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 Professional Effective Date Institutional Effective Date
Magnetic Resonance Imaging (MRI) of the Breast
Measurement of Serum Antibodies to Selected Biologic Agents
Meniscal Allografts and Other Meniscus Implants
Microprocessor-Controlled Prostheses for the Lower Limb
Microwave Tumor Ablation
Minimally Invasive Ablation Procedures for Morton and Other Peripheral Neuromas
Minimally Invasive Approaches to Vertebral Fractures
Molecular Markers in Fine Needle Aspiration of the Thyroid
Molecular Testing for the Management of Pancreatic Cysts, Barrett’s Esophagus, and Solid Pancreaticobiliary Lesions
Monitored Anesthesia Care
Monoclonal Antibodies for Treatment of Alzheimer Disease
Multitarget Polymerase Chain Reaction Testing for Diagnosis of Bacterial Vaginosis
Myocardial Strain Imaging
Myoelectric Prosthetic Components for the Upper Limb
Negative Pressure Wound Therapy
Noninvasive Prenatal Screening for Fetal Aneuploidies, Microdeletions, Single-Gene Disorders, and Twin Zygosity Using Cell-Free Fetal DNA
Noninvasive Techniques for the Evaluation and Monitoring of Patients with Chronic Liver Disease
Open and Thoracoscopic Approaches to Treat Atrial Fibrillation and Atrial Flutter (Maze and Related Procedures)
Optical Coherence Tomography (OCT) of the Anterior Eye Segment
Orthopedic Applications of Platelet-Rich Plasma
Orthopedic Applications of Stem Cell Therapy (Including Allograft and Bone Substitute Products Used With Autologous Bone Marrow)
Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Disorders
Outpatient Pulmonary Rehabilitation
Panniculectomy and Abdominoplasty
Patient-Controlled End Range of Motion Stretching Devices
Percutaneous and Subcutaneous Tibial Nerve Stimulation
Percutaneous Electrical Nerve Stimulation and Percutaneous Neuromodulation Therapy, and Restorative Neurostimulation Therapy
Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, Biacuplasty and Intraosseous Basivertebral Nerve Ablation
Percutaneous Left Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation
Periureteral Bulking Agents as a Treatment of Vesicoureteral Reflux (VUR)
PET Scanning- Oncologic Applications (Bone and Sarcoma)
PET Scanning- Oncologic Applications (Brain, Melanoma, Unknown Primary)
PET Scanning- Oncologic Applications (Breast and Gynecologic)
PET Scanning- Oncologic Applications (Gastrointestinal and Pancreatic)
PET Scanning- Oncologic Applications (Genitourinary)
PET Scanning- Oncologic Applications (Hematologic)
PET Scanning- Oncologic Applications (Lung)
PET Scanning- Oncologic Applications (Thyroid, Neuroendocrine, Head and Neck)
Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers (for Home Use)
Positron Emission Tomography (PET) Scanning: Cardiac Applications
Positron Emission Tomography (PET) Scanning: In Oncology to Detect Early Response During Treatment
Positron Emission Tomography (PET) Scanning: Miscellaneous (Non-cardiac, Non-Oncologic) Applications of Fluorine 18 Fluorodeoxyglucose
Positron Emission Tomography (PET) Selected: Technologies for Evaluation of Alzheimer Disease
Postsurgical Home Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis
Prostatic Urethral Lift
Proteomic Testing for Systemic Therapy in Non-Small-Cell Lung Cancer
Radioembolization for Primary and Metastatic Tumors of the Liver
Radiofrequency Ablation (RFA) of Miscellaneous Solid Tumors Excluding Liver Tumors
Radiofrequency Ablation of Primary or Metastatic Liver Tumors
Recombinant and Autologous Platelet-Derived Growth Factors for Wound Healing and Other Non‒Orthopedic Conditions

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.

Policy Title Date Posted Professional Effective Date Institutional Effective Date
Cone Beam Computed Tomography (CBCT)
Periodontal Soft Tissue Grafting
Temporomandibular Joint (TMJ) Disorder

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
Bronchial Thermoplasty
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
Enhanced External Counterpulsation (EECP)
Fetal Fibronectin
Foot Care Services
Fundus Photography
Gene Expression Profiling for Uveal Melanoma
Genotype-Guided Tamoxifen Treatment
Hyperbaric Oxygen Therapy (HBOT)
Image-Guided Minimally Invasive Decompression for Spinal Stenosis
In Vitro Chemoresistance and Chemosensitivity Assays
Insulin Pump
Interspinous and Interlaminar Stabilization / Distraction Devices (Spacers)
Interspinous Fixation (Fusion) Devices
Keratoprosthesis
KIF6 Genotyping for Predicting Cardiovascular Risk and/or Effectiveness of Statin Therapy
Lysis of Epidural Adhesions
Magnetic Resonance Spectroscopy
Measurement of Exhaled Nitric Oxide and Exhaled Breath Condensate in the Diagnosis and Management of Respiratory Disorders
Off-Label, Approved Orphan, and Expanded Access (Compassionate Use) Drugs
Pachymetry
Pharmacogenomic and Metabolite Markers for Patients Treated with Thiopurines
Photodynamic Therapy for Choroidal Neovascularization
Plugs for Anal Fistula Repair
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
Virtual Colonoscopy / CT Colonography