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 Sort descending Institutional Effective Date
Charged-Particle (Proton or Helium Ion) Radiotherapy for Neoplastic Conditions
Monoclonal Antibodies for Treatment of Alzheimer Disease
Continuous Glucose Monitoring
Tumor Treating Fields Therapy
Extracorporeal Shock Wave Therapy (ESWT) for Plantar Fasciitis and Other Musculoskeletal Conditions
Bioimpedance Devices for Detection and Management of Lymphedema
Zolgensma Medical Drug Criteria
Percutaneous Electrical Nerve Stimulation and Percutaneous Neuromodulation Therapy, and Restorative Neurostimulation Therapy
Minimally Invasive Ablation Procedures for Morton and Other Peripheral Neuromas
Percutaneous Vertebroplasty and Sacroplasty
Prostatic Urethral Lift
Total Artificial Hearts and Ventricular Assist Devices
Circulating Tumor DNA and Circulating Tumor Cells for Cancer Management (Liquid Biopsy)
Percutaneous Balloon Kyphoplasty, Radiofrequency Kyphoplasty, and Mechanical Vertebral Augmentation
Germline Genetic Testing for Hereditary Breast/Ovarian Cancer Syndrome and Other High-Risk Cancers (BRCA1, BRCA2, PALB2)
Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment in Metastatic Colorectal Cancer (KRAS, NRAS, BRAF, and HER2)
Percutaneous and Subcutaneous Tibial Nerve Stimulation
Elevidys® (delandistrogene moxeparvovec-rokl) (Intravenous)
Botulinum Toxin (BT)
Human Growth Hormone
Multitarget Polymerase Chain Reaction Testing for Diagnosis of Bacterial Vaginosis
Low-Level Laser Therapy
Carrier Screening for Genetic Diseases
Vyjuvek (beremagene geperpavec- svdt) Medical Drug Criteria Program Summary
Bevacizumab Medical Drug Criteria Program Summary for Oncological Applications
Gene Expression Profiling and Protein Biomarkers for Prostate Cancer Management
Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer
Monitored Anesthesia Care
ACA Prevention Copay Waiver Criteria – Individual Marketplace, Commercial
Diagnosis and Treatment of Sacroiliac Joint Pain
Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer
Germline and Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment in Breast Cancer (BRCA1, BRCA2, PIK3CA, Ki-67, RET, BRAF, ESR1)
Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment in Non-Small-Cell Lung Cancer (EGFR, ALK, BRAF, ROS1, RET, MET, KRAS)
Electrical Stimulation Devices for Home and Provider Use
Leadless Cardiac Pacemakers
Hemophilia A Gene Therapy Medical Drug Criteria Program Summary
Scanning Computerized Ophthalmic Diagnostic Imaging Devices
Transcatheter Aortic Valve Implantation for Aortic Stenosis
Comprehensive Genomic Profiling for Selecting Targeted Cancer Therapies
Negative Pressure Wound Therapy
Genetic Testing for Diagnosis and Management of Mental Health Conditions
Noninvasive Prenatal Screening for Fetal Aneuploidies, Microdeletions, Single-Gene Disorders, and Twin Zygosity Using Cell-Free Fetal DNA
Site of Care Infusion Management Medical Drug Criteria Program Summary
Human Growth Hormone
Bio-Engineered Skin and Soft Tissue Substitutes
Cardiac Rehabilitation in the Outpatient Setting
Amniotic Membrane and Amniotic Fluid
Home Non-invasive Positive Airway Pressure Devices for the Treatment of Respiratory Insufficiency and Failure
Outpatient Pulmonary Rehabilitation

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.