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 ascending Professional Effective Date Institutional Effective Date
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
Gene Expression-Based Assays for Cancers of Unknown Primary
Amniotic Membrane and Amniotic Fluid
Microprocessor-Controlled Prostheses for the Lower Limb
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
Myoelectric Prosthetic Components for the Upper Limb
Corneal Collagen Cross-Linking
Home Non-invasive Positive Airway Pressure Devices for the Treatment of Respiratory Insufficiency and Failure
Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers (for Home Use)
Outpatient Pulmonary Rehabilitation
Genetic Testing for Predisposition to Inherited Hypertrophic Cardiomyopathy
Human Growth Hormone
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
Surgical Deactivation of Headache Trigger Sites
Genetic Testing for Marfan Syndrome, Thoracic Aortic Aneurysms and Dissections, and Related Disorders
Gastric Electrical Stimulation
Transcatheter Aortic Valve Implantation for Aortic Stenosis
Comprehensive Genomic Profiling for Selecting Targeted Cancer Therapies
Surgical Treatment of Gynecomastia
Zynteglo (betibeglogene autotemcel) Medical Drug Criteria Program Summary
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
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
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
Hemophilia A Gene Therapy Medical Drug Criteria Program Summary
Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease
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 Sort ascending Archived Date
Treatment of Tinnitus
Dynamic Posturography
Ultraviolet Light Therapy for Skin Conditions
Alcohol Injection Therapy for Morton's Neuroma
Pachymetry
Genotype-Guided Tamoxifen Treatment
Automated Percutaneous and Percutaneous Endoscopic Discectomy
Decompression of the Intervertebral Disc Using Laser Energy (Laser Discectomy) or Radiofrequency-Coblation (Nucleoplasty)
Progesterone Therapy as a Technique to Reduce Preterm Birth in High-Risk Pregnancies
Foot Care Services
Total Ankle Replacement
Pharmacogenomic and Metabolite Markers for Patients Treated with Thiopurines
Plugs for Anal Fistula Repair
Hyperbaric Oxygen Therapy (HBOT)
Insulin Pump
Automated Ambulatory Blood Pressure Monitoring for the Diagnosis of Hypertension in Patients with Elevated Office Blood Pressure
Keratoprosthesis
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
Chronic Intermittent Intravenous Insulin Therapy
Sensorimotor and Neurobehavioral Status Exams for Optometric Providers
In Vitro Chemoresistance and Chemosensitivity Assays
KIF6 Genotyping for Predicting Cardiovascular Risk and/or Effectiveness of Statin Therapy
Ultrasonographic Measurement of Carotid Intima-Medial Thickness as an Assessment of Subclinical Atherosclerosis
Lysis of Epidural Adhesions
Computed Tomographic Angiography (CTA) and Magnetic Resonance Angiography (MRA) of the Head, Neck, Abdomen, Pelvis, and Lower Extremities
Automated Point-of-Care Devices for Nerve Conduction Testing
Cardiac Computed Tomography (CT)
Serum Tumor Markers for Breast Malignancies
Diagnosis and Treatment of Chronic Cerebrospinal Venous Insufficiency in Multiple Sclerosis
Fetal Fibronectin
Image-Guided Minimally Invasive Decompression for Spinal Stenosis
Cardiovascular Magnetic Resonance (CMR)