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

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.

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
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
Fetal Fibronectin
Foot Care Services
Genotype-Guided Tamoxifen Treatment
Hyperbaric Oxygen Therapy (HBOT)
Image-Guided Minimally Invasive Decompression for Spinal Stenosis
In Vitro Chemoresistance and Chemosensitivity Assays
Insulin Pump
Keratoprosthesis
KIF6 Genotyping for Predicting Cardiovascular Risk and/or Effectiveness of Statin Therapy
Lysis of Epidural Adhesions
Pachymetry
Pharmacogenomic and Metabolite Markers for Patients Treated with Thiopurines
Plugs for Anal Fistula Repair
Progesterone Therapy as a Technique to Reduce Preterm Birth in High-Risk Pregnancies
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