cysts or Barrett’s Esophagus
replaces PathFinderTG® Molecular Testing
11/20/18 12/20/18 12/20/18
Monitored Anesthesia Care 10/01/18 01/01/17 01/01/17
Multigene Expression Assay for Predicting Recurrence in Colon Cancer 10/01/18 03/04/16 03/04/16
Noninvasive Prenatal Screening for Fetal Aneuploidies and Microdeletions Using Cell-Free Fetal DNA
replaces Noninvasive Prenatal Testing for Fetal Aneuploidies and Microdeletions Using Cell-Free Fetal DNA
10/01/18 10/01/18 10/01/18
Noninvasive Techniques for the Evaluation and Monitoring of Patients with Chronic Liver Disease 03/13/19 03/13/19 03/13/19
Novel Biomarkers in Risk Assessment and Management of Cardiovascular Disease 03/13/19 03/28/18 03/28/18
Off-Label, Approved Orphan, and Expanded Access (Compassionate Use) Drugs 05/10/17 12/07/15 12/07/15
Open and Thoracoscopic Approaches to Treat Atrial Fibrillation and Atrial Flutter (Maze and Related Procedures) 07/09/18 08/08/18 08/08/18
Optical Coherence Tomography (OCT) of the Anterior Eye Segment 11/20/18 12/03/18 12/03/18
Orthopedic Applications of Platelet-Rich Plasma 05/23/18 10/29/15 10/29/15
Orthopedic Applications of Stem-Cell Therapy 02/18/19 02/18/19 02/18/19
Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Disorders 01/01/19 08/17/18 08/17/18
Outpatient Pulmonary Rehabilitation 05/09/18 07/20/16 07/20/16
Pachymetry 01/16/19 08/19/15 08/19/15
Panniculectomy and Abdominoplasty 02/18/19 03/07/11 03/07/11
PathFinderTG® Molecular Testing 10/25/17 08/17/16 08/17/16
Percutaneous Balloon Kyphoplasty, Radiofrequency Kyphoplasty, and Mechanical Vertebral Augmentation 05/23/18 10/28/17 10/28/17
Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, and Biacuplasty 03/01/18 02/15/17 02/15/17
Percutaneous Left Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation 10/01/18 08/08/18 08/08/18
Percutaneous Vertebroplasty and Sacroplasty 08/01/18 01/19/18 01/19/18
Periureteral Bulking Agents as a Treatment of Vesicoureteral Reflux (VUR) 10/01/18 08/17/10 09/16/10
Pharmacogenomic and Metabolite Markers for Patients Treated with Thiopurines 12/20/17 11/05/15 11/05/15
Photodynamic Therapy for Choroidal Neovascularization 01/01/19 07/01/17 07/01/17
Plugs for Anal Fistula Repair 02/27/19 12/14/15 12/14/15
Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers (for Home Use) 05/09/18 04/28/17 04/28/17
Positron Emission Tomography (PET) Scanning: Cardiac Applications 10/26/18 11/26/18 11/26/18
Positron Emission Tomography (PET) Scanning: In Oncology to Detect Early Response During Treatment 10/26/18 11/26/18 11/26/18
Positron Emission Tomography (PET) Scanning: Miscellaneous (Non-cardiac, Non-Oncologic) Applications of Fluorine 18 Fluorodeoxyglucose 10/26/18 11/26/18 11/26/18
Positron Emission Tomography (PET) Scanning: Oncologic Applications 01/18/19 02/18/19 02/18/19
Posterior Tibial Nerve Stimulation 10/01/18 08/08/18 08/08/18
Postsurgical Home Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis
replaces Postsurgical Outpatient Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis
04/11/18 12/01/16 12/01/16
Progesterone Therapy as a Technique to Reduce Preterm Birth in High-Risk Pregnancies 11/07/18 11/07/18 11/07/18
Prostatic Urethral Lift 11/07/18 11/07/18 11/07/18
Proteomic Testing for Systemic Therapy in Non-Small-Cell Lung Cancer 01/04/19 10/01/15 10/01/15
Radioembolization for Primary and Metastatic Tumors of the Liver 08/15/17 03/10/16 03/10/16
Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors 11/07/18 12/07/18 12/07/18
Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors 12/20/17 11/11/16 11/11/16
Radiofrequency Ablation of Primary or Metastatic Liver Tumors 09/01/16 10/01/16 10/01/16
Real-Time Intrafraction Motion Management During Radiotherapy 01/30/19 03/01/19 03/01/19
Recombinant and Autologous Platelet-Derived Growth Factors for Wound Healing and Other Non‒Orthopedic Conditions 03/01/18 03/01/18 03/01/18
Reduction Mammaplasty for Breast-Related Symptoms 03/28/18 01/20/17 01/20/17
Regional Nerve Block and General Anesthesia 11/06/15 11/01/05 11/01/05
Risk-Reducing Mastectomy
replaces Prophylactic Mastectomy
09/12/18 10/28/17 10/28/17
Sacral Nerve Neuromodulation / Stimulation
replaces Sacral Nerve Neuromodulation / Stimulation for Pelvic Floor Dysfunction
