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 Sort ascending
Artificial Intervertebral Disc: Cervical Spine
Surgical Treatment for Gender Dysphoria
Hemophilia B Gene Therapy Medical Drug Criteria Program Summary
Temporomandibular Joint (TMJ) Disorder
Postsurgical Home Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis
Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers (for Home Use)
Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting
Bio-Engineered Skin and Soft Tissue Substitutes
Bone Mineral Density Studies
Intravenous Antibiotic Therapy and Associated Diagnostic Testing for Lyme Disease
Wireless Capsule Endoscopy for Gastrointestinal (GI) Disorders
Identification of Microorganisms Using Nucleic Acid Testing
Noninvasive Techniques for the Evaluation and Monitoring of Patients with Chronic Liver Disease
Transcranial Magnetic Stimulation (TMS) as a Treatment of Depression and Other Psychiatric/Neurologic Disorders
Skysona (elivaldogene autotemcel)
Radiofrequency Ablation (RFA) of Miscellaneous Solid Tumors Excluding Liver Tumors
Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes
Positron Emission Tomography (PET) Scanning: Oncologic Applications
Magnetic Resonance Imaging (MRI) of the Breast
Accelerated Breast Irradiation and Brachytherapy Boost After Breast-Conserving Surgery for Early Stage Breast Cancer
Zynteglo (betibeglogene autotemcel) Medical Drug Criteria Program Summary
Contrast-Enhanced Coronary Computed Tomography Angiography (CCTA) for Coronary Artery Evaluation
Positron Emission Tomography (PET) Scanning: Cardiac Applications
Intensity Modulated Radiotherapy (IMRT)
Hyperthermic Intraperitoneal Chemotherapy for Select Intra-Abdominal and Pelvic Malignancies
Gene Expression Profile Testing and Circulating Tumor DNA Testing for Predicting Recurrence in Colon Cancer
Risk-Reducing Mastectomy
Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment and Immunotherapy in Metastatic Colorectal Cancer (KRAS, NRAF, BRAF, MMR/MSI, HER2, and TMB)
Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome
Cytochrome p450 Genotype-Guided Treatment Strategy
General Approach to Evaluating the Utility of Genetic Panels
Immunoglobulin Therapy
Intravenous Iron Replacement Therapy
Outpatient Pulmonary Rehabilitation
Artificial Pancreas Device Systems
Patient-Controlled End Range of Motion Stretching Devices
Steroid-Eluting Sinus Stents and Implants
Balloon Ostial Dilation for Treatment of Chronic and Recurrent Acute Rhinosinusitis
Gene Expression Profiling for Uveal Melanoma
Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease
Non-invasive Positive Airway Pressure for Chronic Obstructive Pulmonary Disease (COPD)
Testing Serum Vitamin D Levels
Facet Joint Denervation
Laboratory Tests Post Transplant and for Heart Failure
Intravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric Disorders
Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, Biacuplasty and Intraosseous Basivertebral Nerve Ablation
Interventions for Progressive Scoliosis
Esketamine Nasal Spray for Depression
Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence
Analysis of Human DNA in Stool Samples as a Technique for Colorectal Cancer Screening

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.