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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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
Non-invasive Positive Airway Pressure for Chronic Obstructive Pulmonary Disease (COPD)
Novel Biomarkers in Risk Assessment and Management of Cardiovascular Disease
Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment and Immunotherapy in Metastatic Colorectal Cancer (KRAS, NRAF, BRAF, MMR/MSI, HER2, and TMB)
Serologic Diagnosis of Celiac Disease
Panniculectomy and Abdominoplasty
Screening for Lung Cancer Using CT Scanning
Corneal Topography/Computer-Assisted Corneal Topography/Photokeratoscopy
Photodynamic Therapy for Choroidal Neovascularization
Gene Expression-Based Assays for Cancers of Unknown Primary
Outpatient Pulmonary Rehabilitation
Adjustable Cranial Orthoses for Positional Plagiocephaly and Craniosynostoses
Optical Coherence Tomography (OCT) of the Anterior Eye Segment
Low Intensity Pulsed Ultrasound Fracture Healing Device
Patient-Controlled End Range of Motion Stretching Devices
Postsurgical Home Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis
Continuous Passive Motion in the Home Setting
Cardiac Rehabilitation in the Outpatient Setting
Myoelectric Prosthetic Components for the Upper Limb
Corneal Collagen Cross-Linking
Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers (for Home Use)
Genetic Testing for Predisposition to Inherited Hypertrophic Cardiomyopathy
Surgical Treatment for Gender Dysphoria
Intra-Articular Hyaluronan Injections for Osteoarthritis
Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions
Orthopedic Applications of Platelet-Rich Plasma
Deep Brain Stimulation
Artificial Intervertebral Disc: Cervical Spine
Electrical Bone Growth Stimulation of the Appendicular Skeleton
Interspinous Fixation (Fusion) Devices
Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions
Dry Needling of Myofascial Trigger Points
Interspinous and Interlaminar Stabilization / Distraction Devices (Spacers)
Artificial Intervertebral Disc: Lumbar Spine
Surgical Treatment of Femoroacetabular Impingement
Meniscal Allografts and Other Meniscus Implants
Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures
Charged-Particle (Proton or Helium Ion) Radiotherapy for Neoplastic Conditions
Open and Thoracoscopic Approaches to Treat Atrial Fibrillation and Atrial Flutter (Maze and Related Procedures)
Ambulatory Event Monitors and Mobile Cardiac Outpatient Telemetry
Implantable Cardioverter Defibrillators
Extracranial Carotid Artery Stenting
Percutaneous Left Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation
Catheter Ablation as Treatment for Atrial Fibrillation
Wearable Cardioverter Defibrillators
Gene Expression Profiling for Cutaneous Melanoma
Myocardial Strain Imaging
Varicose Veins
Enhanced External Counterpulsation (EECP)
Treatment for Duchenne Muscular Dystrophy
Monoclonal Antibodies for Treatment of Alzheimer Disease

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 Sort descending Archived Date
Cardiovascular Magnetic Resonance (CMR)
Image-Guided Minimally Invasive Decompression for Spinal Stenosis
Fetal Fibronectin
Diagnosis and Treatment of Chronic Cerebrospinal Venous Insufficiency in Multiple Sclerosis
Serum Tumor Markers for Breast Malignancies
Cardiac Computed Tomography (CT)
Automated Point-of-Care Devices for Nerve Conduction Testing
Computed Tomographic Angiography (CTA) and Magnetic Resonance Angiography (MRA) of the Head, Neck, Abdomen, Pelvis, and Lower Extremities
Lysis of Epidural Adhesions
Ultrasonographic Measurement of Carotid Intima-Medial Thickness as an Assessment of Subclinical Atherosclerosis
KIF6 Genotyping for Predicting Cardiovascular Risk and/or Effectiveness of Statin Therapy
In Vitro Chemoresistance and Chemosensitivity Assays
Sensorimotor and Neurobehavioral Status Exams for Optometric Providers
Chronic Intermittent Intravenous Insulin Therapy
Real-Time Intrafraction Motion Management During Radiotherapy
Anodyne® - Skin Contact Monochromatic Infrared Energy as a Technique to Treat Cutaneous Ulcers, Diabetic Neuropathy, and Miscellaneous Musculoskeletal Conditions
Keratoprosthesis
Automated Ambulatory Blood Pressure Monitoring for the Diagnosis of Hypertension in Patients with Elevated Office Blood Pressure
Insulin Pump
Hyperbaric Oxygen Therapy (HBOT)
Plugs for Anal Fistula Repair
Foot Care Services
Total Ankle Replacement
Pharmacogenomic and Metabolite Markers for Patients Treated with Thiopurines
Progesterone Therapy as a Technique to Reduce Preterm Birth in High-Risk Pregnancies
Decompression of the Intervertebral Disc Using Laser Energy (Laser Discectomy) or Radiofrequency-Coblation (Nucleoplasty)
Automated Percutaneous and Percutaneous Endoscopic Discectomy
Genotype-Guided Tamoxifen Treatment
Alcohol Injection Therapy for Morton's Neuroma
Pachymetry
Ultraviolet Light Therapy for Skin Conditions
Treatment of Tinnitus
Dynamic Posturography