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
Reduction Mammaplasty for Breast-Related Symptoms
Risk-Reducing Mastectomy
Sacral Nerve Neuromodulation / Stimulation
Scanning Computerized Ophthalmic Diagnostic Imaging Devices
Screening for Lung Cancer Using CT Scanning
Serologic Diagnosis of Celiac Disease
Serum Antibodies for the Diagnosis of Inflammatory Bowel Disease
Site of Care Infusion Management Medical Drug Criteria Program Summary
Skysona (elivaldogene autotemcel)
Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment in Metastatic Colorectal Cancer (KRAS, NRAS, BRAF, NTRK and HER2)
Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment in Non-Small-Cell Lung Cancer (EGFR, ALK, BRAF, ROS1, RET, MET, KRAS, NTRK)
Sphenopalatine Ganglion Block for Headache
Spinal Cord and Dorsal Root Ganglion Stimulation
Stereotactic Radiosurgery and Stereotactic Body Radiotherapy
Steroid-Eluting Sinus Stents and Implants
Surgical Deactivation of Headache Trigger Sites
Surgical Treatment for Gender Dysphoria
Surgical Treatment of Femoroacetabular Impingement
Surgical Treatment of Gynecomastia
Surgical Treatment of Snoring and Obstructive Sleep Apnea (OSA) Syndrome
Temporomandibular Joint (TMJ) Disorder
Testing Serum Vitamin D Levels
Total Artificial Hearts and Ventricular Assist Devices
Transcatheter Aortic Valve Implantation for Aortic Stenosis
Transcatheter Arterial Chemoembolization (TACE) to Treat Primary or Metastatic Liver Malignancies
Transcranial Magnetic Stimulation (TMS) as a Treatment of Depression and Other Psychiatric/Neurologic Disorders
Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease
Treatment for Duchenne Muscular Dystrophy
Treatment of Hyperhidrosis
Tumor Treating Fields Therapy
Vagus Nerve Stimulation
Varicose Veins
Video Electroencephalogram (EEG) Monitoring
Vyjuvek (beremagene geperpavec-svdt) Medical Drug Criteria Program
Wearable Cardioverter Defibrillators
Wireless Capsule Endoscopy for Gastrointestinal (GI) Disorders
Zolgensma Medical Drug Criteria
Zynteglo (betibeglogene autotemcel) Medical Drug Criteria Program Summary

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
Alcohol Injection Therapy for Morton's Neuroma
Anodyne® - Skin Contact Monochromatic Infrared Energy as a Technique to Treat Cutaneous Ulcers, Diabetic Neuropathy, and Miscellaneous Musculoskeletal Conditions
Automated Ambulatory Blood Pressure Monitoring for the Diagnosis of Hypertension in Patients with Elevated Office Blood Pressure
Automated Percutaneous and Percutaneous Endoscopic Discectomy
Automated Point-of-Care Devices for Nerve Conduction Testing
Bronchial Thermoplasty
Cardiac Computed Tomography (CT)
Cardiovascular Magnetic Resonance (CMR)
Chronic Intermittent Intravenous Insulin Therapy
Computed Tomographic Angiography (CTA) and Magnetic Resonance Angiography (MRA) of the Head, Neck, Abdomen, Pelvis, and Lower Extremities
Decompression of the Intervertebral Disc Using Laser Energy (Laser Discectomy) or Radiofrequency-Coblation (Nucleoplasty)
Diagnosis and Treatment of Chronic Cerebrospinal Venous Insufficiency in Multiple Sclerosis
Dynamic Posturography
Enhanced External Counterpulsation (EECP)
Fetal Fibronectin
Foot Care Services
Fundus Photography
Gene Expression Profiling for Uveal Melanoma
Genotype-Guided Tamoxifen Treatment
Hyperbaric Oxygen Therapy (HBOT)
Image-Guided Minimally Invasive Decompression for Spinal Stenosis
In Vitro Chemoresistance and Chemosensitivity Assays
Insulin Pump
Interspinous and Interlaminar Stabilization / Distraction Devices (Spacers)
Interspinous Fixation (Fusion) Devices
Keratoprosthesis
KIF6 Genotyping for Predicting Cardiovascular Risk and/or Effectiveness of Statin Therapy
Lysis of Epidural Adhesions
Magnetic Resonance Spectroscopy
Measurement of Exhaled Nitric Oxide and Exhaled Breath Condensate in the Diagnosis and Management of Respiratory Disorders
Off-Label, Approved Orphan, and Expanded Access (Compassionate Use) Drugs
Pachymetry
Pharmacogenomic and Metabolite Markers for Patients Treated with Thiopurines
Photodynamic Therapy for Choroidal Neovascularization
Plugs for Anal Fistula Repair
Real-Time Intrafraction Motion Management During Radiotherapy
Sensorimotor and Neurobehavioral Status Exams for Optometric Providers
Serum Tumor Markers for Breast Malignancies
Total Ankle Replacement
Treatment of Tinnitus
Ultrasonographic Measurement of Carotid Intima-Medial Thickness as an Assessment of Subclinical Atherosclerosis
Ultraviolet Light Therapy for Skin Conditions
Virtual Colonoscopy / CT Colonography