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 Sort descending Professional Effective Date Institutional Effective Date
Measurement of Lipoprotein-Associated Phospholipase A2 in the Assessment of Cardiovascular Risk
Hemophilia A Gene Therapy Medical Drug Criteria Program Summary
Scanning Computerized Ophthalmic Diagnostic Imaging Devices
Orthopedic Applications of Stem Cell Therapy (Including Allograft and Bone Substitute Products Used With Autologous Bone Marrow)
Electrical Stimulation Devices for Home and Provider Use
Leadless Cardiac Pacemakers
Bioimpedance Devices for Detection and Management of Lymphedema
Genetic Testing for Cardiac Ion Channelopathies
Recombinant and Autologous Platelet-Derived Growth Factors for Wound Healing and Other Non‒Orthopedic Conditions
Genetic Testing for Diagnosis and Management of Mental Health Conditions
Genetic Testing for the Diagnosis of Inherited Peripheral Neuropathies
Reduction Mammaplasty for Breast-Related Symptoms
Steroid-Eluting Sinus Stents and Implants
Site of Care Infusion Management Medical Drug Criteria Program Summary
Vagus Nerve Stimulation
Cochlear Implant
Gastric Electrical Stimulation
Surgical Deactivation of Headache Trigger Sites
Genetic Testing for Marfan Syndrome, Thoracic Aortic Aneurysms and Dissections, and Related Disorders
Transcatheter Aortic Valve Implantation for Aortic Stenosis
Comprehensive Genomic Profiling for Selecting Targeted Cancer Therapies
Zynteglo (betibeglogene autotemcel) Medical Drug Criteria Program Summary
Surgical Treatment of Gynecomastia
Implantable Bone-Conduction and Bone-Anchored Hearing Aids
Balloon Ostial Dilation for Treatment of Chronic and Recurrent Acute Rhinosinusitis
Gene Expression Profiling for Uveal Melanoma
Temporomandibular Joint (TMJ) Disorder
Chelation Therapy for Off-Label Uses
Negative Pressure Wound Therapy
Human Growth Hormone
Noninvasive Prenatal Screening for Fetal Aneuploidies, Microdeletions, Single-Gene Disorders, and Twin Zygosity Using Cell-Free Fetal DNA
Bio-Engineered Skin and Soft Tissue Substitutes
Corneal Topography/Computer-Assisted Corneal Topography/Photokeratoscopy
Cardiac Rehabilitation in the Outpatient Setting
Amniotic Membrane and Amniotic Fluid
Gene Expression-Based Assays for Cancers of Unknown Primary
Adjustable Cranial Orthoses for Positional Plagiocephaly and Craniosynostoses
Microprocessor-Controlled Prostheses for the Lower Limb
Patient-Controlled End Range of Motion Stretching Devices
Optical Coherence Tomography (OCT) of the Anterior Eye Segment
Low Intensity Pulsed Ultrasound Fracture Healing Device
Continuous Passive Motion in the Home Setting
Postsurgical Home Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis
Corneal Collagen Cross-Linking
Home Non-invasive Positive Airway Pressure Devices for the Treatment of Respiratory Insufficiency and Failure
Myoelectric Prosthetic Components for the Upper Limb
Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers (for Home Use)
Outpatient Pulmonary Rehabilitation
Genetic Testing for Predisposition to Inherited Hypertrophic Cardiomyopathy

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.