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 ascending Institutional Effective Date
Measurement of Exhaled Nitric Oxide and Exhaled Breath Condensate in the Diagnosis and Management of Respiratory Disorders
Orthopedic Applications of Stem Cell Therapy (Including Allograft and Bone Substitute Products Used With Autologous Bone Marrow)
Interspinous and Interlaminar Stabilization / Distraction Devices (Spacers)
Esophageal pH Monitoring
Positron Emission Tomography (PET) Scanning: Miscellaneous (Non-cardiac, Non-Oncologic) Applications of Fluorine 18 Fluorodeoxyglucose
Positron Emission Tomography (PET) Scanning: In Oncology to Detect Early Response During Treatment
Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Disorders
Lumbar Spinal Fusion
Open and Thoracoscopic Approaches to Treat Atrial Fibrillation and Atrial Flutter (Maze and Related Procedures)
Percutaneous Left Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation
Corneal Collagen Cross-Linking
Ambulatory Event Monitors and Mobile Cardiac Outpatient Telemetry
Gene Expression Profiling for Cutaneous Melanoma
Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions
Genetic Testing for Predisposition to Inherited Hypertrophic Cardiomyopathy
Novel Biomarkers in Risk Assessment and Management of Cardiovascular Disease
Recombinant and Autologous Platelet-Derived Growth Factors for Wound Healing and Other Non‒Orthopedic Conditions
Genetic Testing for the Diagnosis of Inherited Peripheral Neuropathies
Vagus Nerve Stimulation
Sphenopalatine Ganglion Block for Headache
Electronic Brachytherapy for Nonmelanoma Skin Cancer
Photodynamic Therapy for Choroidal Neovascularization
Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures
Deep Brain Stimulation
Surgical Treatment of Femoroacetabular Impingement
Reduction Mammaplasty for Breast-Related Symptoms
Dry Needling of Myofascial Trigger Points
Electrical Bone Growth Stimulation of the Appendicular Skeleton
Chelation Therapy for Off-Label Uses
Wearable Cardioverter Defibrillators
Intra-Articular Hyaluronan Injections for Osteoarthritis
Implanted Peripheral Nerve Stimulator (PNS) for Pain Control
Radioembolization for Primary and Metastatic Tumors of the Liver
Gene Expression-Based Assays for Cancers of Unknown Primary
Off-Label, Approved Orphan, and Expanded Access (Compassionate Use) Drugs
Orthopedic Applications of Platelet-Rich Plasma
Cryosurgical Ablation of Primary or Metastatic Liver Tumors
Interspinous Fixation (Fusion) Devices
Serologic Diagnosis of Celiac Disease
Surgical Treatment of Gynecomastia
Serum Antibodies for the Diagnosis of Inflammatory Bowel Disease
Panniculectomy and Abdominoplasty
Bronchial Thermoplasty
Periureteral Bulking Agents as a Treatment of Vesicoureteral Reflux (VUR)
Measurement of Lipoprotein-Associated Phospholipase A2 in the Assessment of Cardiovascular Risk
Computed Tomography (CT) to Detect Coronary Artery Calcification
Artificial Intervertebral Disc: Lumbar Spine
Enhanced External Counterpulsation (EECP)
Magnetic Resonance Spectroscopy

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.