01/01/19 02/15/17 02/15/17
Scanning Computerized Ophthalmic Diagnostic Imaging Devices 08/01/18 08/01/18 08/01/18
Scintimammography and Gamma Imaging of the Breast and Axilla 11/07/18 10/26/16 10/26/16
Screening for Lung Cancer Using CT Scanning 01/16/19 02/18/19 02/18/19
Sensorimotor and Neurobehavioral Status Exams for Optometric Providers 01/01/19 01/01/06 N/A
Serologic Diagnosis of Celiac Disease 03/01/18 03/28/12 03/28/12
Serum Antibodies for the Diagnosis of Inflammatory Bowel Disease 02/01/17 03/28/11 03/28/11
Serum Tumor Markers for Breast Malignancies 02/15/18 03/18/15 03/18/15
Sex Reassignment Surgery 12/20/16 01/01/17 01/01/17
Site of Care Infusion Management 12/19/18 01/01/19 01/01/19
Small Bowel/Liver and Multivisceral Transplant 11/07/18 11/13/17 11/13/17
Sphenopalatine Ganglion Block for Headache 01/04/19 11/13/17 11/13/17
Spinal Cord and Dorsal Root Ganglion Stimulation 01/01/19 07/06/18 07/06/18
Stereotactic Radiosurgery and Stereotactic Body Radiotherapy 12/20/17 12/20/17 12/20/17
Subtalar Arthroereisis 01/01/19 01/27/09 02/26/09
Surgical Deactivation of Headache Trigger Sites 03/28/18 12/11/14 12/11/14
Surgical Treatment of Femoroacetabular Impingement 06/06/18 05/24/17 05/24/17
Surgical Treatment of Gynecomastia 03/28/18 03/15/12 03/15/12
Surgical Treatment of Snoring and Obstructive Sleep Apnea (OSA) Syndrome 02/01/19 02/01/19 02/01/19
Temporomandibular Joint (TMJ) Dysfunction 03/14/18 03/14/18 03/14/18
Testing for Vitamin D Deficiency 02/01/19 06/10/16 06/10/16
Total Ankle Replacement 03/01/18 06/29/10 07/29/10
Total Artificial Hearts and Ventricular Assist Devices
replaces Total Artificial Hearts and Implantable Ventricular Assist Devices
01/01/19 03/29/17 03/29/17
Total Facet Arthroplasty 10/13/15 08/17/10 09/16/10
Transcatheter Aortic Valve Implantation for Aortic Stenosis 06/06/18 06/06/18 06/06/18
Transcatheter Arterial Chemoembolization (TACE) to Treat Primary or Metastatic Liver Malignancies 08/15/17 09/14/17 09/14/17
Transcranial Magnetic Stimulation (TMS) 11/07/18 03/18/15 03/18/15
Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease 03/01/18 07/21/15 07/21/15
Translarna (ataluren) 10/06/17 10/06/17 10/06/17
Transtympanic Micropressure Applications as a Treatment of Meniere's Disease 03/28/18 08/12/11 09/12/11
Treatment of Hyperhidrosis 12/13/16 12/13/16 12/13/16
Treatment of Tinnitus 08/04/16 08/04/16 08/04/16
Tumor Treating Fields Therapy 08/01/18 08/01/18 08/01/18
Ultrafiltration in Heart Failure
replaces Ultrafiltration in Decompensated Heart Failure
07/09/18 09/03/14 09/03/14
Ultrasonographic Measurement of Carotid Intima-Medial Thickness as an Assessment of Subclinical Atherosclerosis 08/01/18 02/27/07 09/23/09
Ultrasound Accelerated Fracture Healing Device 04/11/18 03/01/18 03/01/18
Ultraviolet Light Therapy for Skin Conditions 02/01/19 02/04/15 02/04/15
Vacuum Assisted Wound Closure (VAC) 02/18/19 06/23/17 06/23/17
Vagus Nerve Stimulation 01/01/19 12/21/17 12/21/17
Varicose Veins 01/01/19 02/01/19 02/01/19
Video EEG Monitoring 09/15/16 02/20/14 02/20/14
Virtual Colonoscopy / CT Colonography 11/20/18 12/20/18 12/20/18
Virtual Colonoscopy/CT Colonography 10/25/17 10/25/17 10/25/17
Wearable Cardioverter Defibrillators 06/22/18 08/04/16 08/04/16
Wireless Capsule Endoscopy to Diagnose Disorders of the Small Bowel, Esophagus, and Colon
replaces Wireless Capsule Endoscopy as a Diagnostic Technique in Disorders of the Small Bowel, Esophagus, and Colon
01/04/19 01/04/19 01/04/19

Dental Policies

An Availity login is required to access the dental policies.

Policy Title PDF Files Date Posted Professional Effective Date Institutional Effective Date
Cone Beam Computed Tomography (CBCT) 02/15/18 05/14/13 05/14/13
Periodontal Soft Tissue Grafting 01/16/19 06/27/11 06/27/11
Temporomandibular Joint (TMJ) Dysfunction 01/01/19 03/14/18 03/14/18

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.

Policy Title PDF Files Date Posted Archived Date
Acute and Maintenance Tocolysis 11/07/18 11/07/18
Axial Lumbosacral Interbody Fusion 01/01/19 08/24/18
Digital Breast Tomosynthesis 01/01/19 01/01/19
Identification of Periodontal Microorganisms (dental policy, Availity login required) 10/01/18 10/01/18