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
Magnetic Resonance Spectroscopy
Injectable Bulking Agents for the Treatment of Urinary and Fecal Incontinence
Esketamine Nasal Spray for Depression
Genetic Cancer Susceptibility Panels Using Next Generation Sequencing
Botulinum Toxin (BT)
Transcranial Magnetic Stimulation (TMS) as a Treatment of Depression and Other Psychiatric/Neurologic Disorders
Intravenous Antibiotic Therapy and Associated Diagnostic Testing for Lyme Disease
Laboratory Tests Post Transplant and for Heart Failure
Human Growth Hormone
Carrier Screening for Genetic Diseases
Vyjuvek (beremagene geperpavec- svdt) Medical Drug Criteria Program Summary
Bevacizumab Medical Drug Criteria Program Summary for Oncological Applications
Immunoglobulin Therapy
Multitarget Polymerase Chain Reaction Testing for Diagnosis of Bacterial Vaginosis
Low-Level Laser Therapy
Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome
General Approach to Evaluating the Utility of Genetic Panels
Spinal Cord and Dorsal Root Ganglion Stimulation
Sacral Nerve Neuromodulation / Stimulation
Hyperthermic Intraperitoneal Chemotherapy for Select Intra-Abdominal and Pelvic Malignancies
Interventions for Progressive Scoliosis
Molecular Markers in Fine Needle Aspiration of the Thyroid
Amniotic Membrane and Amniotic Fluid
General Approach to Genetic Testing
Implanted Peripheral Nerve Stimulator (PNS) for Pain Control
Percutaneous and Subcutaneous Tibial Nerve Stimulation
Coronary Computed Tomography Angiography with Selective Noninvasive Fractional Flow Reserve
Intravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric Disorders
Gene Expression Profiling and Protein Biomarkers for Prostate Cancer Management
Endoscopic Radiofrequency Ablation or Cryoablation for Barrett Esophagus
Analysis of Human DNA in Stool Samples as a Technique for Colorectal Cancer Screening
Drug Testing in Pain Management and Substance Use Disorder Treatment
Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer
Noninvasive Techniques for the Evaluation and Monitoring of Patients with Chronic Liver Disease
Esophageal pH Monitoring
Sphenopalatine Ganglion Block for Headache
Measurement of Serum Antibodies to Selected Biologic Agents
Monitored Anesthesia Care
Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment in Non-Small-Cell Lung Cancer (EGFR, ALK, BRAF, ROS1, RET, MET, KRAS)
Positron Emission Tomography (PET) Scanning: Oncologic Applications
ACA Prevention Copay Waiver Criteria – Individual Marketplace, Commercial
Diagnosis and Treatment of Sacroiliac Joint Pain
Proteomic Testing for Systemic Therapy in Non-Small-Cell Lung Cancer
Facet Joint Denervation
Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer
Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease
Homocysteine Testing
Wireless Capsule Endoscopy for Gastrointestinal (GI) Disorders
Testing Serum Vitamin D Levels
Germline and Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment in Breast Cancer (BRCA1, BRCA2, PIK3CA, Ki-67, RET, BRAF, ESR1)

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.