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/ICD-10 code, use this search tool.


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
ACA Prevention Copay Waiver Criteria – Individual Marketplace, Commercial
Accelerated Breast Irradiation and Brachytherapy Boost After Breast-Conserving Surgery for Early Stage Breast Cancer
Adjustable Cranial Orthoses for Positional Plagiocephaly and Craniosynostoses
Aducanumab (Aduhelm) for Alzheimer Disease
Alcohol Injection Therapy for Morton's Neuroma
Ambulatory Event Monitors and Mobile Cardiac Outpatient Telemetry
Amniotic Membrane and Amniotic Fluid
Analysis of Human DNA in Stool Samples as a Technique for Colorectal Cancer Screening
Anodyne® - Skin Contact Monochromatic Infrared Energy as a Technique to Treat Cutaneous Ulcers, Diabetic Neuropathy, and Miscellaneous Musculoskeletal Conditions
Aqueous Shunts and Stents for Glaucoma
Artificial Intervertebral Disc: Cervical Spine
Artificial Intervertebral Disc: Lumbar Spine
Artificial Pancreas Device Systems
Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer
Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions
Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions
Automated Ambulatory Blood Pressure Monitoring for the Diagnosis of Hypertension in Patients with Elevated Office Blood Pressure
Automated Percutaneous and Percutaneous Endoscopic Discectomy
Balloon Dilation of the Eustachian Tube
Balloon Sinuplasty for Treatment of Chronic Sinusitis
Bio-Engineered Skin and Soft Tissue Substitutes
Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment and Immunotherapy in Metastatic Colorectal Cancer
Bone Mineral Density Studies
Botulinum Toxin (BT)
Breast Reconstructive Surgery After Mastectomy
Bronchial Thermoplasty
Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting
Cardiac Rehabilitation in the Outpatient Setting
Catheter Ablation as Treatment for Atrial Fibrillation
Chelation Therapy for Off-Label Uses
Chronic Intermittent Intravenous Insulin Therapy
Circulating Tumor DNA and Circulating Tumor Cells for Cancer Management (Liquid Biopsy)
Circulating Tumor DNA Management of Non-Small Cell Lung Cancer (Liquid Biopsy)
Cochlear Implant
Comprehensive Genomic Profiling for Selecting Targeted Cancer Therapies
Computed Tomography (CT) to Detect Coronary Artery Calcification
Continuous Glucose Monitoring Systems
Continuous Passive Motion in the Home Setting
Contrast-Enhanced Coronary Computed Tomography Angiography (CCTA) for Coronary Artery Evaluation
Corneal Collagen Cross-Linking
Corneal Topography/Computer-Assisted Corneal Topography/Photokeratoscopy
Coronary Computed Tomography Angiography with Selective Noninvasive Fractional Flow Reserve
Cryoablation of Tumors Located in the Kidney, Lung, Breast, Pancreas, or Bone
Cryosurgical Ablation of Primary or Metastatic Liver Tumors
Cytochrome p450 Genotype-Guided Treatment Strategy
Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Select Intra-Abdominal and Pelvic Malignancies
Decompression of the Intervertebral Disc Using Laser Energy (Laser Discectomy) or Radiofrequency-Coblation (Nucleoplasty)
Deep Brain Stimulation
Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome
Diagnosis and Treatment of Sacroiliac Joint Pain

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.

Policy Title Date Posted Professional Effective Date Institutional Effective Date
Cone Beam Computed Tomography (CBCT)
Periodontal Soft Tissue Grafting
Temporomandibular Joint (TMJ) Disorder

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 Date Posted Archived Date
Acute and Maintenance Tocolysis
Automated Point-of-Care Devices for Nerve Conduction Testing
Axial Lumbosacral Interbody Fusion
Cardiac Computed Tomography (CT)
Cardiovascular Magnetic Resonance (CMR)
Charged-Particle (Proton or Helium Ion) Radiotherapy for Neoplastic Conditions
Computed Tomographic Angiography (CTA) and Magnetic Resonance Angiography (MRA) of the Head, Neck, Abdomen, Pelvis, and Lower Extremities
Diagnosis and Treatment of Chronic Cerebrospinal Venous Insufficiency in Multiple Sclerosis
Fetal Fibronectin
Identification of Periodontal Microorganisms
Image-Guided Minimally Invasive Decompression for Spinal Stenosis
In Vitro Chemoresistance and Chemosensitivity Assays
KIF6 Genotyping for Predicting Cardiovascular Risk and/or Effectiveness of Statin Therapy
Lysis of Epidural Adhesions
Serum Tumor Markers for Breast Malignancies
Small Bowel/Liver and Multivisceral Transplant
Subtalar Arthroereisis
Total Facet Arthroplasty
Transtympanic Micropressure Applications as a Treatment of Meniere's Disease
Ultrasonographic Measurement of Carotid Intima-Medial Thickness as an Assessment of Subclinical Atherosclerosis