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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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 Sort descending Professional Effective Date Institutional Effective Date
Intravenous Iron Replacement Therapy
Extracorporeal Shock Wave Therapy (ESWT) for Plantar Fasciitis and Other Musculoskeletal Conditions
Continuous Glucose Monitoring
Zolgensma Medical Drug Criteria
Percutaneous Electrical Nerve Stimulation and Percutaneous Neuromodulation Therapy, and Restorative Neurostimulation Therapy
Artificial Pancreas Device Systems
Tumor Treating Fields Therapy
Minimally Invasive Ablation Procedures for Morton and Other Peripheral Neuromas
Stereotactic Radiosurgery and Stereotactic Body Radiotherapy
Transcatheter Arterial Chemoembolization (TACE) to Treat Primary or Metastatic Liver Malignancies
Hydrogel Spacer use During Radiotherapy for Prostate Cancer
Risk-Reducing Mastectomy
Molecular Testing for the Management of Pancreatic Cysts, Barrett’s Esophagus, and Solid Pancreaticobiliary Lesions
Radioembolization for Primary and Metastatic Tumors of the Liver
Cryoablation of Tumors Located in the Kidney, Lung, Breast, Pancreas, or Bone
Intensity Modulated Radiotherapy (IMRT)
Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment in Metastatic Colorectal Cancer (KRAS, NRAS, BRAF, and HER2)
Electronic Brachytherapy for Nonmelanoma Skin Cancer
Radiofrequency Ablation of Primary or Metastatic Liver Tumors
Accelerated Breast Irradiation and Brachytherapy Boost After Breast-Conserving Surgery for Early Stage Breast Cancer
Gene Expression Profile Testing and Circulating Tumor DNA Testing for Predicting Recurrence in Colon Cancer
Percutaneous Vertebroplasty and Sacroplasty
Prostatic Urethral Lift
Breast Reconstructive Surgery After Mastectomy
Total Artificial Hearts and Ventricular Assist Devices
Hemophilia B Gene Therapy Medical Drug Criteria Program Summary
Germline Genetic Testing for Hereditary Breast/Ovarian Cancer Syndrome and Other High-Risk Cancers (BRCA1, BRCA2, PALB2)
Circulating Tumor DNA and Circulating Tumor Cells for Cancer Management (Liquid Biopsy)
Identification of Microorganisms Using Nucleic Acid Testing
Bio-Engineered Skin and Soft Tissue Substitutes
Percutaneous Balloon Kyphoplasty, Radiofrequency Kyphoplasty, and Mechanical Vertebral Augmentation
Periureteral Bulking Agents as a Treatment of Vesicoureteral Reflux (VUR)
Fundus Photography
Cryosurgical Ablation of Primary or Metastatic Liver Tumors
Lumbar Spinal Fusion
Balloon Dilation of the Eustachian Tube
Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, Biacuplasty and Intraosseous Basivertebral Nerve Ablation
Contrast-Enhanced Coronary Computed Tomography Angiography (CCTA) for Coronary Artery Evaluation
Computed Tomography (CT) to Detect Coronary Artery Calcification
Radiofrequency Ablation (RFA) of Miscellaneous Solid Tumors Excluding Liver Tumors
Positron Emission Tomography (PET) Scanning: In Oncology to Detect Early Response During Treatment
Magnetic Resonance Imaging (MRI) of the Breast
Aqueous Shunts and Stents for Glaucoma
Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes
Bone Mineral Density Studies
Virtual Colonoscopy / CT Colonography
Positron Emission Tomography (PET) Scanning: Cardiac Applications
Elevidys® (delandistrogene moxeparvovec-rokl) (Intravenous)
Positron Emission Tomography (PET) Scanning: Miscellaneous (Non-cardiac, Non-Oncologic) Applications of Fluorine 18 Fluorodeoxyglucose
Microwave Tumor Ablation

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.