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
Radiofrequency Ablation (RFA) of Miscellaneous Solid Tumors Excluding Liver Tumors
Radiofrequency Ablation of Primary or Metastatic Liver Tumors
Recombinant and Autologous Platelet-Derived Growth Factors for Wound Healing and Other Non‒Orthopedic Conditions
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
Site of Care Infusion Management Medical Drug Criteria Program Summary
Skysona (elivaldogene autotemcel)
Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment and Immunotherapy in Metastatic Colorectal Cancer (KRAS, NRAF, BRAF, MMR/MSI, HER2, and TMB)
Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment in Metastatic Colorectal Cancer (KRAS, NRAS, BRAF, and HER2)
Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment in Non-Small-Cell Lung Cancer (EGFR, ALK, BRAF, ROS1, RET, MET, KRAS)
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
Virtual Colonoscopy / CT Colonography
Vyjuvek (beremagene geperpavec- svdt) Medical Drug Criteria Program Summary
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.

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.