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
Leadless Cardiac Pacemakers
Low Intensity Pulsed Ultrasound Fracture Healing Device
Low-Level Laser Therapy
Lumbar Spinal Fusion
Magnetic Resonance Imaging (MRI) of the Breast
Magnetic Resonance Spectroscopy
Measurement of Exhaled Nitric Oxide and Exhaled Breath Condensate in the Diagnosis and Management of Respiratory Disorders
Measurement of Lipoprotein-Associated Phospholipase A2 in the Assessment of Cardiovascular Risk
Measurement of Serum Antibodies to Selected Biologic Agents
Meniscal Allografts and Other Meniscus Implants
Microprocessor-Controlled Prostheses for the Lower Limb
Microwave Tumor Ablation
Minimally Invasive Ablation Procedures for Morton and Other Peripheral Neuromas
Molecular Markers in Fine Needle Aspiration of the Thyroid
Molecular Testing for the Management of Pancreatic Cysts, Barrett’s Esophagus, and Solid Pancreaticobiliary Lesions
Monitored Anesthesia Care
Monoclonal Antibodies for Treatment of Alzheimer Disease
Multitarget Polymerase Chain Reaction Testing for Diagnosis of Bacterial Vaginosis
Myocardial Strain Imaging
Myoelectric Prosthetic Components for the Upper Limb
Negative Pressure Wound Therapy
Non-invasive Positive Airway Pressure for Chronic Obstructive Pulmonary Disease (COPD)
Noninvasive Prenatal Screening for Fetal Aneuploidies, Microdeletions, Single-Gene Disorders, and Twin Zygosity Using Cell-Free Fetal DNA
Noninvasive Techniques for the Evaluation and Monitoring of Patients with Chronic Liver Disease
Novel Biomarkers in Risk Assessment and Management of Cardiovascular Disease
Off-Label, Approved Orphan, and Expanded Access (Compassionate Use) Drugs
Open and Thoracoscopic Approaches to Treat Atrial Fibrillation and Atrial Flutter (Maze and Related Procedures)
Optical Coherence Tomography (OCT) of the Anterior Eye Segment
Orthopedic Applications of Platelet-Rich Plasma
Orthopedic Applications of Stem Cell Therapy (Including Allograft and Bone Substitute Products Used With Autologous Bone Marrow)
Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Disorders
Outpatient Pulmonary Rehabilitation
Panniculectomy and Abdominoplasty
Patient-Controlled End Range of Motion Stretching Devices
Percutaneous and Subcutaneous Tibial Nerve Stimulation
Percutaneous Balloon Kyphoplasty, Radiofrequency Kyphoplasty, and Mechanical Vertebral Augmentation
Percutaneous Electrical Nerve Stimulation and Percutaneous Neuromodulation Therapy, and Restorative Neurostimulation Therapy
Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, Biacuplasty and Intraosseous Basivertebral Nerve Ablation
Percutaneous Left Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation
Percutaneous Vertebroplasty and Sacroplasty
Periureteral Bulking Agents as a Treatment of Vesicoureteral Reflux (VUR)
Photodynamic Therapy for Choroidal Neovascularization
Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers (for Home Use)
Positron Emission Tomography (PET) Scanning: Cardiac Applications
Positron Emission Tomography (PET) Scanning: In Oncology to Detect Early Response During Treatment
Positron Emission Tomography (PET) Scanning: Miscellaneous (Non-cardiac, Non-Oncologic) Applications of Fluorine 18 Fluorodeoxyglucose
Positron Emission Tomography (PET) Scanning: Oncologic Applications
Postsurgical Home Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis
Prostatic Urethral Lift
Proteomic Testing for Systemic Therapy in Non-Small-Cell Lung Cancer

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.